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 Table of Contents  
Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 284-288

Surgical residents and palliative care, hospice care, advance care planning, and end-of-life ethics: An analysis of baseline knowledge and educational session to improve competence

1 Northeast Ohio Medical University, College of Graduate Studies, Rootstown, Ohio, USA
2 Department of Family and Community Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
3 Department of Cardiothoracic Surgery, The Medical Center of Aurora and Rose Hospital, Aurora, Colorado, USA

Date of Submission11-Jun-2018
Date of Acceptance08-Jul-2018
Date of Web Publication24-Dec-2018

Correspondence Address:
Dr. Mark Dalvin
6618 Covington Cove, Canfield, Ohio 44406
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_22_18

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Introduction: The American Board of Surgery expects competence in interdisciplinary palliative care, and dealing with advancing chronic conditions and end-of-life scenarios are part of Accreditation Council for Graduate Medical Education general surgery milestones. Despite established standards, surgical trainees receive limited amounts of formal palliative care training, if any.
Objective: The study purpose was to evaluate baseline knowledge and test effectiveness of an educational session for surgical residents focused on palliative care, hospice care, advance care planning (ACP), and related topics.
Methods: The study was completed at Northeast Ohio Medical University with participation from general surgery residents, students, and faculty at Northside Regional Medical Center in Youngstown, Ohio. Participation involved a pretest, lecture, and posttest surrounding palliative and hospice care, ACP, and related topics to teach and assess baseline knowledge and usefulness of an educational session based on test comparison. Mean group scores for pre/post-tests were calculated. A paired one-tailed t-test was used to assess effective change in mean scores.
Results: Twenty participants completed the session. The mean pretest score for the group was 60%. The mean posttest score for the group was 75%. Results show that, after the 30-min presentation, there was statistically significant improvement between means (P = 0.00002).
Conclusions: Palliative care, hospice care, and ACP are not utilized to potential due to poor residency education as indicated by low mean pretest score. Statistically significant improvement between tests indicates that education focused on these topics can remedy the knowledge gap and presumably improve patient care involving these topics.
The following core competencies are addressed in this article: Practice-based learning and improvement, Interpersonal and communication skills, Professionalism.

Keywords: Education, ethics, hospice, palliative, residents

How to cite this article:
Dalvin M, Aultman J, Firstenberg MS. Surgical residents and palliative care, hospice care, advance care planning, and end-of-life ethics: An analysis of baseline knowledge and educational session to improve competence. Int J Acad Med 2018;4:284-8

How to cite this URL:
Dalvin M, Aultman J, Firstenberg MS. Surgical residents and palliative care, hospice care, advance care planning, and end-of-life ethics: An analysis of baseline knowledge and educational session to improve competence. Int J Acad Med [serial online] 2018 [cited 2021 Dec 2];4:284-8. Available from: https://www.ijam-web.org/text.asp?2018/4/3/284/248326

  Introduction Top

The American Board of Surgery expects surgeons to be competent in providing interdisciplinary palliative care; addressing advancing chronic conditions and end-of-life situations are general surgery milestones according to the Accreditation Council for Graduate Medical Education.[2] Despite established standards, many surgical trainees receive limited or no palliative care training and education.[3] Palliative care, hospice care, and the nuances surrounding their proper utilization in surgical residency education are also critical gaps in the research literature.[3],[4],[5] Thus, this study was to evaluate the effectiveness of a formal educational session for surgical residents with a focus on palliative care, hospice care, and advance care planning (ACP) and decision-making. The hypothesis of this study is to obtain a confirmation of the lack of baseline knowledge of palliative care, hospice care, and ACP among surgical residents and to show the effectiveness of an educational session to remedy it.

  Methods Top

This project was completed at Northeast Ohio Medical University from January 2018 to April 2018 and involved participation from general surgery residents (PGY1-PGY5), medical students, and a general surgery attending physician at the NEOMED affiliated hospital, Northside Regional Medical Center in Youngstown, Ohio.

A pretest including demographic questions and a knowledge assessment of palliative care, hospice care, ACP, and end-of-life ethics was first given to the participants. Tests were coded using a 3-character alphanumerical code consisting of the first initial and last two digits of the participants' most used telephone number. This was done to allow for later analysis of changes in specific pre/post-test participant answers. Due to the lack of generalizable data and identifiable participant information, and methods that fell under the category of program evaluation, rather than human subjects research, this project did not require regulatory oversight by an IRB. The knowledge assessment consisted of multiple choice questions and check-all-that-apply questions. Questions were formed with the utilization of a literature search of background information about these topics. Once the pretest was administered, the participants received a 30-min PowerPoint presentation detailing important information about palliative care, hospice care, ACP, end-of-life ethics, and related topics. More specifically, the presentation first addressed the key differences between palliative care and hospice care services. Then, data were provided to establish that there is currently poor utilization of those services throughout hospitals in the United States. ACP was discussed and included definitions of ACP along with advance directives and ACP billing information. Furthermore, details highlighting the importance of understanding these topics were addressed, and finally barriers for proper utilization of the resources were analyzed. Immediately following the presentation and audience questions, a posttest was administered to evaluate the immediate effectiveness of the presentation. The knowledge portion of the posttest was identical to the pretest. A session evaluation section was included in the posttest, which consisted of 3 Likert Scale (ranging 1–5) questions and a short answer question asking about the effectiveness and usefulness of the session.

  Results Top

A total of 20 participants participated in all three parts of the session (pretest, presentation, and posttest). Among these participants, 8 were medical students, 11 were residents at Northside Regional Medical Center, and 1 was an attending at the same hospital. Pretest results for the group ranged from 29% to 79% correct. The mean percentage for the group was 60%. After the presentation was given, posttest results showed improvement throughout 18 of the 20 participants. The posttest results for the group ranged from 46% to 92% correct. The mean for the group was 75%. A paired one-tailed t-test was used to analyze the changes from pretest and posttest results. Results indicate that, after the 30-min presentation, there was statistically significant improvement between the means of the group (P = 0.00002). Additional data were acquired through the pretest demographic information and posttest session evaluation sections. When asked about previous education in palliative care, hospice care, ACP, and end-of-life ethics, results showed that 18% of residents had previous training in these topics. Sixty percent of participants indicated previous education surrounding these topics in medical school. The pretest demographic questions also showed that 85% of participants think education in these topics is very important or somewhat important for surgical residents to acquire. Posttest session evaluation questions showed 100% of participants thought that the educational session was either very helpful or somewhat helpful in providing an understanding of palliative care, hospice care, and ethical issues surrounding end-of-life care. Nearly 90% agreed that additional training focused on these topics should be incorporated into surgical residency training.

  Discussion Top

Thorough research has been done exploring the benefits of prompt palliative care, hospice care, and ACP for patients with chronic illnesses. Consensus among this research has determined many benefits including improved quality of life for patients and families, increased compliance with patient preferences, and higher satisfaction in quality of care.[6],[7],[8],[9] However, these services are often not utilized to their potential. The 2016 Facts and Figures published by the National Hospice and Palliative Care Organization showed that one-fourth of all hospice patients received only 1–7 days of hospice care, and up to 90% of hospice patients received <3 months of hospice care despite the ability to enter hospice at a 6-month life prognosis.[10] In a 2008 prospective study, it was found that only 37% of patients with advanced cancer had experienced ACP before death.[11] A 2010 study in the NEJM showed that over 30% of patients older than 60 years of age who died between 2000 and 2006 did not have an advance directive.[12] Potential barriers have been explored to explain the poor utilization of palliative care, hospice care, and ACP. A 2017 article in the Journal of Palliative Care highlights and explores a collection of barriers including lack of knowledge among physicians as well as referral reluctance.[7] A study in 2010 at Mayo Clinic showed that physicians were the greatest identified barrier to end-of-life care in the Intensive Care Unit.[13] Thus, this study aimed to scrutinize the knowledge base of physicians.

There is much to discuss regarding the results of this pilot study. First, the results of the paired t-test are very positive. The statistically significant increase in mean test percentage showed that the educational session provided to participants was immediately effective. Despite the significant change in means after the presentation, it is vital to note the concerning pretest mean percentage of the group. Palliative care, hospice care, ACP, and end-of-life ethics are all integral educational topics to study to become a well-rounded physician regardless of specialty. As such, it is vital to understand how each of these topics interconnects.

The questions on the pre and posttest were mostly questions prompting basic knowledge of the topics discussed. Palliative care and hospice care are very similar regarding the goals of care. The idea of both is to improve the quality of life that may be diminished due to a disease. However, palliative care and hospice care are used in different scenarios, and this was clearly not understood by the participants as shown by pretest results. Palliative care is for those with chronic life-threatening illnesses.[14] This encompasses a variety of conditions such as cancers, diabetes, peripheral vascular disease, and even childhood issues such as muscular dystrophy and cystic fibrosis. Hospice care may also be involved in these conditions, but unlike palliative care, there are specific criteria that allow patients to be enrolled in it. To undergo hospice care, a patient must have a life prognosis of 6 months or less, and this must be certified by at least two practicing physicians.[15] The patient must also understand that entering hospice care requires the relinquishment of all curative therapies. Full code status is also removed. In fact, hospice frequently uses aggressive doses of opioids for pain management at the end of life, which may result in a hastened death. This concept is ethically protected by the principle of the double effect, which defends the benefits despite potential harms of opioid use. It is important to highlight that relinquishment of curative treatment is not necessary in palliative care, where both types of treatment can coexist. An additional difference between palliative care and hospice is that Medicare covers a specific option for hospice patients but not for palliative care patients. Advance care planning is strongly interconnected with these topics, as it outlines the patient's health-care wishes moving forward and even through death. It includes all facets of care such as Do-Not-Resuscitates (DNRs), curative treatments, antibiotic usage, pain control, advance directives, and even burial preparations.[16] This discussion has been decidedly so important that it has become billable in recent years.

The low pretest mean indicates that there is a gross lack of these topics among surgical residents. In fact, the lowest scores on the pretest were from the surgical residents despite over 63% of the residents indicating prior education in residency or medical school and the overwhelming agreement of its importance in surgical resident education. Questions arise whether these residents are either failing to retain the information previously learned or if the information was never initially learned. Although the posttest showed improvement, the results are still not overwhelmingly positive. To be comfortable using the knowledge of these topics in practice, results should provide higher percentages. While these results are from a single institution, it beckons the question of whether this gap in knowledge is widespread across US surgical residents. To explore the hypothesis that there is an issue with surgical education and its inclusion of palliative care, hospice care, and ACP training, this pilot study would have to be expanded to many other institutions across the United States. With additional participating residency programs, the potential gap in education could truly be assessed. Furthermore, if there happens to be this gross gap in education in US surgical residencies, efforts can be directed toward remedying it. These efforts would be valuable as means to provide better care to patients who may not be receiving sufficient care and care discussions regarding life goals and quality of life.

The low scores of medical students in this study, who mostly indicated recent education in these topics, are also concerning. It is pertinent to note that the Liaison Committee on Medical Education (LCME) does not require medical schools to teach palliative care competencies. The LCME, with little direction, requires important aspects of end-of-life education to be taught, but this does not adequately include palliative care or ACP. The Association of American Medical Colleges provides more specific recommendations, encouraging inquiry of meaning and spirituality, communication of bad news, communication of advance directives, end-of-life wishes, DNR orders, and palliative care.[18] However, it is important to note that these are solely recommendations, unlike LCMEs requirements. As such, it is foreseeable that the implementation of education covering palliative care, hospice care, end-of-life care, and ACP would be highly variable among medical schools. A study by Dickinson showed that the number of hours of education in end-of-life care ranged from 2 to 80 throughout the 4 years of medical school education.[19] This brings a question of adequacy in medical education to the forefront, and it could be further explored in a study that focuses solely on such matters.

Limitations of this study should be noted to effectively expand upon what it has already done. While the pilot study was successful in teaching the participants of the topics discussed in the presentation, it should be noted that the posttest was given immediately after the presentation. Thus, there is no way to tell from this study whether or not the session allowed for long-term knowledge retention among the participants. To assess long-term retention, a posttest could be provided months after the date of the initial session. The small sample size of 20 should also be noted as a study weakness. In addition to the small sample, each participant belonged to the same residency program. Thus, education in residency for these participants is identical. From this program evaluation project, we are unable to identify the magnitude of gaps in palliative care, hospice care, and ACP education among residency programs. In addition, the educational session was a brief 30 min. Perhaps a 60 min session to take the time to thoroughly teach these issues would prove more effective. Finally, while this study focused on surgical residents, it is important to bring to attention the idea that this lack of knowledge may not be isolated to the surgical field. Many other fields of medicine, if not most fields, have potential to also misunderstand palliative care and hospice care and have a general lack of knowledge of these topics. Upon expansion of this pilot, these improvements are something that can be implemented.

  Conclusions Top

A solid knowledge base of palliative care, hospice care, and ACP is important for surgeons to be able to provide the best possible care to patients. This study shows that there may be a detrimental gap in knowledge and understanding among surgical residents surrounding these topics, and education should be examined to remedy the gap. While an educational session has shown to be effective in providing clarity throughout these topics, it is important to expand upon this area of research. With expansion, a better understanding of the lack of physician knowledge and understanding can be established, and solutions can be implemented to provide better holistic care to patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Ethical conduct of research

The following project required no federal regulatory oversight by an IRB due to the lack of generalizable data, non-identifiable participant information, and data that focused on knowledge acquired from a developed educational program that was presented to a single cohort of residents. Our institutional IRB reviewed the pre- and post- test surveys to ensure this type of project fell under program evaluation rather than human subjects research.

  References Top

The American Board of Surgery. Booklet of Information. American Board of Surgery; 2014-2015.  Back to cited text no. 1
Cogbill TH, Malangoni MA, Potts JR, Valentine RJ. The general surgery milestones project. J Am Coll Surg 2014;218:1056-62.  Back to cited text no. 2
Raoof M, O'Neill L, Neumayer L, Fain M, Krouse R. Prospective evaluation of surgical palliative care immersion training for general surgery residents. Am J Surg 2017;214:378-83.  Back to cited text no. 3
Trickey AW, Newcomb AB, Porrey M, Piscitani F, Wright J, Graling P, et al. Two-year experience implementing a curriculum to improve residents' patient-centered communication skills. J Surg Educ 2017;74:e124-32.  Back to cited text no. 4
Helft PR, Eckles RE, Torbeck L. Ethics education in surgical residency programs: A review of the literature. J Surg Educ 2009;66:35-42.  Back to cited text no. 5
Brinkman-Stoppelenburg A, Rietjens JA, van der Heide A. The effects of advance care planning on end-of-life care: A systematic review. Palliat Med 2014;28:1000-25.  Back to cited text no. 6
Hawley P. Barriers to access to palliative care. Palliat Care 2017;10:1178224216688887.  Back to cited text no. 7
Tassinari D, Drudi F, Monterubbianesi MC, Stocchi L, Ferioli I, Marzaloni A, et al. Early palliative care in advanced oncologic and non-oncologic chronic diseases: A systematic review of literature. Rev Recent Clin Trials 2016;11:63-71.  Back to cited text no. 8
Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-42.  Back to cited text no. 9
NHPCO. Facts and Figures: Hospice Care in America. Alexandria, VA: National Hospice and Palliative Care Organization; September, 2017.  Back to cited text no. 10
Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300:1665-73.  Back to cited text no. 11
Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med 2010;362:1211-8.  Back to cited text no. 12
Festic E, Grewal R, Rabatin JT, Divertie GD, Shannon RP, Johnson MM. End-of-life care in the Intensive Care Unit: The perceived barriers, supports, and changes needed. Acta Med Acad 2010;39:150-8.  Back to cited text no. 13
World Health Organization. WHO Definition of Palliative Care. World Health Organization; 2002a. Available from: http://www.who.int/cancer/palliative/definition/en. [Last retrieved on 2018 Jan 02].  Back to cited text no. 14
U.S. Department of Health and Human Services Health Care Financing Administration. Clarification of Physician Certification Requirements for Medicare Hospice. Program Memorandum. Intermediaries/Carriers. Transmittal AB-01-09; 24 January, 2001.  Back to cited text no. 15
Detering K, Silveira MJ. Advance care planning and advance directives. In: Arnold RM, editor. UpToDate. Waltham, MA: UpToDate Inc. Available from: http://www.uptodate.com. [Last accessed on 2018 Jan 22].  Back to cited text no. 16
Liaison Committee on Medical Eduation. Functions and Structure of a Medical School. Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree; May, 2012. Available from: http://www.lcme.org/functions.pdf. [Last accessed on 2018 Apr 08].  Back to cited text no. 17
Association of American Medical Collages Task Force on the Clinical Skills Education of Medical Students. Recommendations for Clinical Skills Curricula for Undergraduate Medical Education; 2005. Available from: https://www.members.aamc.org/eweb/upload/Recommendations%20for%20Clinical%20Skills%20Curricula%202005.pdf. [Last accessed on 2018 Apr 08].  Back to cited text no. 18
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