Abstract
On the 24th of May 2014 at the 67th session of the World Health Assembly in Geneva, the World Health Organization (WHO) published its Resolution titled ‘Strengthening of Palliative Care as a Component of Comprehensive Care throughout the Life Course’. 1 It recognised that 40 million people require palliative care every year and that the avoidable suffering of treatable symptoms is perpetuated by the lack of knowledge of palliative care. Projections from the European Union suggest that by the year 2050, the proportion of the European population over the age of 65 years will rise from the current 17% to 28%. 2 An ageing population is likely to lead to an increased number of patients with cancer and other chronic, incurable diseases, requiring increasing palliative care support at the end of life. 3 These changes in health and demographic variables present a major challenge to national health care systems. The Worldwide Hospice Palliative Care Alliance (WHPCA) identified that in 2015, almost 18 million people in the world died in ‘unnecessary’ pain. 4
Another significant challenge to the scale and depth of palliative care education required in the health care workforce has been raised by the publication in 2010 by Temel et al.’s 5 paper ‘Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer’ in the New England Journal of Medicine. This study demonstrated positive outcomes from the early integration of palliative care patients suffering from non-small-cell lung cancer. This has provoked the debate regarding the importance and impact in health care systems of early integration of palliative care in oncological disease management and potentially chronic disease management, with significant implications for palliative care education and training.
The WHO Resolution recognises the importance of education and the need for palliative care to be integrated as a routine element of all undergraduate medical and nursing professional education. Furthermore, the Resolution recognises the need for continuing palliative care education and training to be offered to care providers, in accordance with their roles and responsibilities at three levels of training: basic, intermediate and specialist. 1 With this Resolution, the WHO unmistakably calls for the development and promotion of palliative care education worldwide.
The development of curricula and expert guidance is essential in promoting education. From its initial conception, the European Association for Palliative Care (EAPC) has regarded the education and training of health care professionals of the highest importance for the promotion and expansion of palliative care in Europe. It is not only vital for the development of palliative care itself but also more importantly crucial for the care of patients and their families. In 2004, EAPC published a guide for palliative care nurse education. Recommendations by the EAPC Steering Group on Medical Education and Training for the development of a curriculum in Palliative Medicine were published for postgraduate level in 2009 and undergraduate level in 2013. 6 The recommendations at undergraduate level aim to promote and support the inclusion of palliative care across medical schools in Europe and are considered essential for all medical graduates. One of the major goals is to promote the development of appropriate attitudes towards the care of severely ill and dying patients and their families. Another important aspect is to address specific skills in inter-professional team work and the basics of pain and symptom management following the principles described in the definition of palliative care by the WHO in 2002. 7 Guidance has also been published by the EAPC on palliative care education for psychologists, social workers and occupational therapists. A further development in 2013 was the production of a White Paper by the EAPC on core competencies in palliative care for health and social care professionals involved in palliative care 8 which highlighted 10 core competencies, incorporating the physical, psychological, social and spiritual domains of care and the importance of team working, ethical issues and communication skills. To promote palliative care education, further development of palliative care curricula and guidance at international and national level is essential.
What evidence do we have that education in palliative care is developing to meet the call of the WHO? The EAPC Steering Group on Medical Education and Training has supported a number of task forces. 9 The task force led by Centeno conducted a descriptive study of medical education in Europe. 10 A total of 43 European countries (81%) provided the requested information. Three indicators were developed to evaluate medical palliative care education status: in 13 countries (30%), Palliative Medicine was taught in all medical schools, being mandatory in 6 (14%). A full professor of Palliative Medicine was identified in 40% of the countries. The task force led by Mason is undertaking international research to assess the preparedness of newly qualified medical graduates to engage in core tasks of Palliative Medicine and their attitudes to caring for dying patients.
In this issue of Palliative Medicine, there are two articles by Pereira et al. and Walker et al. dealing with palliative care education on an undergraduate level. Pereira et al. show that an immense increase in inclusion of palliative care education into nursing undergraduate curricula in Portugal has taken place from 2005. Walker et al. report in their study that the mean time devoted to palliative care issues in corresponding mandatory courses for medical students in the United Kingdom has nearly been doubled from 2000 to 2013. Similar positive developments of undergraduate medical education within a national setting were described in Germany by Ilse et al. in 2015. However, they also emphasised that there are still heterogeneous teaching conditions and structures. 11 These papers together with the work of the EAPC task force groups provide some evidence that the WHO recommendation for palliative care to be taught in all medical and nursing schools is being achieved in some countries however, it is far from being universally realised, and needs championing by educationalists and palliative care leaders and palliative care organisations on a global basis.
What are the most appropriate approaches and methodologies to teach palliative care? Generally, regarding educational strategies, it is recommended that aspects such as experiential learning including experience in inpatient units, hospital consultative service and community settings together with direct encounters with patients and their families should be included. Debriefing and reflection should be considered a priority. Active rather than passive techniques should be utilised including problem and/or case-based learning, discussion and role play. Multi-professional learning should be encouraged to foster cooperation. Specialists in palliative care should be aware of areas of palliative care taught by colleagues in other disciplines. Repeated occasions for self-reflection and group discussions of difficult situations, including family issues, team problems and grief, should be arranged and ethical and psychosocial considerations should be integrated into all aspects of teaching. 6
Future research needs to continue to map the delivery of undergraduate and postgraduate education at national and international levels to promote and ensure its inclusion in health care training. More in-depth research into the effectiveness of different teaching methodologies in palliative care education and the benefits of uniprofessional and multiprofessional education is also needed. However, perhaps, the greatest challenge is to demonstrate how palliative care educational programmes impact patient and organisational outcomes, described as the fourth step in evaluation by Kirkpatrick. 12 Health care organisations increasingly require evidence of the impact of education, so we must be prepared to develop a robust evidence base to justify the cost and time of delivering education in palliative care. Increasingly, we need intervention studies in education including economic analysis, and funders of research need to recognise the importance of educational research.
The WHO Resolution is a timely call to action for the development and promotion of palliative care education worldwide. We must seize this opportunity not only to expand palliative care education but also to develop the evidence to promote the most effective research-based educational programmes. Only then we will see the avoidable suffering identified by the WHO diminish in the world.