Professional education in end-of-life care: a US perspective.

In 1997 a report from the Institute of Medicine (IOM) of the National Academy of Sciences identified large gaps in knowledge of care at the end of life which demanded attention from biomedical, social science and health service researchers. The report, Approaching Death1, clearly indicted healthcare professionals' lack of education about end-of-life care as a major barrier to improvement of services. The seven recommendations, summarized in Box 1, addressed various decision-makers and deficiencies. Among the fundamental elements of sound professional preparation for end-of-life care the institute listed: command of relevant scientific and clinical knowledge; mastery of technical, communication, interpersonal and other skills; appreciation of ethical and professional principles of care; and development of organizational skills to help patients and families navigate the healthcare system. The report stressed that, although these elements emphasize knowledge and skills, they also reflect a concern for the attitudes, values and feelings that shape and infuse their application. This American perspective expressed in the IOM recommendations is not dissimilar from published international recommendations. The Expert Task Force of the World Health Organization, in its 1990 publication Cancer Pain Relief and Palliative Care2, called on governments to ensure that healthcare workers are adequately trained in palliative care and the relief of pain and recommended that palliative-care courses be an obligatory part of the basic training and certification of healthcare workers. These sentiments were echoed in Recommendation 1418 of the 1999 Parliamentary Assembly of the Council of Europe, ‘Protection of the Human Rights and Dignity of the Terminally Ill and Dying’3. In the Council's view, one factor threatening the fundamental rights of terminally ill and dying patients was a lack of continuing education and psychological support for professionals working in palliative medicine. The Council recommended that member States be encouraged to develop and implement standards for highquality training. In short, there is growing international advocacy for professional education in end-of-life care. The United States' efforts to improve education in end-of-life care consist of a series of initiatives focused on: undergraduate, graduate and continuing education; faculty development; and a series of overarching efforts, such as the development of palliative care associations, programmes in distance learning and website networks. These approaches, directed at reducing the barriers for healthcare professionals, are briefly described in the following sections. They represent a wide range of efforts at various stages of development, and their impact on professional education cannot yet be assessed—and still less the impact on care for the 2.5 million Americans who die each year. Concurrent efforts to transform the culture of death in America and eliminate institutional, economic and social barriers are also underway. Box 1 Recommendations from the Institute of Medicine's Approaching Death (Ref. 1) People with advanced, potentially fatal illnesses and those close to them should be able to expect and receive reliable, skilful and supportive care Physicians, nurses, social workers, and other health professionals must commit themselves to improving care for dying patients and to using existing knowledge effectively to prevent and relieve pain and other symptoms Because many deficiencies in care stem from system problems, policymakers, consumer groups, and purchasers of healthcare should work with healthcare practitioners, organizations, and researchers to: Strengthen methods for measuring the quality of life and other outcomes of care for dying patients and those close to them Develop better tools and strategies for improving the quality of care and holding healthcare organizations accountable for care at the end of life Revise mechanisms for financing care so that they encourage rather than impede good end-of-life care and sustain rather than frustrate coordinated systems of excellent care Reform drug prescription laws, burdensome regulations, and State medical board policies and practices that impede effective use of opioids to relieve pain and suffering Educators and other health professionals should initiate changes in undergraduate, graduate and continuing education to ensure that practitioners have the attitudes, knowledge and skills to care well for dying patients Palliative care should become, if not a medical specialty, at least a defined area of expertise, education, and research The nation's research establishment should define and implement priorities for strengthening the knowledge base for end-of-life care A continuing public discussion is essential to develop a better understanding of the modern experience of dying, the options available to patients and families and the obligations of communities to those approaching death.