Training Programs Essential to Improve End-of-Life Care

HOUSTON--Recent studies suggest that the key to improving end-of-lifecare is ensuring that the medical staff, including physicians, is properlytrained to support patients physically, emotionally, and spiritually duringtheir final days.

"It is the responsibility of the caregiver to ensure the highestpossible level of well-being until death," Richard Payne, MD, saidat a symposium on cancer and the central nervous system, sponsored by TheM.D. Anderson Cancer Center, where Dr. Payne is chief of the Section ofPain and Symptom Management.

Cancer care has historically focused on delivering state-of-the-arttherapies with a curative intent, Dr. Payne noted. "We are realizingnow that we need to place the same emphasis on palliative care, which iscare designed to minimize suffering through pain and symptom control, rehabilitation,and other critical areas of end-of-life needs."

In the current society, the medical staff is ill prepared to providean effective level of palliative care. "There is a lack of formaltraining, a lack of role definition, and a lack of empathy," Dr. Paynesaid.

In addition, he noted, end-of-life care is generally not consideredthe doctor's job and is usually delegated to a nurse or other staff member.This goes against the findings of recent studies indicating that end-of-lifecare should be directed by a team of professionals including physicians,nurses, psychiatrists, clergy, and others as appropriate.

In addition to their medical expertise, Dr. Payne said, these individualsneed core competency in the key areas of palliative care: interviewing/counseling,pain and symptom control, rehabilitation, empathy, and ethics.

Training Programs Lacking

The AMA recently reported that only 1,851 (16%) of 7,048 residency programsoffered a course in the medical and legal aspects of end-of-life care.

A national survey of residency programs found that 15% of 1,168 accreditedprograms in primary care offered no formal training in palliative care,and that most residents and fellows in these programs coordinated end-of-lifecare for 10 or fewer patients annually.

The Study to Understand Prognosis and Preferences for Outcomes and Risksof Treatment (SUPPORT) found substantial shortcomings in the care beinggiven to seriously ill patients, and the investigators suggested that moreeducation for physicians and the public is needed to improve care for thedying.

In response to these and other reports, the American College of Physiciansand the Academy of Hospice Physicians have outlined the skills deemed necessaryto ensure competency in end-of-life care and symptom control.

Also, the Committee on Care at the End-of-Life, established by the Instituteof Medicine, is evaluating current knowledge about end-of-life care andmaking recommendations to policy makers for improving care of terminallyill patients. Input from oncologists and other practitioners who care forpatients with chronic medical illnesses, especially cancer, has been criticalto the process.

Dr. Payne described palliative care as care that affirms life, regardsdeath as a natural process, provides relief from pain and other distressingsymptoms, ensures respect for the patient's preferences, and provides rehabilitationto restore some level of independence.

"Our patients do not want to die, but they appear less fearfulof death than of the suffering and indignities associated with death,"he said. "They do not want to be in pain; they want to be alert andable to talk with loved ones, and have some control over 'how' they die."