How should palliative care be taught to medical and nursing students? An integrative literature review

Medeiros, Ricardo Vilela; Trovo, Mônica Martins; Duarte, Carolina Sarmento; Barros, Danielle de Magalhães de; Fukuda, Márcio Veronesi; Freitas, Arabella Claudine Soares de; Latorre, Gabriela Varajão de; Herbst, Lívia Grigoriitchuk

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Brasil

Revista Brasileira de Educação Médica

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Brasil

Español English

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Sumário

REVISÃO • Rev. bras. educ. med. 48 (4) • 2024 • https://doi.org/10.1590/1981-5271v48.4-2023-0332 copy

How should palliative care be taught to medical and nursing students? An integrative literature review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Introduction:

Ensuring the provision of Palliative Care (PC) to patients and their families who face serious and life-threatening diseases is an ethical responsibility of health systems and professionals. Several actions are listed to guarantee the provision of this type of care, with emphasis on the teaching of PC for health professionals. In Brazil, the inclusion of PC training in undergraduate courses is an exception, both for medicine and nursing courses. This study aims to identify which palliative competencies are recommended for the teaching of palliative care in undergraduate medicine and nursing, and characterize the best practices for the teaching of PC for undergraduates of these courses.

Method:

This is an integrative literature review, with the chosen descriptors being Medical Students, Nursing Students, Education, Learning, Teaching and Palliative Care. The search was performed using the Boolean resource OR and AND, in the electronic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Latin American and Caribbean Literature in Health Sciences (LILACS), PubMed, Scopus and Web of Science.

Results:

The search strategy generated 182 potential articles for inclusion in the review. Of these, 85 were excluded due to failing to meet the inclusion criteria and 13 were excluded because they were not available for access on the digital platform. The articles included brought aspects of the competencies to be developed for the practice of PC, teaching strategies and curricular structure.

Discussion:

Most of the included studies focused on teaching strategies, especially active methodologies that aimed at not only knowledge transfer, but also the development of skills and attitudes to offer care that aims to alleviate suffering.

Final Considerations:

An integrative literature review allowed us to identify the competencies to be acquired during the medicine and nursing undergraduate courses so that future professionals can offer primary PC, as well as the best teaching strategies used.

Keywords:
Medical Student; Nursing Student; Education; Palliative Care

População	AND	Intervenção	AND	Área do conhecimento
Medical student OR Nursing student		Education OR Learning OR Teaching		Palliative care

Temática relacionada à prática dos cuidados paliativos	Competências a serem desenvolvidas
Princípios e filosofia	• Definir a filosofia e o papel dos cuidados paliativos em todo o ciclo de vida, aplicável aos mais diversos tipos de doenças.
	• Diferenciar os cuidados paliativos ofertados conforme a evolução da doença.
	• Promover a integração dessa abordagem na trajetória da doença a fim de garantir um cuidado de qualidade¹⁸18. Schaefer KG, Chittenden EH, Sullivan AM, Periyakoil VS, Morrison LJ, Carey EC, et al. Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents. Acad Med. 2014;89(7):1024-31. doi: https://doi.org/10.1097/ACM.0000000000000271. https://doi.org/https://doi.org/10.1097/... ^)-(²⁰20. Lippe M, Davis A, Stock N, Mazanec P, Ferrell B. Updated palliative care competencies for entry-to-practice and advanced-level nursing students: new resources for nursing faculty. J Prof Nurs. 2022;42:250-61. doi: https://doi.org/10.1016/j.profnurs.2022.07.012. https://doi.org/https://doi.org/10.1016/... .
Aspectos éticos e legais	• Aplicar princípios éticos no cuidado de pacientes com doenças graves e seus familiares.
	• Conhecer e aplicar as leis estaduais e federais e as políticas institucionais relevantes para o cuidado de pacientes com doenças graves e suas famílias.
	• Descrever os princípios éticos que embasam a tomada de decisão em contextos de doenças ameaçadoras da vida, incluindo o direito de não instituir ou suspender o tratamento de suporte artificial à vida.
	• Entender a importância do planejamento antecipado dos cuidados e auxiliar a discussão sobre a tomada de decisões no final da vida, apoiando na definição das preferências dos pacientes e resultados aceitáveis.
	• Entender o fundamento legal e a relevância das diretivas antecipadas de vontade, bem como a possibilidade do paciente em definir um substituto para a tomada de decisão.
	• Elicitar e demonstrar respeito pelos valores, preferências, objetivos de cuidado e tomada de decisão compartilhada do paciente e da família durante doenças graves e no final da vida¹⁸18. Schaefer KG, Chittenden EH, Sullivan AM, Periyakoil VS, Morrison LJ, Carey EC, et al. Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents. Acad Med. 2014;89(7):1024-31. doi: https://doi.org/10.1097/ACM.0000000000000271. https://doi.org/https://doi.org/10.1097/... ^)-(²⁴24. Pieters J, Dolmans DHJM, van den Beuken-van Everdingen MHJ, Warmenhoven FC, Westen JH, Verstegen DML. A national, palliative care competency framework for undergraduate medical curricula. Int J Environ Res Public Health. 2020;17(7):2396. doi: https://doi.org/10.3390/ijerph17072396. https://doi.org/https://doi.org/10.3390/... .
Comunicação	• Comunicar-se de forma eficaz, respeitosa e compassiva com pacientes, familiares, membros da equipe interprofissional e o público sobre cuidados paliativos.
	• Demonstrar técnicas de comunicação centradas no paciente ao dar más notícias e discutir as preferências de cuidados.
	• Explorar a compreensão do paciente e da família sobre a doença, preocupações, objetivos e valores que norteiam o plano de cuidados.
	• Saber conduzir uma reunião familiar¹⁸18. Schaefer KG, Chittenden EH, Sullivan AM, Periyakoil VS, Morrison LJ, Carey EC, et al. Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents. Acad Med. 2014;89(7):1024-31. doi: https://doi.org/10.1097/ACM.0000000000000271. https://doi.org/https://doi.org/10.1097/... ^),(²⁰20. Lippe M, Davis A, Stock N, Mazanec P, Ferrell B. Updated palliative care competencies for entry-to-practice and advanced-level nursing students: new resources for nursing faculty. J Prof Nurs. 2022;42:250-61. doi: https://doi.org/10.1016/j.profnurs.2022.07.012. https://doi.org/https://doi.org/10.1016/... ^),(²⁵25. Pieters J, Verstegen D, Dolmans D, Neis E, Warmenhoven F, van den Beuken- van Everdingen M. Spiritual dimension in palliative medicine: a qualitative study of learning tasks: medical students, teachers, educationalists. BMJ Support Palliat Care. 2023;13(e2):e408-e414. doi: 10.1136/bmjspcare-2021-0030 https://doi.org/10.1136/bmjspcare-2021-0... .
Controle de sintomas	1. Sintomas físicos
	• Compreender a fisiopatologia dos principais sintomas da doença grave (por exemplo, dispneia, dor, náuseas/vômitos, delirium, ansiedade) e aplicar esse conhecimento na escolha do tratamento.
	• Avaliar a dor sistematicamente e distinguir as síndromes de dor nociceptiva das neuropáticas.
	• Entender o conceito de dor total e seu impacto no planejamento de cuidados paliativos.
	• Aplicar instrumentos específicos de avaliação de sintomas para avaliar e monitorar sintomas frequentes em cuidados paliativos.
	• Compreender os princípios da prescrição adequada dos tratamentos não farmacológicos e farmacológicos necessários para o controle dos sintomas.
	• Analisar e comunicar-se com a equipe interprofissional no planejamento e na intervenção no manejo da dor e de outros sintomas¹⁸18. Schaefer KG, Chittenden EH, Sullivan AM, Periyakoil VS, Morrison LJ, Carey EC, et al. Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents. Acad Med. 2014;89(7):1024-31. doi: https://doi.org/10.1097/ACM.0000000000000271. https://doi.org/https://doi.org/10.1097/... ^),(²⁰20. Lippe M, Davis A, Stock N, Mazanec P, Ferrell B. Updated palliative care competencies for entry-to-practice and advanced-level nursing students: new resources for nursing faculty. J Prof Nurs. 2022;42:250-61. doi: https://doi.org/10.1016/j.profnurs.2022.07.012. https://doi.org/https://doi.org/10.1016/... ^)-(²⁴24. Pieters J, Dolmans DHJM, van den Beuken-van Everdingen MHJ, Warmenhoven FC, Westen JH, Verstegen DML. A national, palliative care competency framework for undergraduate medical curricula. Int J Environ Res Public Health. 2020;17(7):2396. doi: https://doi.org/10.3390/ijerph17072396. https://doi.org/https://doi.org/10.3390/... .
	2. Sintomas psicossociais e espirituais
	• Reconhecer e considerar os sentimentos dos pacientes e familiares, e a influência que exercem sobre o bem-estar dos envolvidos.
	• Identificar sofrimento psicossocial em pacientes e familiares utilizando ferramentas baseadas em evidências quando necessário.
	• Saber quando solicitar avaliação de outros profissionais para atender às necessidades psicossociais e espirituais de pacientes gravemente enfermos e seus entes queridos¹⁸18. Schaefer KG, Chittenden EH, Sullivan AM, Periyakoil VS, Morrison LJ, Carey EC, et al. Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents. Acad Med. 2014;89(7):1024-31. doi: https://doi.org/10.1097/ACM.0000000000000271. https://doi.org/https://doi.org/10.1097/... ^),(²⁰20. Lippe M, Davis A, Stock N, Mazanec P, Ferrell B. Updated palliative care competencies for entry-to-practice and advanced-level nursing students: new resources for nursing faculty. J Prof Nurs. 2022;42:250-61. doi: https://doi.org/10.1016/j.profnurs.2022.07.012. https://doi.org/https://doi.org/10.1016/... ^),(²¹21. Eychmüller S, Forster M, Gudat H, Lütolf UM, Borasio GD. Undergraduate palliative care teaching in Swiss medical faculties: a nationwide survey and improved learning objectives. BMC Med Educ . 2015;15:213. doi: https://doi.org/10.1186/s12909-015-0485-0. https://doi.org/https://doi.org/10.1186/... ^),(²²22. Ferrell B, Malloy P, Mazanec P, Virani R. CARES: AACN’s new competencies and recommendations for educating undergraduate Nursing students to improve palliative care. J Prof Nurs . 2016;32(5):327-33. doi: https://doi.org/10.1016/j.profnurs.2016.07.002. https://doi.org/https://doi.org/10.1016/... ^),(²⁴24. Pieters J, Dolmans DHJM, van den Beuken-van Everdingen MHJ, Warmenhoven FC, Westen JH, Verstegen DML. A national, palliative care competency framework for undergraduate medical curricula. Int J Environ Res Public Health. 2020;17(7):2396. doi: https://doi.org/10.3390/ijerph17072396. https://doi.org/https://doi.org/10.3390/... ^),(²⁵25. Pieters J, Verstegen D, Dolmans D, Neis E, Warmenhoven F, van den Beuken- van Everdingen M. Spiritual dimension in palliative medicine: a qualitative study of learning tasks: medical students, teachers, educationalists. BMJ Support Palliat Care. 2023;13(e2):e408-e414. doi: 10.1136/bmjspcare-2021-0030 https://doi.org/10.1136/bmjspcare-2021-0... .
Trabalho em equipe	• Trabalhar em equipe multidisciplinar e interdisciplinar, demonstrando familiaridade com os deveres e as responsabilidades dos demais profissionais de saúde envolvidos.
	• Saber quando solicitar avaliação de outros profissionais para atender às necessidades apresentadas pelo paciente e por seus familiares.
	• Colaborar efetivamente com a equipe interprofissional para coordenar a prestação de cuidados paliativos de alta qualidade em ambientes de saúde²⁰20. Lippe M, Davis A, Stock N, Mazanec P, Ferrell B. Updated palliative care competencies for entry-to-practice and advanced-level nursing students: new resources for nursing faculty. J Prof Nurs. 2022;42:250-61. doi: https://doi.org/10.1016/j.profnurs.2022.07.012. https://doi.org/https://doi.org/10.1016/... ^)-(²⁴24. Pieters J, Dolmans DHJM, van den Beuken-van Everdingen MHJ, Warmenhoven FC, Westen JH, Verstegen DML. A national, palliative care competency framework for undergraduate medical curricula. Int J Environ Res Public Health. 2020;17(7):2396. doi: https://doi.org/10.3390/ijerph17072396. https://doi.org/https://doi.org/10.3390/... .
Cuidado centrado na pessoa e aspectos culturais	• Compreender a importância das questões culturais no cuidado na fase final da vida.
	• Demonstrar respeito pelo cuidado centrado na pessoa, alinhando o plano de cuidado com os valores, as crenças, as preferências e os objetivos do cuidado do paciente e da família.
	• Respeitar a diversidade cultural, espiritual e outras formas de diversidade para os pacientes e suas famílias na prestação de serviços de cuidados paliativos.
	• Fornecer cuidados competentes, compassivos e culturalmente sensíveis aos pacientes e às suas famílias durante toda a trajetória da doença, incluindo o processo de morrer e após a morte¹⁹19. Bush SH, Roze des Ordons A, Chary S, Boyle AB. The development and validation of updated palliative and end-of-life care competencies for medical undergraduates in Canada. J Palliat Med . 2019;22(12):1498-500. doi: https://doi.org/10.1089/jpm.2019.0160. https://doi.org/https://doi.org/10.1089/... ^)-(²²22. Ferrell B, Malloy P, Mazanec P, Virani R. CARES: AACN’s new competencies and recommendations for educating undergraduate Nursing students to improve palliative care. J Prof Nurs . 2016;32(5):327-33. doi: https://doi.org/10.1016/j.profnurs.2016.07.002. https://doi.org/https://doi.org/10.1016/... .
Autocuidado no exercício profissional	• Reconhecer os próprios valores e crenças (culturais e espirituais) sobre doenças graves e a morte e sua influência na prestação do cuidado.
	• Refletir sobre a dinâmica da relação de cuidado com um paciente e seus familiares na assistência paliativa.
	• Refletir sobre as próprias reações emocionais diante do processo de morrer e morte dos pacientes
	• Ter consciência de seus próprios limites pessoais e profissionais na prestação do cuidado.
	• Implementar estratégias de autocuidado para apoiar o enfrentamento do sofrimento, da perda, do sofrimento moral e da fadiga por compaixão¹⁸18. Schaefer KG, Chittenden EH, Sullivan AM, Periyakoil VS, Morrison LJ, Carey EC, et al. Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents. Acad Med. 2014;89(7):1024-31. doi: https://doi.org/10.1097/ACM.0000000000000271. https://doi.org/https://doi.org/10.1097/... ^),(²⁰20. Lippe M, Davis A, Stock N, Mazanec P, Ferrell B. Updated palliative care competencies for entry-to-practice and advanced-level nursing students: new resources for nursing faculty. J Prof Nurs. 2022;42:250-61. doi: https://doi.org/10.1016/j.profnurs.2022.07.012. https://doi.org/https://doi.org/10.1016/... ^),(²¹21. Eychmüller S, Forster M, Gudat H, Lütolf UM, Borasio GD. Undergraduate palliative care teaching in Swiss medical faculties: a nationwide survey and improved learning objectives. BMC Med Educ . 2015;15:213. doi: https://doi.org/10.1186/s12909-015-0485-0. https://doi.org/https://doi.org/10.1186/... ^),(²²22. Ferrell B, Malloy P, Mazanec P, Virani R. CARES: AACN’s new competencies and recommendations for educating undergraduate Nursing students to improve palliative care. J Prof Nurs . 2016;32(5):327-33. doi: https://doi.org/10.1016/j.profnurs.2016.07.002. https://doi.org/https://doi.org/10.1016/... ^),(²⁴24. Pieters J, Dolmans DHJM, van den Beuken-van Everdingen MHJ, Warmenhoven FC, Westen JH, Verstegen DML. A national, palliative care competency framework for undergraduate medical curricula. Int J Environ Res Public Health. 2020;17(7):2396. doi: https://doi.org/10.3390/ijerph17072396. https://doi.org/https://doi.org/10.3390/... ^),(²⁵25. Pieters J, Verstegen D, Dolmans D, Neis E, Warmenhoven F, van den Beuken- van Everdingen M. Spiritual dimension in palliative medicine: a qualitative study of learning tasks: medical students, teachers, educationalists. BMJ Support Palliat Care. 2023;13(e2):e408-e414. doi: 10.1136/bmjspcare-2021-0030 https://doi.org/10.1136/bmjspcare-2021-0... .

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