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The over-riding consensus of the workgroup was that all clinical professionals should have at least an introductory education in providing care for those near the end of life. This should include basic communication skills, topics related to grief and bereavement, aspects of cultural sensitivity, the fundamentals of symptom management and how to work in an interprofessional team. Despite differences in the structure of education, the USA and the UK face similar challenges in integrating palliative medicine into mainstream clinical care.
The advent of HIV/AIDS has particularly raised the need for cultural competence, since many of those affected by this disease are on the fringes of the usual healthcare system or even excluded from it. Respect for the individual is paramount. In the USA there has been a major thrust to teach ‘attending’ (consultant) physicians more about palliative care, in the hope that they will become role models for clinical students; in the UK there is some thought that a focus on students in training may be more cost-effective. The inclusion of examination questions for all disciplines is being pursued on both sides of the Atlantic, and in the UK palliative care specialists participate in qualifying examinations.
HIV/AIDS, representing all chronic illness, highlights the deficiencies in our current systems of care. In our workshop discussions we recognized that, in fact, many different groups are to some extent socially excluded—for example, ethnic minorities, the bereaved, prisoners, physicians and their families, gay/bisexual people, homeless people, those with no general practitioner, illegal immigrants, asylum-seekers and even private patients. Before discussing ‘next steps’ for education in palliative care we reviewed the strengths and weaknesses of the two healthcare systems.
Palliative care topics exist in many but not all professional training programmes. In the UK more than in the US, there are opportunities for interprofessional education. In Wales, medical students themselves have provided first-hand teaching of attitudes, practices and beliefs in their own various cultural groups. In both the UK and the US medical students have started clinics in ‘disadvantaged’ neighbourhoods, where they obtain experience with traditionally under-served populations. A teaching method LEARN (Listen, Educate, Assess, Reflection, Negotiate) encourages the student to focus on the individual and not to make assumptions based on groups; this can be particularly useful for cross-cultural conversations.
The Ryan White CARE Act in the USA has provided funding for comprehensive services similar to those offered by the British National Health Service, and private foundations such as the Robert Wood Johnson Foundation and the Open Society's Project on Death in America have funded schemes to bring palliative care services into the mainstream. Thus additional funding has been the mechanism for jump-starting the education of professionals around end-of-life issues.
Although some interprofessional education exists, this is not widespread and more demonstration projects are needed. Curricula are congested and palliative care is hard to accommodate. In both countries there are attitudinal problems—in particular, the notion that the death of a patient must represent failure. There is a tendency to compartmentalization, so that teachers find themselves preaching to the converted. Outside funding sometimes has ‘strings’ attached that work against best use of the money.
The workgroup identified the following levers for change in educational processes:
Proposed next steps were as follows: