Medical Education 1986,20,342-348

How successful is teaching on terminal care?

CHRISTINE M A S O N t & G. FENTONS

tDepartment of Community Medicine and $Department of pqchiatry, Ninewells Hospital and Medical School, Dundee

Summary. Teaching on terminal care in the Dundee University Medical School is being evaluated over the next 4 years (1985-89). The paper describes the present course and the intended procedures of evaluation. A pilot evaluation was conducted on a class of fourth- year students during the academic year 1984- 85. Students’ recall of factual information pre- sented 2 years and also z terms prior to the pilot evaluation was acceptable although ques- tions relating to pain relief were not well answered. When asked to rate ten areas of medical management from most to least satis- fying and worrying, the majority of students saw both the care of the terminally ill and speaking with those about to face bereavement as relatively high on worry and low on satisfac- tion. The overall results of the pilot study challenged teachers to consider the cost- effectiveness of their chosen methods of teaching on terminal care.

Key words: *Terminal care; *Education, medical, undergraduate; Grief; Attitude of health personnel; Scotland

Introduction

The past 3 decades have seen a flourishing interest in the care of the terminally ill and the bereaved. Suggested reasons for such a growth are many and have been well described in a number of books and articles: for example,

Correspondence: Dr Christine Mason, Department of Community Medicine, Ninewells Hospital and Medical School, Dundee DDI g S Y , Scotland.

Doyle et a l . (1979). In the now large body of literature on dying, death and bereavement, one theme is conspicuous: the need to rectify the neglect of terminal care which has been a source of distress to the dying, the grieving and to care providers. Responding to the urgency of this need, the number of hospices has increased dramatically and with them the de- velopment of new skills in pain and symptom relief and increasing understanding of the com- plex, indivisible relationships between the psychological, social and spiritual aspects of care. This ethic which emphasizes the ‘whole person’ and the quality of his or her life has more general application to the delivery of care to those who suffer chronic illnesses. For this reason we have chosen to reconsider our teaching on the subjects of dying, death and bereavement in our medical undergraduate programme. Our present course is described below.

Undergraduate teaching on terminal care and bereavement

The main core of teaching has been orga- nized since 197s as part of the behavioural science course taking place in second year. The whole class is given two I-hour lectures in the autumn term and a 3-hour symposium in the spring term. The first lecture seeks to show students how changes in the care of the dying and grieving are rooted in the social structure and ideology obtaining during any historical period. Against a background of psychological, sociological and epidemiological research find-

Undergraduate teaching on terminal care 343

ings, present practices in terminal care are examined in the second lecture. Supporting the lectures are extended hand-outs and reading material which elaborate the themes presented in class and challenge students to consider their implications for other caring situations. The spring term symposium draws together five or six practitioners from the disciplines of medi- cine, nursing, theology and behavioural scien- ces. Students are encouraged to raise their own concerns. Communicating the diagnosis and the proper balance between professional in- volvement and detachment are matters of con- siderable interest to students. Hearing and discussing the experiences of those who have worked with the dying provide a background against which students can formulate their own attitudes as they come to be challenged in caring situations themselves.

Whole-class teaching ceases in the summer term to be replaced entirely by seminar work which involves the study in depth of a selected topic. Depending on the availability of seminar leaders, between 6 and I 2 topics are offered and students are asked to indicate their first and second choices on a form given out in spring term. Attempts are made to equalize the num- ber of students in each group and to give as many as possible their first choice of subject. Places in groups begin to be filled as forms are returned; late returns are allocated to groups low in student numbers.

The subject of dying and bereavement is always offered as a topic, and since this form of summer teaching has been arranged the num- ber of students nominating it as first choice has remained fairly constant at 25% of the class. The organization and content of seminar teaching on this subject vary slightly from year to year reflecting the interests of students comprising the group. The titles of the six seminars in the summer term of 1985 were: introduction; medical aspects; spiritual aspects; emotional aspects; the hospice movement; and dealing with feelings. Teaching methods in- cluded role-play, interview and video demon- strations as well as drawing on the experience and expertise of invited professionals in the field.

The class of on average IIO students is exposed to 5 hours of teaching on terminal care

and bereavement with a considerable amount of private study expected. About 15 students have a further 24 hours of teaching and are required to write an essay on their study in the special topic section of the degree examination.

As well as this core of teaching in second year, the subject of terminal care is introduced later in the curriculum. For example, the prob- lem of pain control is considered in therapeutics and surgery, while pathological grief is discus- sed in psychiatry. In 1983, the Undergraduate Medical Education Committee of Faculty ex- pressed the wish to develop a fully co- ordinated approach to teaching on terminal care. A working party was convened, its first task being to discover precisely how much teaching was taking place, at what stage and under whose direction. As a result of the working party’s investigations, four decisions were taken. ( I ) Second-year input to the programme

would remain unaltered. (2) Teaching on pain control would be in-

creased by the addition of a 3-hour syrnpo- sium on the subject. An interdisciplinary symposium, similar to that occurring in second year would be arranged in fourth year to recapitulate themes introduced at the earlier stage and to take advantage of the clinical experience which students had acquired since second year. The effect of teaching would be evaluated.

Evaluation of expanded teaching on terminal care

In monitoring the effect of second- and fourth- year teaching, students’ knowledge and atti- tudes will be examined a t the beginning and end of second year, at the beginning and end of fourth year and at the end of fifth year. This schedule of evaluation began in the academic year 1985-86 and will continue until June 1989 when the 1985 class of second-year students will be graduating.

During the academic year 1984-85, the two new fourth-year symposia, the first (A) recapi- tulating the second-year symposium and the second (B) on pain control, took place. Addi-

3 44 Christine Mason G G. Fenton

tionally, a questionnaire was compiled and piloted on the fourth-year class. The question- naire was given out to students at the begin- ning of symposium A and collected immediate- ly on completion and before the symposium began. Fifteen minutes were occupied with this administrative task.

The questionnaire had three sections which are presented in summary form in Table I .

Section I asked for the following information: age; sex; personal experience of bereavement in the family; and whether or not students had taken part in the second-year summer term seminars on terminal care. The second section consisted of zs true/false format questions. Ten were based on factual information which had been presented in second year. Ten related to the symptoms of abnormal grief, a subject discussed in psychiatry in the autumn term of fourth year. Three of the remaining five ques- tions of section I1 were intended to assess students’ existing knowledge of pain control before the new symposium relating to this theme had taken place. Section I11 of the questionnaire contained five questions which assessed attitudes about the subjects of dying and bereavement and which were based on second-year teaching themes.

Table I. Content of questionnaire used in pilot evaluation of terminal care teaching

Section Content

I Four questions on age, sex, bereave- ment experience, participation in semi- nars Group I : 10 questions on second-year teaching Group 2: 10 questions on fourth-year psychiatric teaching Group 3: 5 questions including 3 on pain control

I11 Five attitude questions, based on second-year teaching

I1

Results

Section I

Seventy-four of the class of 103 students were present on the day of the symposium and all completed the questionnaire. One or two of the students left blank some of the individual

Table 2. Responses to section I of evaluation ques- tionnaire: gender, bereavement experience, participa- tion in second-year seminars

NO Yo

Gender Male 45 60.8 Female 27 36.5 No response z 2.7

Attend seminars Yes 21 28.4 No 32 43.2 Can’t remember 19 25.7 No response 2 2.7

Experience of Yes 48 649 bereavement No 24 32.4

No response 2 2.7

questions and where this was the case, it is indicated in the Tables.

The gender of responding students is shown in Table 2, the ratio of men to women being the same as in the fourth-year class as a whole. Also shown in Table z is the number of students indicating personal experience of be- reavement in their own families and the num- ber who participated in the second-year sum- mer term seminars on terminal care.

Section 11

The zs knowledge questions were analysed in three separate groups: group I (old question score), those 10 questions referring back to second-year teaching; group z (psychiatric), the 10 questions on symptoms of abnormal grief; group 3 (new question score), 5 questions, 3 of which measured baseline knowledge on pain control.

The class means and standard deviations obtained in these three groups of questions are shown in Table 3. The percentage of students answering group I questions correctly ranged from 87.8 to IOO~/O. The range in group 3 was

Table 3. Question groups I , 2, 3 of section I1 of evaluation questionnaire; maximum allocated scores, class means, standard deviations and standard errors

Question Maximum Class SD SE group score mean

I I0 8.07 1 . 0 ~ 5 0.119 2 I0 745 1.356 0.158 3 5 2.45 1.148 0,134

Undergraduate teaching on terminal care

Table 4. Section 111 of evaluation questionnaire: questions I , 2, 3 , and responses to them

345

Question

(I) When doctors have been looking after patients over an extended period of time they should not show personal feelings of grief in front of relatives when patients die.

(2) It requires special training in a hospice for doctors to know how to deal with terminal illness.

(3) Would you want to know if you were suffering a terminal illness?

Responses

Agree Disagree Don’t know N o reply Agree Disagree Don’t know N o reply Yes N o N o redv

No. %

19

8 46

I

22

46 5

68

I

I c

25.7 62.2 10.8

1.4

29.7 62.2 6.8 I .4

91.9 * .4 6.8

243-79,7%. The questions on pain control were answered incorrectly by 50% or more of the students. In group z (psychiatric), 6 of the 10 were answered correctly by more than 80% of the respondents.

The scores of men and women were com- pared and were not found to be significantly different. Nor was there any significant differ- ence either between the scores of students who had and had not attended second-year seminars or between those who had or had not experi- enced family bereavement.

Section III

The first three questions in the attitude section of the questionnaire and students’ re- sponses to them are shown in Table 4.

In the fourth attitudinal question, a list of 10 situations which a doctor might be expected to encounter at some time in his or her career was offered to students. The list together with instructions for completion in the first part of the question are shown in Fig. I. In the second part of the question, students were asked to rate the same situations, again from I (most) to 10 (least) but on this occasion with respect to how worrying they felt each might be.

Results are presented in Fig. 2. In this histogram, the stimulus situations are shown on the horizontal axis and are ordered accord- ing to the descending proportions of students rating each as high (1-3) on the satisfying dimension. Thus 76.5% of respondents rated ‘looking after a woman during and after preg- nancy’ as I , z or 3 , I I .O% rated ‘looking after

As a doctor you will be involved in lots of different aspects of care. We would like you to grade various aspects of care which you feel at the moment are going to be the most down to the least satisfying.

There are ten aspects of care. Put a number from I to 10 by the side of each. I =the aspect you feel is going to be the most satisfying

ro=the aspect you feel is going to be the least satisfying SATISFYING

i. Encouraging people to change their behaviour (preventive medicine) (PREVENTION*) ii. Looking after a person with multiple sclerosis (MS)

iii. Working in a team with other professionals (TEAM-WORK) iv. Looking after the terminally ill (DYING) v. Marriage guidance (MG)

vi. Looking after a person with acute pneumonia (PNEUMONIA) vii. Speaking with relatives of those with incurable cancers (BEREAVEMENT) viii. Looking after a woman during and after pregnancy (PREGNANCY)

ix. Being called to a man suffering a myocardial infarction (MI) x. Looking after people with long-term depression (DEPRESSION) *The variable names were not included in the format offered to students.

Figure I . Situations offered to students and instructions for completion of Section 111, question 4a of evaluation questionnare.

23

..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ‘~ .....

..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .....

1 0

01

02

OE Ip

s oi7 g 3 0s

09

OL

08

Aspect of care Figure 2. Section 111, question 4-proportion of students rating stimulus situations either I , 2 or 3 on the dimensions satisfying and worrying.

people with long-term depression’ as I , 2 or 3. Ratings 1-3 on the worry dimension are pre- sented in the same histogram for comparison.

The two stimulus situations of particular interest in the context of this paper are ‘looking after the terminally ill’ and ‘speaking with the relatives of those with incurable cancer’. O n

the satisfaction dimension, the first was rated high (1-3) by 12.3% of students, the second by 11.1%; this is respectively seventh and ninth in descending order. The comparable figures on the worry dimension were 42.3% (4th) and 65.3% (1st). Thus it would appear that these two aspects of care were seen by the majority

Table 5. Section 111, question 5 ; numbers and percentage of students responding to alternative strategies of management offered

Medical opinion is divided about whether patients should or should not know when they are terminally ill. At the moment which of the following management strategies do you think is best for the well-being of patients?

Put one tick by the side of the strategy which you favour.

Response provided NO Yo

(a) Witholding information about prognosis from a - - patient for as long as possible.

only when he or she asks for it.

truth is known by the attending doctor. (d) Enabling the patient to ask questions about prog-

nosis and answering questions as and when they arise.

(e) Don’t know I 1.4 (No reply) I 1.4

(b) Giving information about prognosis to a patient 4 5.4

(c) Telling a patient about prognosis as soon as the 3 4.1

65 87.8

Undergraduate teaching on terminal care 347

of students as relatively high on worry and low on satisfaction.

The final stage of this particular analysis sought to test the prediction that there would be a significant negative correlation between the two rated dimensions, satisfying and wor- rying. A correlation analysis was performed for each of the 10 stimulus situations offered. None was significant.

The fifth and last question in the attitude section of the questionnaire and students’ re- sponses to it are shown in Table 5 .

The three variables sex, experience of family bereavement and participation in second-year seminars were examined in relation to students’ responses to attitude questions. No significant differences were identified.

Discussion

The results have raised questions about our approach to teaching on terminal care in par- ticular and the learning experience offered to students in general.

Responses to questions on pain relief high- light the need for the specific education on this subject recommended by teachers and planned in the form of a symposium to take place later in the term. Despite some therapeutics teaching and a year of clinical experience, ignorance was shown about the most basic aspects of pain management. For example, believing that the taking of opiates automatically gives rise to addiction, half of the respondents shared a misconception which too frequently acts as a barrier to effective pain control in both hospital and general practice.

However, teaching does not only seek to impart information. We try to encourage stu- dents to consider issues and come to their own conclusions and in their questionnaire re- sponses, they appeared to demonstrate attitudes which we believe are desirable for good patient care. For example, no student favoured with- holding information from patients with terminal illness; the majority advocated a strategy of facilitative communication.

Before embarking on the pilot evaluation, one of the guiding assumptions in our teaching on terminal care had been that if students were anxious about their ability to cope they would

be unlikely to see care in that situation as affording professional satisfaction. We had hoped that in providing factual information and opportunities for discussion early in the curri- culum, students would come to see terminal care as less worrying and more potentially satisfying. Ultimately, we are concerned that as doctors they will have confidence in their skills and will be less likely to employ the avoidance tactics which have been so frequently and poignantly described by both professionals and patients alike. However, despite acceptable knowledge, at least with respect to two-thirds of the questions asked of them, in comparison with other areas of work offered as stimuli, terminal care was rated by the majority of students as low on satisfaction and high on worry.

There were no significant differences in either knowledge or attitudes between those who had and had not experienced the second- year additional seminar teaching. It may be suggested that the instrument of evaluation was insensitive to the subtle effects of such experi- ences, or the 5 hours of basic teaching given to all students is sufficient in terms of that which we desire to achieve. Although 19 students could not remember whether they had attended the seminars, immediately after completing the series the majority of participants expressed personal benefit and enjoyment. But seminars are greedy of scarce teaching resources and personal growth may be achieved equally well in other ways.

Questions about our teaching and its evalua- tion have been raised by the findings of the pilot study. In the future we shall consider even more carefully the form, content and timing of different contributions to teaching. We shall also examine additional methods of assessing changes in students’ knowledge and attitudes. We continue to assert the importance of teaching on terminal care for all medical under- graduates. The ways in which this teaching can best be provided will occupy us for some years to come.

Acknowledgements

Thanks are due to Miss Ruth Miller for data- processing assistance, Mr Mark Reilly for

3 48 Christine Mason G G. Fenton

advice on data presentation, Professor Charles Florey and anonymous reviewers for valuable comments, Miss Una Beaton and Mrs Helen McHardy for typing earlier drafts and Mrs caroline ~ i ~ ~ i ~ l ~ ~ for preparing the final manuscript.

Reference

Doyle D. (ed.) (1979) Terminal Care. Churchill

Received I9 August 1985; editorial cominents to authors 12 November 1985; accepted f o r prrblication 17 December 1985

Livingstone, Edinburgh,