I read with interest “Does a one day hospice placement for medical students do more harm than good?” [1]. As a 4th year medical student at The University of Liverpool, and having recently undertaken a 4 week palliative care placement, I would like to weigh in on the themes discussed.
As Ward et al. pointed out, Foundation year 1 doctors (interns) regularly care for patients at the end of life, but undergraduate training is often deficient. Issues around dying and death is one of the most commonly reported sources of junior doctors stress [1][2].
Personal distress from the care of the dying is a factor to burnout; a well-documented condition with detrimental outcomes for healthcare professionals and patients. Given the central reality of death in medicine, it seems paradoxical these issues are not better addressed in undergraduate medical training [2] [3] [4].
The GMC’s publication ‘Tomorrow’s Doctors’, states “Graduates must know and understand the principles of treatment including...palliative care”. Despite this, a systematic review found inconsistent palliative care teaching within undergraduate curriculums. As a result, junior doctors are often unprepared and distressed when caring for palliative care patients [5] [6].
During the 4th year of the MBChB curriculum at The University of Liverpool, students undertake a 4 week palliative care and oncology placement. This consists of three weeks in a local hospice, one week at a specialist cancer hospi...
I read with interest “Does a one day hospice placement for medical students do more harm than good?” [1]. As a 4th year medical student at The University of Liverpool, and having recently undertaken a 4 week palliative care placement, I would like to weigh in on the themes discussed.
As Ward et al. pointed out, Foundation year 1 doctors (interns) regularly care for patients at the end of life, but undergraduate training is often deficient. Issues around dying and death is one of the most commonly reported sources of junior doctors stress [1][2].
Personal distress from the care of the dying is a factor to burnout; a well-documented condition with detrimental outcomes for healthcare professionals and patients. Given the central reality of death in medicine, it seems paradoxical these issues are not better addressed in undergraduate medical training [2] [3] [4].
The GMC’s publication ‘Tomorrow’s Doctors’, states “Graduates must know and understand the principles of treatment including...palliative care”. Despite this, a systematic review found inconsistent palliative care teaching within undergraduate curriculums. As a result, junior doctors are often unprepared and distressed when caring for palliative care patients [5] [6].
During the 4th year of the MBChB curriculum at The University of Liverpool, students undertake a 4 week palliative care and oncology placement. This consists of three weeks in a local hospice, one week at a specialist cancer hospital and three day-long communication skills sessions.
When introduced, a study evaluating the placement found it significantly increased student confidence in palliative care. Since then, the programme has been refined in accordance with the new integrated curriculum. After the placement, 4th year students report feeling better equipped to deal with the emotional toll they face when caring for patients at the end of life [7].
Palliative care placements in the undergraduate medical curriculum - as a core theme - allows medical students to be immersed in the environment and culture. It encourages them to face the difficult but important topics that arise at the end of life. A longer structured clinical placement is one way students can prepare for the difficult and complex situations they will face as junior doctors, to meet GMC requirements and better care for themselves and their patients.
References
1. Ward J, Rayment C, Hallam J. Does a one day hospice placement for medical students do more harm than good? BMJ Supportive & Palliative Care 2019;9:A8.
2. Firth‐Cozens J, Morrison LA. Sources of stress and ways of coping in junior house officers. Stress & Health 1989;5(2):121-126.
3. BMJ. Doctors' emotional reactions to recent death of a patient: cross sectional study of hospital doctors. BMJ 2003;327:185.
4. Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Health Care Professionals: A Call for Action. AJCC 2016;25(4):368-376.
5. GMC. Tomorrow’s Doctors. GMC 2003 [Cited 26 June 2019]. Available from: https://www.educacionmedica.net/pdf/documentos/modelos/tomorrowdoc.pdf
6. Lloyd-Williams M, Macleod RDM. A systematic review of teaching and learning in palliative care within the medical undergraduate curriculum. Medical Teacher 2004;26(8):683-690.
7. Mason SR, Ellershaw JE. Undergraduate training in palliative medicine: is more necessarily better? Palliative Medicine 2010;24(3):306-309.
We read and agreed with several points in the editorial [1] that accompanied our main research paper about UK clinicians' views on blood transfusion practice [2]. We have additional responses to the editorial.
We recognise the lack of evidence about red cell transfusion within palliative care, which is why we undertook the largest audit of transfusion practice to date [3]. We analysed 465 transfusion episodes over 3 months from 121 UK hospices. Patients were not usually investigated for the anaemia. Of those that were, a significant proportion would have benefited from B12, folate or iron supplements, although rarely used. Despite being at higher risk of transfusion-associated circulatory overload (TACO), risk-mitigation practices like weighing patients or restricting transfusion to one unit (before review), were only undertaken in 15% of patients. In terms of patient benefit only 83 (18%) had improvement maintained at 30 days; 142 (31%) <14 days, and 50 (11%) had none. 150 patients (32%) were dead at 30 days, over double the predicted number.
While documented death rates and major morbidity from red cell transfusion are low in the general population, there is growing evidence of under recognition and under reporting. A study across 157 UK hospitals showed that 4.3% of inpatients >60 years had increasing respiratory distress post-transfusion, but only one-third diagnosed with TACO by the hospital were reported to the SHOT Haemovigilance Group [...
We read and agreed with several points in the editorial [1] that accompanied our main research paper about UK clinicians' views on blood transfusion practice [2]. We have additional responses to the editorial.
We recognise the lack of evidence about red cell transfusion within palliative care, which is why we undertook the largest audit of transfusion practice to date [3]. We analysed 465 transfusion episodes over 3 months from 121 UK hospices. Patients were not usually investigated for the anaemia. Of those that were, a significant proportion would have benefited from B12, folate or iron supplements, although rarely used. Despite being at higher risk of transfusion-associated circulatory overload (TACO), risk-mitigation practices like weighing patients or restricting transfusion to one unit (before review), were only undertaken in 15% of patients. In terms of patient benefit only 83 (18%) had improvement maintained at 30 days; 142 (31%) <14 days, and 50 (11%) had none. 150 patients (32%) were dead at 30 days, over double the predicted number.
While documented death rates and major morbidity from red cell transfusion are low in the general population, there is growing evidence of under recognition and under reporting. A study across 157 UK hospitals showed that 4.3% of inpatients >60 years had increasing respiratory distress post-transfusion, but only one-third diagnosed with TACO by the hospital were reported to the SHOT Haemovigilance Group [4]. People treated in hospices commonly have several TACO risk factors (as outlined in the editorial). TACO symptoms are non-specific and include cyanosis, dyspnoea and tachycardia which can be mistaken for deterioration of underlying advanced disease.
There is a misconception about how long it takes to correct abnormal haematinics; B12 and folate treatment can increase haemoglobin within 7–10 days and worth considering before transfusion if the cause of anaemia [5]. Intravenous iron to correct deficiency in palliative care is uncommon; however, it is offered by some services and increasingly seen as safer than red cell transfusion.
We believe that our paper [2] suggests UK clinicians might be out of step with the evolving evidence base and clinical guidelines about red cell transfusions. This particularly applies to more rigorous anaemia investigation, increased use of alternative therapies and a more restrictive approach to red cell transfusions. Clinicians should discuss the limited benefit versus potentially higher risks in hospice patients to inform treatment decisions.
References
1) Brown E. Blood transfusions: time for a change in practice. BMJ Support Palliat Care, 2019
2) Neoh K, Stanworth S, Bennett MI. How does blood transfusion practice by UK palliative medicine doctors compare with NICE guidance? BMJ Support Palliat Care 2019
3) Neoh K , Gray R, Grant-Casey J, Estcourt L, Malia C, Boland JW, Bennett MI. National Comparative Audit of Red Blood Cell Transfusion Practice in Hospices: Recommendations for Palliative Care Practice. Palliative Medicine 2019, Vol. 33(1) 102–108 2019
4) The TACO Audit Working Group, on behalf of the National Comparative Audit in Blood Transfusion (NCABT) Steering Group. The 2017 audit of Transfusion Associated Circulatory Overload (2018). NHSBT
Accessed online https://hospital.blood.co.uk/audits/national-comparative-audit/medical-a...
5) Devalia, V, Hamilton, MS, Molloy, AM. Guidelines for the diagnosis and treatment of cobalamin and folate disorders. Br J Haematol 2014; 166: 496–513.
This was a very interesting article. As a professional with frequent intensive care duties early discussions about patient’s wishes are best. Ideally, these should take place away from the acute setting. This is what we always hope to have for our unconscious patients being admitted to the unit.
Unfortunately, these discussions are a bonus rather than routine practice even in end stage disease. Perhaps this partly explains the difference in expectation between the medical team and the family. This leads to management disagreements. It is not uncommon to hear a family “wanting everything doing” for their loved ones in a DNACPR conversation.
In our training we have always been taught that DNACPR is a medical decision. It is good practice nevertheless to communicate any such major management decisions to the family. Nevertheless, there appears to be a move towards completely patient/family centred care. There are multiple occasions a DNACPR is not put in place as the family will not agree, despite a consensus among multiple consultants.
In this climate, with the family often seen as the representative of the patient without capacity, is a DNACPR decision still a medical decision?
I read with interest “Does a one day hospice placement for medical students do more harm than good?” [1]. As a 4th year medical student at The University of Liverpool, and having recently undertaken a 4 week palliative care placement, I would like to weigh in on the themes discussed.
Show MoreAs Ward et al. pointed out, Foundation year 1 doctors (interns) regularly care for patients at the end of life, but undergraduate training is often deficient. Issues around dying and death is one of the most commonly reported sources of junior doctors stress [1][2].
Personal distress from the care of the dying is a factor to burnout; a well-documented condition with detrimental outcomes for healthcare professionals and patients. Given the central reality of death in medicine, it seems paradoxical these issues are not better addressed in undergraduate medical training [2] [3] [4].
The GMC’s publication ‘Tomorrow’s Doctors’, states “Graduates must know and understand the principles of treatment including...palliative care”. Despite this, a systematic review found inconsistent palliative care teaching within undergraduate curriculums. As a result, junior doctors are often unprepared and distressed when caring for palliative care patients [5] [6].
During the 4th year of the MBChB curriculum at The University of Liverpool, students undertake a 4 week palliative care and oncology placement. This consists of three weeks in a local hospice, one week at a specialist cancer hospi...
We read and agreed with several points in the editorial [1] that accompanied our main research paper about UK clinicians' views on blood transfusion practice [2]. We have additional responses to the editorial.
We recognise the lack of evidence about red cell transfusion within palliative care, which is why we undertook the largest audit of transfusion practice to date [3]. We analysed 465 transfusion episodes over 3 months from 121 UK hospices. Patients were not usually investigated for the anaemia. Of those that were, a significant proportion would have benefited from B12, folate or iron supplements, although rarely used. Despite being at higher risk of transfusion-associated circulatory overload (TACO), risk-mitigation practices like weighing patients or restricting transfusion to one unit (before review), were only undertaken in 15% of patients. In terms of patient benefit only 83 (18%) had improvement maintained at 30 days; 142 (31%) <14 days, and 50 (11%) had none. 150 patients (32%) were dead at 30 days, over double the predicted number.
While documented death rates and major morbidity from red cell transfusion are low in the general population, there is growing evidence of under recognition and under reporting. A study across 157 UK hospitals showed that 4.3% of inpatients >60 years had increasing respiratory distress post-transfusion, but only one-third diagnosed with TACO by the hospital were reported to the SHOT Haemovigilance Group [...
Show MoreThis was a very interesting article. As a professional with frequent intensive care duties early discussions about patient’s wishes are best. Ideally, these should take place away from the acute setting. This is what we always hope to have for our unconscious patients being admitted to the unit.
Unfortunately, these discussions are a bonus rather than routine practice even in end stage disease. Perhaps this partly explains the difference in expectation between the medical team and the family. This leads to management disagreements. It is not uncommon to hear a family “wanting everything doing” for their loved ones in a DNACPR conversation.
In our training we have always been taught that DNACPR is a medical decision. It is good practice nevertheless to communicate any such major management decisions to the family. Nevertheless, there appears to be a move towards completely patient/family centred care. There are multiple occasions a DNACPR is not put in place as the family will not agree, despite a consensus among multiple consultants.
In this climate, with the family often seen as the representative of the patient without capacity, is a DNACPR decision still a medical decision?
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