Palliative care: challenges for health education

Abstract

This integrative literature review analyzed the scientific production on palliative care and the education of health undergraduates. Data was collected by searching the Periódicos Capes database, using the descriptors “ cuidados paliativos ” (palliative care) and “ ensino ” (education), only in Portuguese, filtering for the last five years. After reading of titles and abstracts, ten articles were selected from the 61 found. Results show that the curricula of most health programs do not include palliative care education, resulting in theoretical, practical, and psychological unpreparedness. The analysis highlighted the key role played by philosophy and bioethics in the education of health professionals, inducing more ethical, appropriate, and humane professional conduct. The theory-practice dynamics was the most suggested as a means of properly introducing palliative care in the training process of health programs.

Palliative care; Teaching; Professional training

Resumo

Esta revisão de literatura objetivou analisar a produção acerca dos cuidados paliativos e da formação de profissionais da saúde durante a graduação. Foi realizada revisão integrativa de literatura na base Periódicos Capes, com os descritores “cuidados paliativos” e “ensino”, apenas em português, dos últimos cinco anos. Dos 61 artigos encontrados, após filtros e leitura de título e resumo, foram selecionados dez. Constatou-se que as grades curriculares da maioria dos cursos de saúde não incluem o ensino dos cuidados paliativos, ocasionando despreparo teórico, prático e psicológico. Evidenciou-se o papel fundamental que a filosofia e a bioética têm na formação dos profissionais de saúde, como indutoras de condutas profissionais mais éticas, adequadas e humanas. A dinâmica teoria-prática foi a mais sugerida como forma de inserir adequadamente os cuidados paliativos no processo de formação dos cursos de saúde.

Cuidados paliativos; Ensino; Formação profissional

Resumen

Esta revisión bibliográfica tenía como objetivo analizar la producción sobre los cuidados paliativos y la formación de los profesionales de la salud durante el pregrado. Se realizó una revisión bibliográfica integradora en la base Periódicos Capes, con los descriptores “cuidados paliativos” y “enseñanza”, solo en portugués, de los últimos cinco años. De los 61 artículos encontrados, después de filtrar y leer el título y el resumen, se seleccionaron diez. Se comprobó que los planes de estudio de la mayoría de los cursos de salud no incluyen la enseñanza de los cuidados paliativos, ocasionando falta de preparación teórica, práctica y psicológica. Se ha demostrado el papel fundamental que la filosofía y la bioética tienen en la formación de los profesionales de la salud, como inductoras de conductas profesionales más éticas, adecuadas y humanas. La dinámica teoría-práctica fue la más sugerida como forma de insertar adecuadamente los cuidados paliativos en el proceso de formación de los cursos de salud.

Cuidados paliativos; Enseñanza; Capacitación profesional

According to the World Health Organization (WHO)¹ , palliative care is an approach that improves the quality of life of patients and families facing issues associated with life-threatening illness by preventing and relieving suffering. Palliative care requires early identification, assessment and treatment of pain, and other physical, psychosocial and spiritual issues.

Its current concept was established by the International Association for Hospice and Palliative Care (IAHPC) – which has an official relation with the WHO – in 2018, after a project developed with more than 400 members from 88 countries. Per its updated definition, palliative care is the active holistic care of individuals across all ages with serious health-related suffering due to severe illness, and especially of those near the end of life, mainly aiming to improve the quality of life of patients, their families and their caregivers² .

Therefore, individuals of any age group (children, adults and older adults) with a chronic, degenerative and/or life-threatening illness can benefit from the palliative approach³ .

According to the principles defined by the WHO⁴ , palliative care:

• Provides relief from pain and other distressing symptoms;

• Affirms life and regards dying as a normal process;

• Intends neither to hasten or postpone death;

• Integrates the psychological and spiritual aspects of patient care;

• Offers a support system to help patients live as actively as possible until death;

• Offers a support system to help the family cope during the patient’s illness and in their own bereavement;

• Uses a team approach to address the needs of patients and their families, including bereavement counselling;

• Will enhance quality of life, and may also positively influence the course of illness;

• Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life;

• Includes diagnostic investigations needed to better understand and manage distressing clinical complications.

Currently, technological and scientific advances in healthcare have increased life expectancy and longevity in Brazil and worldwide⁵ . With population aging, chronic and/or degenerative illness increase, resulting in damage to the functional capacity of individuals and making them dependent in their routines and lives⁶ .

A decline in an individual’s health condition can lead to palliative care, and according to the Worldwide Palliative Care Alliance⁷ , more than 100 million people a year benefit from this type of care, including patients and their caregivers and families. As significant as this figure is, it means that less than 8% of the population requiring this type of care is guaranteed access to it.

Dignity and quality of life must be provided in the end of life; therefore, with increased longevity, the population’s access to palliative care must be improved. Nonetheless, education in this field remains insufficient in the curricula of health programs in Brazil⁵ . Hence, health professionals from different areas face ethical dilemmas when providing palliative care and seek answers for their interventions based on autonomy, dignity, the human dimension of relationships and the uniqueness of each being⁸ .

Palliative care interventions raise controversial issues around therapeutic obstinacy, euthanasia and assisted suicide, for example. Such issues influence the quality of life of patients and their social milieu, thus requiring the enhancement of palliative care education to minimize ethical conflicts⁹ .

Since population aging is a global certainty and that consequently the number of palliative care patients will increase, this literature review analyzes the challenges of palliative care teaching in the undergraduate education of health students. We seek thus to contribute to discussions about the relevance of including palliative care in the curricula of different undergraduate health programs, seeing as these professionals must be prepared to address all the ethical dilemmas involved in providing care to these patients.

Method

Based on the research question “What are the challenges of palliative care education in undergraduate health programs?” we carried out an integrative literature review in the Periódicos Capes database, of the Coordination for the Improvement of Higher Education Personnel (Capes)¹⁰ , using “any term” containing the Health Sciences Descriptors (DeCS) “cuidados paliativos” [palliative care] and “ensino” [education], only in Portuguese, filtered for the last five years, from May 2015 to May 2020. The filters applied in stage 2 of the search were those available in the Periódicos Capes database ( Figure 1 ).

Figure 1
Flowchart of study identification and selection

Results

Table 1 describes each article that makes up this review.

Table 1
Articles included and analyzed

Title	Authors	Objective	Journal (year)	Method	Main findings
“Formação em cuidados paliativos: experiência de alunos de medicina e enfermagem”5.	Costa, Poles, and Silva.	To know the experience and education of medical and nursing students in caring for patients under palliative care.	Interface: Comunicação, Saúde, Educação (2016).	Descriptive and qualitative study. Data was analyzed by thematic analysis.	The study showed that practical activities, appreciation of multidisciplinary work, suffering by the process of self-identification with the end-of-life patient, and the cycle of empathy and detachment resulting in emotional maturity are essential during palliative care education.
“Avaliação do conhecimento em cuidados paliativos em estudantes durante o curso de medicina”11.	Lemos and collaborators.	To assess knowledge on palliative care among medical students at the Escola Superior de Ciências da Saúde (Brasília, Distrito Federal, Brazil).	Revista Brasileira de Educação Médica (2017).	Cross-sectional study with application of an anonymous questionnaire, with questions about age, gender, and another 19 questions about knowledge on palliative care.	Knowledge on palliative care among students is unsatisfactory. No knowledge gain between the fourth and sixth grades. Need to improve palliative care teaching-learning, especially in internship settings.
“Reflexões sobre o Ensino de Bioética e Cuidados Paliativos nas Escolas Médicas do Estado de Minas Gerais, Brasil”12.	Oliveira and collaborators.	To analyze the curricula of medical schools in the state of Minas Gerais, assessing how palliative care education is conducted in undergraduate programs.	Revista Brasileira de Educação Médic a (2016).	Qualitative and exploratory case study using fieldwork and three operational instruments (structured questionnaire, interview and computerized document).	Bioethics knowledge emphasizing palliative care during medical education does not sufficiently meet the emerging needs of this area of health care. There is a need for programmatic action for teacher training and subsequent specific and longitudinal curricular introduction of bioethics and palliative care education in undergraduate medical schools in Minas Gerais.
“Adaptação transcultural do Bonn Palliative Care Knowledge Test: um instrumento para avaliar conhecimentos e autoeficácia”13.	Minosso, Martins, and Oliveira.	To cross-culturally adapt the Bonner Palliativ wissens test to assess knowledge and beliefs of self-efficacy in palliative care.	Referência Revista de Enfermagem (2017).	Methodological study, based on a theoretical framework for cross-cultural adaptation.	The study showed that the final Portuguese version of the Bonn Palliative Care Knowledge Test has potential to become an important tool for assessing the level of knowledge of professionals and students.
“Ensino da bioética convergente de Ricardo Maliandi nos cursos de medicina”14.	Mugayar, Carraro-Eduardo, and Sá.	To point out the deficiency in medical curricula compared to the human sciences and to advocate the study of Ricardo Maliandi and Oscar Thüer’s convergent bioethics.	Revista Brasileira de Educação Médica (2017).	Theoretical essay on therapeutic limitation, where the authors sought to combine the literature with the applicability in a real case.	The authors propose the use of Maliandi and Thüer’s bioethics for an in-depth technical analysis of each case as to its prognosis and the establishment of consensus within the medical team, including the understanding of the conflictive structure in question, so that, through ethical reflection, the resources available for health care are used more rationally and morally.
“A ordem dos fatores altera o produto: reflexões sobre educação médica e cuidados paliativos”15.	Blasco.	To reflect on the humane and technical training of physicians. Work on the correct posture in palliative care, imbued with philosophical values and permeated by ethics.	Educación Médica (2018).	Reflection on the humane and technical training of physicians by means of a literature review.	Medical education must consider comfort as something to always be achieved (high prevalence). The formal introduction of palliative care in the medical curricula will help to prioritize comfort over cure during medical training.
“Processo educativo em cuidados paliativos e a reforma do pensamento”16.	Carvalho and collaborators.	To know the contributions of palliative care education in undergraduate courses for the professional performance of nurses in the care of end-of-life patients.	Investigación y Educación en Enfermería (2017).	Qualitative research using discursive thematic analysis, based on Morin’s theory of complexity.	Palliative care education is essential for nurses as to systematize patient care. Nursing programs should enable students to develop awareness of the complexity of human beings and their relationship with multiple biopsychosocial and spiritual aspects.
“A morte no cotidiano da graduação: um olhar do aluno de medicina”17.	Duarte, Almeida, and Popim.	To describe how human medicine students cope with situations involving death.	Interface: Comunicação, Saúde, Educação (2015).	Qualitative research using the theoretical-methodological framework of phenomenology.	Issues related to death and dying require students to have technical and emotional skills for processing and coping. Undergraduate education should provide opportunities for both skills to be enhanced, based on scientific, ethical, and legal knowledge.
“Interface do testamento vital com a bioética, atuação profissional e autonomia do paciente”18.	Pirôpo and collaborators.	To analyze the relation between living will and bioethical aspects, professional performance – including education and patient autonomy.	Revista de Salud Pública (2018).	Theoretical reflection based on a literature search in the Biblioteca Virtual de Saúde, Pubmed and SciELO databases.	The living will needs greater dissemination and knowledge among health professionals and the population, since its applicability can facilitate medical decision-making, respecting the patient’s wishes.
“Grupo de Educação para a Morte: uma estratégia complementar à formação acadêmica do profissional de saúde”19.	Oliveira-Cardoso and Santos.	To describe the experience of implementing the Education for Death Group and to understand the participants’ perception regarding this experience.	Psicologia: Ciência e Profissão (2017).	Experience report of an Education for Death Group implemented in a university hospital in the countryside of São Paulo.	The Education for Death Group enabled reflections and led to questioning and reflections about death and dying in the hospital by meaningful learning, integrating cognitive and affective aspects, considering the experience of clinical practice. The authors suggest investing in the expansion of educational work with professors and supervisors in health and education, as well as establishing dialogue beyond the professional and academic environment.

Discussion

Considering the increased number of individuals who will require palliative care, developing skills in this area during the medical education is key²⁰ , since education on this subject promotes changes in values and attitudes in students, recognized as essential for medical training²¹ .

The palliative care skills needed involve person-centered care, respect for autonomy and family care; therefore, they involve technical, cultural and ethical issues, reducing invasive medical intervention and providing resources to improve quality of life. But this care raises different ethical issues, such as respect for patient autonomy, the principle of beneficence – health professionals acting for the good of the patient –, the principle of non-maleficence – health professionals do not cause harm/damage to the patient –, and the principle of justice, which defends the right to health.

Besides, certain bioethical issues can directly affect the conduct of health professionals in palliative care, if there is no appropriate understanding of euthanasia – a medical procedure that aims to shorten the life of terminally ill patients, which is prohibited in Brazil according to the codes of ethics of medicine and nursing – ; of dysthanasia – exaggerated prolongation of life, even when the patient has an incurable disease – ; and of orthothanasia – death in its natural process, without accelerating or delaying the process²² .

Discussing such issues during undergraduate education is therefore paramount for health professionals to be ethically grounded and able to provide quality care to end-of-life patients.

After reading the ten articles listed in Table 1 , data was treated and organized into four categories: 1) palliative care and the curricula of health programs; 2) feelings of health undergraduates regarding death and palliative care; 3) importance of philosophy and bioethics in health courses; and 4) proposals for introducing palliative care in the education of medical students.

Palliative care

Curricula of health programs

The articles were unanimous in pointing out flaws in the curricula of health courses regarding topics such as end of life and death and palliative care, highlighting the need to revise the political-pedagogical project of different health programs in Brazil to include these topics in the curricula.

Costa, Poles, and Silva⁵ , who addressed palliative care education, observed that the curricular approach is insufficient to spark students’ interest in the topic. Extracurricular activities were cited as major sources of learning in theory and practice.

Undergraduates who participated in the research emphasized the need for a curricular reform that gives more space to palliative care. The authors concluded that the lack of curricular theoretical subjects creates difficulties in palliative care learning and, although elective courses are an option to correct this failure, they do not cover all undergraduates⁵ .

According to Pinheiro and collaborators²³ , palliative care education emerged in Brazil only ten years ago and, as a result, physicians were unprepared to provide care to end-of-life patients. What would be the reasons for the deficient – or even non-existent – introduction of such topic in education? Could it be that professors are unprepared, or that curricula have been developed ignoring the demands of society?

Oliveira and collaborators¹² point out that the issue lies in the lack of interest of medicine professors in working with the topic and in the absence of pedagogical proposals that foster the implementation of a subject on the care of end-of-life patients. The authors argued that the lack of interest in the topic could be associated with the feeling of fear and the unpreparedness of these professionals when faced with the death of a patient.

Blasco¹⁵ states that the path taken by medicine in recent years prioritizes technique and ignores humanism, reiterating that until 2016 there was no palliative care education in the curricula of medical schools in Brazil and agreeing with Oliveira collaborators¹² about the unpreparedness of health professionals to cope with human suffering and death.

Duarte, Almeida, and Pompim¹⁷ observed that until 2015 the School of Medicine of Botucatu (FMB), at the São Paulo State University (Unesp), had only one class on palliative care, included in the discipline of Psychology. Although topics related to the end of life were also addressed in contents referring to humanization in health care, students reported that their undergraduate studies were insufficient for them to know how to cope with death in practice and, therefore, they felt unprepared.

In the current curriculum, available on the FMB-Unesp website, the topic “palliative care” is included in the ethics and morals module of the third year, with an eight-hour load. Despite a dedicated discussion, the topic has yet to reach the level of a module or discipline²⁴ .

Corroborating these statements, Lemos and collaborators¹¹ showed that the level of knowledge on palliative care among the research participants was unsatisfactory. Nevertheless, they also observed that knowledge gain occurs during undergraduate medical education, when comparing first and fourth year students, but the progressive gain of knowledge does not occur during internship. These results, therefore, also reinforced the need for investments in palliative care teaching-learning.

Minosso, Martins, and Oliveira¹³ corroborate these findings⁵ , ¹¹ , ¹² , ¹⁵ , ¹⁷ and argue that one obstacle to promoting quality palliative care is the lack of training of health professionals, who have little knowledge about this type of care. It is thus evident that undergraduate health courses have not introduced the topic satisfactorily in their curricula.

Such educational gaps lead to technical and practical unpreparedness, negatively impacting the quality of the care provided. According to Azeredo, Rocha, and Carvalho²⁵ , the unpreparedness to cope with death-related issues generates in future health professionals feelings of frustration and incapacity, which, in turn, can cause stress and physical and psychological exhaustion²⁶ . Prolonged chronic stress in the workplace, today known as burnout syndrome, results from a combination of emotional exhaustion, depersonalization, and low personal accomplishment²⁷ .

The syndrome can trigger poor work performance, more mistakes made, wrong procedures, negligence, recklessness, lack of integration between team members, and increased costs of time and money due to high employee turnover. This is because health professionals affected by burnout are more prone to absenteeism and presenteeism, and to generate lower patient satisfaction regarding care²⁸ .

Given this scenario, we must think about what intervention would improve the preparation of health professionals in palliative care. In this regard, a study developed in the undergraduate nursing course at the Catholic University of Pelotas examined the perspective of nursing professionals who attended a discipline focused on palliative care¹⁶ . Seven nurses who had attended this discipline – and who later care for end-of-life patients – and six nursing professors who taught disciplines related to end-of-life and palliative care.

Based on the participants’ answers, the authors concluded that the palliative care discipline contributed to change how future professionals think, making them prioritize the use of therapies that provide relief from signs and symptoms, focusing on quality of life. Moreover, students began to consider as a mistake the use of healing treatments, under any circumstances, that cause suffering to patients, their families and health professionals¹⁶ . It is thus necessary to include palliative care in the curricula of health courses, since studies point to flaws in addressing the issue, which compromise dignified and authentic care, a right of every individual.

Another possibility to improve the preparation of health professionals, as proposed by Azeredo, Rocha, and Carvalho²⁵ , is to invest in discussion spaces for sharing the emotions that arise when facing death during graduation, to minimize their consequences. The authors believe that discussing death and the therapeutic limits in formal education, as well as giving permanent attention to the topics, can contribute to more assertive behavior by health students and professionals.

Feelings of health undergraduates

Regarding death and palliative care

Health professionals’ theoretical insufficiency to cope with death and the end of life goes hand in hand with psychological unpreparedness, raising negative feelings that shake the emotional state of students and professionals or desensitize professionals to an issue that demands humanity over technique. As Carvalho and collaborators¹⁶ and Blasco¹⁵ point out, palliative care remains a challenge, as nursing and medicine courses understand the death of a patient as a phenomenon that prevents professional success.

Duarte, Almeida, and Pompim¹⁷ , in a study that described how FMB-Unesp fourth and sixth year undergraduates cope with situations involving death, showed that they feel fear, unpreparedness, insecurity, guilt, fragility and anguish when facing end-of-life issues, highlighting that death is a problematic topic.

Oliveira-Cardoso and Santos¹⁹ report that the feeling of having little or no technical and emotional preparation, or even the recognition of unpreparedness to address death situations, is found in undergraduates of different health courses, such as Nursing, Medicine and Psychology. The authors also state that the approach to death and dying in undergraduate health programs is technical, which consequently limits questions as to the professional’s feelings regarding the care and possible loss of a patient¹⁹ .

In the study by Costa, Poles, and Silva⁵ , medical and nursing undergraduates reported that identifying with the patient was considered a facilitating factor, because they can put themselves in the place of suffering. This sensitization occurs, according to the undergraduates, because palliative care puts the psychological state of the patient in evidence, and therefore health professionals also have their emotional state affected.

Still according to this study⁵ , some undergraduates reported that, at the beginning of the internship – when students have contact with practice –, they were more sensitized, but during consultations they began to distance themselves from the patient’s context. In situations where identification with the patient did not occur, they reported trivializing death, not putting themselves in the patient’s place, not knowing how to provide palliative care and becoming cold.

Mufato and Gaíva²⁹ indicated that empathy should be a core link in the relationship between health professionals and patients, as it favors a better understanding between them. An empathetic professional would be able to promote comprehensive and quality care, leaving the patient satisfied. Oliveira and collaborators¹² highlighted that skills and attitudes such as empathy, ethical and bioethical reflection, communication, and deliberation should be included in the curricula of undergraduate health courses, since they need to be trained and improved to promote a more qualified education for future health professionals.

In the context of undergraduate courses, an Education for Death group was implemented in a university hospital in the countryside of the state of São Paulo. The group was requested due to the students’ high vulnerability to stress and professional burnout. The group had an informative and critical-reflexive character, seeking to provide participants with some basic theoretical and experiential elements about death and dying. Its action enabled a critical and expanded perspective on clinical practice, in order to achieve a more humanized care by professionals in training. Besides, it provided an opportunity for embracing and reflecting on distressing situations experienced by students¹⁹ .

Participants highlighted the importance of discussing the practical situations experienced, which led to reflections and changes in how one approaches the topic. The change in attitude towards death was also reflected in the changes perceived in the feelings and sensations reported after the intervention, which became relief, capacity, tranquility, maturity, acceptance, trust, sensitivity, understanding, partnership, and solidarity¹⁹ .

Once again, educational institutions need to review their methodologies, because during training, feelings of unpreparedness, vulnerability, and fear must be transformed into feelings of security, curiosity, and confidence.

Consequently, there needs to be a close association between education and practice, to promote greater psychological and emotional preparation regarding end-of-life care, providing experience and understanding of feelings.

Finally, educational institutions must teach and practice humanity by promoting listening spaces to students and spaces for sharing feelings mobilized when facing new experiences.

Health-related courses

Education in philosophy and bioethics

Some of the articles analyzed here pointed to philosophy and bioethics as fundamental in health undergraduate courses, not only regarding issues surrounding palliative care and the end of life, but in relation to humanized care that prioritizes the person, and not the disease.

As such, Costa, Poles, and Silva⁵ advocated the implementation of a palliativist philosophy during curricular practical activities as a way to enhance education in the field of health, contributing to a good performance in palliative care.

Oliveira and collaborators¹² highlighted that the ethical and bioethical aspects and the principles of palliative care are necessary for the education and training of medical students, since they are essential to ensure an excellent care for end-of-life patients. Palliative care advocates dying with dignity and, thus, bioethics is essential to foster discussions on the curricular teaching of bioethics and palliative care.

Duarte, Almeida, and Pompim¹⁷ also pointed out bioethics as fundamental in the reflections about end of life and palliative care, since they raise issues related to the different ways of dying, such as euthanasia, dysthanasia, orthothanasia, and humanization in hospitals.

Mugayar, Carraro-Eduardo, and Sá¹⁴ argued that philosophy is deficient in the curricula of undergraduate medical courses and that physicians face ethical conflicts regarding their actions when addressing illness and dying. These conflicts end up harming the human aspect involved, and professionals adopt technicist actions, without empathy towards patients or their families. The authors proposed, then, to introduce bioethics in the medical curriculum, so that education enables an ethical and humanized medical practice.

Blasco¹⁵ pointed out the need for preparation beyond the technique to know how to face death professionally. The author suggested that philosophy should be at the base of medical training and argued that, with an ethical basis, one understands the correct dimension of care, the perspective is expanded beyond technique, emphasizing dignified care, without the need to prolong the patient’s life.

Silva Pirôpo and collaborators¹⁸ , by analyzing the relation between the living will and bioethical aspects, professional performance, and patient autonomy, showed that bioethics is of great importance to address end of life and palliative care. According to the authors, to develop a correct conduct that respects patient autonomy, professionals need to be guided by ethical thinking, in which bioethics has proved elementary to help in decision-making based on the patient’s wishes.

Broadly speaking, autonomy is the capacity to decide for oneself. As such, health care professionals have the duty to provide all the technical information necessary to guide the patient’s decisions, without influence or manipulation. Respect for patient autonomy is a basic feature of palliativist philosophy³⁰ .

The principle of autonomy breaks with the model of the health professional as the holder of decision-making power³¹ . Hence, bioethics and palliative care have much to contribute to the education of health professionals, so they can respect the autonomy of their patients.

Carvalho and collaborators¹⁶ state that approaching the topic in the form of a discipline or mandatory content in the curricula would be insufficient. They advocate, thus, that the philosophical principles underlying palliative care be included transversely: sensitivity, respect for patient autonomy, understanding regarding the dying process, communication skills and skills to cope with feelings and emotions, and solidarity.

Another key element for providing quality palliative care is communication. As Poles, Costa, and Silva⁵ and Theobald and collaborators³² point out, health professionals are unprepared to address situations where communication and support are necessary for end-of-life patients. Moreover, Blasco¹⁵ states that communication is a skill that needs to be developed and improved, while Duarte, Almeida, and Popim¹⁷ suggest that introducing the topic in the curricula of undergraduate medical courses would enhance the communication skills of future health professionals.

Simply teaching palliative care is, therefore, not enough. We must provide a good philosophical base and equip medical students with values, meanings, humanity, beliefs, and empathy, that is, they must be trained ethically, so that their future actions as health professionals are based on bioethics.

Training of medical students

Proposals for introducing palliative care

For palliative care to be properly introduced in undergraduate health courses, the studies mainly suggested theory-practice dynamics. In the study by Costa, Poles, and Silva⁵ , for example, most respondents suggested that the topic be approached more often in clinical and psychosocial disciplines, better developing the theoretical aspect. The authors conclude by suggesting greater promotion of theoretical and practical teaching of the topic in the curricula of medical programs, for then professionals would be qualified to provide quality palliative care.

Duarte, Almeida, and Pompim¹⁷ highlighted the possibility of including the topic of death in undergraduate health curricula and advocated the need for theoretical and practical training in palliative care.

Oliveira-Cardoso and Santos¹⁹ emphasized that theoretical and practical follow-up, especially for professionals in training, is highly valued by undergraduates, who often feel lonely and without support in health care practice, trying to balance their anxieties and insecurities with the obligations, expectations, and demands. They also proposed courses on education for death as a way to offer discussion spaces for health professionals to work on topics avoided or ignored during undergraduate health courses, such as: the dying process, attitudes towards death, palliative care, professional’s mourning process, anticipatory grief, grieving process, among others. The group suggested investing in the expansion of educational work with professors and supervisors in the areas of health and education, as well as in discussions beyond the professional and academic environment¹⁹ .

For Oliveira and collaborators¹² , simply discussing issues related to bioethics and palliative care would already transform the behavior of physicians, making them more capable of coping with the end of life. The authors argued that introducing disciplines and implementing academic leagues focused on palliative care and bioethics from the first year would enable the training of skilled, ethical, prudent, and virtuous professionals.

Blasco¹⁵ argued that medical education should prioritize the logic of comfort over cure, since comfort must be provided to all patients, regardless of whether the disease is treatable or not, considering that cure is not possible for all diseases. Moreover, by focusing on comforting, patients are seen in their entirety, while they are forgotten when cure is prioritized, considering only the disease. For the author, most educators agree on the need to teach the topic in undergraduate and residency programs, and the path could be to foster palliative care leagues.

As previously discussed, theory, practice, empathy, philosophy, bioethics, psychological and emotional preparation are necessary elements for health professionals to be able to provide quality care. Educational institutions must review their political-pedagogical project, so that it contemplates humanization and humanity, and that care is established as the basic function of any health professional.

Final considerations

The present literature review showed that the curriculum of most health courses does not include palliative care education and that, besides the insufficient theoretical instruction, students are psychologically and emotionally unprepared, which generates fear, anguish, anxiety, guilt, fragility, among other negative feelings. We also noted the fundamental role played by philosophy and bioethics in the training of health professionals, promoting more ethical, appropriate, and humane conducts. Finally, the theory-practice dynamics was the most suggested as a means of properly introducing palliative care in undergraduate health courses.

The studies analyzed here addressed specifically palliative care education in nursing and medical courses; therefore, further research and reviews are needed to understand the scenario in other health-related programs.

Given the findings, there is evident need to transform the current educational model in health-related undergraduate courses, as they do not meet the needs of patients and professionals, since the latter graduate unprepared to act in the complex demands of health care. We must overcome the technicist model, understanding that more than technical care, human beings need comprehensive care to meet all their needs.

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• This research was funded by a Capes scholarship.

Publication Dates

• Publication in this collection
  09 May 2022
• Date of issue
  Jan-Apr 2022

History

• Received
  14 July 2020
• Reviewed
  24 Feb 2022
• Accepted
  26 Feb 2022