Palliative care in medical education: the students’ perception

Introduction: Population aging, longer life expectancy and the increase in the prevalence of chronic diseases have brought new health demands, among them, palliative care (PC). Although present in the clinical routine, this topic has not yet been included in most medical schools in Brazil. Objective: To know the teaching-learning process in PC according to the perception of medical students from schools that have this subject. Method: Qualitative method through interviews with 35 medical students from 14 medical schools located in the Northeast, Southeast and South regions of the country. Results: The reports were classified into three categories: conception of PC, changes perceived after exposure to PC teaching, challenges and successful strategies identified in PC teaching. Students recognize the value of teaching in PC and have a greater understanding of PC approach and its early indication for people with complex chronic conditions. The inclusion of the topic contributed to the overcoming of fears and taboos related to death, providing greater comfort to deal with human suffering, adding emotional skills. The formal education in PC allowed understanding the person in their biopsychosocial and spiritual dimension. They stressed the importance of communication skills to communicate difficult news, symptom management, teamwork and an individualized approach to the person and their family. Although they identify little theoretical-practical integration in the teaching-learning scenario in PC, they report an interest in the topic, and indicated successive experiences as strategies throughout the training, in a humanist axis. Conclusion: PC teaching brings contributions to medical training that go beyond the learning of the subject and reinforces the development of empathy and compassion, recognized as essential in this profession, as well as the relevance of assertiveness in the management of suffering and the comprehensive care of people with advanced diseases.


INTRODUCTION
Population aging and the increase in life expectancy, with the increasing burden of chronic diseases, are considered to have had important effects on the health care network. In 2000, it was verified that 662,068 people required palliative care, and the estimate for 2040 is that approximately 1,166,279 people will require this type of assistance in Brazil 1 . The world is on the move and educational systems must prepare and train professionals in line with the current requirements, including core competencies in PC. Given these data, the urgent need for a curriculum that is in line with these population needs is evident. This can be considered a set of articulated pedagogical and administrative action plans, anchored in political-historical realities 2 .
Palliative care (PC) is a therapeutic approach advocated by the World Health Organization (WHO) as the most appropriate for people who are suffering, whether adults or children. Despite the great demand for this type of assistance in health services, little time is devoted to the teaching of PC in the medical curriculum. Evidence indicates benefits in incorporating this approach to people with life-threatening diseases, providing a dignified finitude for the individual and their family 3 . The management of the palliative care approach involves social and ethical issues, such as the reduction of inappropriate and ineffective use of heavy medical interventions and the underutilization of others that would improve the quality of life 4 .
The overall domains in PC comprise the person-and family-centered approach, respect for cultural competence, attention to the patient's physical, psychological, social and spiritual dimensions, as well as dealing with the challenges of clinical and ethical decision-making in PC and the development of communication and integration skills that are essential to teamwork 5 .Although the core competencies in PC are diverse in the curricula, even in countries where palliative medicine has become mandatory in medical schools, three domains predominated: respect to the different patient values in the process of dying, considering the principles and practices of PC, communication skills in the decision-making process at the end of life and management of pain and symptoms 6,7 .
The teaching of PC in Brazil is still incipient and only 44 medical schools include this topic in their curricula, which represents 14% of the total number of schools in the country 8 . There are few records regarding the contributions that PC teaching brings to medical training from the perspective of students. The present study aims to analyze the perception of medical school students who have PC as a discipline on the teaching-learning process, the achieved benefits, the identified challenges and possible paths as a teaching strategy to guarantee the training of physicians capable of contributing to a dignified life for people suffering from incurable diseases.

METHOD
Given the specificity of the object under study, i.e., the perception of medical students about the teaching and learning of PC, a qualitative method was used, since it is the most adequate to answer comprehensive questions. Consistent with the study by Castro et al (2021), this is part of a larger investigation on the teaching of PC in Brazil, in which all Higher Education Institutions (HEIs) related to medical teaching in Brazil and their curricula were mapped to identify those that include PC teaching and the analysis of how it is being developed according to the perception of coordinators, teachers and students.
In the first stage, a search for the curriculum matrix was carried out in the official Brazilian database of registered schools and in non-governmental websites of medical schools 9,10 .
A total of 315 medical schools were identified in the period from August to December 2018. Subsequently, 315 school curriculum matrices were analyzed on the sites, and only 44 institutions were found to have the Palliative Care discipline in their curriculum matrix. Seven of them were excluded because they had been operating for less than 6 years, and therefore still did not have a graduated class. Contact was made with the 37 remaining schools. Eight did not respond, two refused to participate in the study for several reasons and two were excluded because they reported not teaching the discipline of PC due to the absence of the teachers.
Of the 25 schools eligible for the study, interviews were carried out with students in 14 HEIs, as eleven of them had no student availability or there were difficulties on the part of the teacher in contacting them. The inclusion criteria adopted for the medical students were the following: attending the school in which the PC discipline was part of the curriculum matrix, having already had the subject and agreeing to participate in the study. To recruit the students applying to the interviews, the HEI that had the discipline in its curriculum matrix was identified. Then, telephone and/or e-mail contact was made with the HEI for the presentation of the research to the coordinator, identification of the teacher responsible for the discipline at the HEI and random

RESULTS
Thirty-five interviews were carried out with students, and the majority (25=71%) of the HEIs were located in the Southeast, the Brazilian region with the highest number of medical schools. Six interviews (17%) were carried out with students from HEIs located the South Region and four (12%) in the Northeast region. The predominant age group was 20 to 29 years old (89%) and only four respondents were 30 years old or older. Regarding the students' origin, 18 had graduated from public high schools and 17 from private ones. As for the type of discipline, 28 (80%) students took compulsory disciplines and seven (20%) took optional ones. Regarding religion, nine reported being Catholic (26%), seven (20%) were Protestant and 10 (29%) declared they were not linked to any religion (Table 1).
As for the characteristics of the curriculum and PC discipline according to the type of school, it was observed that the subject is a compulsory one in most of them, lasting a semester and with a workload of between 40 and 100 hours.
The difference related to the administrative nature of the school was the type of curriculum, which is predominantly modular in public schools and traditional in private schools ( Table 2). The interviewees reported changes in the representation and symbolic value of topics related to the process of dying and death, after exposure to PC teaching. Another information obtained from the students' narratives refers to the opportunities that students had to resignify their experiences with groups such as the elderly and children with complex chronic conditions. These were used to reveal that the PC approach can also be offered to patients in the pediatric and youth groups, according to the student's narrative below: After reading the interviews, the data were classified into three categories: students' conception of PC; perceived transformations after exposure to PC teaching, and challenges and coping strategies identified in PC teaching.
The interviewed group consisted mostly of young adults, where the regional characteristics, the interviewee's gender and religion and the administrative nature of the school did not represent outstanding differences in the students' statements regarding the study object and for this reason, the data were classified together.

Conception about palliative care
This category includes the student's perception on PC, its meaning and the teaching-learning process, as well as the importance given to the topic for their education.
Convergence was observed in the students' narratives, both in the HEIs in which the subject was compulsory and in those where it was optional. They express that this discipline should be offered to all students in the healthcare area, regardless of the specialty they will follow, since it is part of the clinical routine of the profession. In summary, the students' narratives showed that the conception of PC, previously restricted and indicated to the population in the end-of-life phase, after the teaching-learning experience was extended to other groups and with an early inclusion. This change in the perception of PC makes it possible for students to deal with difficult, necessary and inevitable topics in medical education, such as the process of dying and death.

Challenges and coping strategies in PC teaching
The interviewees' speeches reflected a common scenario in health practices, the difficulty in dealing with death and the end of life, which lead the professionals to deny and distance themselves from situations in which they are faced with this problem. On the other hand, issues related to PC were evidenced as being of great interest to the interviewees, perhaps precisely because of the lack of discussion on these topics during the medical course, and the explicit denial in the previous category.

Doubts about the limits of interventionist measures, about
what to offer in the face of little or no curative proposal, were repeated in the narratives. To deal with these demands, the strategy of talking and discussing topics involving dying and death was suggested. As the student points out: The appreciation of practical scenarios and the use of the health care network with a view to PC allow the development of the family approach, taking care of those who care. As reported by the student: "I thought it was just the patient, I forgot about the family, it is important to take care of those who take care." (male, 21 years old, South) Students report that, with successive experiences, they feel more comfortable talking with the patient, extracting the history, and thinking about possible actions aimed at the person. The students' narratives identified taboos and prejudices related to the topic of death and the dying process, the core competencies in PC, the necessary scenarios for learning, and the PC teaching model as the main challenges, and the students pointed out pathways and strategies that will allow the inclusion of PC teaching.

DISCUSSION
The students' perception of PC is in line with the expanded concept of the topic as an approach that improves the quality of life 12 . The international entities in PC reinforce characteristics such as active and comprehensive care through the prevention of suffering, which means early identification, not only offered at the end of life, and the management of pain and other physical, psychosocial and spiritual problems 13,14 . Therefore, the pediatric and youth population with complex chronic diseases, which are now reaching adolescence and adulthood, can benefit from the PC approach. The teaching of PC allows the expansion of resources in the management of suffering, in any medical specialty 15,16 .
The reflections pointed out by the students highlight that PC education should be offered to all students, which is corroborated by international entities, by recommending the training of professionals in undergraduate school, regardless of the future physician's area of specialization, since the approach of core competencies in PC is applied in different scenarios and levels of care 17,18 .
According to the students' narratives, the acquisition of  The still hegemonic teaching model is the biomedical one, prioritizing the disease-centered view, which was criticized by the interviewees, since attention should focus on the patient, and not on the disease. The PC teaching might be a driving force for the integrality model 33,34 .
The limitations of the present study are highlighted, as it was restricted to a portion of medical school students who have PC training. However, it brings contributions and subsidies to education and health policies by emphasizing the relevance and need for PC teaching beyond the learning of the subject, reinforcing the development of empathy and compassion, acknowledged as essential in this profession.

FINAL CONSIDERATIONS
The knowledge produced in this study indicates that the teaching-learning process regarding the process of dying and death allows medical students to be more assertive when dealing with people with severe illnesses. A formal PC education provides the acquisition of emotional skills to deal with human suffering. For that purpose, the importance of practical scenarios and the integration of learning in successive experiences, in a humanist axis, was highlighted. Therefore, PC teaching-learning contributes to the training of physicians who are more competent when dealing with people with incurable diseases, offering them more dignity at this stage of their lives.
The demographic and epidemiological changes, together with the incorporation of technology in health and aspects of health care bring needs to medical education. Death as a natural and inexorable event in the course of life must be a present topic, in a systematic and interdisciplinary way, during professional training. It is not just about including one more subject in the curriculum, but the construction of a longitudinal axis that works with the core principles of PC throughout the future physician's training.
Physicians face many uncertainties and expectations during care. Patients yearn for healing, but when that is impossible in a time of suffering, the PC approach offers a dignified and embracement approach. A physician-patient relationship must be based on the Hippocratic principles: "to cure sometimes, to relieve often, to comfort always". This is the heart of care.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.