Perception of Palliative Care among Medical Students in a Teaching Hospital

Introduction: Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness. Palliative care must be a part of every medical personnel’s practice. But still medical education curriculums have not included palliative care in its syllabus, sufficiently due to which most of the health professional are not aware about this specialty. The purpose of this study is to find out the perception of the medical students in palliative care in a teaching hospital.


INTRODUCTION
Palliative care (PC) is a specialized medical care for patients with serious and life threatening illness.It focuses on providing patients with relief from symptoms and stress of a serious illness.The goal is to improve quality of life for both the patients and the family. 1 Although the concept of palliative care is not new, most physicians have tend to focus on trying to cure patients.Treatments for the alleviation of symptoms were viewed as hazardous and seen as inviting addiction and other unwanted side effects. 2 PC has been included in undergraduate medical curriculum in different countries worldwide.WHO advocate for PC to be compulsory in courses leading to a basic professional qualification.PC had not been included in the medical curriculum in Nepal until PatanvAcadamy of Health Science (PAHS) included in the year 2008.Institute of Medicine (IOM), the pioneering medical school in the country, has just started only a sensitization class since 2007.
The purpose of this study is to find out the perception
The number was very low among the students at the beginning of their medical education stating only seven (12.5%) of students in first year were aware that PC exists.The number of the students who were aware of PC increases significantly with the level of education by up to 50 (94.33%) in final year (Table 1).Among them, 33 (67%) had understanding of PC approach as interdisciplinary (Table 2).Total 142 (93.4%) students said that PC is to relieve the suffering and improve the life of patients of life threatening illness (Table 3).Only 130 (85.5%) students knew PC provides psychological and spiritual support (Table 4) and 68 (44.73%) students were aware that it provides bereavement support.Total 84 (55%) students felt it can be provided early in the cases of life threatening illness, irrespective of prognosis (Table 5).
Total 72 (47.3%) students are familiar with the method to assess the pain in patients with terminal illness and chronic pain syndrome.Only 85 (31.48%) students thought providing PC to the patients with end stage renal disease is appropriate (Table 6).PC doesn't hasten or postpone death was felt by 72 (47.36%) students (Table 7).And 36 (23.68%) students had some experience of PC given to somebody they know.Total 59 (21.85%) students did not know palliative medicine is not included in the curriculum.As a whole, 227 (84 %) students were interested in learning about PC and felt it should be an integral part of their curriculum.

DISCUSSION
The knowledge and perception of PC was found to be inadequate in medical students in our study.The number was strikingly low and among the students at the beginning of their medical education with only 12.5% of students in first year are aware that PC exists.The number of the students who are aware of PC increases significantly with the level of education reaching 94.33% in final year.
One surprising finding of the study is that knowledge and perception among fourth year students are higher than that of final year.This may be due to PC sensitization class they receive at the end of third year.And lack of clinical practice may have beclouded the knowledge of final year students.
55 % of 152 students who have heard the word "PC" before, felt it can be provided early in the cases of life threatening illness, irrespective of prognosis.Only a few students knows about palliative care and hospice care not being same and palliative care can also be given in early stage of care.Significant number of students feels that palliative care intends to hasten or postpone death.And few have idea about bereavement support included under it.However, majority of students were willing to learn more about palliative care.[9] Similar to our study, a study in Manipal University in India showed that the basic knowledge of palliative care among undergraduate students was inadequate, and students are unprepared and uncertain in their approach of delivering end-of-life care. 10The effect of a curriculum without compulsory courses in palliative medicine on students' knowledge, kills and attitudes towards the care of dying patients and decisions at the end of life was poor overall. 11e demand for palliative care services across globe is expected to increase over time due to the continued growth and ageing of the population.The incidence of cancer and other chronic illness are increasing, and most of the burden is shifting to low and middle income countries where patients are often present with latestage disease and severe pain. 12Awareness regarding proper pain management and PC seems to be poor among the physicians in Nepal.Some non-government organizations such as Hospice Nepal have made several attempts to educate health care professionals in this regard.However, the number is small and majority of the health care professionals still have little knowledge about the PC.In addition, the significant fraction of health care professionals is not receptive to the approach of palliative care and focus on cure rather than alleviation of the symptoms.University of California states that third year medical students' experiences with dying patients affect their skills and attitutude in end of life care, as well as the emergence of their professional identities. 13][19] Hence, each medical school in Nepal should develop an integrated curriculum on PC to provide adequate exposure to palliative care and hospice care early in their education.
Medical students tend to welcome teaching learning on PC.It positively influences student attitudes towards the patients with chronic illness, and enhances communication skills.Majority of the students in our study were willing to learn PC and end of life care given any opportunity.
A study in University of Navarra, reported the course for all undergraduate students as a core component of curricula.Students specially found out that what they learned in the course is applicable to all patients and prepares them to work better as a doctor. 20From 2013, Palliative care has become the mandatory examination subject in medical curriculum in Germany. 3But in Nepal almost all medical colleges except PAHS don't have curriculum of PC.A study in University of North Carolina, nurses who have cared for patients with cancer are more knowledgeable and have more liberal attitude towards pain management from nurses who have not cared for patients with cancer. 21Most developed countries, therefore, have included PC as an integral part of the medical education. 22dical textbook fall short of providing relevant information for clinical management of terminal illness.Also, teaching here is more focused on acquisition of knowledge and skills rather than attitude, which is also an important part in clinical practice.Integration of Palliative Care in curriculum will renew and replenish the motivation of future doctors to carry out their duties, giving them a new professional and personal perspective of growth.

Pandey et al. Perception of Palliative Care among Medical Students in a Teaching Hospital
The limitations of our study include small sample size, single center, and descriptive nature of the study.A larger study with inclusion of several medical colleges will be able to provide more clear-cut information in this regard.However, we hope this study will be a step towards integration of PC in the medical education in every medical college in the country, which will help to produce physicians focusing on not only curing people but also healing them.

CONCLUSIONS
Our study demonstrates inadequate knowledge and perception of PC among medical students.Integration of Palliative care in medical education is highly critical to provide adequate exposure to palliative care and make the future doctor competent enough to treat the patients not just the diseases.
Perception of Palliative Care among Medical Students in a Teaching Hospital

Table 1 . Showing the perception of palliative care in medical student.
Pandey et al.Perception of Palliative Care among Medical Students in a Teaching Hospital