Skip to main content
SpringerLink
Log in

Using a Pocket Card to Improve End-of-life Care on Internal Medicine Clinical Teaching Units: A Cluster-randomized Controlled Trial

  • Original Article
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Background

End-of-life care is suboptimally taught in undergraduate and postgraduate education in Canada. Previous interventions to improve residents’ knowledge and comfort have involved lengthy comprehensive educational modules or dedicated palliative care rotations.

Objective

To determine the effectiveness of a cheap, portable, and easily implemented pocket reference for improving residents’ knowledge and comfort level in dealing with pain and symptom management on the medical ward.

Design

Cluster-randomized controlled trial conducted from August 2005 to June 2006.

Setting

Medical clinical teaching units (CTUs) in 3 academic hospitals in Toronto, Canada.

Participants

All residents rotating through the medical CTUs who consented to participate in the study.

Intervention

Residents at 1 hospital received a pocket reference including information about pain and symptom control, as well as 1–2 didactic end-of-life teaching sessions per month normally given as part of the rotation. Residents at the other 2 hospitals received only the didactic sessions.

Main Outcome Measures

A 10-question survey assessing knowledge and comfort level providing end-of-life care to medical inpatients, as well as focus group interviews.

Results

One hundred thirty-six residents participated on 3 CTUs for a participation rate of approximately 75%. Comfort levels improved in both control (p < .01) and intervention groups (p < .01), but the increase in comfort level was significantly higher in the intervention group (z = 2.57, p < .01). Knowledge was not significantly improved in the control group (p = .06), but was significantly improved in the intervention group (p = .01). Greater than 90% of residents in the intervention group used the card at least once per week, and feedback from the focus groups was very positive.

Conclusions

Our pocket card is a feasible, economical, and educational intervention that improves resident comfort level and knowledge in delivering end-of-life care on CTUs.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1

Similar content being viewed by others

References

  1. Lloyd-Williams M, MacLeod R. A systematic review of teaching and learning in palliative care within the medical undergraduate curriculum. Med Teach. 2004;26:683–90.

    Article  PubMed  Google Scholar 

  2. Oneschuk D, Moloughney B, Jones-McLean E, Challis A. The status of undergraduate palliative medicine education in Canada: a 2001 survey. J Palliat Care. 2004;20:32–7.

    PubMed  Google Scholar 

  3. Field D, Howells K. Dealing with dying patients: difficulties and strategies in final year medical students. Death Stud. 1988;12:9–20.

    Article  Google Scholar 

  4. Tiernan E, Kearney M, Lynch AM, et al. Effectiveness of a teaching programme in pain and symptom management for junior house officers. Support Care Cancer. 2001;9:606–10.

    Article  PubMed  CAS  Google Scholar 

  5. Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: a national report. J Gen Intern Med. 2003;18:685–95.

    Article  PubMed  Google Scholar 

  6. The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT). JAMA. 1995;274:1591–8.

    Article  Google Scholar 

  7. Field MJ, Cassel CK (eds), Approaching Death: Improving Care at the End of Life. Report from the Institute of Medicine Committee on Care at the End of Life. Washington, DC: National Academy Press; 1997.

  8. Wear D. “Face to face with it”: medical students’ narratives about their end-of-life education. Acad Med. 2002;77:271–7.

    Article  PubMed  Google Scholar 

  9. Maxwell TL, Passow ES, Plumb J, Sifri RD. Experience with hospice: reflections from third-year medical students. J Palliat Med. 2002;5:721–7.

    Article  PubMed  Google Scholar 

  10. Von Gunten CF, Twaddle M, Preodor M, et al. Evidence of improved knowledge and skills after an elective rotation in a hospice and palliative care program for internal medicine residents. Am J Hosp Palliat Care. 2005;22:195–203.

    Article  Google Scholar 

  11. Yacht AC, Suglia SF, Orlander JD. Evaluating an end-of-life curriculum in a medical residency program. Am J Hosp Palliat Care. 2006;23:439–46.

    Article  PubMed  Google Scholar 

  12. Stanton RN. Ambulatory hospice training in family medicine residency. J Palliat Med. 2003;6:782–5.

    Article  PubMed  Google Scholar 

  13. Okon T, Evans JM, Gomez CF, Blackhall LJ. Palliative educational outcome with implementation of PEACE tool integrated clinical pathway. J Palliat Med. 2004;7:279–95.

    Article  PubMed  Google Scholar 

  14. Critchley PP, Grantham M, Plach N, et al. An evaluation of the use of and satisfaction with the palliative care pain and symptom pocket card. J Palliat Care. 2002;18:307–11.

    PubMed  Google Scholar 

  15. Librach SL. The Pain Manual: Principles and Issues in Cancer Pain Management. Montreal, Quebec: Pegasus Healthcare International; 2002.

    Google Scholar 

  16. Ian Anderson Continuing Education Program in End-of-life Care modules in Pain Management and Symptom Management. http://www.cme.utoronto.ca/endoflife/Modules.htm. Accessed on 12 July 2007.

  17. Canadian Pharmacists Association. Compendium of Pharmaceuticals and Specialties, 39 edn. Ottawa, Canada: Canadian Pharmacists Association; 2004.

    Google Scholar 

  18. Liao S, Amin A, Rucker L. An innovative, longitudinal program to teach residents about end-of-life care. Acad Med. 2004;79:752–7.

    Article  PubMed  Google Scholar 

  19. Nelson JE, Angus DC, Weissfeld LA, et al. End-of-life care for the critically ill: a national intensive care unit survey. Crit Care Med. 2006;34:2547–53.

    Article  PubMed  Google Scholar 

  20. Schulman-Green D. How do physicians learn to provide palliative care? J Palliat Care. 2003;19:246–52.

    PubMed  Google Scholar 

  21. Clark JM, Lurie JD, Claessens MT, et al. Factors associated with palliative care knowledge among internal medicine housestaff. J Palliat Care. 2003;19:253–7.

    PubMed  Google Scholar 

  22. Fischer SM, Gozansky WS, Kutner JS, et al. Palliative care education: an intervention to improve medical residents’ knowledge and attitudes. J Palliat Med. 2003;6:391–9.

    Article  PubMed  Google Scholar 

  23. Lester D. The Collett–Lester Fear of Death Scale: the original version and a revision. Death Stud. 1990;14:451–68.

    Article  Google Scholar 

  24. Templer DI. The construction and validation of a death anxiety scale. J Gen Psychol. 1970;82:165–77.

    PubMed  CAS  Google Scholar 

  25. Rosenthal R, Jacobson L. Pygmalion in the classroom. Expanded edition. New York: Irvington; 1992.

    Google Scholar 

Download references

Acknowledgements

This research was funded by grants provided by Associated Medical Services, Inc. and the University of Toronto Faculty of Medicine Dean’s Excellence Fund in Medical Education. Neither had a role in the design and conduct of the study; the collection, management analysis, or interpretation of the data; or the preparation, review, or approval of the manuscript.

JM contributed to the conception and design, analysis and interpretation of the data, drafting and critical revision of the manuscript, obtaining funding, and general supervision of the study. JM had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. JD contributed to the conception and design, acquisition of data, analysis and interpretation of the data, drafting and critical revision of the manuscript, obtaining funding, providing administrative support, and general supervision of the study. LB contributed to the acquisition, analysis and interpretation of data, the drafting of the manuscript, and the statistical analysis.

Conflict of Interest

None disclosed.

Author information

Authors and Affiliations

  1. Division of Hematology-Oncology, Mayo Clinic, Arizona, USA

    Joseph Mikhael MD, MEd, FRCPC

  2. Mayo College of Medicine, Scottsdale, USA

    Joseph Mikhael MD, MEd, FRCPC

  3. University Health Network, Toronto, Canada

    Lindsay Baker MSc

  4. Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada

    James Downar MD, FRCPC

  5. Interdepartmental Division of Palliative Care, University of Toronto, Toronto, Canada

    James Downar MD, FRCPC

Authors
  1. Joseph Mikhael MD, MEd, FRCPC
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lindsay Baker MSc
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. James Downar MD, FRCPC
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Joseph Mikhael MD, MEd, FRCPC.

Appendix A

Questionnaire: Pre and Post Intervention Survey (All Sites)

Year of Training CC3 CC4 PGY1 PGY2 PGY3

Program Medicine Surgery Family Other:

Date (months of rotation):

Were you given a copy of the Study Pocket Card? YES NO

Have you ever used the Pocket Card? YES NO

If yes, how many times per week did you use the card? __________

In treating acute pain, the approximate equivalence dose between oral and parenteral (IV) morphine is:

  1. a.

    1:1

  2. b.

    2:1

  3. c.

    4:1

  4. d.

    5:1

  5. e.

    7:1

Which of the following is an appropriate adjuvant medication for treating neuropathic pain?

  1. a.

    Pamidronate (Aredia)

  2. b.

    Carbamazepine (Tegretol)

  3. c.

    Hydromorphone (Dilaudid)

  4. d.

    Haloperidol (Haldol)

All of the following are appropriate first-line drugs for opioid-induced nausea except:

  1. a.

    Metoclopramide (Maxeran)

  2. b.

    Prochlorperazine (Stemetil)

  3. c.

    Ondansetron (Zofran)

  4. d.

    Haloperidol (Haldol)

The composition of a “Tylenol #2” is:

  1. a.

    Acetaminophen 300 mg + Codeine 10 mg + Caffeine 15 mg

  2. b.

    Acetaminophen 300 mg + Codeine 15 mg + Caffeine 15 mg

  3. c.

    Acetaminophen 300 mg + Codeine 20 mg + Caffeine 15 mg

  4. d.

    Acetaminophen 300 mg + Codeine 30 mg + Caffeine 15 mg

When treating pain, breakthrough (PRN) doses of oral opiates should be given with what frequency?

  1. a.

    1 hour

  2. b.

    2 hours

  3. c.

    4 hours

  4. d.

    8 hours

Electronic supplementary material

Below is the link to the electronic supplementary material.

Online Appendix (DOC 78.0 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Mikhael, J., Baker, L. & Downar, J. Using a Pocket Card to Improve End-of-life Care on Internal Medicine Clinical Teaching Units: A Cluster-randomized Controlled Trial. J GEN INTERN MED 23, 1222–1227 (2008). https://doi.org/10.1007/s11606-008-0582-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-008-0582-4

KEY WORDS

Search

Navigation