End-of-life care in the Dutch medical curricula

More people are living to ever increasing ages which has resulted in a large part of healthcare being devoted to chronic age-related diseases. Additionally, numerous diseases that used to be fatal have been turned into more chronic diseases by improved treatments. Medical and technical possibilities at the end of life have also increased substantially. All these developments have led to an increasing number of people needing complex end-of life care (ELC). To complicate matters, people also increasingly believe in the manipulability of the human life course and wish to be actively involved in decision-making. For the work of medical doctors, good ELC, as part of palliative care [1], is more important than ever before. At the moment, however, ELC is not yet optimal. For example, on the ICU, a third of the doctors questioned thought the care for at least one patient at that moment was disproportional, of which most care was considered futile and potentially harmful [2]. Moreover, doctors often offer palliative care too late and end-of-life discussions are not carried out frequently enough and often too late [3‐5]. These factors influence the quality of life of terminal patients in a negative way [6, 7]. To improve the quality of life at the end of life doctors should be properly trained in ELC as a part of palliative care. Research has shown that students should be taught about ELC especially in the preclinical years of medical education, since these years are the most important for the development of basic skills, attitudes and knowledge for general medical practice. Besides, training in ELC does not conflict with other medical educational agendas since the acquired skills are useful to every healthcare specialization [8‐10].

Worldwide, many studies have been performed to assess the attention to ELC in medical curricula. After having assessed the status quo of ELC in medical education, medical schools in several countries adapted their curricula to implement themes related to ELC, such as palliative care, hospice care and terminal care. In the United States, the first study that assessed the quality and quantity of ELC education was conducted in students and residents in 2003, concluding that fourth year medical students did not feel well-prepared to provide ELC and suggesting curricular changes and improvements in the medical working and educational sphere for students to learn how to provide good ELC [11]. In 2004, the same authors interviewed the deans of 51 medical schools in the US about ELC education in the curricula of their schools and concluded that most deans were willing to improve ELC education [12]. In Europe, the status of palliative care medical education in the undergraduate curricula of 43 countries was evaluated in 2015. Although palliative medicine was taught in a vast majority of European countries, there were substantial differences in the level of development of education about palliative medicine [13]. Several individual countries such as Switzerland, the United Kingdom and Germany studied their medical curricula and recommended curricular changes such as the addition of internships in hospices and more education about palliative care [14‐17]. By contrast, little is known about the status of ELC in the Dutch medical curricula. In a report on appropriate care in the last phase of life, the Royal Dutch Association on the Advancement of Medicine (KNMG) stressed the importance of appropriate caregiving to terminally ill patients and of proper education about ELC [18]. However, no studies have been performed yet to determine to what extent ELC is taught in the Dutch medical curricula. Therefore, this study assesses ELC in the Dutch national blueprint (Raamplan Artsopleiding 2009) [19] and the Dutch medical curricula.

To investigate to what extent ELC is currently taught at Dutch medical schools, we used the following definition of end-of-life, as described by the KNMG: ‘the phase of very old age, or the phase of a condition that will be life-threatening in the near future.’ Care for those who are at the end of life includes concepts such as appropriate care, curative and palliative care and over- or under-treatment [18].

To study the themes regarding ELC systematically, we designed a checklist. This checklist combined the criteria for essential elements in ELC education established by two international expert groups, [8, 20] and consisted of five main domains and twenty-two subdomains of ELC education (see Tab. 1).

To assess the national blueprint and the medical curricula in the Netherlands, we took the same approach as a Dutch assessment of medical education on geriatrics: [21] we assessed the national level by studying the national blueprint and we assessed the faculty level by contacting the bachelor and master directors of medical curricula of the Dutch medical faculties.

Firstly, the national blueprint for higher medical education was studied using our checklist [19]. The national blueprint serves to secure that future doctors are trained in the basic competencies they need in their medical practice. This was done by two researchers (JdB en MV) independently. If they came to different assessments, their findings were discussed until agreement was reached.

Secondly, we assessed the curricula of the eight medical faculties by developing a questionnaire based on our checklist. The questionnaire studied the content and the didactic form of the current formal ELC education at the Dutch medical faculties. All eight medical schools in the Netherlands were approached: University of Groningen, University of Amsterdam, VU University Amsterdam, Leiden University, Erasmus University Rotterdam, Utrecht University, Maastricht University and Radboud University Nijmegen. To investigate the formal medical curricula, the coordinators of the bachelor and master programs of each medical faculty were invited to participate in the study. They could either submit the questionnaire by email or were interviewed (telephone interviews) using the questionnaire, which was done in almost all cases. In addition, the elective courses of each medical faculty were studied using online course catalogues or by contacting coordinators of the elective programs when course catalogues were not available online.

The study was carried out in accordance with the Declaration of Helsinki, including, but not limited to, there being no potential harm to participants, that the anonymity of participants was guaranteed, and that informed consent of participants was obtained. The study was approved by the institutional scientific review board.

The five domains of ELC that are considered essential are currently not taught to medical students of all faculties. This is an important observation when taking into account the growing attention to the patients’ quality of life at the end of life which demands proper training in ELC for all medical doctors.

Our study shows that ELC is sparsely described in the Dutch blueprint for medical education: it is not explicitly mentioned as a compulsory subject and not all domains that are considered essential knowledge and skills by the international standards are represented in the national blueprint. This has consequences for the planning and execution of the medical curricula at the faculty level. First of all, ELC was part of the formal curricula, but none of the faculties taught all the subjects that were considered a necessary basis for ELC practice. Moreover, ELC was not offered as an individual course in any of the Dutch bachelor and master medical curricula. Secondly, none of the medical faculties taught the five domains on ELC and met international criteria. To improve ELC education, we recommend addition of all the ELC domains that are internationally accepted to the national blueprint. Besides, we recommend medical faculties to offer a separate compulsory course on ELC to educate and prepare their future doctors properly, so that people in an ageing world can rely on young medical doctors who feel ready and well-informed when providing appropriate ELC.