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1st appeared
10
February
2000
Medical Texts Fail in Addressing Care for the Dying Medical textbooks often offer little information on end-of-life care, according to a UCSF study. Michael W. Rabow, MD, assistant clinical professor in the division of general internal medicine and colleagues at UCSF reviewed 50 leading medical textbooks, analyzing the content and quality of end-of-life care information presented. The study, published in the February 9 issue of the Journal of the American Medical Association, found that of the 50 textbooks reviewed, about a quarter had helpful information on likely end-of-life subject areas, but 19 percent gave the subject minimal attention, and 57 percent none at all. The textbooks that most lacked end-of-life content were in surgery, infectious diseases, AIDS, and oncology. Textbooks with the highest percentage of helpful end-of-life care content were in family medicine, geriatrics and psychiatry. Content domains covered least well were social, spiritual, ethical, and family issues, as well as physician after-death responsibilities, according to the study. "Unfortunately, specialty textbooks that physicians might read for information about a particular disease did not contain helpful information about caring for patients dying from that disease," wrote the UCSF researchers. "In several important instances, general rather than specialty textbooks had better end-of-life coverage for a particular disease. Finally, our analysis also confirmed major deficiencies in the indexing of end-of-life topics." The 13 end-of-life domains included epidemiology, natural history, pain management, nonpain symptom management, psychological issues, social and demographic issues, spiritual issues, family issues, definition of end-of-life care, ethics, law and policies, physician after-death responsibilities, physician roles, and context of care. According to the UCSF authors, many patients in the United States currently receive suboptimal care at the end of life. Inadequate physician training likely contributes to both deficient care for dying patients and increased anxiety for caring physicians. Medical education typically provides little training in care of the dying. Most medical schools, residencies, and fellowships offer almost no formal training in palliative care, the information taught is not well integrated into the curricula, and the few courses available are generally elective. National medical licensing examinations have relatively few questions assessing students' end-of-life care competence. In general, students and physicians report feeling ill-prepared to provide end-of-life care. "Given the failing grade for medical textbooks, efforts should be undertaken to improve them," the authors write. "Change has already begun. Partly in response to textbook reviews, publishers have already commissioned updates of end-of-life care content in a major textbook in each of the disciplines of nursing, pediatrics, and psychiatry and in two medical textbooks, including the creation of new chapters devoted to end-of-life care. Increasingly, our national professional accreditation and licensing bodies (including the Joint Commission on Accreditation of Healthcare Organizations, the National Board of Medical Examiners, and the US Medical Licensing Examination are requiring a higher standard of physician competence in end-of-life care. This may prove to be a powerful motivation for improvement in best-selling textbooks." Co-authors of the study were Stephen J. McPhee, MD, professor of medicine; Grace E. Hardie, PhD, RN, clinical nurse; and Joan M. Fair, PhD, RN, assistant clinical professor of physiological nursing. This research was supported by a grant from the Robert Wood Johnson Foundation. Links:
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