PEDIATRICS Vol. 105 No. 3 March 2000, pp. 575-584
Medical Education About End-of-Life Care in the Pediatric Setting: Principles, Challenges, and Opportunities
Received July 30, 1998; accepted Sep 3, 1999.
,
, and
From the * Departments of Pediatrics, Psychiatry, Medical
Humanities, and Oncology, University of Rochester Medical Center,
Rochester, New York; the Department of Pediatrics, IWK Grace Health
Centre and Dalhousie University, Halifax, Nova Scotia; the
§ Departments of Pediatrics, Internal Medicine, and Family Medicine,
University of Texas Medical Branch at Galveston, Galveston, Texas; the
Center to Improve Care of the Dying and the Department of Health
Care Sciences, George Washington University Medical Center, Washington,
District of Columbia; ¶ Departments of Psychiatry and Pediatrics,
Columbia College of Physicians and Surgeons, New York, New York.
Objective. To identify the opportunities for and barriers to medical education about end-of-life (EOL) care in the pediatric setting.
Methods. A working group of pediatric specialists and ethicists was convened at the National Consensus Conference on Medical Education for Care Near the End-of-Life sponsored by the Open Society Institute's Project Death in America and the Robert Wood Johnson Foundation. The charge to the working group was to consider the unique aspects of death in childhood, identify critical educational issues and effective instructional strategies, and recommend institutional changes needed to facilitate teaching about EOL care for children.
Conclusions. Although providing EOL care can be challenging, the cognitive and psychologic skills needed can be taught effectively through well-planned and focused learning experiences. The ultimate goals of such instruction are to provide more humane care to very sick children, enhance bereavement outcomes for their survivors, and develop more confident clinicians. Six specific principles regarding EOL care in the pediatric setting emerged as essential curricular elements that should be taught to all medical care providers to ensure competent patient-centered care. 1) Cognitively and developmentally appropriate communication is most effective. 2) Sharing information with patients helps avoid feelings of isolation and abandonment. 3) The needs of the patient are served when the ethical principles of self-determination and best interests are central to the decision-making process. 4) Minimization of physical and emotional pain and other symptoms requires prompt recognition, careful assessment, and comprehensive treatment. 5) Developing partnerships with families supports them in their caregiving efforts. 6) The personal and professional challenges faced by providers of EOL care deserve to be addressed. These principles actually transcend patient age and can be used to inform medical education about the care of any terminally ill patient. Similarly, these principles of effective communication, ethical decision-making, and attention to the quality of life of patients, families, and providers apply to the care of all children regardless of diagnosis and prognosis. With this in mind, teaching about EOL care does not require a new and separate curriculum, but rather taking better advantage of the many teachable moments provided by caring for a dying patient. Key words: end-of-life care, death and dying, terminal illness, chronic illness.
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