The approach of internal medicine healthcare personnel to palliative care

Introduction

End-of-life (EOL) care aims to optimize the patient’s well-being through shared decision-making and a symptom-based approach to the patient’s EOL (1). To achieve that a more balanced approach to the physical, spiritual, and psychosocial aspects of patient care is needed (2). Even though palliative care is traditionally associated with oncology patients, the definition of palliative care and the spectrum of diseases within it has broadened significantly. It includes evidence-based care for patients with end-stage heart failure or end-stage lung disease, end-stage renal disease, and many others (2).

There is no doubt that health workers experience a strong sense of purpose and meaning in their work (3), however, they may feel emotionally drained, especially when treating terminal patients at challenging times such as the coronavirus pandemic. That is why the multidisciplinary staff might face some stressors (4) including burnout (2); stress and compassion fatigue (5,6). Additionally, lower-level familiarity with the palliative care niche and the inability to understand its essence might also contribute to burnout (7-10) which in turn can lead to a poorer patient quality of life (11,12).

This is why those challenges are widely acknowledged among healthcare personnel (13) and for that reason, many healthcare facilities initiate intervention plans that aim to support the healthcare teams. EOL programs positively impact nurses’ and medical doctors’ attitudes toward EOL care, directly improving the patient and his family’s well-being (14,15). Other healthcare disciplines that play an important role in the care of terminally ill patients but don’t get enough emotional support are dietitians, physiotherapists, social workers, and spiritual practitioners. The dietitians set up the palliative nutrition, guide the patient and the family, and provide his dietetic needs. The physiotherapists assess the patient’s physical status and provide him and his family with guidance, physical and emotional support accordingly. The social workers coordinate between the patients and health care facilities and assist them in overcoming psychological barriers and stressors. Finally, the spiritual practitioner facilitates the patient and his family emotionally by accompanying them through the last stages of life (16).

While most studies have focused on specialized palliative teams, the effect of palliative care on internal medicine workers needs to be better investigated with special care. Many terminally ill patients are admitted to general or internal medicine wards or die while admitted to an acute care ward. In most middle- and high-income countries internal medicine wards provide a relatively large proportion of palliative care for patients who cannot or do not want to be treated in outpatient settings. Despite this, the care provided in acute wards is lacking when compared to specialized palliative care units (17).

This study delves deeper into the multifaceted attitudes of internal medicine teams in the field of palliative care. More specifically, we aimed to explore the attitude of internal medicine staff and analyze personal and demographic factors that are associated with this approach. Furthermore, we assumed that revealing the emotional state and the attitudes of the healthcare personnel in internal medicine could help us shape a future intervention plan that hopefully might help us to provide the terminal patients in the internal departments with better care (18). Apart from this, we aimed to investigate specific features that haven’t been checked before in the Israeli hospitals. This includes attitudes regarding the law of the terminal patient, attitudes regarding the organizational support, attitudes regarding intrinsic factors that might affect the healthcare staff during the palliative treatment and to test the healthcare knowledge.

Methods

The study was conducted in six internal medicine departments at Rambam Healthcare Campus (RHCC), Haifa, Israel. RHCC is a 1,100-bed tertiary-level care center situated in northern Israel. A questionnaire assessing the attitudes of staff of internal medicine wards towards palliative care was distributed among a multidisciplinary team. Healthcare workers, including nurses, medical doctors, physiotherapists, social workers, and dieticians who regularly treat terminally ill patients, were asked to participate in the study.

The questionnaire used in this study was novel and developed due to the lack of questionnaires consisting of items addressing the specific attitudes of healthcare workers in internal medicine wards toward palliative care. The items were chosen based on their relevance to the clinical practice in the internal departments. While we did not assess the tool’s reliability or validity due to its exploratory nature, this is acknowledged as a limitation. Future research will focus on validating the questionnaire, including internal consistency (e.g., Cronbach’s alpha), content validity through expert review, and pilot testing with a larger sample.

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the ethics board of Rambam Healthcare Institution (No. 0469-22-RMB) and informed consent was waived by the ethical institution. The EOL (Appendix 1) and the and demographic questionnaires (see Appendix 2) were sent to the participants. The EOL questionnaire is a concise 20-item questionnaire on different aspects of palliative care. These aspects included the challenges of caring for terminal patients, the value of palliative care, the self-assessed level of knowledge and education about palliative care, the importance of emotional expression, the need for emotional support, and the effectiveness of support from the medical establishment or close relatives. For all answers, we used a Likert score of 0 to 10 when 0 designates not agreeing at all and 10 strongly agreeing. Furthermore, this questionnaire aimed to evaluate the participants’ self-perceived knowledge of palliative care.

Participants were also given a demographic questionnaire to examine their age, gender, profession, years of professional experience, ethnicity, and level of religiosity. The different ethnic groups residing in northern Israel included Jews, Muslims, Christians, Druze, and “unwilling to answer”. The level of religiosity was defined as religious, traditional, secular, and unwilling to answer (see Table 1). Furthermore, we did not include employees who did not actively participate in the palliative care of hospitalized patients. In addition, the demographic questionnaire also examined the caregivers’ profession, age, years of service, gender, nationality, and degree of religiosity.

Statistical analysis

The data obtained from the questionnaires were assessed using SPSS software; one-way analysis of variance (ANOVA) was used to detect differences in the perceptions of various aspects of EOL care among nurses, medical doctors, and other healthcare professionals. A chi-squared test was performed to evaluate the categorical variables and their impact on the caregivers’ responses. Data collection was performed by an independent research assistant, who administered the questionnaires via Google Forms sent to all the participants.

Results

Overall, 106 healthcare workers were included in the study. The average age was 40±13.5 years, 59 participants (55.7%) were females, and 46 (43.4%) were males; one participant did not disclose her/his sex. The study sample included 60.4% nurses, 32.1% Doctors of Medicine (MD), and 6.6% other healthcare professionals. Participants came from heterogeneous demographic, social, ethnic, religious, and professional backgrounds. Most participants defined themselves as Jewish (42.5%), Muslim (34.9%), or Christian (17%); half of all participants described themselves as secular, and the rest as either religious (15.1%) or traditional (33%). Additional demographic characteristics are detailed in Table 1.

Participants graded their knowledge and training in palliative care as only moderately adequate [6.0 on a scale of 1 to 10, 95% confidence interval (CI): 5.5–6.5, and 5.6/10, 95% CI: 5.1–6.2, respectively], and reported that time allocated to palliative care was insufficient (4.2, 95% CI: 3.7–4.8). In addition, participants stated that the Organizational support for staff administrating palliative care was moderate (6.0/10, 95% CI: 5.4–6.5). Moreover, most participants felt that they had sufficient knowledge of the legal aspects of palliative care (8.0/10, 95% CI: 7.5–8.5).

Although general emotional support was judged to be quite important (8.1/10, 95% CI: 7.6–8.6), the participant’s levels of the need for emotional support were rated much lower (6.1/10, 95% CI: 5.5–6.7). Moreover, participants stated that practicing palliative care is not difficult with a relatively low mean score of 3.6/10 (95% CI: 2.6–4.2). Additionally, the Healthcare workers reported receiving relatively more emotional support from family and friends (6.5/10, 95% CI: 5.9–7.2) than from the organization (4.8/10, 95% CI: 4.2–5.4). Contrary to this, the participants expressed disagreement with the statement that the group therapy sessions would upgrade the way in which they provided palliative care (5.9, 95% CI: 5.4–6.6, indicating only moderate agreement). Virtually all participants strongly disagreed with the notion that palliative care should be reserved only for patients with shorter life expectancy (1.4/10, 95% CI: 1.0–1.8) and moderately supported the statement that unnecessary treatment is administered to the terminal patients (5.6/10, 95% CI: 4.9–6.3).

Differences between nurses, medical doctors, and other health professionals in their attitude toward palliative care

Our ANOVA analyses have revealed differences in the perceptions of various aspects of EOL care. We discovered three key areas with statistically significant variations. Firstly, the perception of when palliative care should be administered. In fact, the healthcare workers strongly disagreed with the notion that palliative care should be limited only to the terminal patients. Generally, the mean score of the participants was 2.89/10. Specifically, the mean score of the medical doctors was 2.53/10 and the mean score of the nursing staff was 3.41 (F=3.704, P=0.03).

Secondly, although participants agreed with the notion that there was adequate time available for the performance of palliative conversations during daily work, nurses’ and medical doctors’ attitude means were relatively low (mean scores of 7.43, 4.80, and 4.18, respectively, F=4.286, P=0.02). Thirdly, we found out that the participants’ attitudes regarding the belief that palliative conversations should be provided only by trained medical teams differed significantly. While the participants were strongly favored of such a notion, this approach was less salient among nurses and medical doctors (mean scores of 6.90, 5.74, and 4.76, respectively with F=3.238, P=0.04).

Though all participants strongly disagreed with the notion that palliative care should be administered only to dying patients, allied healthcare professionals were significantly more inclined to reject this view (mean scores of 1.5, 1.5, and 0 for nurses, medical doctors, and other healthcare personnel, respectively; P=0.03). Also, there were no statistically significant differences between the three groups of healthcare workers in the difficulty felt during palliative care, perceived adequacy of knowledge and training, perceived importance and personal need of emotional support, familiarity with legal aspects of palliative care, amount of unnecessary medical care administered to patients, and level of emotional support received from the organization and family and friends.

Self-perceived adequacy of knowledge about palliative care

A significant association between marital status and perceived adequacy of knowledge in handling EOL situations was observed (P=0.02). Married participants generally reported higher levels of perceived knowledge (6.1±2.89), when compared to single or divorced participants (5.8±2.0, P=0.05 for the comparison). Not surprisingly, healthcare personnel with more work experience had higher scores of self-perceived adequacies of knowledge (P=0.005).

Perceived importance of emotional support

We revealed a statistically significant association between academic degrees and the perceived importance of emotional support provided for the caregiver (χ²=83.236, df=50, P=0.020). Individuals with Bachelor of Arts (BA), reported the highest need for emotional support followed by those with a Master of Arts (MA) and MD. Participants without children also reported a greater need for such support (χ²=86.893, df=60, P=0.01). There was no linear association between the number of children and the need for emotional support among healthcare workers with children. Moreover, we found a statistically significant association between respondents’ marital status and their perceived importance of receiving emotional support from the workplace during the treatment of EOL patients. Married healthcare workers viewed emotional support as more important when compared to non-married participants (χ²=45.102, df=30, P=0.04).

Perceived need for organizational support

Significant associations were found between the number of years of practice and the perceived need for organizational support. Not surprisingly, healthcare workers with fewer years of work experience felt they needed more organizational support (χ²=377.293, df=310, P=0.005).

Self-perceived familiarity with legal issues concerning EOL treatment

Males reported slightly higher levels of self-perceived knowledge of legal issues that relate to palliative care (with mean scores of 8.4/10 and 7.6/10, respectively. P=0.049).

Several factors were not associated with any significant difference in attitude towards palliative care such as age, religious affiliation (Muslim, Christian, Jewish, or Druze), or degree of religiosity (religious, traditional, or secular).

Discussion

This study underscores the importance of considering individual differences in healthcare approaches to EOL care. We found out that factors such as age, gender, ethnicity, academic background, years of practice, religious affiliation, marital status, and work seniority all influence perceptions about palliative care. Recognizing these findings is crucial for developing targeted interventions and supporting the healthcare staff in need.

We found a strong correlation between work seniority and a sense of preparedness, emphasizing the effect of experience on both knowledge and support needs. With increased seniority, healthcare professionals accumulate knowledge through hands-on experience and professional development opportunities. Despite this, nurses with less work seniority might feel less capable while treating EOL patients compared to the more experienced ones. Such findings were demonstrated in a study by Reid et al. (19). Moreover, not only the nurses but also the medical doctors claimed to receive enough organizational support while treating terminal patients. Therefore, those factors should be considered cautiously before initiating any intervention plans and should be relatively strict to the specific clinical settings and organizational features. However, the new healthcare staff might need more tailored organizational support, intensive training, and emotional support. That is why a more robust support system that include mentorship programs and individual counseling could potentially help workers navigate the numerous clinical and emotional complexities of EOL care (19).

Although cultural and religious aspects are important factors that impact palliative care, not only from the patient’s perspective but also from the staff’s point of view (20), neither ethnic affiliations (i.e., Muslim versus Christian versus Jewish versus Druze) nor the degree of religiosity (religious versus secular) were related to caregivers’ attitudes towards palliative care. The heterogeneity of the healthcare staff and the effects of professional socialization in the medical facility affect the individual perceptions and attitudes toward palliative care (21).

This study has several limitations. Since it is a single-center study, generalizability is uncertain, and results may be different in other institutions or other countries. Some factors, such as ethnicity or organizational work structure, may be specific to northern Israel, and not applicable elsewhere. However, the fact that academic degrees and work experience do have a clear impact on healthcare workers’ approach to palliative care is noteworthy. Due to the sample size, it is very well possible that the study may not have been powered to detect more subtle associations between demographic and professional parameters and aspects of palliative care.

Conclusions

The findings highlight the need for targeted training, enhanced organizational support, and mentorship programs to address gaps in palliative care delivery within internal medicine departments. Addressing these needs can improve healthcare workers’ preparedness and ultimately raise the quality of care for terminally ill patients. Further research should explore in more detail cultural and specific institutional nuances. We have shown that gender, previous first hand experience, marital status, and level of education all impact healthcare workers self-assessed emotional and educational needs. The actual impact of these crucial factors on specific palliative care programs will have to be assessed more closely.

Acknowledgments

None.

Footnote

Data Sharing Statement: Available at https://apm.amegroups.com/article/view/10.21037/apm-24-152/dss

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-24-152/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-24-152/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the ethics board of Rambam Healthcare Institution (No. 0469-22-RMB) and informed consent was waived by the ethical institution.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Farrer O, Tieman J. What Evidence Exists to Support Palliative Allied Health Practice in Aged Care: A Scoping Review. Healthcare (Basel) 2024;12:1973. [Crossref] [PubMed]
2. Silberman M, Berger A. Global perspectives in cancer care: Religion, spirituality, and cultural diversity in health and healing. Oxford University Press; 2022.
3. Ablett JR, Jones RS. Resilience and well-being in palliative care staff: a qualitative study of hospice nurses' experience of work. Psychooncology 2007;16:733-40. [Crossref] [PubMed]
4. Campos I, Arnal A, Galiana L, Sánchez-Ruiz J, et al. Cross-Sectional Study of the Professional Quality of Life of Palliative Care Professionals during the COVID-19 Pandemic. Healthcare (Basel) 2023;12:4. [Crossref] [PubMed]
5. Alston W. Internalism and externalism in epistemology. Philos Top 1986;14:179-221.
6. Gustafsson T, Hemberg J. Compassion fatigue as bruises in the soul: A qualitative study on nurses. Nurs Ethics 2022;29:157-70. [Crossref] [PubMed]
7. Galekop MMJ, van Dijk HM, van Exel J, et al. Views of professionals and volunteers in palliative care on patient-centred care: a Q-methodology study in the Netherlands. BMC Palliat Care 2019;18:97. [Crossref] [PubMed]
8. Hanssen L, Goodel T, Dehaven J, et al. Nurses’ perception of end-of-life care after multiple interventions for improvement. Am J Crit Care 2009;18:263-71. [Crossref] [PubMed]
9. Tay J, Compton S, Phua G, et al. Perceptions of healthcare professionals towards palliative care in internal medicine wards: a cross-sectional survey. BMC Palliat Care 2021;20:101. [Crossref] [PubMed]
10. Freeman R. Social workers’ perceptions of their role in providing palliative care to patients with life-limiting illnesses: a qualitative study among social workers in primary care settings in Namibia. University of South Africa; 2017.
11. Awny MM, Al-Touny SA, Gaafar SEM. Physicians' Knowledge, Attitude and Practice toward Ethical and Medical Issues of Palliative Care in Suez Canal University Hospital. Indian J Palliat Care 2022;28:391-7. [Crossref] [PubMed]
12. Tsao L, Slater SE, Doyle KP, et al. Palliative Care-Related Knowledge, Attitudes, and Self-Assessment Among Physicians in Vietnam. J Pain Symptom Manage 2019;58:1015-1022.e10. [Crossref] [PubMed]
13. Shor V, Kushnir T, Delbar V, et al. An instrument to assess hospital nurses' perceived self-efficacy in providing palliative end-of-life care: a validation study. Harefuah 2022;161:293-8.
14. Frommelt KH. The effects of death education on nurses' attitudes toward caring for terminally ill persons and their families. Am J Hosp Palliat Care 1991;8:37-43. [Crossref] [PubMed]
15. Charmillot PA, Van den Block L, Oosterveld-Vlug M, et al. Perceptions of healthcare professional about the "PACE Steps to Success" palliative care program for long-term care: A qualitative study in Switzerland. Nurs Open 2023;10:4413-23. [Crossref] [PubMed]
16. McCallum M, Carver J, Dupere D, et al. Developing a Palliative Care Competency Framework for Health Professionals and Volunteers: The Nova Scotian Experience. J Palliat Med 2018;21:947-55. [Crossref] [PubMed]
17. Carneiro R, Barbedo I, Costa I, et al. Comparative study of end-of-life care in an internal medicine ward and a palliative care unit. Acta Med Port 2011;24:545-54.
18. Blaževičienė A, Laurs L, Newland JA. Attitudes of registered nurses about the end - of - life care in multi-profile hospitals: a cross sectional survey. BMC Palliat Care 2020;19:131. [Crossref] [PubMed]
19. Reid JC, Hoad N, Willison K, et al. Learning needs and perceived barriers and facilitators to end-of-life care: a survey of front-line nurses on acute medical wards. BMJ Open Qual 2023;12:e002219. [Crossref] [PubMed]
20. Duivenbode R, Hall S, Padela AI. Assessing Relationships Between Muslim Physicians' Religiosity and End-of-Life Health-Care Attitudes and Treatment Recommendations: An Exploratory National Survey. Am J Hosp Palliat Care 2019;36:780-8. [Crossref] [PubMed]
21. Moon S, Chang SJ. Professional socialization of hospital nurses: A scale development and validation study. BMC Nurs 2023;22:2. [Crossref] [PubMed]