Introduction

In 2019, the author Carlotta Bellon (CB) had the opportunity to take part in a one-year long Health Disparity and Global Health Internship at the Binaytara Foundation in Issaquah, WA. As a Binaytara Foundation Intern, CB received direct mentorship from the co-founders of the Binaytara Foundation, and participated in assessing, developing, and implementing programs and services to minimize health disparities in the United States and Globally. CB has gained experience in health disparity research, program planning, grant writing, educational activity planning, database and record keeping, volunteer coordination & leadership skills, communication, collaboration, networking. Part of the internship was based in Nepal at the Binaytara Foundation Cancer Center in Janakpurdham. There, CB had the opportunity to conduct the following study on palliative care education in Nepal.

Background

I. Overview of Palliative Care

History and definition of Palliative Care

The holistic approach of palliative care aims at improving the life of patients with life-threatening diseases and their families through early identification, assessment, and treatment of physical, psychological, or spiritual pain.¹ The ideas of modern hospice care were first articulated in the 1950s by Dr. Saunders, but it was only in 2004 that the “Clinical Practice Guidelines for Quality Palliative Care” were first released.² Of the estimated 40 million people that require palliative care every year, only 14% receive the care that they need, and 78% of them are in low-and-middle income countries.¹

Low-income countries

Despite the recognition of palliative care as a human right and essential for the improvement of the quality of life of patients – and their families – with life-threatening illnesses, many low-income countries either lack palliative care services or have limited access to it; this lack of services is due to misinformation, lack of financial support, cultural beliefs on death,³ lack of an appropriate clinical system or guidelines,⁴ and training and awareness among health professionals.¹ As suggested by the WHO, one of the steps that countries can take to eliminate these barriers is to include palliative care into the core curricula of all new health professionals.

II. Palliative care education

The European Association for Palliative Care (EAPC) curriculum recommendation for Palliative Care

The goals of educating undergraduate medical students in Palliative care is to show that patients should be treated holistically, the care and treatment should consider both the needs, wishes, and values of the individual as well as those of the relatives and non-medical caregivers, and team-working, medical ethical issues and communications are crucial in the treatment of patients.⁵

The European Association for Palliative Care (EAPC) suggest the curriculum to include seven “topics” for a basic level understanding of Palliative Care: (1) definition of Palliative Care and Palliative Medicine; (2) Pain; (3) Neuropsychological symptoms; (4) Management of other symptoms; (5) Ethics and law; (6) Patient/family/ non-clinical caregivers perspectives; (7) Clinical communication skills.⁵ The EAPC suggest a total of 40 hours to be dedicated to palliative care during undergraduate medical education; while this is based on European general medical school curriculum, it is safe to say that it can be applied to other type of academic curricula, as long as the proportions of modules are respected.⁵ The modules suggested to be included in the syllabus are the following: (1) basics of palliative care; (2) pain and symptoms management; (3) psychosocial and spiritual aspects – very important in Nepal for cultural values - ; (4) ethical and legal issues; (5) communication; (6) teamwork and self-reflection.⁵

IV. Palliative care in Nepal: lack of services and education

While being ranked among the lowest 20% of the world’s developed countries, Nepal has been developing in the last 20 years, mainly in Kathmandu and in cancer services; and like other low-income countries is experiencing a shift in mortality causes from communicable diseases to non-communicable diseases.⁶ Cancer accounts for around 10 million deaths per year globally and in low-income countries 80% of end stage cancer patients experience pain lasting an average for 90 days; families and caregivers also go through a stressful and grave time, palliative care exists to tackle these issues.⁷ A study in 2019 showed that 58,000 adults required palliative care in Nepal in 2012, and the majority of them lived in rural areas.⁸ Palliative care in Nepal is still new, as it was introduced in the 1990s and a limited number of specialized healthcare are present.⁸ Palliative care was first included in the medical curriculum of the Patan Academy of Health Science (PAHS) only in 2008.⁹ A Previous study among students at the Institute of Medicine (IOM) in Kathmandu showed an inadequate knowledge and perception on Palliative care.⁹ In 2009 the Nepalese Association of Palliative Care (NAPCare) was established to improve palliative care services in the country and educate healthcare personnel by creating a National Strategy for Palliative care in co-ordination with the Ministry of Health and WHO. Between 2010 and 2013 various institution have conducted weeks and month-long training programs for doctors and nurses.⁷

Goal

The purpose of this study was to evaluate the working knowledge of palliative care among undergraduate medical students, and the presence of it in their academic curriculum.

Methods

This analytical study was designed during my internship at the Binaytara Foundation Cancer Center in Nepal. The study was conducted among undergraduate medical students between March 6^th, 2020 to July 6^th, 2020. With the support of a medical student, Anish Shah, a questionnaire was sent out to 140 students and completed by the students on Google forms; the questionnaire included 16 questions (Figure 1). Of the sample size only 57 students completed the questionnaire; results were entered on Microsoft Excel and then analyzed.

Results

I. Demographic

Of the 57 respondents, 42 (73.7%) students were from the BP Koirala Institute of Health Science, 1 (1.8%) student was from the College of Medical Science, Bharatpur , 4 (7.05%) were from the Kathmandu University, 3 (5.3%) from the Manipal College of Medical Sciences, 5 (8.8%) from the Patan Academy of Health Sciences, 1 (1.8) from T.U., and 1 (1.8%) from UCMS (Table 1).

Among the students from the BP Koirala Institute of Health Science, 5 were on their 1^st year, 31 were on their 2^nd year, 4 were on their 3^rd year, 2 were on their 5^th year, and none were on their 4^th year. The student from the College of Medical Sciences, Bharatpur Nepal, was on its 2^nd year; from Kathmandu University, 1 student was in its 2^nd year, 2 were in their 3^rd year, and 1 was in its 5^th year. Among the students from the Manipal college of medical sciences, 1 was in its 3^rd year, and 2 were in their 5^th year. The students from the Patan Academy of Health Science, were from 2^nd (4) and 3^rd year (1); the respondent from TU was a 2^nd year student, as well as the student from UCMS. (Table 1)

II. Education/Knowledge

First, students were asked if they have heard about Palliative Medicine and if they knew the World Health Organization (WHO) definition of palliative care. Among the 57 respondents, 36 (63.2%) have heard of “Palliative Medicine”, while 21 (36.9%) had not heard of it; 18 (31.6%) responded that they know the WHO definition of palliative care, while 39 (68.4%) did not (Table 2). Students were then asked five questions based on the WHO definition of palliative care. Of the respondents, 54 (94.7%) agreed that palliative care is to relieve sufferings and improve the quality of life of threatening illness, while 3 (5.3%) did not; and 50 (87.7%) responded “yes” to whether palliative care provides psychological and spiritual support, while 7 (12.3%) responded “no” (Table 2). 28 (49.1%) of the students agreed that palliative care is an interdisciplinary approach, only 2 (3.5%) disagreed and 27 (47.4%) responded that they did not know; among the same 57 students, 33 (57.9%) agreed that palliative care services can be offered early in the case of life threatening illness, irrespective of prognosis, 15 (26.3%) responded that they did not know, and 9 (15.8%) disagreed (Table 3). Lastly, students were asked to indicate whether palliative care hasten or postpone death, they were also given the option to answer, “I don’t know”. Among the 57 students, 22 (38.6%) said that palliative care postpone death, 3 (5.3%) that it hastens death, and 32 (56.1%) did not know. (Table 4)

III. Curriculum

Among all the students from the different universities, 19 (33.3%) said that palliative care is part of their curriculum, while 38 (66.6%) said it is not (Table 5). The breakdown by university is the following:

B.P. Koirala Institute of Health Science

Among the 42 students from the B.P. Koirala Institute of Health Science, 11 students confirmed that palliative care was part of their curriculum, while 31 said it is not. Among those who said “no”, 16 had heard of Palliative Medicine, while 15 had not. Among those who responded “yes”, 9 said they had heard of Palliative medicine, while 2 had not. (Table 6)

Patan Academy of Health Science

Among the 5 students from PAHS, all said that palliative care was part of their curriculum and have heard of Palliative Medicine. (Table 7)

Kathmandu University

Among the 4 students from Kathmandu University, 1 student said that palliative care is present in their curriculum, while 3 said it is not. Among those who responded “no”, 2 said they had heard about palliative medicine, while 1 had not. The only student who responded “yes”, also had heard of Palliative Medicine. (Table 8)

Manipal College of Medical Sciences

Among the 3 student from the Manipal college of medical sciences, 2 said that palliative care was part of their curriculum, while 1 said it was not. Of those who responded “yes”, 1 had heard about Palliative Medicine while the other did not; and the only student who responded “no”, had heard of Palliative Medicine (Table 9).

The last 3 students were from the College Of Medical Sciences Bharatpur (Table 10), Universal College of Medical Sciences (Table 11) and Tribhuvan University (Table 12) respectively. All of them indicated that palliative care was not part of their curriculum; the student from the College of Medical Science heard of palliative medicine, while the students from UCMS and TU had not.

The students were then asked to respond to whether they were aware of the European Association for Palliative Care recommendation of curriculum in palliative care for undergraduate medical education. Among the 57 respondents, 8 (14.0%) responded “yes”, while 49 (86.0%) responded “no” (Table 13)

Lastly, the student responded to whether they thought Palliative care should be part of the curriculum, and if so in what year it should be introduced in the curriculum. Among the 57 students, 56 (98.2%) said palliative care should be part of the curriculum while 1 (1.8%) said it shouldn’t (Table 14)

Of the respondents, 29 said palliative care should be introduced the 1^st year, 9 in the 2^nd year, 15 in the 3^rd year, 1 the 4^th year, and 3 the 5^th year (Table 15)

Discussion

As Palliative Care is starting to be more present in medical schools and healthcare settings, it was not unexpected that more than half of the respondents (63.2%) heard of Palliative Medicine, but it is important to notice that the majority (68.4%) did not know the WHO definition of palliative care. The most important response is regarding palliative care being an interdisciplinary approach, which is the foundation of Palliative Medicine; and while 49.1% agreed, 47.4% indicated that they did not know. It is important to focus on this group, as it shows that there is still a need to improve palliative care teaching in medical schools. Worthy of notice are the conflicting responses from each university on whether palliative care exists in the curriculum or not, an example is the B.P. Koirala Institute of Health Science where 11 students said Palliative Care was in their curriculum, while 31 said it wasn’t; this may be due to a misinterpretation on the concept of palliative care. The results align with a previous study that demonstrated inadequate knowledge and perception of palliative care among undergraduate medical students in Nepali institutions.⁹

Conclusion

Considering these and previous study results, and the increasing number of people that will be needing palliative care in Nepal, incorporating a strong syllabus on palliative care in medical school curricula would set a strong base for the next generation of doctors to be able to appropriately meet the needs of patients who suffer from long-term life-threatening diseases. In Nepal only two medical institutions have included palliative care education in the undergraduate curriculum about a decade ago.⁷

While the development of such curriculum should be adapted to Nepali medical schools based on resources and its school system, the European Association for Palliative Care (EAPC) indications on a palliative care curriculum could be taken as a blueprint for developing a tailored one for medical schools in Nepal.

Conflict of Interest

None

Funding information

None

Ethical statements

N/A

Acknowledgement

N/A

Author contribution

i. Carlotta Bellon: conception and design
ii. Carlotta Bellon, Anish Shah: data collection and assembly and manuscript writing.
iii. Carlotta Bellon: data analysis, manuscript writing.
iv. Tara Shah: oversight and manuscript editor

All authors have approved the manuscript.

Appendices

Appendix 1. Tables and Figures

Appendix 2. Questionnaire for students