How can training in care of the dying be improved?

Care of the dying patient is an intrinsic part of the role of Foundation Year doctors (FYs). This study aimed to explore FYs’ experiences of training and their perceived training needs for their role in care of the dying.

21 individual interviews were conducted with 47 participants. Interview recordings were transcribed verbatim and framework analysis was undertaken. Findings: Key themes derived from the interviews included FYs' teaching opportunities regarding care of the dying and their learning methods for this subject matter which included learning from experience, observation, simulation, written guidance and supervision. Areas for further training was another key theme and training needs identified included prescribing, communication, recognising dying, documentation, societal perspective and emotional resilience. Discussion: FYs' training experiences in this area vary. This study identifies training needs that can be used to inform both undergraduate and postgraduate curricula.

INTRODUCTION
I n the UK, following medical school graduation, doctors Foundation Year (FYs) undertake a 2-year training programme within a Foundation school that oversees their training. FYs are expected to care for dying patients and the General Medical Council mandates that UK graduates will be able to do this. 1 However, undergraduate education has been criticised for failing to prepare doctors for care of the dying. 2 FYs feel unprepared 3 and have unfulfilled learning needs. 4 The UK guidance on care of the dying was published in Priorities for Care of the Dying Person. 5 Five areas of care are recommended: 'recognise', 'communicate', 'involve', 'support' and 'plan and do' . 5 The aim of this study was to explore FYs' experiences in care of the dying. We posed three research questions (Box 1). We found that FYs' experiences are variable and, within the five priorities, 5 good practice and areas for improvement exist. 6 In this paper we present the primary data analysis related to question three.

METHODS
We conducted a qualitative study using semi-structured face to face, telephone and videoconferencing interviews to allow for exploration of experiences and to maximise participation. All FYs in the North Yorkshire and East Coast Foundation School in England were invited through e-mail, social media, posters and word of mouth to form a convenience sample. Participants provided informed consent and completed a demographic questionnaire.
Priorities for Care of the Dying Person 5 was used as the conceptual framework because it outlines nationally recognised areas for care. The conceptual framework was used to derive the standardised interview question stems alongside other published literature. Following a pilot interview, which was formed of one videoconferencing group interview with three participants, the question stems were agreed (Box 2).
Between January and March 2016, we held eight group interviews (with between two and five participants in each) and 21 individual interviews, each conducted by one researcher (SG, JP, MR or GF). Interviews were recorded and transcribed verbatim. As a result of the use of a conceptual framework, the data were analysed in accordance with framework analysis, with familiarisation of the interview transcripts, line-by-line coding, formation of a coding framework, charting of the data and interpretation. 7 There were some predetermined codes as a result of the conceptual framework and interview questions, but the authors were open to other codes as the data were inductively analysed. Coding was primarily conducted by MR but was reviewed by others (JP, SG and GF). The themes and sub-themes were formed from the predetermined codes and the codes found on analysis. Data analysis software was used to organise the data. Thematic saturation was reached as no new themes emerged from the data. Ethical approval was granted by Hull York Medical School; institutional approvals were granted from the involved NHS trusts.

RESULTS
A total of 47 (14%) out of 335 FYs participated and none withdrew. A total of 44 of the participants had attended medical schools in the UK. … we actually had one week of placement in fourth year and final year in a palliative hospice, which I found was very useful again because you see the day-to-day management, erm, of a palliative patient … in real time, it's not something you're going to read in, in a book or something you're going to learn … on a theoretical basis … G3P2 C. Simulation. Death presented emotional challenges, and preparation for this was lacking. … a really important aspect is, erm, how to emotionally deal with … the patient dying, but it's something that … was never taught or discussed in medical school. I13

DISCUSSION
Given that FYs are expected to care for dying patients, it is important to understand their training experiences and needs. The variation in training, despite curriculum specification, was notable. Training needs ranging from biomedical aspects of clinical practice through to psychosocial issues and emotional resilience were identified. The clinical and psychosocial training needs map to the Foundation programme curriculum item of 'manages palliative and end of life care' . 8 Addressing these learning needs will also enable FYs to be able to achieve the Priorities for Care of the Dying Person 5 recommendations.
There is a need to improve training and ensure learning opportunities are maximised for undergraduates and postgraduates, for example, the use of hospices as training sites. 9 Consistent with previous findings 2,3,10 our participants described learning about care of the dying through experience, observation, simulation and written and verbal guidance, therefore these methods should be further utilised to meet FYs' needs. It was noted that the timing of this learning had significant impact on its value and that it Undergraduate training must meet the General Medical Council requirements of 'management of symptoms, practical issues of law and certification, and effective communication and teamworking' . 1 Following this study, the authors also recommend: • Training in care of the dying should be integrated into the spiral curriculum, to allow students to build their knowledge, skills and experience over time.
• All medical students should receive basic teaching about the meaning and principles of care of the dying, how to recognise dying, the pharmacology of medications used in care of the dying, how to verify death and how to complete death certification paperwork.
• All students should be provided with training and some practical experience via simulated scenarios of breaking bad news.
• All medical students should be provided with some practical experience of care of the dying, with time in a hospice and/or working with in-patient or out-patient palliative care services if possible. Particularly in the later years of medical school to prepare for starting work and to gain an understanding of the teamwork involved.
• All medical students should be introduced to the concept of emotional resilience and how to prepare for this.
Foundation training must meet the curriculum items as outlined by the Foundation programme. 8 Following this study, the authors also recommend: • To continue training within a spiral curriculum by building upon knowledge, skills and experience acquired at medical school, with more focus on real-life care events but to use classroom-based study days and hospice placements as appropriate.
• For care events encountered at work to be a trigger for learning, with support from the senior members of the clinical team via clinical debriefing and supervision.
• To observe senior members of staff breaking bad news or have conversations on the topic of care for the dying with patients and/or families. Depending on an FY's competence and the senior support available, there may be an opportunity for the FY to lead this conversation. Simulated scenarios would offer a safe environment for FYs to learn and practise their communication skills further.
• All FYs should receive training on prescribing, recognising the dying patient and the ethical, legal and cultural aspects of care for the dying.
• All FYs should be provided with support on how to document care in the medical record appropriately. All FYs should be supported in completing death certificates and cremation forms by senior members of the health care team.
• All FYs should be made aware of where NHS trust guidance on care of the dying can be accessed and how to contact the palliative care team.
• All learning events or care of the dying experiences should be an opportunity for building emotional resilience, with support from more senior members of the health care team.
should occur when it was most clinically relevant. Our data show that exposure to care of the dying was welcomed as a medical student, particularly during more senior years, and that simulation exercises in a safe environment had a valuable role. In practice, spiral curriculum approaches would seem appropriate, where earlier 'safer' practice could be built upon when the topic was revisited later in the course after more clinical exposure. This education could be further supported by training early in the Foundation programme. Within this spiral curriculum, emotional resilience could be fostered with each learning event. Table 1 outlines recommendations for training.
Strengths of this work include reaching thematic saturation and using a convenience sample, which may have resulted in recruiting participants with extreme views. Limitations include relying on participants' memory of events, over months or years, and participants having a variable duration in post at the time of the interviews (ranging between 5 and 19 months), which may have resulted in different opportunities.
At the time of conducting the interviews, SG, JP and MR were FYs, which may have helped participants to express their opinions or may have been a barrier to discussions for fear of peer judgement. To ensure fair data interpretation, GF and MJ, both experienced researchers and not FYs, were involved in the data analysis.

CONCLUSIONS
Training experiences vary and training needs exist around prescribing, communication, recognising dying, documentation, societal perspective and emotional resilience. Many of these training needs reflect the Foundation programme syllabus and when addressed will help FYs achieve the Priorities for Care of the Dying Person 5 recommendations. It is important to acknowledge the FYs' expressed training needs and use them to improve training. Teaching this topic at clinically relevant times in a spiral curriculum is suggested as a way to deliver this teaching across undergraduate and early postgraduate training using existing learning methods.