Palliative care training and research: the development in europe and the bologna experience.

Development of palliative care (PC) culture spur the need of proper and formal training. Palliative medicine is not fully recognized as an academic medical discipline due to its humanistic influences, and studies show that physicians declare to be not prepared to provide care and pain management to dying patients. Nowadays, despite leading countries in PC being considered more innovative than other countries,such as Italy, facts show that the achievement of acknowledged discipline went through a long process. In Italy,professionals from about 450 PC units and organizations need to receive a proper and homogeneous training. In Italy, palliative medicine official certification is an undergoing process advocated by a few organizations and in Bologna the Academy of the Sciences of Palliative Medicine operates since 2007 with the defined mission of developing PC culture, also within the University. In order to be as much effective in pursuing its mission, the Academy has strengthened several international cooperation programs and today is leader in PC professional training and research in Italy. The recent law and its feasibility is fastening the process of development of Palliative Care Culture in Italy even if training is not properly regulated and official certification for physician is under evaluation. In Europe, the European Association of Palliative Care is stressing the need for training programs in palliative medicine and the outcomes of the dedicated task force on official certification and specialty in Palliative Medicine will remarkably force policy makers and national councils to officially recognize the discipline.

INTRODUCTION

In the past few years, palliative medicine has developed and changed to respond to the unmet humanistic and social need for providing support to patients suffering from incurable illnesses.[123]

Palliative care (PC) has developed by focusing on a day-to-day healthcare tasks rather than in response to intellectual exploration, new discoveries, and scientific implementation. Palliative medicine is poorly defined, and its humanistic components have been predominantly developed through cultural, economic, and religious domains rather than academic exploration and science.[45]

The literature shows clearly how the development of PC has been and still is very difficult, in particular, in the academic field. It is clear that it is necessary to direct more resources toward the study and analysis of palliative medicine to give this discipline a solid base.

A study conducted on 6,783 Spanish general practitioners in 1998 showed that 94% of the physicians stated lack of adequate training in the care of incurable patients, underlining the need to develop training programs.[6] A survey, conducted by the European Society of Medical Oncology in 2003, demonstrated that only 52% of oncologists were formally trained in PC.[7] More recently, a study on medical and nursing staff conducted in Italy showed that only 50% of the participants could properly define PC and that 65% received inadequate training.[8]

Several studies have shown a lack of thoroughness and appropriateness.[7] Another study compared the quantity, designs, and scopes of palliative oncology publications in the first 6 months of 2004 with those in the first 6 months of 2009, showing a consistent reduction in the percentage of oncological studies concerning PC.[9] This is probably due to an academic structure having difficulties in adapting to an integrated field where ethical, psychological, and spiritual aspects are of the greatest importance.

Training in leading and non-leading countries

The United Kingdom (UK), the United States, and Canada have pioneered the development of modern-day PC and palliative medicine. However, even in “leading countries,” the development of a culture in palliative medicine has received a belated contribution from the academia. In fact, the development of teaching and training programs has undergone a slow growth; moreover, these programs were not established until at least 20 years after the movement was raised.[5]

Lectures about PC and clinical exposure have only recently been added and are usually brief and unsystematic despite the fact that death is a universal part of healthcare.[1011]

In Italy, the origin of PC involved a local event outside the university field. Following the example of the homecare program created in Milan in the 1980s (the “Floriani Model”), PC organizations developed in other areas of the country. The movements were sustained by philanthropic organizations and individual initiatives and were partially supported by the public health system.[51213]

In 2000, the Italian Government launched the national hospice program focused on developing Hospices all over the country and without considering the possible increasing of misperception in a still-immature field.[1415]

Meanwhile, academic input into the development of this discipline was absent; therefore, universities responded with heterogeneous courses and teaching programs. At present, there is a disarray of training programs, with disparate technical, clinical, and holistic approaches, producing a large number of professionals with different educational backgrounds and perhaps limited common skills and comprehension levels. This kaleidoscopic situation does not allow the development of a proper Italian culture in PC, palliative medicine, and action.[5]

In Europe and Italy

In Europe, countries whose PC movement was playing a fundamental role, struggled considerably in order to ensure a systematic education in core principles, providing students with skills in new science, and the role of evidence to inform clinical practice and granting “academic dignity.” Although UK has pioneered, along with United States and Canada, the development of current PC and palliative medicine, when referring to UK as a PC “leading country,” we must acknowledge the belated contribution received by the academia. In fact, the development of teaching and training programs has undergone a slow growth, and institutionalized training programs were established in the middle of 1980s. In the UK, the palliative medicine specialty was created in 1987, although St. Christopher Hospice was founded in 1967.[13]

European Countries analyzed by Centeno, Noguera, Lynch, and Clark showed a heterogeneous landscape when referring to the development of academic programs.[16]

In fact, in Europe, as well as in other leading countries, the education in palliative medicine has been historically lacking not only from the curricula of general healthcare education for physicians but also in nurses, social workers, and others. Among programs developed by the faculties of Medicine, it is possible to spot the recently added lectures and clinical exposure even if they are often brief and unsystematic despite the fact that death is a universal part of healthcare.

So far, Spain is counted among the countries that recently fully acknowledged the palliative medicine chair at the University.[17]

In 1997, the European Association for Palliative Care (EAPC) proposed to create a national network for training in this discipline.[18] In 2007, the EAPC established useful guidelines to define the requirements for training in PC, both for physicians and nurses, and identify the most essential educational skills for teachers.[19]

In particular, these guidelines indicated the following:

The training may be divided into mandatory and elective training periods

The training should be undertaken in at least two different services/settings (e.g., Hospital, community care)

The training should include 6 months’ training in oncology, if prior experience has not been adequate

A major challenge to the provision of a more systematic palliative medicine education is the lack of a large cohort of trained academicians to teach the discipline.[5]

Focusing on Italy, there are currently 450 PC units, meaning that a great number of professionals are working in this field. The need to provide proper education and training in order to care for patients and provide excellent PC settings is strong.

However, in Italy, undergraduate training in PC is very scarce. The majority of universities do not offer any courses on this subject, and, those that do, have few and often not required courses. In Italy, as to the postgraduate training for physicians, there currently are no certificates in PC and some universities have recently included optional PC classes on medical oncology, geriatrics, and anesthesiology specialization training.

Italy featured thorough the 2000s, the launch of several master's programs in PC, addressed to physicians, nurses, and other professionals interested in developing PC skills and improve their practice. However, these master's degrees are not mandatory and are scheduled without a national definition and homogenization of contents.

A turning point in the development of training in PC was the Law 38 of 2010 “Dispositions to guarantee access to Palliative Care and Pain Management,” which the government intervened to give more homogeneity to the training and education.[20]

The law supervises and guarantees:

Right to PC and pain management for all citizenships

Access to PC and pain management with dignity, autonomy, need of health, equity, quality of cure

Customized care models for each patient

Protection of the patient's dignity and autonomy

Quality of life to all patients until the end

Proper and professional assistance of patients and families.

Every member of the team has a specific role and consequently the training has to be different for every category of health professionals according to the three levels to PC services delivery internationally defined, as follows:

Level A: Basic expertise. This is required for all physicians and must be acquired in medical school. In Italy, this has not been achieved yet, although, internationally, there have been developments in this direction.[21]

Level B: Necessary expertise for physicians who have PC as a part of their clinical practice. This includes, but is not limited to, primary care physicians, surgeons, gynecologists, and pulmonologists who provide PC to patients as a part of their work.

Level C: Necessary expertise for physicians who lead or work in a PC team or unit. This level is consistent with the specialist level.

Following the law requirements about education and training, a group of experts appointed by the Ministry of University and Research defined the national PC university postgraduate training programs for physicians and for other professionals.

Starting from 2013, there will be a 2-years master's degree in PC and pediatric PC for physicians and first-level master's degree in PC for nurses and other health professionals. However, the master programs are organized by universities, but are not mandatory for working in PC units or teams and do not provide recognized certification.

The engagement of the academic sector in palliative medicine has many aims, such as promoting the exploration of the culture, humanities, and science of our discipline; generating evidence to support our practice; creating a legion of educators to train our workforce and inform our clinical colleagues of the role of palliative medicine; and bringing order into the chaotic state of our discipline.

Postgraduate programs should be organized by universities to reflect the cultural, economic, and social characteristics of a given country. It is extremely important that the established training programs refer to a common academic base and that trained professionals are capable of playing specific roles in a multidisciplinary team.[5]

In Bentivoglio-Bologna

In 2007, the MariaTeresa Chiantore Seràgnoli Hospice Foundation and the Isabella Seràgnoli Foundation together with the Cassa di Risparmio in Bologna Foundation established the Academy of Sciences of Palliative Medicine (ASMEPA) in Bentivoglio. ASMEPA is managed by the Isabella Seràgnoli Foundation and works in collaboration with the University of Bologna and local health public authorities for the provision of training and research programs in palliative medicine [Figure 1]. ASMEPA aims at giving formal structure and scientific continuity to those PC programs that can substantially contribute to the development of a better practice and knowledge in palliative medicine. Accordingly, the main programs through which ASMEPA is nationally and internationally acknowledged are the Master Program in Palliative Medicine addressed to all health professional, the II level Master Program addressed to physicians, the Course in Pediatric Palliative Care, and Continuing Medical Education (CME) courses. As to the research activities, ASMEPA is running several research projects in collaboration with several national and international research centers such as the MD Anderson Cancer Center, the Duke University, the University of Navarra, the University of Bologna, the University of Verona, and several Italian Hospices.

Figure 1

Campus bentivoglio main features

The core activities of the ASMEPA are as follows:

Educational courses in collaboration with the University of Bologna [Figure 2]

Figure 2

Master details

Continuing Medical Education courses

Research [Figure 3]

Figure 3

ASMEPA Main research activities

Publication and culture dissemination [Figure 4].

Figure 4

Cultural dissemination activities

Since 2007, the ASMEPA, in collaboration with the University of Bologna, has been organizing the first-level master's degree in PC address to a maximum of 30 students in a multi-team and multidisciplinary approach. The ASMEPA collaborates with the ANT Foundation (National Cancer Association), which delivers home-care services to 65,000 patients in Italy, in order to provide all the insights of PC services including residential, out-patients clinic care, and home care. Since 2007, the ASMEPA has been training 193 students from the university master programs (an average of 30 students per year) and about 1000 professionals in Continuing Medical Education courses.

As to the research activities, the ASMEPA has 4 main research fields involving clinical, translational, observational, and academic aspects of palliative medicine, and it coordinates 16 main researchers in the framework of the following activities and partnerships:

Doctorate in Palliative Medicine in collaboration with the University of Bologna

Partnership agreement with the “Giorgio Prodi Interdepartmental Research Center for Cancer”

Acknowledgement from the Ministry of Education, University and Research for the research field on Intercultural aspects in PC[22]

A partnership with the General Practitioners Society for the research entitled “Surprise question”

A Partnership with the MD Anderson Cancer Research, University of Texas for Deep sequencing research project and development of theories and models of communication in palliative medicine[23]

Full integration with the three hospices managed by the Maria Teresa Chiantore Seràgnoli Hospice Foundation for clinical research projects

A membership in the European Association for Palliative Care Task Force on certified Specialty on Palliative Medicine for the project on “Comparative analysis of the path of specialization in Palliative Medicine in Europe” carried out in partnership with the University of Navarra

A partnership with the ANT Foundation for the research analysis on the preferred and the final place of death.[24]

The ASMEPA operates since 2007 for the spreading of PC culture in Italy and connects Italy with the leading countries through high level training and scientific research. In order to accomplish its Mission, the ASMEPA developed several cooperative programs all over the world [Figure 5].

Figure 5

ASMEPA international network

Cooperative programs are signed with the aim of including postgraduate training such as master programs and research projects in PC.

Programs are carried out considering the policies and programs of national and international scientific organizations and a possible further development is an official cooperation agreement between interested universities with PC programs. The agreement should strengthen the development of international master's programs, research programs, exchanges of teachers and students, and development of a policy of wide diffusion of the PC culture, considering different cultures, social assessments, laws, and funds.

CONCLUSION

As the Law 38-2010 in PC development has been published and several commissions have been set up to decline the law regulations, PC training programs should be uniformed and effective to operate in the field.

The World Health Organization recently considered the Law 38 as a juridical model to be followed and duplicated worldwidly.

The ASMEPA operates in the framework of the Law 38-2010 to stress on the importance of a recognized specialty in palliative medicine with defined contents and programs. In fact, several features shows that Italy can be acknowledged as a leading country in the near future, and this could be easily achieved if health professionals involved in delivering hospice and in-home PC all over the country could join a common specialized training and develop a strong connection with international guidelines in PC education.