Palliative care and end of life care (PEOLC) is widely regarded as an important component of undergraduate medical education. However, this subject remains optional in many areas, which fails to prepare doctors for the inevitable reality that patients will die while in their care. The COVID-19 pandemic brought this issue into sharp relief as healthcare providers around the world have struggled to meet demand as hospitals became overwhelmed with sick and dying patients. While New Zealand (NZ) has fared better than most countries during the pandemic, the death rate from life-limiting diseases is expected to double by 2068 with most deaths occurring in people aged >85 years. This increase will be reflected across all healthcare settings, with a 51% rise in palliative care need by 2038 . These statistics reflect a global challenge in healthcare that is, unfortunately, not amenable to a vaccine.
Approximately one-third of deaths in NZ occur in acute care hospitals where at least 20% of inpatients meet the Gold Standards criteria for palliative care . Most graduates complete their first two years of clinical practice in hospital settings so they are likely to encounter people with palliative and end of life care needs on a regular basis. In fact, a study from the United Kingdom (UK) which investigated medical students’ attitudes towards palliative care, reported that junior doctors care for approximately 40 people who die, and a further 120 people who are close to the end of life, in their first year after qualifying . Given the NZ statistics previously mentioned, it seems likely that NZ graduates may experience a similar reality.
PEOLC has not traditionally been included in undergraduate teaching due to an emphasis on curative medicine and the availability of treatments and investigations which seek to prolong life at any cost. Unfortunately, this denies patients and their whānau (family) the care and support they need at a time when quality of life should be a priority. In the absence of such training, newly qualified doctors are likely to enter clinical practice without the necessary knowledge, skills or attitudes to provide basic palliative care. However, attitudes are changing and this content is now being integrated into undergraduate curricula around the world, which is a fundamental step towards improving awareness, workforce capacity and increasing access to primary (non-specialist) palliative care [4, 5].
The very nature of caring for people with life-limiting conditions is inherently challenging, and studies report that newly qualified doctors find caring for people toward the end of life stressful and emotionally distressing [3, 6, 7]. This is perhaps, not surprising. However, deficiencies in undergraduate education such as lack of meaningful contact with people who are dying, lack of role modelling by senior physicians, curative oriented health systems and variable teaching, fails to prepare students for one of the most challenging aspects of their work. These issues ultimately compromise patient care and increase graduates’ anxiety at a critical point in their professional development [6, 8, 9]. Negative personal attitudes and beliefs about death and dying may also influence graduates’ willingness to care for people at the end of life , although education has been shown to be effective in addressing these issues [11, 12]. In the absence of such education, graduates must rely on their intuition and guidance from colleagues, which may be neither available nor appropriate if their colleagues have not received formal training in palliative and end of life care (PEOLC).
In 2014, a declaration by the World Health Assembly stated that “palliative care should be integrated as a routine component of undergraduate medical education” to improve access to primary palliative care . International recommendations suggest teaching should be based on nationally agreed and developmentally appropriate competencies with dedicated clinical exposure, reflection and discussion about challenging cases, assessment and multidisciplinary input [14, 15]. A variety of international guidelines and competency frameworks have since been developed to support this work. For example, the EDUPALL curriculum, based on recommendations from the European Association for Palliative Care (EAPC) (edupall.eu); Educating Future Physicians in Palliative and End of Life Care curriculum in Canada (EFPPEC); Palliative Care for Undergraduates sponsored by the Australian government (pcc4u.org); All Ireland Institute of Hospice Palliative Care competence framework (http://aiihpc.org/), and the Northern Ireland Health and Social Care Palliative and End of Life Care Competency Assessment Tool.
Early efforts to include PEOLC in undergraduate curricula tended to be optional, fragmented and lacked coordination . However, there is now greater consistency in curricular offerings . Canada, the UK, Austria, Belgium, Estonia, Switzerland, Israel, Luxembourg, Moldova, Belgium, France, and Germany now include PEOLC as a mandatory component of undergraduate medical education. A further 13 European countries teach PEOLC combined with another medical specialty, e.g. palliative care and oncology [17–19]. Unfortunately, few European countries offer more than 20 hours of formal palliative care teaching or mandatory clinical experience in palliative care. In the US, medical schools are not required to teach palliative care competencies. While a 2014 review reported that palliative care is included in most medical schools’ curricula, teaching varies widely and is underdeveloped . Similarly, a 2014 report described PEOLC teaching in Australian medical schools as variable, fragmented and disjointed. Despite global efforts to increase undergraduate PEOLC education, overcrowded curricula, insufficient time, lack of faculty expertise and leadership, and a lack of funding and assessment, thwart the ability to do so [15, 20–22]. Despite that, student evaluations show they value this teaching, consider it relevant to general clinical practice, and feel it improves confidence in their ability to care for people near the end of life . Palliative care teaching has also been shown to foster holistic patient-centred care and professional development .
New Zealand is currently ranked third on the global Quality of Death Index, which rates the provision of palliative care worldwide based on income as a predictor of the availability and quality of services . Specialist palliative care services are well established in urban centres throughout NZ, although people in rural and remote communities often have to travel long distances to access this care. Therefore, up to 80% of palliative care is provided by health professionals who may not have had any formal training in palliative care , supported by specialist palliative care services where available, and the national guidelines: Te Ara Whakapiri - Principles and Guidance for The Last Days of Life . However, there is an impending shortage of palliative medicine specialists, and district health boards report difficulty recruiting and retaining suitably qualified staff, which has led to inequities in access for patients and families needing care and for healthcare providers seeking support . These issues were highlighted in the NZ Ministry of Health Palliative Care Action Plan , which prioritised workforce development by “supporting work to modify undergraduate education and training to provide the minimum knowledge and skills related to primary palliative care” (p.23). This statement provides a clear mandate for medical schools to ensure PEOLC is comprehensively addressed in the undergraduate curriculum to ensure graduates have the necessary skills to provide equitable access to primary palliative care across all healthcare settings and geographic locations. Unfortunately, the shortage of palliative medicine specialists required to teach this material may undermine the ability to deliver on this priority.
There are two accredited providers of undergraduate medical education in NZ (the University of Otago and the University of Auckland), with a combined annual intake of around 550 students. Students gain entry through a highly competitive one-year health sciences course, or the alternate pathway for those with a prior degree, followed by two years of pre-clinical education with some early clinical exposure, and three years of clinical training in hospital and community settings. The sixth and final year is spent working as a Trainee Intern. Graduates obtain provisional registration and are awarded with a Bachelor of Medicine and Bachelor of Surgery degree (MBChB). They then undertake a further two years of prevocational training as a House Officer (PGY1-2) before being registered as a medical practitioner . Medical students at Otago University complete the first three years of the course in Dunedin, then divide into thirds for years 4-6 in one of three clinical teaching campuses in Dunedin, Christchurch and Wellington. Students at Auckland University follow a similar pathway with clinical attachments in hospital and community settings throughout Auckland and regional centres in the North Island.
While MBChB programmes are accredited by the Australian Medical Council, the Medical Council of New Zealand  sets the standards for medical practice, which includes care at the end of life. Learning outcomes and objectives in PEOLC are included in each universities’ curriculum documents to influence curriculum planning, development and delivery. There are no academic professors of palliative medicine at either of NZ’s medical schools and only a handful of academic appointments to teach palliative care.
In 1997, a palliative care curriculum for undergraduate medical students was introduced by the Australian & New Zealand Society for Palliative Medicine (ANZSPM) and accepted by the Deans of all medical schools in Australia and NZ but unfortunately, little change eventuated. However, collaboration between Otago and Auckland universities to address deficiencies in PEOLC teaching has since resulted in the development of a national undergraduate PEOLC curriculum and implementation framework, which incorporates the previous work done by ANZSPM. It is against this background that the first national survey of NZ medical schools was undertaken to provide a baseline for further development.