Communication Skills Education in Advance Care Planning: a Survey Study in Medical Students at the University of Antwerp

Background Palliative Care (PC) medicine is strongly emerging worldwide. Despite the effort to implement PC in the basic medical curriculum in Belgium, little time is spent on it during theoretical training. For two consecutive years, a survey was presented to all students from the second master’s year medicine from the University of Antwerp. The survey consisted of demographic questions, a knowledge test about PC and an evaluation about students’ self-condence regarding communicative skills used in end-of-life conversations. First, to evaluate students’ self-condence regarding end-of-life conversation and mapping out possible gaps in the palliative care training at our university. Second, to assess whether our classes are able to get students to adequately reect on possible factors that may inuence end-of-life conversation. Results

knowledge video on the topic We also ask the students to re ect on their own wishes and standards regarding ACP. In the rst part, the video focuses deeper on speci c subjects such as when is a patient palliative (surprise question), legal content surrounding euthanasia, declaration of intent and palliative sedation. In the second part, we work on speci c communication skills in the plenary lesson. We want to provide tools to make various aspects of ACP discussions easier (e.g. discussing Do Not Resuscitate (DNR) code with the Allow Natural Death (AND)-method). (11) Lastly, we want to make sure that students are able to identify the tipping points that make it easier for doctors to start a conversation about ACP. This is an important issue since timing of an APC conversation remains challenging. In this way, situations that initially present themselves as barriers for a conversation can be transformed into a facilitating environment. (12) In normal conditions, 8 teachers (for approximately 15 students each) give experiential sessions regarding communicative skills in palliative care. In 2020 however, the coronavirus-disease (covid) pandemic challenged our education system in many ways. Real-life classes were compulsorily converted to online classes. As a result, this lesson was given online for more than 100 medical students, by only 2 teachers. The lesson was given in plenary in combination with breakout rooms to give the students the opportunity to practice and make the session more interactive.
With this study, we wanted to determine whether medical students believe that they have acquired su cient skills to work with palliative patients in practice. We tested the theoretical knowledge about PC and the self-con dence of students regarding speci c communication skills on this topic. Secondly, we looked at whether the current way of teaching was able to improve student's speci c communication skills on this topic. Thirdly, we took a look at how the corona pandemic caused a shift from live to online teaching and if this affected the training. Lastly, we wanted to know if we could succeed in getting students to understand that certain circumstances can be used to start a conversation about ACP. Therefore, we gauged students' opinions on how the corona pandemic might in uence the conversation about ACP. With all this information we can map out possible gaps in the palliative care training and take them into account for further training.

Materials & Methods
Current Flemish education lasts six years and consists of a three-year bachelor's program and a threeyear master's program. In the bachelor's program, focus lies on normal organ function and physiology. In the master's program, focus lies on different pathologies and application of knowledge in clinical practice. After approval from the ethics committee, for two consecutive years (2019 and 2020), two cohorts of students from the second master's year from the University of Antwerp were recruited.
The survey consists of three parts. The rst part contains demographic data of the participant. The second part contains four questions that assess the current knowledge about palliative care (scored on 11). As there is no standard questionnaire for palliative care knowledge, these questions were designed by our own teachers and according to the content of the palliative care lesson taught. ( After obtaining informed consent, the survey was completed a rst time right before the lessons regarding communicative skills around advance care planning and a second time right after these lessons occurred. In the rst cohort, the survey was manually distributed during another plenary lesson. The second round of the survey was then questioned online to the participants a few weeks later. In the second cohort, both parts of the survey were questioned online with a few weeks in between. The online survey program "LimeSurvey" was used to collect the online surveys. Data was exported to SPSS version 27. And SPSS version 27 was used for descriptive analysis.
In the second cohort we added a qualitative part to our survey. We asked students if they saw the Covid-19 pandemic as a possible barrier or facilitator in engaging in end-of-life/advance care planning conversation. For this qualitative descriptive part of the study, the students' text responses were thematically analysed by two independent researchers using Excel. In a rst phase, each researcher labeled the students' responses individually using open codes, close to the students' words. Notes and interpretations were added. In a next step, these open codes and text fragments were compared and categorized in overarching themes, while differences in interpretations where discussed in a joint session. Finally, an overview of the different themes was made.

Results
A total of 220 students participated in this study. Table 1 shows demographics of the questioned students and Fig. 1 shows the ow diagram of the participants.  Table 2.1 shows the percentage of students answering 'yes' on the following questions: "Do you think that enough time is spent on end-of-life-education?"; "Do you feel you have gained enough knowledge from the end-of-life classes?"; "Do you feel that you are able to choose the right moment in time and independently have a conversation with a patient about advance care planning?". In 2019, about 60% of the students think that enough time is spent on end-of-life education. In 2020, this is only true for about 50% of the students. In both years (82% for 2019 and 77% for 2020), a large proportion of students indicate that they have insu cient knowledge regarding palliative care. After the given lesson, the students feel that their knowledge has clearly improved, 67% and 70% indicate that they have acquired su cient knowledge for 2019 and 2020 respectively. A minority of the students indicate that they are su ciently able to independently conduct a conversation around advance care planning. (10% in 2019 and 12% in 2020). After the lesson, this number increases signi cantly to 48% of students in 2019 and 40% of students in 2020.  Table 2.2 shows the average scores on part 2 of the survey (the knowledge test). In general, the students score well on these questions. The average scores before the lesson are lower than those after the lesson. Report the death of a patient to family members 29% 45% 44% 50% Table 3 shows the self-reported con dence of our students in different domains of communication skills concerning palliative care and advance care planning. Students questioned in 2019 report a high con dence on the topics: empathic attitude towards patients and/or family members, empathic attitude in conversations and respect for other cultures and beliefs. Students report a low con dence on the topics advance care planning, coping with a palliative patient and discussing the impending death with patient and/or family members. Students questioned in 2020 scored likewise results for the high con dence and a minor shift to the topic discuss withholding of life-prolonging treatment in the low con dence category. After the speci c communication lessons in 2019, students score a higher con dence on most categories. The only topic scoring lower after the lessons is resolve con icts or negotiate con icts. In 2020 students score a higher con dence on all topics after the lessons.   Table 4.1 shows the raw extracted answers of the study question into 5 general categories. Before the lesson and the presentation of the article, the students' opinions were clearly divided into a "for" or "against". Most students (39%) saw that the covid-19 pandemic could act as a barrier in engaging end-of-life conversations. On the contrary, a large group of students (31%) felt that the pandemic could just act as a facilitator. A considerable amount of students (21%) had no idea and a negligible amount of students (1%) felt that there was no in uence of the pandemic on engaging these conversations. Only a small amount of students (8%) described both facilitating as limiting factors. After the lesson, the students' opinions were more nuanced.
Most of the students (59%) saw the pandemic as merely facilitating and a smaller amount of students (14%) saw the pandemic as merely limiting the end-of-life conversation. More students on T2 (14%) described both facilitating and limiting factors of the pandemic, compared to T1.   Table 4.2 shows the more extensive responses, categorized in 5 main themes. Category 1 (pandemic as a facilitator) and category 2 (pandemic as a barrier) are further divided into 5 and 6 subcategories respectively. Overall, category 1 describes all factors that could contribute in engaging end-of-lifeconversations. The most frequently cited reason is that confrontation with the coronavirus causes people to re ect more frequently on their own desires for extended therapy. This confrontation happens both through the media and through people in the environment who fall ill. Another important reason is that the pandemic can be used as a starting point for end-of-life conversations. The potential hindering factors in category 2 are mainly described as being practical concerns: wearing a mouth mask, distance during conversations, online consultations rather than real-life consultations, organizing conversations,.... Another important category is that of delayed care due to regional measures. Of particular note is that students often indicate that there is a large factor of fear/emotion going on with the patient. This can both initiate and avoid the conversation around the end of life. Students' responses that state they had no idea of an in uence between the pandemic and engaging end-of-life conversations were included in category 3. Category 4 includes all responses that consider advance care planning to be a purely logistical thing, namely: home nursing, home care, admissions to a palliative unit,.... In category 5, we see the responses of students who believe that they cannot learn from a lesson or article, but that they have to learn in real life and the responses where the question was misinterpreted.

Discussion
The students participating in this study are only one step away from their internships and their immediate contact with possible palliative patients. At this stage, a large proportion of students indicate that there is not enough time spent on palliative care and advance care planning. At the University of Antwerp, very limited time is spend on this topic at the moment. Despite this fact, students have a good background medical knowledge around palliative care.
Our study shows that students score themselves overall as being con dent in general communicative skills (e.g.. empathically engage in a conversation, have respect for different cultures and believes, ask for informed consent). However, when it comes to communicative skills speci c to palliative care and advance care planning (e.g. able to cope with a palliative/dying patient, discuss advance care planning, negotiate treatment goals), they score themselves as being non-con dent before the lesson and insu cient-con dent after the lesson. These speci c skills need to be intensively trained during the internships. Students may underestimate the power of good communication skills in clinical practice. Even in situations where own clinical expertise is lacking, good communication can help overcome insecurities and improve patient-doctor relationship.
We see from the results that after the speci c lessons, the students feel more competent to start a conversation about advance care planning. A few topics remain di cult. First of all, when we look at the topic 'discussing DNR code', we see that this skill clearly improves after the lesson, but that there is still room for further improvement. Discussing a DNR-code is a very important issue in every hospital (and residential care facilities). Especially during the covid pandemic, it turned out that this is not obvious. It therefore seems to us to be a correct judgement of the students to label this skill as di cult. The di culty of a DNR discussion is twofold. On the one hand, there is the medical aspect where underlying comorbidities play an important role in the possible decision to restrict therapy. On the other hand, the timing and how to initiate this conversation, is an important communication skill that is regularly violated in practice. It goes without saying that this is a skill that students will only develop over time and with practice. Communicating this message in the lesson itself can already be helpful for students. This does not alter the fact that this remains a topic on which further work is needed. To explore this further, we have created a new survey to explore how this impacts physicians and physician assistants in clinical practice. Secondly, students also indicate that they nd it di cult to inform relatives that a patient has died or will die soon. In our opinion, this seems to be a situation that can be practised on. (15) Telling the family that a patient is dying or has died is an important task as a doctor. Every doctor should be able to do this. Because of this result, we decided to implement a new scenario during the lesson "breaking bad news" in which the student has to tell a simulation patient that a family member is shortly going to die. Lastly, resolving or negotiating con icts is scored as a di cult topic. Here, too, we share the view that this remains a di cult topic in practice. During the lesson on diversity, we try to provide tools for doctors to deal with other cultures, religions, norms and values. There is also a speci c lesson in which we work with a potentially angry or aggressive patient. Further experience in practice is needed to develop this skill.
Another important result is that we notice the same trend in con dence scoring when teaching in real life or teaching online. Therefore, in the context of student's self-con dence, online teaching forms a good alternative for the intense and focused group discussions. This could be of great importance as there are less teachers needed for teaching online compared to teaching these skills face-to-face in focused and limited groups. Nevertheless, for the effective learning of these communication skills, it seems appropriate to be able to teach these lessons in real-life.
The extra survey question regarding the covid-19 pandemic showed that students rst of all think about the possible practical obstacles for end-of-life conversations (time constraints, little face-to-face contact, absence of family members, annoying aspect of mouth masks in both verbal and non-verbal communication, ...). After a re ective article as well as bringing it up in class, more students saw the possible bene ts of the pandemic (self-re ection of patients, norms and values of individuals and families, the impossibility of receiving visitors during hospitalisation, …). With this lesson, we initiated a more considerate attention in students to recognise challenging situations as a starting point for entering into end-of-life conversations.
As possible limitations for our study we note that in the rst year of our research, response for the second survey was much lower than for the rst survey. This could possibly imply a selection of students with speci c interest in the topic palliative care. Also, this study only provides a picture of the situation at our own university.

Conclusion
A lot of students indicate that there is not enough time spent on palliative care and advance care planning. Despite this fact, theoretical knowledge regarding palliative care is su cient. Our study also shows that students score themselves as being con dent in general communicative skills, but lack con dence in speci c communicative skills regarding palliative care and advance care planning. Con dence in these communication skills becomes stronger after speci c lessons focusing on advance care planning and palliative care, but this remains challenging. As a result of this survey, some lessons in the subject "communicative skills" were adapted. This allowed us to provide students with new tools to address the gaps in their self-con dence. These speci c skills must be trained intensively during the internship year. As an internship supervisor, it is therefore important to pay su cient attention to engaging students in end-of-life conversations. We notice the same trend in this con dence scoring when teaching in real life or teaching online. We therefore state that the online way of teaching forms a good alternative for the focused group sessions. Availability of data and materials

List Of Abbreviations
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
No funding was obtained for this research

Authors' contributions
MvdW was responsible for the practical design and implementation of this study, as well as the preparation and analysis of the database. She was a major contributor in writing the manuscript. KB is responsible for the lessons regarding advance care planning and helped analyse and interpret the qualitative data. AJ was the supporting factor for distribution of the survey to the students and responsible for the lessons regarding advance care planning. All authors read and approved the nal manuscript.