Knowledge of Resident Doctors Regarding Palliative Care: A Systematic Review

Background: Palliative care aims to improve life quality of patients and their families, preventing and relieving people's suffering in coping life-threatening diseases. Many challenges are linked to palliative care, such as the lack of specic disciplines in doctors training; the scarcity of services and specialized programs in palliative care in public and private health systems and the lack of training for resident doctors. Objective: To identify knowledge of resident doctors regarding palliative care. Method: A systematic review according to PRISMA (2009), with searches carried out in Cochrane Library, MEDLINE / PubMed, Scopus, Web of Science databases and gray literature of Brazilian Digital Library of Theses and Dissertations (BDTD), with the acceptance of articles in English, Portuguese and Spanish, without delimitation of publication date, geographic location and type of study. Only studies with resident doctors were included. Results: During the search, 931 articles were found. Of these, 363 were discarded because they were duplicated and 568 were discarded after reading titles and abstracts, leaving 24 articles for complete reading, which after reading and consensus of the three researchers, only 07 of these articles were included in the comparative synthesis. Three intervention studies, two cross-sectional and two qualitative studies were found. In the observed data, all the analyzed studies had a sample of less than 100 subjects, with a total of 442 subjects, of which 137 (30.99%) were women and 111 (25.12%) men, with average age ranging from 26.6 to 32.1. Conclusions: The studies analyzed in this review indicate that the knowledge of resident doctors was limited and insucient related to palliative care, what indicates the need of greater investments in training, through teaching-learning methods based on rotation, simulation and others, thus improving not only knowledge, but also the practice in palliative care.

vision of the human being, through a multiprofessional team, compounded by doctors, nurses, psychologists, social workers, religious, volunteers and other professionals, when necessary. This movement represents the philosophy of palliative care [6].
The rst palliative care unit was founded in 1960 in Korea, at the Calvary Hospice of Kangnung. In the 1970s, the concern about palliative care in some countries arises, what made some institutions emerge as the International Association for the Study of Pain and the Japanese Association for Clinical Research on Death and Dying. In the 1980s, the World Health Organization (WHO) inserted palliative care in its concepts and raised the need of a program as part of the approach to cancer patients. In the 1990s, the early introduction of palliative care in the course of oncological disease was recommended [7].
The rst Palliative Care de nition published by WHO, in 1990, was "Active and total care for patients whose disease is not responsive to healing treatment. The control of pain, other symptoms and psychosocial and spiritual problems is essential". This de nition was revised in 2002, rea rmed and replaced in 2017, as an approach that improves life quality of patients and their families, who face life-threatening diseases. Palliative care aims to prevent and relieve suffering through early identi cation, correct assessment and pain treatment, as well as other physical, psychological, socio-family and spiritual problems [8].
In Brazil, palliative care started in the 1980s, with the rst services instituted in Rio Grande do Sul, São Paulo, Santa Catarina and Rio de Janeiro. It began with the creation of Cancer Hospital IV, from National Cancer Institute (NCI), which works since 1989 speci cally for palliative care in outpatient care, hospitalization, in addition to home care. It is a national reference in health professional education and training for end-of-life care. In 2005, the National Academy of Palliative Care (NAPC) was founded by a group of doctors from different areas of activity, such as Geriatrics, Pediatrics, Oncology and Family Medicine, whose main objective is to disseminate, clarify and promote the palliative care in Brazil [9,10].
In Brazil, there is a training center for palliative doctors in Santa Catarina, in which the medical clinic resident can choose to take the third year in palliative medicine. Other states are also already offering medical residency in palliative care such as Brasília, Rio de Janeiro and São Paulo [11]. The training in palliative medicine should develop in the professional the ability to communicate, teamwork, competence in decision-making in the face of the life-threatening illness, management of speci c drugs, such as painkillers, intestinal regulators, sedatives and antipsychotics, as well as support techniques for coping with death and grief. It is also known that the professionals' lack of preparation to deal with death is caused by cultural and spiritual issues and the teaching in the health sector, which emphasizes technical-scienti c training in detriment of the approach of emotional, spiritual and social aspects [12]. Often, death can be understood as defeat, a personal frustration that goes beyond technical limitations. Because of this perspective, death is seen as fearful and doctors try to avoid it at all costs, although throughout their medical residency they are trained to deal with it everyday and con icting situations, in real and hidden curricular modality [13,14 ].
Human terminality process should not be a problem in medicine eld, as it is a natural event, such as birth, growth and development. In this painful process of impossibility of cure, the patient needs love, understanding, solidarity and his dignity consideration. Therefore, it is necessary that medical education also makes professors and students aware about the humanization of people who are on the edge of life and death. Thus, it is necessary to introduce topics about death and the dying process, life nitude and palliative care, in the interdisciplinary doctors training and other professionals in the health areas [15,16,17].
In Brazil, the Medical graduation courses must follow the National Curriculum Guidelines (NCG) proposed by Education Ministry [18]. However, for the most medical residency programs, there are no proposed national program guidelines on palliative care, as well as requirements for evaluation processes for certi cation at the end of specialist training.
Palliative care's philosophy suggests that, when addressed during medical students' training, it can provide better therapeutic resources when a cure is possible and better resources for palliative care when a cure cannot take place [19]. It is necessary and important to include palliative care studies in medicine courses' programs, just as in all courses from health area and also during professional practice, so patients can be attended in an ethical, holistic and human way, especially in the impossibility of the disease's cure. [20].
According to the National Association of Palliative Care (NAPC) [21], in Brazil, medical courses do not teach students how to deal with terminally ill patients, how to recognize symptoms or manage this situation in a humanized and active way. However, the doctor in palliative care is a very important professional. He will contribute in providing clari cations on diagnoses and prognosis for the patient whose death is certain, guiding the team, always cultivating a good communication with the other professionals, making decent the last moments of the patient's life.
It is essential to search for suitable knowledge so that a comprehensive care can be provided to the patient in the last phases of life. It is also important to expand the discussion and training on palliative care, improving medicine graduation courses programs and other health areas, with subjects that address death and care, as well as raising the awareness of the population itself, who knows little about the topic [22].
Based on studies already carried out on palliative care practices worldwide, and also, taking into account the medical skills (knowledge, practices and attitudes) that are necessary to improve the quality of survival of patients seeking a cure, this systematic review may serve as a dissemination and expansion tool to discuss palliative care, both in medicine and in area of health care.
There is an urgent need for studies that present and systematize palliative care at the medical residency, especially in the face of a worldwide scenario of increased life expectancy for the population and concern for the life quality of any patient, especially those in terminal condition. The role of the resident doctor, in this new context, is no longer just a curative, reduced to a limited vision of human health. In this way, the professional starts to perform a function that involves a humanized, systemic and biopsychosocial approach with terminal patients, meeting a broader, updated concept of health-disease and better suited to new educational needs.
Considering the relevance of the topic and the discussions in the scienti c literature regarding care for terminally ill patients, this study has the following question as its guiding thread: What is the knowledge of the resident doctors in palliative care assistance?

General objective
To identify knowledge of resident doctors regarding palliative care.

Method
A systematic review, which protocol was published on the prospective international registration site for systematic reviews -PROSPERO (CRD42020159428).
Structured according to Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines -PRISMA (2009) [23], according to Additional le 1.

Eligibility criteria
The studies were selected according to the criteria: Participants (Population): Individuals of both sexes, any age and any geographical location.
Exposure: Any specialty and at any level of medical residency (R1, R2, R3 and R4).
Comparison: With or without a comparison group.
Outcomes: Knowledge level of resident doctors regarding palliative care.
Study design: All types of study; gray literature was considered (theses and dissertations) from any geographical location; in Portuguese, English and Spanish. Without delimitation of publication date. Editorials, letters and literature review articles were excluded.

Research strategy
The search was made in the databases of Cochrane Library, MEDLINE / PubMed, Scopus, Web of Science and Brazilian Digital Library of Theses and Dissertations (BDTD) gray literature.
To guarantee the literature saturation, reference lists of included studies or relevant reviews identi ed through manual search were analyzed. A research for gray literature was also made.
The following keywords or descriptors were used in the research strategy: "palliative care" OR "palliative medicine" OR "terminal patient" OR "end of life care" OR "terminal care" AND "resident doctors" OR "medical residency" OR "medical students" AND "knowledge" OR "practices".
The research was carried out according to the guidelines of each database, as shown in the research strategy in Table 1. Research terms (Descriptors) Results Scopus "palliative care" OR "palliative medicine" OR "terminal pacient" OR "end of life care" OR "terminal care" AND resident doctors" OR "medical residency" OR "medical students" AND "knowledge" OR "practices" 377 EMBASE palliative care OR palliative medicine OR terminal pacient OR end of life care OR terminal care AND resident doctors OR medical residency OR medical students AND knowledge OR practices 216 Wed Science "palliative care" OR "palliative medicine" OR "terminal pacient" OR "end of life care" OR "terminal care" AND "resident doctors" OR "medical residency" OR "medical students" AND "knowledge" OR "practices" 201 MEDLINE/PubMed "palliative care" OR "palliative medicine" OR "terminal pacient" OR "end of life care" OR "terminal care" AND resident doctors" OR "medical residency" OR "medical students" AND "knowledge" OR "practices" 114 BDTD/Gray Literature "palliative care" OR "terminal patient" OR " nal stage of life" OR "resident doctors" OR "medical residency" AND "knowledge" OR "practices"

16
Cochrane Library "palliative care" OR "palliative medicine" OR "terminal pacient" OR "end of life care" OR "terminal care" AND "resident doctors" OR "medical residency" OR "medical students" AND "knowledge" OR "practices" 08 Total 931

Data selection and extraction
The three researchers conducted the research and selected the studies independently, using speci c reference management software (EndNote Web).
The selection took place in four stages and after each one, the researchers veri ed inclusions and exclusions, seeking consensus among the results. There was no need for a reviewer to solve differences.
In phase 1 (Identi cation), the studies were searched and the duplicates were identi ed, using the EndNote software, and then removed; In phase 2 (Screening), the titles and abstracts of the articles were read and the exclusion and inclusion criteria were applied; In phase 3 (Eligibility), there was a manual research and the reading of the full articles was carried out and then those which met the eligibility criteria were selected (Participants, Exposure, Comparison, Results, Study design); In phase 4 (Inclusion), a table was constructed with the authors identi cation, objectives, methods, results and conclusions and a subsequent qualitative synthesis of the studies.

Risk of Bias (Risk of Bias -RoB)
To assess the risk of bias in the selected studies, the tools of Joana Briggs Institute -JBI [24] were used, considering the studies that met the JBI requirements in (≥ 7 points) of "high" quality and low risk of bias. Those which scored 5 to 6 points were classi ed as "medium" quality and moderate risk of bias. The articles that achieved a score (≤ 4 points) were considered to have "low" quality and a high risk of bias.

Summary of Evidences
The reading of the full articles enabled to verify that the studies are heterogeneous, which compromised the performance of a meta-analysis.
A table was constructed with the authors identi cation, objectives, methods, results and conclusions with subsequent comparative studies synthesis.

Studies Selection
Initially, 931 records were identi ed in the databases. 363 duplicates were excluded, leaving 568 for the next phase. 458 were excluded during the reading phase of the titles and 86 when the abstracts were read because they did not meet the inclusion criteria, leaving 24 records for full reading.
No records were found in the manual search, remaining 24 for the full text reading.
Upon reading the complete studies, 17 records were excluded. Seven studies were selected for comparative data synthesis, as shown in Picture. 1. Tabela 2 Seven articles met the inclusion criteria, as well as this work proposal.

Descriptive Synthesis of the included studies
Regarding the geographical region where the studies were developed, they were published in Canada, India, Switzerland, the United Kingdom, Saudi Arabia and the United States.
In the observed data, all studies analyzed had a sample of less than 100 subjects. 42.86% had a sample of between 50 and 100 subjects and 57.14% had a sample of less than 50 subjects.
The total of sample from the referred research was 442 subjects, being 137 (30.99%) women, 111 (25.12%) men and 194 (43.89%) individuals without gender speci cation. The average age ranged from 26.6 to 32.1 years.
In relation to instruments, each article used a different instrument for data collection, such as: multiple choice survey adapted from David E. Weissman, MD (personal communication) [25], Pediatric Palliative Care survey ( PPCQ) [26], Quality care at endof-life [27], survey on palliative care education and training during residency (instrument's name was not identi ed in the study) [28], Quality care at the end-of-life -knowledge of care at end-of-life [29] and interview script [30,31]. The instruments used in studies 26 and 29 were previously validated; the others were in the process of validation or this item was not mentioned.
The studies are heterogeneous, both in terms of objectives and instruments, as well as in the residents' area of acting and in the results presentation. The articles were divided into groups, three of which were developed in medical clinic [29,30,31], one in pediatrics [26], one in oncology [28], one in family medicine [27] and one in rotation system [25].
As for the teaching method, simulation techniques, didactic training and rotation in hospital units were used in the articles studied.
Studies [25,27,31] indicate that they received support from universities and foundations; the other studies were not supported or did not specify this item. Only one study [31] showed the presence of con ict of interest.
The studies' results [27, 28, 29, 30 31] demonstrate that residents' knowledge of palliative care is limited and insu cient. In addition, in one study [27] it was observed that there was no signi cant difference between rst and second year residents.
Knowledge of hospitalized terminal patients care was perceived as one of the main di culties among resident doctors, who admit to have little knowledge of basic palliative care.
Newly quali ed doctors realize that they receive little formal education on palliative or end-of-life care in their new role, and the culture in the hospital environment does not encourage learning on this subject. And that most of them learn with 'trial and error' while 'doing the job', but that their skills and knowledge are limited.
No signi cant differences were found between R1 and R2 [27] with regard to residents' knowledge in palliative care at the endof-life, which may indicate that the medical residency program did not develop such knowledge. Some resident doctors have stated that the rotation system has improved knowledge on palliative care for end-of-life patients.
As for the simulation-based program, it proved to be an effective method to improve comfort, education and consultations in palliative care, but a more frequent practice is needed to lead to sustained improvements in communication skills.
The studies [25,26] present rotation and simulation programs as effective methods of improving knowledge in palliative care during medical residency period, without, however, statistically signi cant difference.

Risk of Bias Assessment
The Bias risk analysis was carried out with the Joana Briggs Institute's instruments according to each type of study, as shown in Table 3.

Discussion
This general objective of this review is to identify the resident doctors' knowledge regarding palliative care. As far as it is known, no systematic review found addressed this topic, which justi es the elaboration of the study in question.
The studies analyzed in this review show that resident doctors' knowledge proved to be limited and insu cient in relation to palliative care. It was not possible to assess whether there are differences in the level of knowledge of residents in relation to age, sex, medical specialty, stage of residence, geographic location where the studies were carried out and instruments used for data collection.
In the study by Luthy et al. [30] some di culties in palliative care are also identi ed, such as: ability to provide adequate information, understand patients' needs, have su cient theoretical knowledge, recognize limitations as a professional and also be prepared to help patients and their families. In the research by Brugugnolli, Gonsaga and Silva [32], doctors knowledge about palliative care proved to be precarious, pointing to the need for speci c education on this topic.
The study by Roldi and Moritz [33] concluded that due importance is not given to palliative care and that there is a need for optimization and dissemination of this topic among health professionals, mainly due to the growth of aging population and the consequent increase in the prevalence of non-communicable chronic diseases.
Such results may be related to the fact that undergraduate programs do not offer su cient and adequate training focused on knowledge in palliative care [7], which demonstrates the need for changes in the undergraduate courses program with the inclusion of disciplines and practices aimed at this topic and change in the behavior of health professionals with regard to palliative care practices [34].
The study by Conceição et al. [35] concluded that most doctors did not receive enough information about terminally ill patients at graduation and only a small amount had high rates of correct answers in speci c questions. This result points to the aws and the need for changes in medical training.
In Schaefer's study [36], some skills needed by resident doctors were pointed out that can be used to measure the training process' results in palliative care. Such skills must be developed on both undergraduate and medical residency.
For Arai et al. [37] in the medical residency period, skills should be taught in the direction of how to deal with uncertainties, contradictions and limitations, as well as provide opportunities for communication with other members of the multidisciplinary team and promote moments for the residents' experiences to be shared and discussed collectively.
In a study [38] carried out in The United States, competence-based training in primary palliative care was implemented and the results were positive, as it enabled greater learning for pediatric residents. The results of this study show that there was no signi cant difference between rst and second year residents, which reinforces the need for improvements also in residency programs, with greater use of teaching-learning methods that emphasize practice, such as rotation and simulation, which can also be observed in the study by Yacht, Suglia and Orlander [25].
Besides the methods presented, the home visit of patients is shown to be an effective way of training residents in palliative care, which in Brazil is provided for in the Family Health Program [39].

Strenghts And Limitations
One of this study's strengths is the fact that it is a systematic review of literature, as it allows syntheses and analyzes from other studies and as far as is known, this is the rst systematic review on the topic. Another relevant aspect is low risk of bias found in the selected articles, which demonstrates their high quality and consequently strengthens the conclusions of this review.
One of this review's limitations is the relatively small amount of primary studies found that emphasize the knowledge of resident doctors in palliative care, especially in developing countries, more speci cally in Latin America. Another limitation is the high heterogeneity of the studies, which made the analysis di cult, mainly by subgroups.
In databases used for this review, no study was found that addressed the practices of resident doctors related to palliative care, which made it impossible to achieve one of the speci c objectives of the research and highlights the need for investments aimed at practice, not only knowledge.
It was not possible to assess knowledge variation in the different medical specialties due to the diversity of instruments and ways of presenting the results (average, percentage, total score, content analysis by categories).

Conclusion
The studies analyzed in this review show that resident doctors' knowledge proved to be limited and insu cient in relation to palliative care, which reveals the need for greater investments in training, through teaching-learning methods based on rotation, simulation and other techniques, improving thus, not only knowledge, but also the practice in palliative care.
In view of this conclusion, it is suggested that new primary studies be carried out, taken place mainly in developing countries, in order to increase the quantity of publications on this topic. This systematic review explains the aws in the educational process of resident doctors, pointing out the need for improvements in the undergraduate educational program and medical residency program.

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download.