It is possible to observe that the living process has extended exponentially in the last decades, due to technological innovations that impacted the increase in survival. Despite the increase in cancer prevalence and several chronic diseases, it is clear that death, in most of cases, is no longer an episode, but a process, which is often extended, and may take years and even decades depending on the illness .
Every disease, especially the ones that threatens to interrupt life, can cause a series of losses, such as the loss of autonomy, self-image, security, physical capacity, respect, not to mention concrete material losses, such as employment, purchasing power and therefore the social status with which the patient and family are forced to live, almost always without being prepared for this situation. This event often causes anxiety, depression and hopelessness, interfering negatively in the evolution of the disease, in the intensity and frequency of symptoms, which can be difficult to control .
There is a daily increase in elderly patients’ health services sent to special care. Especially people with dementia syndromes from the most diverse etiologies or even with severe neurological sequels. In this regard, the palliative care appears as an option, to fill this gap in the active care for patients in the last phases of life, in a more dignified way. A decent finitude can be defined as the one without pain and suffering, minimized with the palliative care suited to the patient's needs [3, 4].
The expressions “patient in the last phases of life” and “out of therapeutic possibilities” are the labels given to patients with diseases which doesn’t have any possibility of cure. These are progressive diseases like degenerative neurological diseases, cancer and AIDS. The treatment of the patient in the last phases of life, no longer suggests a cure, but the relief of symptoms and the preservation of life .
Cicely Saunders who was a nurse, doctor and social worker, during the 1960s, made efforts to introduce the Hospices movement which were institutions designed to soften the pain caused by terminal illnesses, providing care for people to have the possibility of dying in peace, with dignity and with life quality through special care. This kind of care seeks for a whole 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 .
The first 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 .
The first Palliative Care definition 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 definition was revised in 2002, reaffirmed 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 identification, correct assessment and pain treatment, as well as other physical, psychological, socio-family and spiritual problems .
In Brazil, palliative care started in the 1980s, with the first 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 specifically 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 . 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 specific 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-scientific training in detriment of the approach of emotional, spiritual and social aspects . 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 conflicting situations, in real and hidden curricular modality [13,14 ].
Human terminality process should not be a problem in medicine field, 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 finitude 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 . 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 certification 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 . 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..
According to the National Association of Palliative Care (NAPC) , 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 clarifications 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 .
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 scientific 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?
To identify knowledge of resident doctors regarding palliative care.
- To assess knowledge of resident doctors regarding palliative care;
- To identify practices of resident doctors regarding palliative care;
- To check if there are variations in knowledge and practices in palliative care in different medical specialties.