The nursing and PharmD are the main professions in PPC team members as well they play a vital role in practice and improving the PPC (16). Future nurses and PharmDs can play a major role to facilitate decision taken by terminally ill child and families through communicating, educating, advocating, and collaborating with terminally ill children, families, and other health care providers (12).Thus, studies were focused on assessing nursing and other health professions knowledge in a different situation and contexts like nursing students which are considered the future health professionals, (17–21). Yet, few studies evaluated the ratings of end-of-life knowledge/ beliefs, understanding/ experience, expertise, and the appropriateness of the workplace settings concerning established and progressive learning of PPC among future nurses and PharmD (17, 18). The authors in this study created a descriptive cross-sectional survey that was issued to 402 nursing and PharmD students.
The current study found that knowledge of nursing and PharmD students regarding PPC was satisfactory according to the scale used. According to Karkada et al and Yousef et al (8,9), it was revealed that nursing students have insufficient knowledge in PPC. The knowledge of future health providers such as nursing students in developing countries toward PPC has been explored in a few studies and no study explored PharmD knowledge regarding PPC. For instance, the conduct of nursing students of Muslim and other faiths in relation to PPC has been investigated in Turkey (10) and in Saudi Arabia (11). The multivariate assessment revealed that receiving formal PPC education and having working experience in a hospice had a relationship with greater understanding (19). Conner et al during his study in PPC areas found that students have poor knowledge about PPC concepts, death meaning and dying care and this required an urgent education to improve their knowledge and impact their attitude. A literature review conducted by Gillan who found insufficient end-of-life content in nursing books and deficient palliative care content in undergraduate nursing curricula. Furthermore, there are poor knowledge among nursing students regarding palliative principles and philosophy. Basic concept that defining the concept and objective, essence of palliative care, and the philosophical underpinnings of palliative are not covered within the curriculum. Notably, the study also revealed poor knowledge in the psychosocial and spiritual care dimension of palliative care (14). Studies have reported that insufficient information of nursing students in spirituality in relation to health and spiritual nursing care in PPC (24, 25)
Current results showed that there a significant difference in palliative between nursing and PharmD students (t=1.969, p=.050). The PharmD students had higher knowledge score toward PPC. This difference may relate to more exposure of PharmD students to end of life patients or having more training during their program. There are no previous studies that compared knowledge toward PPC between nursing and PharmD students. However, there are many studies compared knowledge between nurses and physicians.
The current study found that all demographic factors are not associated of knowledge toward PPC (p value > 0.05) except mother education (t= 2.158, p= .032) and being a nursing or PharmD student ( t=1.969, p=.050).Based on multi-linear regression of Cui et al (24), three issues may have affected the needs of nurses in death education: past education (t = 2.32, p = .021), past training regarding death education (t = 4.02, p < .001), and the size of the hospital (t = -5.49, p < .001). Many studies found that many nurses regardless of faith, held several misconceptions about PPC. Moreover, a previous study showed that while there are many variations in knowledge between religions, there are also several similarities in regards to how future nurses and deal with death and the treatment of dying terminally ill children (9, 10).
According to a previous study, most of the nursing students were in the 21-year age group (51%), of which 92% were females. Only 43.3% of the respondents knew the meaning of palliative care; they remembered it from their clinical education (8). The results showed that 79.5% of the students had poor palliative care knowledge, while the attitudes of 92.8% of the students favored palliative care. Chi-square results indicated a significant relationship between the knowledge and age of the student of nursing (χ 2 = 18.52, p < .01) (8). Other investigators have found that senior nursing students had significantly higher scores compared to those of sophomore students, indicating that nursing education and experience contribute to greater generalist knowledge about palliative care (24). This is not consistent with the levels of knowledge of the participants who were in their second year were higher than those of the participants in their fourth year (16, 28). This difference may be attributed to the integration of palliative care concepts into the course on Fundamentals of Nursing that taught for somphere students during the first years. The information regarding this concept, as partially discussed in the Fundamentals of Nursing. These findings suggest that nurse educators may integrate content on palliative and end-of-life care into standard nursing curricula using PPC core course and have positive learning outcomes even if there is some overlap in the content.
According to Karkada et al., (8) and Wesisman (25) , there was a negative association between the scores of knowledge and attitudes of nursing students towards palliative care. Moreover, there was a significant relationship between the nursing students’ age and their palliative care knowledge (8). Likewise, Weissman (25) explored the knowledge and attitude of nursing students receiving communication module regarding end-of-life and students without communication. The study had seventeen nursing student respondents (intervention group: n = 9; control group: n = 8).
Implication for practice
Insights and different thinking ways were generated using critical reflection. Department developed belief and caring conditions for instructing on the content of end-of-life. Environments like these assisted students in sharing their thoughts since they created new ideas and understanding regarding issues that had no previous examination. Nursing and pharmacy programs that teaches PPC can promote transformative education by integrating the content of end-of-life training and the nursing curriculum teaching approaches to guide the teaching of care interventions that could reduce students' discomfort when dealing with mentally ill individuals. Furthermore, end-of-life education was considered beneficial to learning, but not enough since graduates were still novices in the nursing role and sought experience. Besides, future nurses and PharmD encountered challenges in compassion balancing and meeting the responsibilities of a nurse. Researchers recommend that these results provide beneficial explanations of the challenges of executing PPC in clinical activities while helping the ill and their relatives through death.
Ethics in Palliative Care
Caring for patients with serious and complex illnesses that can compromise their quality of life (QoL) poses many ethical challenges. Healthcare providers strive to make decisions and offer guidance with difficult and complex treatment choices and improve the QoL of patients and their caregivers. Facing advanced and terminal illnesses could be very stressful and may result in patients having complex medical needs. Thus, palliative care aims at optimizing QoL and alleviating distress through managing symptoms and complex needs (26–28). Although palliative care decisions are geared towards controlling the patient’s symptoms in difficult medical situations and putting QoL at the center of patient care, several medical decisions need to be morally justified to maintain patient’s dignity and confidence as well as avoid conflicts in values between physicians and patient or patients’ families (28,29). According to the ethical principles of autonomy, justice, and dignity, the patient’s desires should be respected (30) . These ethical principles become evident when patients receive treatment with care and compassion like anyone in a similar medical situation (30). Therapeutic options need to be tailored based on different patients’ factors, physicians’ discretions and ethical obligations can become more challenging when offering palliative care services (29). If patients were self-discouraged or unable to be involved in making medical decisions, physicians must make decisions in their best interest unless the patient expressed his wishes earlier (29,30). Further, many patients receiving palliative care prefer not to perceive the uncertainty of physical decline or death, allowing healthcare providers choose the ultimate course of action that should be aligned with patients’ desired outcomes after clarifying possible health consequences and the possibility to achieve safe and effective transitions of care (30). Nevertheless, physicians are not obligated to offer medical interventions that have physiologically ineffective outcomes or when concerns about types and levels of care that should be delivered for patients experiencing intolerable pain or with a limited life expectancy arise. Thus, patients might prefer not to receive a treatment or have some proxy decision-makers involved in their healthcare decisions (30).
Since Cardiopulmonary resuscitation (CPR) would be physiologically useful for some patients, it might not be the case for other patients due to the severity of their illness, the number of morbidities, and multiple CPRs received, who might, therefore, carry an increased psychological burden (31). Barriers to physicians’ referrals for palliative care include fears that palliative care will deprive patients from receiving life-prolonging therapy and limit access to expensive treatments such as chemotherapy and transfusions (31). However, previous studies revealed that the early introduction of palliative care for patients with terminal illness could improve patients’ QoL and potentially reduce the need for intensive intervention while being relatively cost-saving, suggesting that adequate access to palliative measures along with other indispensable therapies could be a good practice guide to not only balance patients’ uncertainties in palliative care but also to keep physicians from diverting patients away from receiving palliative therapy and possibly delaying their care (26–28). Moreover, difficult decisions regarding withdrawing treatment could be made by physicians once these palliative measures are no longer of benefit in terms of disease recovery, comfort, or improving QoL. As patients’ health needs are always at the forefront of care, it is significant to explain to patients and patients’ families the extent to which palliative care can be effectively provided to relieve symptoms rather than irrelevantly delaying or hasten the death of patients (30). The need for palliative care should be discussed openly with the patient before it is undertaken, which helps avoid the ethical dilemmas that may arise when patients believe that they were not being appropriately treated. Lack of clear guidelines and boundaries on the levels of palliative care that have been delivered is another challenging difficulty that needs to be controlled to better ensure delivery of care and enhance patients’ dignity.