Journal of General Internal Medicine

, Volume 18, Issue 9, pp 685–695

The status of medical education in end-of-life care

A national report
  • Amy M. Sullivan
  • Matthew D. Lakoma
  • Susan D. Block
Original Articles


OBJECTIVE: To assess the status of medical education in end-of-life care and identify opportunities for improvement.

DESIGN: Telephone survey.

SETTING: U.S. academic medical centers.

PARTICIPANTS: National probability sample of 1,455 students, 296 residents, and 287 faculty (response rates 62%, 56%, and 41%, respectively) affiliated with a random sample of 62 accredited U.S. medical schools.

MEASUREMENTS AND MAIN RESULTS: Measurements assessed attitudes, quantity and quality of education, preparation to provide or teach care, and perceived value of care for dying patients. Ninety percent or more of respondents held positive views about physicians’ responsibility and ability to help dying patients. However, fewer than 18% of students and residents received formal end-of-life care education, 39% of students reported being unprepared to address patients’ fears, and nearly half felt unprepared to manage their feelings about patients’ deaths or help bereaved families. More than 40% of residents felt unprepared to teach end-of-life care. More than 40% of respondents reported that dying patients were not considered good teaching cases, and that meeting psychosocial needs of dying patients was not considered a core competency. Forty-nine percent of students had told patients about the existence of a life-threatening illness, but only half received feedback from residents or attendings; nearly all residents had talked with patients about wishes for end-of-life care, and 33% received no feedback.

CONCLUSIONS: Students and residents in the United States feel unprepared to provide, and faculty and residents unprepared to teach, many key components of good care for the dying. Current educational practices and institutional culture in U.S. medical schools do not support adequate end-of-life care, and attention to both curricular and cultural change are needed to improve end-of-life care education.

Key words

medical education end-of-life care palliative care 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Field MJ, Cassel CK. Approaching death: Improving Care at the End of Life. Washington, DC: National Academy Press; 1997.Google Scholar
  2. 2.
    The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. JAMA. 1989;274:1591–8.Google Scholar
  3. 3.
    Billings JA, Block SD. Palliative care in undergraduate medical education: status report and future directions. JAMA. 1997;278:733–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Emanuel LL, von Gunten CF, Ferris FD. Gaps in end-of-life care. Arch Fam Med. 2000;9:1176–80.PubMedCrossRefGoogle Scholar
  5. 5.
    Buss MK, Marx ES, Sulmasy DP. The preparedness of students to discuss end-of-life issues with patients. Acad Med. 1998;73:418–22.PubMedCrossRefGoogle Scholar
  6. 6.
    Block SD, Billings JA. Nurturing humanism through teaching palliative care. Acad Med. 1998;73:763–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Solomon MZ, O’Connell L, Jennings B, et al. Decisions near the end of life: professional views on life-sustaining treatments. Am J Public Health. 1993;83:14–23.PubMedGoogle Scholar
  8. 8.
    Teno JM, Hakim RB, Knaus WA, et al. Preferences for cardiopulmonary resuscitation: physician-patient agreement and hospital resource use. The SUPPORT Investigators. J Gen Intern Med. 1995;10:179–86.PubMedCrossRefGoogle Scholar
  9. 9.
    Saunders CM. The Management of Terminal Illness. New York, NY: Hospital Medicine Publications; 1967.Google Scholar
  10. 10.
    Block SD. Perspectives on care at the close of life. Psychological considerations, growth, and transcendence at the end of life: the art of the possible. JAMA. 2001;285:2898–905.PubMedCrossRefGoogle Scholar
  11. 11.
    Block SD. Medical education in end-of-life care: the status of reform. J Palliat Med. 2002;5:243–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Fins JJ, Nilson EG. An approach to educating residents about palliative care and clinical ethics. Acad Med. 2000;75:662–5.PubMedCrossRefGoogle Scholar
  13. 13.
    Wood EB, Meekin SA, Fins JJ, Fleischman AR. Enhancing palliative care education in medical school curricula: implementation of the palliative education assessment tool. Acad Med. 2002;77:285–91.PubMedCrossRefGoogle Scholar
  14. 14.
    Medical College of Wisconsin End of Life Palliative Education Resource Center. Available at: Accessed July, 2003.Google Scholar
  15. 15.
    Weissman DE. Pre-clinical palliative medical education at the medical college of Wisconsin. J Cancer Educ. 1993;8:191–5.PubMedCrossRefGoogle Scholar
  16. 16.
    Weissman DE. Palliative medicine education at the Medical College of Wisconsin. Wis Med J. 1995;94:505–8.PubMedGoogle Scholar
  17. 17.
    Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69:861–71.PubMedCrossRefGoogle Scholar
  18. 18.
    Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med. 1998;73:403–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Code of Federal Regulations. Title 45, Public Welfare, Part 46: Protection Of Human Subjects. Department Of Health And Human Services, National Institutes Of Health Office For Protection From Research Risks. Revised November 13, 2001. Available at: Accessed January, 2001.Google Scholar
  20. 20.
    American Medical Association Fellowship and Residency Electronic Interactive Database. Available at: Accessed January, 2001.Google Scholar
  21. 21.
    Hoyert DL KM, Murphy SL. National Vital Statistics Reports. Deaths: Final Data for 1997. PHS 99-1120. Hyattsville, Md: U.S. Department of Health and Human Services Centers for Disease Control and Prevention, National Center for Health Statistics; 1999:47.Google Scholar
  22. 22.
    Hoyert DL KK, Murphy SL. National Vital Statistics Reports. Deaths: Final Data for 1997. Hyattsville, Md: U.S. Department of Health and Human Services Centers for Disease Control and Prevention, National Center for Health Statistics; 1999:48.Google Scholar
  23. 23.
    Dillman DA. Mail and Telephone Surveys: The Total Design Method. New York, NY: John Wiley & Sons, Inc.; 1978.Google Scholar
  24. 24.
    Fowler FJ Jr. Improving Survey Questions: Design and Evaluation, vol 38. Thousand Oaks, Calif: Sage Publications, Inc.; 1995.Google Scholar
  25. 25.
    Agrawal M, Emanuel EJ. Attending to psychologic symptoms and palliative care. J Clin Oncol. 2002;20:624–6.PubMedGoogle Scholar
  26. 26.
    Weissman DE. Consultation in palliative medicine. Arch Intern Med. 1997;157:733–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Ogle KS, Mavis B, Rohrer J. Graduating medical students’ competencies and educational experiences in palliative care. J Pain Symptom Manage. 1997;14:280–5.PubMedCrossRefGoogle Scholar
  28. 28.
    Schonwetter RS, Robinson BE. Educational objectives for medical training in the care of the terminally ill. Acad Med. 1994;69:688–90.PubMedCrossRefGoogle Scholar
  29. 29.
    Franks PJ, Salisbury C, Bosanquet N, et al. The level of need for palliative care: a systematic review of the literature. Palliat Med. 2000;14:93–104.PubMedCrossRefGoogle Scholar
  30. 30.
    Curtis JR, Wenrich MD, Carline JD, Shannon SE, Ambrozy DM, Ramsey PG. Understanding physicians’ skills at providing end-of-life care: perspectives of patients, families, and health care workers. J Gen Intern Med. 2001;16:41–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Wenrich MD, Curtis JR, Shannon SE, Carline JD, Ambrozy DM, Ramsey PG. Communicating with dying patients within the spectrum of medical care from terminal diagnosis to death. Arch Intern Med. 2001;161:868–74.PubMedCrossRefGoogle Scholar
  32. 32.
    Harvard Medical School Center for Palliative Care Program in Palliative Care Education and Practice. Available at: Accessed July, 2003.Google Scholar
  33. 33.
    Block SD, Bernier GM, Crawley LM, et al. Incorporating palliative care into primary care education. National Consensus Conference on Medical Education for Care Near the End of Life. J Gen Intern Med. 1998;13:768–73.PubMedCrossRefGoogle Scholar
  34. 34.
    Danis M, Federman D, Fins JJ, et al. Incorporating palliative care into critical care education: principles, challenges, and opportunities. Crit Care Med. 1999;27:2005–13.PubMedCrossRefGoogle Scholar
  35. 35.
    Steel K, Ribbe M, Ahronheim J, et al. Incorporating education on palliative care into the long-term care setting. National Consensus Conference on Medical Education for Care Near the End of Life. J Am Geriatr Soc. 1999;47:904–7.PubMedGoogle Scholar
  36. 36.
    Weissman DE, Block SD, Blank L, et al. Recommendations for incorporating palliative care education into the acute care hospital setting. Acad Med. 1999;74:871–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Barnard D, Quill T, Hafferty FW, et al. Preparing the ground: contributions of the preclinical years to medical education for care near the end of life. Working Group on the Pre-clinical Years of the National Consensus Conference on Medical Education for Care Near the End of Life. Acad Med. 1999;74:499–505.PubMedCrossRefGoogle Scholar
  38. 38.
    Billings JA, Ferris FD, Macdonald N, Von Gunten C. The role of palliative care in the home in medical education: report from a national consensus conference. J Palliat Med. 2001;4:361–71.PubMedCrossRefGoogle Scholar
  39. 39.
    Sahler OJ, Frager G, Levetown M, Cohn FG, Lipson MA. Medical education about end-of-life care in the pediatric setting: principles, challenges, and opportunities. Pediatrics. 2000;105:575–84.PubMedCrossRefGoogle Scholar
  40. 40.
    Rappaport W, Witzke D. Education about death and dying during the clinical years of medical school. Surgery. 1993;113:163–5.PubMedGoogle Scholar
  41. 41.
    Ruddy S, Harris ED, Clement B, Sledge CB, eds. Kelley’s Textbook of Rheumatology, 6th ed., W. B. Saunders Company; 2001. Available at: Accessed May, 2003.Google Scholar
  42. 42.
    Lee EU, Forthofer RN, Lorimer RJ. Analyzing Complex Survey Data, vol 71. Thousand Oaks, Calif: Sage Publications; 1989.Google Scholar
  43. 43.
    Levinson W, Gordon G, Skeff K. Retrospective versus actual precourse self-assessments. Eval Health Prof. 1990;123:445–52.CrossRefGoogle Scholar
  44. 44.
    Sapir R, Catane R, Strauss-Liviatan N, Cherny NI. Cancer pain: knowledge and attitudes of physicians in Israel. J Pain Symptom Manage. 1999;17:266–76.PubMedCrossRefGoogle Scholar
  45. 45.
    Mullan P, Weissman DE, Ambuel PB, von Gunten CF. End-of-life care education in internal medicine residency programs: interinstitutional study. J Palliat Med. 2002;5:487–96.PubMedCrossRefGoogle Scholar
  46. 46.
    Simon SR, Pan RJ, Sullivan AM, et al. Views of managed care: a survey of students, residents, faculty, and deans at medical schools in the United States. N Engl J Med. 1999;340:928–36.PubMedCrossRefGoogle Scholar
  47. 47.
    Zinn WM, Sullivan AM, Zotov N, et al. The effect of medical education on primary care orientation: results of 2 national surveys of students’ and residents’ perspectives. Acad Med. 2001;76:355–65.PubMedCrossRefGoogle Scholar
  48. 48.
    American Board of Internal Medicine. Portfolio for Internal Medicine residency programs. Evaluating your residents: new competencies, new forms. July 2001-June 2002. Available at: Accessed May, 2003.Google Scholar
  49. 49.
    Association of American Medical Colleges. Report 1: Learning objectives for medical student education: guidelines for medical students. Medical Schools Objectives Project. June 1998. Available at: Accessed May, 2003.Google Scholar
  50. 50.
    Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the M.D. degree. March 2003. Available at: Accessed May, 2003.Google Scholar

Copyright information

© Society of General Internal Medicine 2003

Authors and Affiliations

  • Amy M. Sullivan
    • 2
    • 1
  • Matthew D. Lakoma
    • 2
  • Susan D. Block
    • 2
    • 1
  1. 1.Brigham and Women’s HospitalHarvard Medical SchoolBoston
  2. 2.Division of Psychosocial Oncology and Palliative CareDana-Farber Cancer InstituteBoston

Personalised recommendations