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Insufficient training, manpower to care for terminally-ill, survey finds

About 74 per cent of doctors and 46 per cent of nurses say medical professionals do not know enough about how to provide care for such patients, according to a survey commissioned by the Lien Foundation.

SINGAPORE: While almost all doctors and nurses consider hospice palliative care important for those with life-threatening illnesses, a number of them feel that medical professionals do not know enough about this approach to care-giving, a survey commissioned by the Lien Foundation revealed.

The report on the findings of the survey, released on Wednesday (June 18), showed that 95 per cent of doctors and 94 per cent of nurses surveyed considered hospice palliative care important for the terminally-ill, while 98 per cent of doctors and 95 per cent of nurses want such care to be made readily available.

Hospice palliative care is a holistic approach to caring for patients going through the last stages of their lives, by meeting their needs - physical, emotional, psychosocial and social - to alleviate suffering and maximise the quality of life for patients and their loved ones.

The report suggested the following areas of action for the local healthcare community and policy-makers to consider:

  • Enhancing basic medical and nursing education as well as continuing professional training to increase the skills and knowledge of hospice palliative care of doctors and nurses

  • Equipping all doctors and nurses with the skills of how to talk about death and dying with their supports

  • Incorporating palliative care principles in all healthcare settings, and fostering a culture and environment that supports better end-of-life care

The Lien Foundation commissioned Blackbox Research to conduct the survey, polling more than 200 doctors and 400 nurses on their views on death and dying. The survey was conducted from February to April this year.


The survey found that 74 per cent of doctors and 46 per cent of nurses felt medical professionals do not know enough about hospice palliative care. Among those with frequent contact with terminally-ill patients, about half - 44 per cent of doctors and 59 per cent of nurses - said they were familiar with hospice palliative care.

"This suggests a gap in the knowledge needed to support patients in end-of-life matters," the Lien Foundation said in the report.

One possible reason could be the lack of education in palliative care. According to the survey, 62 per cent of doctors and 38 per cent of nurses said basic medical or nursing education was not enough to prepare them to support patients with life-threatening illnesses.

Lee Poh Wah, CEO of Lien Foundation, said: "It's a reality check. Doctors and nurses are insiders, they have seen death, dealt with death up close, they know the limits of medicine"

"It is important that patients can have informed choices, they can clarify their care preferences, but at the end of the day, the supply side must also meet their needs. The supply side meaning the health care institutional capacity, the skills of the clinicians, must match up to the demands of the public," Lee added.

Medical students at the Yong Loo Lin School of Medicine at National University of Singapore (NUS) receive about four days of training in palliative care in their entire medical course.

For those at the Lee Kong Chian Medical School at Nanyang Technological University (NTU), it's one week.

Palliative care is an elective component for enrolled nurses here, while nursing degree and diploma holders receive four to six hours of lectures on the subject in their entire course.

In contrast, nurses in degree courses in the UK, like Manchester University, get two weeks of classroom teaching and one week of hospice attachment.

Doctors and nurses say the system's weaknesses in supporting the dying, are insufficient training and expertise, lack of information on palliative care, not enough hospice facilities or bed shortage, affordability and discomfort talking about it.

Source: Lien Foundation Survey of Death Attitudes

The subject of palliative care is delicate for doctors to raise because patients or their family members may think they are giving up on treatment.

Associate Professor Pang Weng Sun, Vice-Dean Clinical Affairs, Lee Kong Chian School of Medicine at NTU, said: "The line between responding to treatment and no longer responding to treatment is not always clear. Sometimes we know there are more we can do to help a patient, to continue treating the patient but it may only help to a certain extent, it may not really cure the patient. But when do we throw in the towel and say let's stop all treatment becomes a very difficult decision even for the clinicians sometimes."

There's also a shortage of trained personnel. There are only 46 palliative care medicine specialists, that's equal to 0.4 per cent of Singapore's close to 11,000 doctors.

The situation for nurses is also dismal -- 1.9 per cent of the 36,000 nurses here are trained in palliative care.

How medical professionals are trained also plays a part, said Dr Noreen Chan, Senior Consultant of Palliative Medicine at National University Health System.

Dr Chan said: "We are very good at telling people how the body works, what happens when the body breaks down, and how to fix that problem. This is what I call the disease-oriented approach, and that has worked well for a very, very long time.

"But I think the downside to such an approach is when we can't fix the problem, when the disease runs beyond our control, then the natural reaction is for all of us to feel like failures but now we're beginning to realise that not being able to cure a disease or even to stop its ravages or its progression is not a failure, because there's always a person who has that disease and if you move away from the disease-focused approach to a person-focused approach. There's always something we can do for people and their families. That is really the underlying philosophy of palliative care."

Patients, too can opt to make the shift to palliative care.

The findings echo an earlier survey of Singaporeans, which found that many saw the need for more awareness and dialogue about death and dying. Medical experts say national conversations are crucial in helping people understand their role as patients.


There are plans afoot to enhance the training of healthcare professionals in this area of care. The Yong Loo Lin School of Medicine at NUS, for instance, will expand its training in palliative medicine.

Associate Professor Yeo Khay Guan, Dean of Yong Loo Lin School of Medicine at NUS, said: "Currently, undergraduate students at the NUS School of Medicine receive training in palliative care from the third year of studies. We plan to expand and enhance the training in palliative medicine from the third to the fifth year of studies, in a variety of practice settings including hospices, home care and in hospitals."

At NTU's Lee Kong Chian School of Medicine, medical students will receive hospice palliative care training in their fourth year of studies, while Duke-NUS Graduate Medical School provides one-day exposure and training in hospice palliative care for students, according to the report.

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