JOURNAL OF PALLIATIVE MEDICINE

Volume 18, Number 4, 2015

ª Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2014.0270

Curricular Innovations for Medical Students

in Palliative and End-of-Life Care:
A Systematic Review and Assessment of Study Quality

Jennifer DeCoste-Lopez,1 Jai Madhok, MD, MSE,2 and Stephanie Harman, MD1

Abstract
Background: Recent focus on palliative and end-of-life care has led medical schools worldwide to enhance
their palliative care curricula.
Objective: The objective of the study was to describe recent curricular innovations in palliative care for medical
students, evaluate the quality of studies in the field, and inform future research and curricular design.
Methods: The authors searched Medline, Scopus, and Educational Resource Information Center (ERIC) for
English-language articles published between 2007 and 2013 describing a palliative care curriculum for medical
students. Characteristics of the curricula were extracted, and methodological quality was assessed using the
Medical Education Research Study Quality Instrument (MERSQI).
Results: The sample described 48 curricula in 12 countries. Faculty were usually interdisciplinary. Palliative
care topics included patient assessment, communication, pain and symptom management, psychosocial and
spiritual needs, bioethics and the law, role in the health care system, interdisciplinary teamwork, and self-care.
Thirty-nine articles included quantitative evaluation, with a mean MERSQI score of 9.9 (on a scale of 5 to 18).
The domain most likely to receive a high score was data analysis (mean 2.51 out of 3), while the domains most
likely to receive low scores were validity of instrument (mean 1.05) and outcomes (mean 1.31).
Conclusions: Recent innovations in palliative care education for medical students represent varied settings,
learner levels, instructors, educational modalities, and palliative care topics. Future curricula should continue to
incorporate interdisciplinary faculty. Studies could be improved by integrating longitudinal curricula and
longer-term outcomes; collaborating across institutions; using validated measures; and assessing higher-level
outcomes including skills, behaviors, and impact on patient care.

Introduction found that approaches to palliative care education are highly

variable between medical schools, with some schools re-

I n the past two decades, a national focus on the im-

portance of palliative and end-of-life care1 has led medical
schools to enhance their palliative care curricula.2 Since
2000, the Liaison Committee for Medical Education
(LCME), the accrediting body for all allopathic medical
schools in the United States and Canada, has required that all
medical schools include education in palliative care and
communication skills.3 Longitudinal surveys of medical
school administrators over the past 35 years have demon-
strated that overall offerings in palliative care education have
been consistently increasing; and since 2000, 100% of U.S.
medical schools have had at least some offering regarding
death and dying.2 However, in their recent review of surveys
of medical educators in the United States, Horowitz, et al.
porting as little as two hours of classroom time, while others
require weeks of training or clinical experience. Given that
medical schools already suffer from overstrained curricula,
the authors advocate integrating developmentally appropri-
ate, basic palliative care competencies into each year of the
medical school curriculum to avoid both neglect of the topic
and educational overload.4 A recent national survey of pal-
liative care experts arrived at a proposed set of competencies
for medical students.5
As palliative care educators advocate for scarce curricular
time and select educational methods, it is imperative to
identify rigorously tested curricula that can be used. Al-
though previous reviews related to palliative care education
exist, these have largely focused on the overall state of

1
Department of Medicine, 2Department of Anesthesia, Stanford University School of Medicine, Stanford, California.
Accepted November 24, 2014.

338
SYSTEMATIC REVIEW OF PALLIATIVE CARE CURRICULA
palliative care education in the United States, rather than
evaluations of discrete curricula or innovations made in the
field worldwide.4,6,7 Furthermore, to our knowledge there has
been no systematic assessment of the quality of the evidence
supporting such interventions. Therefore, we undertook a
systematic literature review to inform curricular develop-
ment at our own medical school, to understand recent trends
in this field, and to evaluate the quality of the literature.
Methods
We conducted this systematic review in adherence with the
PRISMA standards8 as applied to a systematic review with-
out meta-analysis. Meta-analysis was not pursued, because
the literature in this area consists of heterogeneous inter-
ventions and outcomes, as well as many pilot or qualitative
studies that are not amenable to this methodology.
Questions
These are the research questions we sought to answer:
 What educational interventions have recently been de-
scribed to teach palliative care topics to undergraduate
medical students?
 What is the methodological quality of the studies in this
field?
Study eligibility
We included academic articles published in the English
language between 2007 and 2013. We chose this date range
because a previous review in this topic area reviewed the
literature through the end of 2006.6 Articles were included if
the population of interest was undergraduate allopathic
medical students and if the article described the evaluation of
a curriculum in a palliative care topic. Articles that described
new curricula but did not include evaluation of any learner
outcome were excluded.
Study identification
In collaboration with a medical librarian we designed
searches of Medline via PubMed, Scopus, and Educational
Resource Information Center (ERIC) databases for relevant
articles. We performed iterative searches in each database to
optimize the relevance and comprehensiveness of the results.
We last performed the searches on January 16, 2014. The
search strings used were:
Medline: ((terminal care OR ‘‘palliative care’’ OR ‘‘palliative
medicine’’ OR ‘‘end of life’’ OR ‘‘end-of-life’’) AND (educa-
tion, medical, undergraduate OR ‘‘medical students’’))
Scopus: ((‘‘palliative care’’ OR ‘‘palliative medicine’’ OR ‘‘end
of life’’ OR ‘‘end-of-life’’ OR ‘‘hospice’’) AND (‘‘undergrad-
uate medical education’’ OR ‘‘medical students’’))
ERIC: ((‘‘palliative care’’ OR ‘‘palliative medicine’’ OR
‘‘end of life’’ OR ‘‘end-of-life’’ OR ‘‘hospice’’ OR ‘‘terminal
illness’’ OR death) AND (‘‘medical students’’))
Study selection
Two authors ( JD and JM) independently screened all ar-
ticles, first reviewing titles and abstracts and then full texts.
Conflicts were resolved by consensus. In the three instances
339
in which a single intervention was reported in more than one
article, we identified the article that provided the most
complete description and excluded the others.
Data extraction
Study characteristics for each included article were sum-
marized, including country, learner level, instructors, setting,
educational modality, duration of intervention, and palliative
care topics addressed.
Two authors ( JD and JM) independently tabulated a Medical
Education Research Study Quality Instrument (MERSQI)
score9 for all articles that included a quantitative evaluation.
Disagreements between the two raters were resolved by re-
review and consensus to assign the final score. The MERSQI
was developed by Reed, et al. in 2007 as a measure of meth-
odological rigor of medical education studies. The MERSQI
scores studies across six domains: study design, sampling, type
of data, validity of evaluation instrument, data analysis, and
outcomes. These domains are further divided to yield 10 items.
Each of the six domains has a maximum score of 3, giving a
possible score for each study ranging from a minimum of 5 to a
maximum of 18. This scoring system is summarized in the first
three columns of Table 1.
Results
Trial flow
Our initial database searches identified 1167 results, and
after de-duplication, 829 were found to be unique articles.
After filtering the results for English language and date of
publication, we reviewed the titles and abstracts of the re-
maining 299. Sixty-eight met our inclusion criteria based on
review of titles and abstracts. Full-text review led to the ex-
clusion of an additional 20, yielding a final sample of 48
articles (see Fig. 1).
Study characteristics
The included studies describe 48 unique curricula deliv-
ered in 12 countries, which are summarized in Appendix 1:
Summary of Curriculum Characteristics.10–57 Twenty-two
articles were from the United States; 7 from the United
Kingdom; 4 from Canada; 3 from Taiwan; 2 each from
Australia, Croatia, and Germany; and 1 each from Brazil,
Hungary, India, Ireland, Japan, and Poland. Educational set-
ting was most often a mix of classroom and clinical settings
(n = 21, 44%). Seventeen (35%) were in a classroom setting
only, 7 (15%) in a clinical setting only, and 6 (13%) included
online instruction.
The targeted learners were clinical medical students
(I = 27, 56%), preclinical medical students (I = 17, 35%), or
both (n = 3, 6%). Five studies (10%) delivered the interven-
tion to medical students together with other learners, such as
nursing students, social work students, pharmacy students,
residents, and/or practicing health professionals.
Physicians served as instructors for 29 interventions
(60%), including 19 (40%) in which the faculty included
hospice and palliative medicine specialists. It was also very
common to involve other health professionals as teachers,
most commonly nurses or nurse practitioners (n = 15, 31%),
social workers (n = 7, 15%), and chaplains (n = 7, 15%). In 12
articles (25%) the instructors were not specified.
340 DECOSTE-LOPEZ ET AL.

Table 1. Medical Education Research Study Quality Instrument (MERSQI) Scores

for Studies with Quantitative Evaluation
Number Mean Mean
Domain MERSQI item Score of studies (item) (domain)
Study design 1) Study design 1.53 1.53
Cross-sectional or single-group posttest only 1.0 12 (31%)
Single group pretest and posttest 1.5 17 (44%)
Nonrandomized, two-group 2.0 8 (21%)
Randomized controlled trial 3.0 2 (5%)
Sampling 2) Number of institutions studied 0.53 1.74
1 0.5 38 (97%)
2 1.0 0
>2 1.5 1 (3%)
3) Response rate 1.22
Not applicable 0
< 50% or not reported 0.5
50%–74% 1.0
‡ 75% 1.5
Type of data 4) Type of data 1.77 1.77
Assessment by study participant 1.0 24 (62%)
Objective measurement 3.0 15 (38%)
Validity of instrument 5) Internal structure 0.38 1.05
Not applicable 0
Not reported 0 24 (62%)
Reported 1.0 15 (38%)
6) Content 0.59
Not applicable 0
Not reported 0 16 (41%)
Reported 1.0 23 (59%)
7) Relationships to other variables 0.08
Not applicable 0
Not reported 0 36 (92%)
Reported 1.0 3 (8%)
Data analysis 8) Appropriateness of data analysis 0.90 2.51
Inappropriate for study design or type of data 0 4 (10%)
Appropriate for study design or type of data 1.0 35 (90%) 1.62
9) Complexity of analysis
Descriptive analysis only 1.0 15 (38%)
Beyond descriptive analysis 2.0 24 (62%)
Outcomes 10) Outcomes 1.31 1.31
Satisfaction, attitudes, perceptions, 1.0 21 (54%)
opinions, general facts
Knowledge, skills 1.5 14 (36%)
Behaviors 2.0 3 (8%)
Patient/health care outcome 3.0 1 (3%)
Total score 9.91

A variety of educational modalities were employed, in-
cluding lectures (n = 29, 60%), group discussion (n = 27,
56%), clinical exposure, which we defined as education that
takes place in a clinical setting but does not involve direct
patient care responsibilities (n = 14, 29%), patient care
(n = 13, 27%), simulation or role play (n = 13, 27%), written
assignment (n = 12, 25%), online module (n = 6, 13%), stu-
dent presentation (n = 6, 13%), reading assignment (n = 6,
13%), multimedia (n = 6, 13%), and arts activity or perfor-
mance (n = 2, 4%).
The curricular time spent for the educational interventions
ranged from 45 minutes to 25 hours. Some articles described
single teaching sessions, while others evaluated complex
curricula delivered over longer periods (up to four years).
Topics within palliative care addressed by the curricula
included communication (n = 30, 63%), role of palliative and
end-of-life care in the health care system (n = 26, 54%), pain
and symptom management (n = 22, 46%), clinical assessment
of patients (n = 20, 42%), addressing psychosocial and spir-
itual needs (n = 19, 40%), ethics and the law (n = 18, 38%),
interdisciplinary teamwork (n = 15, 31%), and self-care
(n = 11, 23%). Five studies (10%) did not specify the topics
covered.
Study quality
Of the 48 studies meeting the inclusion criteria, 39 in-
cluded quantitative methods and were assigned MERSQI
SYSTEMATIC REVIEW OF PALLIATIVE CARE CURRICULA
FIG. 1. Trial flow for systematic review.
scores, while the others were solely qualitative. Table 1
summarizes the MERSQI scoring system and the results for
our sample. Scores ranged from 5 to 15 (possible range 5 to
18), with a mean score of 9.9 and standard deviation of 2.7.
The most common study design was single-group pretest
and posttest (n = 17, 35%). However, 10 studies (21%) in-
volved a control group, including 2 (4%) that randomized
their participants.
The domain most likely to receive a high score was data
analysis, with a mean of 2.51 out of 3. Twenty-four articles
(50%) received the maximum possible score for both ap-
propriateness and complexity of data analysis.
The domains that scored lowest in our sample were
validity of the evaluation instrument and outcomes. The
mean score for the validity domain was 1.05 out of 3,
with 15 articles (31%) scoring zero points on all three
items in the domain. The mean score for the outcomes
domain was 1.31 out of 3. Twenty-one articles (44%)
received the lowest possible score in this domain, indi-
cating that outcomes were measured at the level of sat-
isfaction, attitudes, perceptions, opinions, or general facts,
but did not assess knowledge, skills, behaviors, or patient
or health care outcomes.
341
Discussion
Characteristics of palliative and end-of-life
care educational interventions
To inform curricular development at our own and other
medical schools, we undertook a systematic literature review
to describe recent curricular innovations in palliative care
education for medical students. We also assessed the quality
of the evidence for effectiveness of these curricula. We found
that emerging approaches in the field vary widely in scope,
ranging from stand-alone didactic sessions to longitudinal
four-year curricula. Lecture and group discussion were the
most commonly cited educational modalities. However, most
interventions employed a mix of modalities, with lecture or
group discussions used to prepare for, supplement, or debrief
a clinical experience, simulation, or role-play.
One important pattern that emerged from our review is that
palliative care curricula tend to employ a broadly interdis-
ciplinary faculty. Of the 36 articles that specified the pro-
fession of the instructors, only 9 were taught by physicians
alone. The other instructors included not only nonphysician
health professionals (nurses, nurse practitioners, social
workers, chaplains, psychologists, pharmacists, physical
342
therapists, and massage therapists), but also teachers from
nonmedical disciplines such as ethics, law, theology, drama,
philosophy, and sociology. Given this wealth of experience in
incorporating interdisciplinary faculty, the field of palliative
care should serve as a model for how to incorporate non-
physician educators into medical student education to pro-
mote interdisciplinary collaboration.
One common limitation of the studies included in this re-
view is that many of the curricula were not described in
enough detail to be replicated by other educators. For some
articles we were unable to ascertain even basic information
such as which palliative care topics were covered or who
served as the instructors. As medical educators look to the
literature to design their own curricula, this is an important
limitation, which likely results from the space constraints
of academic journals. One way to address this would be to
include online supplemental materials that provide de-
tailed descriptions of educational objectives, content, format,
and educational materials. For example, Radwany, et al.
addressed this issue effectively even for their complex, lon-
gitudinal, four-year intervention.40 Within the text of the
article they provided a broad curriculum map and general
description of the curriculum format and content. They then
included two additional files, which contained detailed, rep-
licable descriptions of the components that they considered to
be ‘‘cornerstones’’ of their curriculum: a mandatory hos-
pice experience and a case-based group discussion prior to
graduation.
Another limitation of the sample is the narrow scope of
many of the curricula, most of which evaluate the immediate
effect of a single teaching session or circumscribed clinical
experience. Because the field of palliative care encompasses
such breadth of content that spans many medical specialties,
more studies should evaluate palliative care curricula longi-
tudinally as students engage the topics within the context of
their general medical curriculum. For example, Morrison,
et al. used a waitlist-control crossover design to demonstrate
improvements in students’ knowledge and attitudes follow-
ing a palliative care curriculum that spanned the entire third
year of medical school.34 Even for smaller-scale interven-
tions, educators should assess the long-term retention of
learning objectives whenever possible. For example, Stevens,
et al. demonstrated that students who participated in their
pain management curriculum performed better on pain
management domains of a clinical skills exam 1.5 years
later.48
Study quality
In recent years, increasing emphasis has been placed on
improving the methodological rigor of medical education
research. Cook and Bordage have found that many essential
elements of scientific reporting are frequently absent from
articles describing medical education experiments.58 The
MERSQI was developed by Reed and colleagues in 2007 as a
measure of rigor for experimental studies in medical educa-
tion, and has been shown to correlate well with expert quality
ratings, number of citations, and journal impact factor.9 We
used this instrument to assess the quality of our sample of
recent studies in palliative care.
The studies in our sample had a mean MERSQI score of
9.9 (standard deviation 2.7, range 5–15). This result is quite
DECOSTE-LOPEZ ET AL.
similar to the mean of 9.95 (standard deviation 2.34, range 5–
16) from the first reported MERSQI sample, which was a
broad, interdisciplinary sample of 210 medical education
studies published between 2002 and 2003.9 More recently,
systematic reviews of medical education in topic areas un-
related to palliative care that utilized MERSQI have reported
mean scores ranging from 9.0 to 11.4.59–66 Overall, this
suggests that palliative care education studies are of similar
methodological quality to other medical education studies.
We found that within our sample most studies received
high scores in the domain of data analysis. This indicates that
the authors go beyond descriptive analysis to assess statistical
significance of the effectiveness of their intervention and that
the data analysis methods used are appropriate. Another area
of strength was the ‘‘response rate’’ item within the sampling
domain, indicating that the authors’ conclusions are based on
a representative sample of the students exposed to the inter-
vention.
However, also within the sampling domain, the item
‘‘number of institutions studied’’ was the MERSQI item most
likely to receive the lowest possible score. In fact, only one
study in our sample implemented and evaluated their inter-
vention with students from more than one institution. This
aspect of study quality has important implications for gen-
eralizing study findings, and future researchers should en-
deavor to collaborate with other institutions to test the
intervention in multiple settings or with multiple student
populations. While multiple-institution collaboration is ex-
tremely difficult for implementing longitudinal, integrated
curricula, it would be feasible for short-term, discrete inter-
ventions. For example, Tsai, et al. were able to implement a
four-hour curriculum including a lecture, a hospice patient
visit, communication skills practice, and group discussion
with students in attendance from three local medical
schools.52
Because trainees’ self-assessments of their skills may not
predict the patient’s assessment of the interaction, it is im-
portant that educators measure behavioral and patient out-
comes, rather than relying solely on student assessments to
demonstrate the effectiveness of a curriculum. However, in our
sample the vast majority of studies (35 out of 39, 90%) mea-
sured outcomes either at the level of satisfaction, perceptions,
and attitudes (usually measured by self-assessment on a Likert
scale) or at the level of knowledge acquisition (usually mea-
sured by multiple-choice examination). Three studies (8%)
measured student behaviors, with two measuring behaviors in
a simulated patient encounter and one measuring self-reported
communication behaviors. Only one study (3%) assessed a
patient outcome: Green and Levi measured patient satisfaction
after a medical student assisted the patient in filling out an
advance directive.22 Because many of the educational inter-
ventions being studied already involve direct patient care, it
would likely be feasible in future studies to incorporate patient
outcomes into the evaluation.
Finally, validity of the evaluation instrument was a clear
weakness in study quality. Fifteen studies reported no attempt
to establish validity of their instrument regarding internal
structure, content, or relationship to other variables. Instead,
most studies relied upon surveys created by the authors,
which did not undergo any formal development process. One
positive example in this domain was the study by Chang,
et al., who developed their instrument to measure changes in
SYSTEMATIC REVIEW OF PALLIATIVE CARE CURRICULA
palliative care knowledge and attitudes before and after a
five-day course. They began with a literature review, piloted
the initial form of the instrument, retained only the most
reliable items for the final instrument, and calculated the
relationship between attitude scores, knowledge scores, and
demographic data.13
Limitations
One limitation of this review is that our methods only
assessed the quality of the subset of studies that included
quantitative analysis. In the fields of medical education and
palliative care, qualitative analysis of data such as focus
groups, interviews, open-answer survey responses, and
written reflections form the core of many studies. In our
sample, 9 of the 48 studies reported qualitative data alone,
and another 13 studies used mixed quantitative and qualita-
tive methods. Our review does not speak to the methodo-
logical rigor of these qualitative analyses.
Another limitation of our review is that our database
searches did not include items published in peer-reviewed
repositories of educational products, such as MedEdPortal,
which are often used for reporting and dissemination of
curricula across medical schools.
Conclusions
Many recent innovations have been made in the field of
palliative care education for medical students, representing a
variety of learner levels, settings, educational modalities, and
topics. One strength of palliative care education is the in-
corporation of interdisciplinary faculty, which should serve
as a model for interdisciplinary collaboration in other parts of
the medical curriculum. Future innovations in the field should
endeavor to collaborate across multiple institutions, integrate
more longitudinal curricula and study longer-term outcomes,
make use of better-validated measures of effectiveness, and
assess higher-level outcomes including skills, behaviors, and
impact on patient care.
Acknowledgments
The authors would like to thank Lauren Maggio for her
guidance regarding systematic review methodology. This
work was funded by the Medical Scholars program at Stan-
ford University School of Medicine.
Author Disclosure Statement
The authors have no conflicts of interest to disclose.
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(Appendix follows /)
 Appendix 1. Summary of Curriculum Characteristics
Educational
Study Country Learner level Instructors Setting modalities Duration Topicsa MERSQI Scoreb
Auret and Starmer Australia Clinical HPM physicians, non- Classroom Group discussion, 2 hours 1, 2, 3, 6 7
2008 HPM physician, simulation
nurses, pharmacist
Bell and Crawford United Preclinical Physician, nurse, Classroom Lecture, group 20–25 hours (over 5, 6, 7 7.5
2011 Kingdom ethicist, theologian, discussion, written 12 weeks)
attorney assignment, student
presentation, online
module, simulation,
clinical exposure
Brownfield and United States Clinical Unspecified Clinical, classroom Lecture, group 1 week 3, 6 10.5
Santen 2009 discussion, patient
care
Chang, et al. 2009 Taiwan Preclinical HPM physicians, Clinical, classroom Lecture, group 1 week 4, 5, 6, 7 14
nurse, social discussion, clinical
workers, chaplain exposure
Chittenden, et al. United States Clinical None Online Online module 45 minutes 2 14
2013
Corcoran, et al. United States Clinical, preclinical Nurses, social workers, Clinical Clinical exposure 4 hours Unspecified Q
2013 chaplains
Dando, et al. 2012 United Clinical, also Physician, nurse, Clinical Group discussion, 3 weeks 7 5
Kingdom nursing, physical physical therapist patient care

346
therapy, and
occupational
therapy students
Ellman, et al. 2009 United States Clinical HPM physician, non- Clinical, classroom Written assignment, Variable 1, 2, 3, 7, 8 7
HPM physicians student presentation,
patient care
Ellman, et al. 2012 United States Clinical, also Physician, nurse, social Classroom, online Group discussion, 2 hours 1, 2, 3, 4, 6, 7 10.5
nursing, social worker, chaplain online module,
work, and simulation
chaplaincy
students
Gadoud, et al. 2013 United Clinical Unspecified Clinical Patient care Unspecified Unspecified Q
Kingdom
Goldberg, et al. United States Clinical HPM physicians, Clinical, classroom Lectures, group 1 week 2, 3, 4 10
2011 nurse, social worker, discussion, patient
chaplain, massage care
therapist
Goldsmith, et al. United States Clinical HPM physician, non- Clinical, classroom Lectures, multimedia, 12 hours 1, 2, 3, 6, 7 Q
2011 HPM physicians, patient care
nurses, social
workers, chaplains,
psychologists,
patients
(continued)
 Appendix 1. (Continued)
Educational
Study Country Learner level Instructors Setting modalities Duration Topicsa MERSQI Scoreb
Green and Levi United States Preclinical None Clinical, online Online module, patient Variable 2, 5 15
2011 care
Hall, et al. 2011 Canada Clinical, also Physicians, nurses, Classroom Group discussion, 3 hours 1, 2, 3, 4, 5, 7 8
interprofessional interdisciplinary simulation
students health professionals
Head, et al. 2012 United States Clinical Unspecified Clinical Written assignment, 1 week 2, 3, 8 Q
patient care
Hegedus, et al. Hungary Preclinical, also Unspecified Classroom Lectures Unspecified 2, 3, 4, 6 11
2008 health care
professionals
Jacoby, et al. 2011 United States Clinical Unspecified Clinical Lecture, reading 1 week 1, 2, 6, 7 Q
assignments, written
assignment, patient
care
Jeffrey, et al. 2012 United Clinical and HPM physicians, Classroom Drama performance, 2 weeks 2 Q
Kingdom preclinical drama educators group discussion,
reading assignment,
written assignment
Kato, et al. 2011 Japan Clinical Unspecified Classroom Lecture 1 hour 3, 6 10
Kaufert, et al. 2010 Canada Preclinical Physicians, patients Classroom Lecture, group 4 hours 4, 5 Q
discussion
Kitzes, et al. 2008 United States Clinical HPM physicians, non- Classroom Group discussion 4 hours 1, 2, 3, 4, 5, 6, 8 8.5
HPM physicians

347
Korzeniewska- Poland Clinical Physicians, Classroom Lecture, group 10 hours 1, 2, 3, 4, 5, 6, 8 7
Eksterowicz, psychologist discussion
et al. 2012
Lubimir and Wen United States Clinical Unspecified Classroom Group discussion, 3 hours 2, 4, 5 6
2011 written assignment,
simulation
Mason and United Clinical Unspecified Clinical, classroom Lecture, group 2 or 4 weeks 2, 5 10.5
Ellershaw 2010 Kingdom discussion, student
presentation, patient
care
Morrison, et al. United States Clinical HPM physicians, Clinical, classroom, Lectures, group 8 hours (over 46 1, 4, 6, 7 13
2012 interdisciplinary online discussion, written weeks)
health professionals assignment, student
presentation, online
module, clinical
exposure
Murtagh, et al. Ireland Preclinical HPM physicians Clinical, classroom Lecture, reading 15 hours (over 10 1, 4, 6, 7 11
2012 assignments, student weeks)
presentation, clinical
exposure
Nwosu, et al. 2013 United Clinical Physician Online Written assignment 11–59 minutes Unspecified 7
Kingdom
Oliver and Jezek Croatia Preclinical HPM physician Classroom Lectures, group 3 days 1, 2, 3, 4, 6 7.5
2013 discussion,
multimedia
(continued)
 Appendix 1. (Continued)
Educational
Study Country Learner level Instructors Setting modalities Duration Topicsa MERSQI Scoreb
Philip and India Preclinical Nurses, hospice Clinical, classroom Lecture, group 3 days 2, 6, 7 6
Remblabeevi volunteers discussion,
2010 simulation,
multimedia, clinical
exposure
Pinheiro, et al. 2010 Brazil Unspecified Not specified Clinical Reading assignments, Variable Unspecified Q
medical students, written assignment,
also residents patient care
Radwany, et al. United States Clinical and Physicians, Clinical, classroom Lectures, group 4 years 1, 2, 3, 4, 5, 6, 7, 8 6.5
2011 preclinical interdisciplinary discussion,
health professionals simulation, written
assignments, clinical
exposure
Sanchez-Reilly, United States Clinical HPM physicians, Clinical, classroom Lectures, written 8 hours (over 4 1, 2, 6, 7, 8 13
et al. 2007 nurses, social assignments weeks)
workers, chaplains,
psychologists,
patients
Schillerstrom, et al. United States Preclinical HPM physicians, Classroom Lecture, group 4 hours 6 9
2012 psychiatrists, discussion
psychologists,
interdisciplinary
health professionals

348
Schulz, et. al. 2013 Germany Clinical Unspecified Clinical, classroom Lectures, group 23 hours (over 2 1, 2, 3, 6, 7, 8 10.5
discussion, semesters)
simulation, written
assignment, clinical
exposure.
Shih, et al. 2013 Taiwan Preclinical HPM physicians, Clinical, classroom Lectures, simulation, 1 day 1, 2, 5, 7 13
interdisciplinary multimedia, clinical
health professionals exposure
Silk, et al. 2009 United States Clinical Unspecified faculty, Clinical, classroom Lecture, group 7.5 hours 2, 6 9
nurses discussion,
simulation,
multimedia, clinical
exposure
Sorta-Bilajac, et al. Croatia Preclinical Physician, ethicist, Classroom Lectures, multimedia, 7.5 hours 4, 5, 6 10.5
2007 theologian, written assignment,
philosopher, student presentation
sociologist, attorney
Stecho, et al. 2012 Canada Preclinical Nurse, hospice Clinical, classroom Lectures, patient care 30–40 hours Unspecified 10
volunteers
Stevens, et al. 2009 United States Preclinical HPM physicians, non- Classroom Lectures, group 10 hours 1, 2, 3 14
HPM physicians, discussion,
nurses simulation
Tai, et al. 2013 Australia Clinical Unspecified Clinical, classroom Lectures, group 1 week 3, 4, 5 12
discussion, patient
care
(continued)
 Appendix 1. (Continued)
Educational
Study Country Learner level Instructors Setting modalities Duration Topicsa MERSQI Scoreb
Tan, et al. 2013 Canada Clinical None Online Online module Variable 1, 3, 4 11
Tchorz, et al. 2013 United States Clinical Non-HPM physicians, Classroom Group discussion, 2 hours 1, 2, 3, 4, 5 11
ethicist multimedia,
simulation
Tsai, et al. 2008 Taiwan Preclinical HPM physicians Clinical, classroom Lecture, group 4 hours 2, 5, 6 14
discussion, reading
assignment, clinical
exposure
von Gunten, et al. United States Clinical HPM physicians, Clinical, classroom Lectures, simulation, 4 days (over 4 1, 2, 3, 4, 5, 6, 7, 8 13
2012 nurses, social patient care weeks)
workers, chaplains
Weber and United States Preclinical HPM physician Clinical, classroom Arts activity or Unspecified 6 Q
Mascagna 2008 performance, group
discussion, written
assignment, student
presentation, clinical
exposure
Weber, et al. 2011 Germany Preclinical HPM physicians Clinical, classroom Lecture, group 1.5 hours 4, 6, 8 9.5
discussion, clinical
exposure
Wechter, et al. 2013 United States Preclinical HPM physicians Clinical, classroom Group discussion, 4 hours 2, 4, 5, 6, 8 9.5
reading assignments,
clinical exposure

349
Yardley, et al. 2013 United Clinical Unspecified Classroom Lecture, group 7 hours 1, 2, 3, 5, 6 7
Kingdom discussion,
simulation
a
Palliative and End-of-Life Care topics are listed only if they were specifically reported in the article. Coding is as follows: 1 = patient assessment, 2 = communication, 3 = pain and symptom
management, 4 = addressing psychosocial and spiritual needs, 5 = ethics and the law, 6 = role in the health care system, 7 = interdisciplinary teamwork, 8 = self-care.
b
Q indicates that the study was qualitative, and did not receive a MERSQI score.
HPM, hospice and palliative medicine; MERSQI, Medical Education Research Study Quality Instrument.
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