Medical knowledge in Brazil about palliative care: Integrative systematic review

This study aims to show medical knowledge about palliative care in Brazil. Palliative care (PC) is a term used to designate a set of actions employed by a highly skilled multidisciplinary team in order to alleviate the suffering of patients and families facing terminal illnesses. This is bibliographical research, of the integrative review type, through a search in the databases: SCIELO, MEDLINE and LILACS. The present study used the following descriptors: “Palliative care”, “Medical education”, “P atient car e” in association with Boolean operators AND and OR. Data collection was carried out following six methodological steps: The first step was related to the proposed objectives. The second step was to determine the inclusion or exclusion criteria for articles. The third stage was collecting information from the selected studies and stratifying them. The fourth stage was the evaluation of the methods used in the studies. The fifth stage was the interpretation and discussion of the results, and the last stage was the presentation, argumentation and conclusion. 150 articles were identified, of which only 100 met the eligibility criteria, however, 85 of them did not meet the project regulations. Thus, 5 articles were selected that relate medical knowledge about palliative care. The discussion was conducted on the results, respecting comparative criteria between objective, thematic associations and conclusion. In conclusion, it appears that the inclusion of CP teaching in undergraduate courses is deficient in Brazil, and all studies reveal the need to address the topic to improve students’ comprehensive vision.


Introduction
According to the World Health Organization (WHO), the current definition of palliative care represents actions related to assistance provided by a multidisciplinary team to improve the quality of life of patients and their families facing any life-threatening illness, through the prevention and relief of suffering related to pain or any physical, social, psychological, and spiritual symptom (WHO, 2002).
Currently, palliative care is implemented from the early stages of certain serious illnesses that may progress to death, providing comfort throughout the course of the disease (Glajchen et al., 2022).
Palliative care is provided in various settings, including hospitals, palliative care centers, and even homes, depending on the patient's needs.They are based on ethical and humanitarian principles that recognize the dignity and worth of each patient, regardless of their condition or prognosis (Dos Santos et al., 2022).
However, despite its importance, palliative care is often undervalued in many countries around the world.
Consequently, a growing global movement aims to expand access to this care and raise awareness among patients and their families about its importance (Parekh et al., 2022).
The recent demographic and epidemiological transition in Brazil demonstrate a growing aging population and an increase in the prevalence of chronic-degenerative diseases, highlighting end-of-life care.In this perspective, it is important to emphasize the need for better training of healthcare professionals to clearly discuss the processes of preparation for the end of life, determining a specific need for the teaching of palliative care (PC) in the undergraduate curricula of health courses, improving patient care (Cowey et al., 2021).
The current medical education system has prepared professionals capable of promoting the healing of sick patients, however, it lacks in terms of caring for those with serious and incurable diseases (Nyatang & Glenny, 2021).
This study aims were to present an integrative literature review in Brazil on medical knowledge about comprehensive care for patients with severe, progressive diseases that threaten the continuity of life.

Methodology
An integrative literature review was conducted, contributing to evidence-based healthcare practice (Ercole et al., 2014).
Data collection was carried out following six methodological steps: The first step was related to the objectives proposed.The second step was the determination of inclusion or exclusion criteria for the collected articles.The third step was the collection of information from the selected studies and their stratification.The fourth step was the evaluation of the methods used in the studies.The fifth step was the interpretation and contextualization of the results, and the final step was the presentation, argumentation, and review of the selected studies (Ercole et. al, 2014).
In the first step, the main question was established, relating medical knowledge in Brazil to palliative care.Four independent reviewers conducted the screening and selection of articles, following the sequence: reading the titles and subsequently the full abstracts.Disagreements were resolved through mutual agreement.Subsequently, eligibility criteria were established for obtaining and selecting the articles.For article searches, the standardized descriptors used by the healthcare system in Portuguese, English, and Spanish were used, respectively, according to the Health Sciences Descriptors (DeCS) The research scope was limited to the period between 2014 and 2023 as a defined temporal study.
The analyzed items followed a rigorous sequence: 1) relevant objective and justification related to the topic; 2) appropriate method used; 3) discussion relevant to the results and well contextualized; 4) correct sample selection; 5) details regarding data collection; 6) relationship between researcher and researched; 7) preservation of ethical determinants; 8) rigorous analysis and well-founded interpretation of the data; 9) presentation and discussion of the results; 10) contributions, limitations, and indications of new research questions (Figure 1).

Results and Discussion
The articles included in this literature review will be related to medical knowledge in Brazil about palliative care.
They will follow the comparative criteria between objective, associations of the theme, and conclusions in an orderly sequence: Authors and year/Objective/Study design/according to conclusions.A total of 5 articles were included for discussion in this review (Table 1).When organizing the selected studies, the need for the inclusion of PC in medical education becomes clear.The above studies show that none of the institutions had this discipline regularly included in their curriculum, despite its importance, as the teaching of palliative care is being recognized worldwide (Who, 2002;Brown et al., 2018, Kim et al., 2022).
According to (Pastrana et al., 2016, Smith et al., 2019), it is evident that the curricular frameworks of medical courses in Brazil are varied and important topics such as communication skills, pain and symptom management, psychosocial and spiritual aspects, bioethics and legislation, the role of the healthcare system, and interdisciplinary teamwork and self-care are not addressed.
The definition of dying with dignity should recognize human values including physical comfort, quality of life, and autonomy.Preserving dignity and avoiding conflicts are responsibilities of healthcare professionals who care for patients at the end of life.There is a paradigm shift, as the focus becomes alleviating suffering rather than curing the patient's disease (Cook & Rocker, 2014;Taquete et al., 2015;Peh et al., 2017;Kriesen et al., 2018).The CCP among students is not good, and the CCP gain between fourth and sixth grade did not show statistical significance.This denotes the need to improve the teaching-learning process in palliative care, especially in the internship settings.
Pereira EAL; Rangel AB; Giffoni, JCG 2019 Identify the level of knowledge in Palliative Care (PC) in the medical education of sixth-year medical students at a medical school in the state of Goiás, understand the perception of students regarding the learning of PC during their medical education, and discuss the inclusion of PC in the medical education of the institution under study and in Brazil.
The study is of a quantiqualitative, cross-sectional nature, and a questionnaire with nine questions was applied to assess the level of knowledge in Palliative Care of sixth year medical students from a medical school in the state of Goiás.
Although the evaluated academics are familiar with some principles Palliative Care (PC), they are not sufficient.Students claim a lack of approach to the subject, emphasizing the need for the implementation of Palliative Care as a mandatory discipline in the Brazilian curriculum.
Sousa MNA; Roriz MIC; 2021 Evaluate the knowledge of internal medicine students from different Brazilian universities about pain in palliative care.
This is a descriptive study with a quantitative approach.These students were in the last four semesters of college.
The acquisition of these topics in specific disciplines, according to skills, competencies, and attitudes in their teaching plans, would be essential for valuing work in a multidisciplinary team, which would improve the quality of life for terminally ill patients.
The processes of knowledge fragmentation in all aspects of medical education induce a great associative difficulty for medical students, hindering their learning.Our study corroborates with the studies of (Smith et al., 2019), which show the need to include the management of physical and psychological symptoms, spiritual needs, respect for advance directives, and respect for cultural differences.The topics of greatest interest to students are management in the last days, communication to address treatment preferences, and psychological symptoms.
According to (Schaeffer et al., 2014), the author highlights knowledge about the control of signs and symptoms and spiritual and religious aspects, aiming to minimize the suffering of those facing the end-of-life phase.Our studies corroborate the need to discuss, especially among students, the topic of death and develop communication skills, teamwork, and support for the family, assisting in a more peaceful and tranquil process of dying.Most of the articles studied reveal a great prejudice towards the topic of death.Perhaps many of the frustrations of medical students are related to the non-acceptance of death as a natural process of life, which can create stress and even depression in the majority (Lisboa et al., 2021).

Conclusion
The inclusion of PC teaching in undergraduate medical courses is deficient in Brazil, and all studies reveal the need to address the topic to improve the comprehensive vision of medical students.In this context, research must be carried out to create or develop protocols for the inclusion in the teaching of medical students in Brazil.
criteria: Cuidados Paliativos (Palliative Care), Palliative Care, Cuidados Paliativos (Palliative Care), Educação Médica (Medical Education), Education, Medical, Educación Médica (Medical Education), Morte (Death), Death, Muerte (Death).For the research, searches were conducted in specific databases to obtain indexed results: Medical Literature Analysis and Retrieval System Online (MEDLINE®), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS®), and Scientific Electronic Library Online (SciELO®).Duplicate studies and publications not available in full were excluded from the selection process.The chosen Boolean terms were OR and AND.The search techniques used were: Cuidados Paliativos OR Educação Médica (Palliative Care OR Medical Education) AND Morte (Death).

Figure 1 -
Figure 1 -Study Design Drawing.Flowchart of the studies used in this review.

Table 1 -
Identification of data 2023.Source: MEDLIN, LILACS e Scientific SciELO.Most of the studies conducted are qualitative in nature, applying questionnaires about medical students' knowledge of palliative care (PC).This study observed a great need for educational interventions in Brazilian universities regarding PC.