Using a pocket card to improve end-of-life care on internal medicine clinical teaching units: a cluster-randomized controlled trial

J Gen Intern Med. 2008 Aug;23(8):1222-7. doi: 10.1007/s11606-008-0582-4. Epub 2008 Apr 30.


Background: End-of-life care is suboptimally taught in undergraduate and postgraduate education in Canada. Previous interventions to improve residents' knowledge and comfort have involved lengthy comprehensive educational modules or dedicated palliative care rotations.

Objective: To determine the effectiveness of a cheap, portable, and easily implemented pocket reference for improving residents' knowledge and comfort level in dealing with pain and symptom management on the medical ward.

Design: Cluster-randomized controlled trial conducted from August 2005 to June 2006.

Setting: Medical clinical teaching units (CTUs) in 3 academic hospitals in Toronto, Canada.

Participants: All residents rotating through the medical CTUs who consented to participate in the study.

Intervention: Residents at 1 hospital received a pocket reference including information about pain and symptom control, as well as 1-2 didactic end-of-life teaching sessions per month normally given as part of the rotation. Residents at the other 2 hospitals received only the didactic sessions.

Main outcome measures: A 10-question survey assessing knowledge and comfort level providing end-of-life care to medical inpatients, as well as focus group interviews.

Results: One hundred thirty-six residents participated on 3 CTUs for a participation rate of approximately 75%. Comfort levels improved in both control (p < .01) and intervention groups (p < .01), but the increase in comfort level was significantly higher in the intervention group (z = 2.57, p < .01). Knowledge was not significantly improved in the control group (p = .06), but was significantly improved in the intervention group (p = .01). Greater than 90% of residents in the intervention group used the card at least once per week, and feedback from the focus groups was very positive.

Conclusions: Our pocket card is a feasible, economical, and educational intervention that improves resident comfort level and knowledge in delivering end-of-life care on CTUs.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cluster Analysis
  • Education, Medical, Graduate / methods*
  • Female
  • Humans
  • Internal Medicine / education*
  • Internship and Residency
  • Male
  • Ontario
  • Statistics, Nonparametric
  • Surveys and Questionnaires
  • Teaching Materials*
  • Terminal Care*