COMMUNICATION AT THE END OF LIFE AND APPLICATION OF PALLIATIVE CARE IN THE INTERNAL MEDICINE RESIDENCY

Abstract

Background: The prevailing curative imperative in medical training often generates gaps in the management of patients facing end-of-life care, frequently resulting in resident moral distress and dysthanasia in clinical wards. Structured communication stands out as a crucial clinical and bioethical tool to restore therapeutic proportionality. Objectives: To report medical residents' clinical experience conducting family conferences to establish a therapeutic ceiling in an internal medicine ward, grounding these qualitative reflections in a systematic literature review. Methodology: A hybrid approach combining a descriptive-qualitative experience report (based on participant observation and medical chart reviews) with an integrated systematic literature review. The systematic search was conducted across PubMed/MEDLINE, Web of Science, and BVS databases, applying the PRISMA framework and grading cumulative evidence certainty with the GRADE system. Results: Clinical experience showed that informal, fragmented prognosis discussions led to communication noise and therapeutic obstinacy. Structuring formal family conferences using the SPIKES Protocol restored clinical dignity to vulnerable, elderly cancer patients with terminal illness. The systematic review synthesized 8 original studies (encompassing 800 trained professionals and 1,614 multivariately analyzed medical records), showing that simulation-based training and SPIKES curriculum lead to significant communication self-efficacy gains (an 11.5-point increase on the SE-12 scale; p = 0.003), substantial increases in formal Do-Not-Resuscitate (DNR) documentation on admission (adjusted OR = 1.89; 95% CI: 1.16–3.07), and a 50% decrease in inappropriate ICU transfers (OR = 0.5), despite half of the evidence presenting very low certainty (GRADE). Conclusion: Structured family conferences utilizing the SPIKES protocol are trainable clinical skills that provide essential technical and ethical support to medical trainees. Early therapeutic ceiling definition is a vital humanitarian intervention that prevents iatrogenesis and safeguards patient dignity in the terminal stage of life.