Communication and educational gaps in end-of-life care in Italian internal medicine wards: a cross-sectional study

BACKGROUND: End-of-life (EOL) care is a frequent and complex aspect of internal medicine, yet data on physicians' training, clinical practices, and perceived challenges are limited. This study aimed to explore current practices, knowledge gaps, and unmet needs in EOL care among Italian internal medicine physicians and residents. METHODS: A cross-sectional survey was conducted under the auspices of the Piedmont-Liguria-Aosta Valley Section of the Italian Society of Internal Medicine (SIMI). The survey included 25 closed-ended questions addressing five domains: epidemiological, pharmacological, practical, psychological, and educational aspects of EOL care. Physicians actively involved in clinical care from multiple internal medicine wards participated voluntarily. Responses were collected anonymously via paper and online formats. Descriptive statistics were used to summarize data. Differences between groups (specialists vs. residents, oncology/hematology vs. non-oncology wards, low vs. medium vs. high clinical intensity wards) were assessed using the Mann-Whitney U and Kruskal-Wallis tests. Associations between ordinal variables were evaluated using Spearman's rank correlation coefficient. P-values were adjusted using the Benjamini-Hochberg procedure. RESULTS: Of approximately 7,400 invited physicians, 619 completed the survey (response rate ≈ 8.4%; median age 38 years; 60.5% female; 70.8% board-certified internists). More than 88% reported facing terminal patients at least weekly, yet only 2.5% were aware of Advance Directives for > 25% of inpatients. Use of sedatives and analgesics during terminal sedation varied, while discontinuation of active therapies, total parenteral nutrition (TPN), and transfusions was widely accepted. Internal protocols and dedicated multidisciplinary discussions were infrequently used. Most respondents reported difficulties communicating with patients and families at EOL. Formal training in EOL care was perceived as largely inadequate during undergraduate, residency, and postgraduate education. Compared with residents, board-certified internists more frequently reported postgraduate/Master training, whereas residents more frequently reported undergraduate and residency training in EOL. Exploratory correlation analyses generated hypotheses linking communication difficulties with patients to those with family members and training experiences across educational stages. CONCLUSIONS: The study highlights substantial gaps in training, communication, and organizational support, independent of clinical setting. Structured education and integration of psychological support are urgently needed. These findings can inform curriculum development, hospital policies, and future research to improve physician preparedness and patient-centered EOL care.