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Blackstone EC, Daly BJ. The Need for Specialized Oncology Training for Clinical Ethicists. HEC Forum 2024; 36:45-59. [PMID: 35426566 DOI: 10.1007/s10730-022-09477-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 01/22/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
Abstract
Numerous ethical issues are raised in cancer treatment and research. Informed consent is challenging due to complex treatment modalities and prognostic uncertainty. Busy oncology clinics limit the ability of oncologists to spend time reinforcing patient understanding and facilitating end-of-life planning. Despite these issues and the ethics consultations they generate, clinical ethicists receive little if any focused education about cancer and its treatment. As the field of clinical ethics develops standards for training, we argue that a basic knowledge of cancer should be included and offer an example of what cancer ethics training components might look like. We further suggest some specific steps to increase collaboration between clinical ethicists and oncology providers in the outpatient setting to facilitate informed consent and proactively identify ethical issues.
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Affiliation(s)
- Eric C Blackstone
- Department of Bioethics, Case Western Reserve University, 10900 Euclid Avenue, 44106, Cleveland, OH, USA.
| | - Barbara J Daly
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, 44106, Cleveland, OH, USA
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2
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Zaza SI, Zimmermann CJ, Taylor LJ, Kalbfell EL, Stalter L, Brasel K, Arnold RM, Cooper Z, Schwarze ML. Factors Associated With Provision of Nonbeneficial Surgery: A National Survey of Surgeons. Ann Surg 2023; 277:405-411. [PMID: 36538626 PMCID: PMC9905263 DOI: 10.1097/sla.0000000000005765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We tested the association of systems factors with the surgeon's likelihood of offering surgical intervention for older adults with life-limiting acute surgical conditions. BACKGROUND Use of surgical treatments in the last year of life is frequent. Improved risk prediction and clinician communication are solutions proposed to improve serious illness care, yet systems factors may also drive receipt of nonbeneficial treatment. METHODS We mailed a national survey to 5200 surgeons randomly selected from the American College of Surgeons database comprised of a clinical vignette describing a seriously ill older adult with an acute surgical condition, which utilized a 2×2 factorial design to assess patient and systems factors on receipt of surgical treatment to surgeons. RESULTS Two thousand one hundred sixty-one surgeons responded for a weighted response rate of 53%. For an 87-year-old patient with fulminant colitis and advanced dementia or stage IV lung cancer, 40% of surgeons were inclined to offer an operation to remove the patient's colon while 60% were inclined to offer comfort-focused care only. Surgeons were more likely to offer surgery when an operating room was readily available (odds ratio: 4.05, P <0.001) and the family requests "do everything" (odds ratio: 2.18, P <0.001). CONCLUSIONS Factors outside the surgeon's control contribute to nonbeneficial surgery, consistent with our model of clinical momentum. Further characterization of the systems in which these decisions occur might expose novel strategies to improve serious illness care for older patients and their families.
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Affiliation(s)
- Sarah I Zaza
- Department of Surgery, University of Wisconsin. Madison, WI
| | | | | | | | - Lily Stalter
- Department of Surgery, University of Wisconsin. Madison, WI
| | - Karen Brasel
- Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Robert M Arnold
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Grier K, Koch A, Docherty S. Pediatric Goals of Care Communication: A Socioecological Model to Guide Conversations. J Hosp Palliat Nurs 2023; 25:E24-E30. [PMID: 36622315 DOI: 10.1097/njh.0000000000000923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The purpose of this article is to explore factors that influence pediatric patients and their parents during provider-led goals-of-care conversations. Our framework can help providers enhance holistic communication by approaching difficult topics (ie, quality of life, end of life) with an understanding of the multilayered external influences that affect patient/parent decision making. A 5-layer model is presented that describes facilitators to conversations about quality goals of care and advance directives. Each year, complex health conditions (a) affect approximately 500 000 children in the United States, 8600 of whom meet current palliative care criteria, and (b) account for over 7 million child deaths globally. Nurses can use knowledge of the unique values and culture of families with children who have complex health conditions to support them by providing high quality, ongoing goals-of-care conversations, especially if their access to pediatric palliative care is limited.
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Tavares W, Piquette D, Luong D, Chiu M, Dyte C, Fraser K, Clark M. Exploring the Study of Simulation as a Continuing Professional Development Strategy for Physicians. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2022; 43:188-197. [PMID: 36728972 DOI: 10.1097/ceh.0000000000000470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Practicing physicians have the responsibility to engage in lifelong learning. Although simulation is an effective experiential educational strategy, physicians seldom select it for continuing professional development (CPD) for reasons that are poorly understood. The objective of this study was to explore existing evidence on simulation-based CPD and the factors influencing physicians' engagement in simulation-based CPD. METHODS A scoping review of the literature on simulation-based CPD included MEDLINE, Embase, and CINAHL databases. Studies involving the use of simulation for practicing physicians' CPD were included. Information related to motivations for participating in simulation-based CPD, study objectives, research question(s), rationale(s), reasons for using simulation, and simulation features was abstracted. RESULTS The search yielded 8609 articles, with 6906 articles undergoing title and abstract screening after duplicate removal. Six hundred sixty-one articles underwent full-text screening. Two hundred twenty-five studies (1993-2021) were reviewed for data abstraction. Only four studies explored physicians' motivations directly, while 31 studies described incentives or strategies used to enroll physicians in studies on simulation-based CPD. Most studies focused on leveraging or demonstrating the utility of simulation for CPD. Limited evidence suggests that psychological safety, direct relevance to clinical practice, and familiarity with simulation may promote future engagement. DISCUSSION Although simulation is an effective experiential educational method, factors explaining its uptake by physicians as a CPD strategy are unclear. Additional evidence of simulation effectiveness may fail to convince physicians to participate in simulation-based CPD unless personal, social, educational, or contextual factors that shape physicians' motivations and choices to engage in simulation-based CPD are explored.
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Affiliation(s)
- Walter Tavares
- Dr. Tavares: Assistant Professor and Scientist, Wilson Centre for Health Professions Education, Temerty Faculty of Medicine, Institute for Health Policy Management and Evaluation, University Health Network, University of Toronto, Toronto, Ontario, Canada, and York Region Paramedic and Senior Services, Community Health Services Department, Regional Municipality of York, Newmarket Ontario, Canada. Dr. Piquette: Assistant Professor, Inter-Department Division of Critical Care Medicine, University of Toronto, Staff Physician, Sunnybrook Health Sciences Centre, Centre Researcher, The Wilson Centre, Toronto, Ontario, Canada. Ms. Luong: Research Associate II, KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada. Dr. Chiu: Associate Professor, Department of Anesthesiology and Pain Medicine, Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada. Dr. Dyte: Clinical Lecturer and Anesthesiologist, Department of Anesthesia, Perioperative and Pain Medicine, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada. Dr. Fraser: Clinical Professor of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. Dr. Clark: Clinical Associate Professor of Surgery, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
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Brown J, Myers H, Eng D, Kilshaw L, Abraham J, Buchanan G, Eggimann L, Kelly M. Evaluation of the 'Talking Together' simulation communication training for 'goals of patient care' conversations: a mixed-methods study in five metropolitan public hospitals in Western Australia. BMJ Open 2022; 12:e060226. [PMID: 35922109 PMCID: PMC9353005 DOI: 10.1136/bmjopen-2021-060226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION In partnership with Cancer Council Western Australia (WA), the East Metropolitan Health Service in Perth, WA has developed a clinical simulation training programme 'Talking Together' using role play scenarios with trained actors as patients/carers. The aim of the training is to improve clinicians' communication skills when having challenging conversations with patients, or their carers, in relation to goals of care in the event of clinical deterioration. METHODS AND ANALYSIS A multisite, longitudinal mixed-methods study will be conducted to evaluate the impact of the communication skills training programme on patient, family/carer and clinician outcomes. Methods include online surveys and interviews. The study will assess outcomes in three areas: evaluation of the 'Talking Together' workshops and their effect on satisfaction, confidence and integration of best practice communication skills; quality of goals of patient care conversations from the point of view of clinicians, carers and family/carers; and investigation of the nursing/allied role in goals of patient care. ETHICS AND DISSEMINATION This study has received ethical approval from the Royal Perth Hospital, St John of God and Curtin University Human Research Ethics Committees. The outputs from this project will be a series of research papers and conference presentations.
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Affiliation(s)
- Janie Brown
- Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
| | - Helen Myers
- Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
| | - Derek Eng
- Palliative Care, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Lucy Kilshaw
- Aged Care, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Jillian Abraham
- East Metropolitan Health Service Executive, East Metropolitan Health Service, Perth, Western Australia, Australia
| | - Grace Buchanan
- Cancer Council Western Australia, Subiaco, Western Australia, Australia
| | - Liz Eggimann
- Cancer Council Western Australia, Subiaco, Western Australia, Australia
| | - Michelle Kelly
- Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
- Clinical & Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Serious Illness Discussion in Palliative Care—A Case Study Approach in an African American Patient with Cancer. Crit Care Nurs Clin North Am 2022; 34:79-90. [DOI: 10.1016/j.cnc.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Ma JE, Haverfield M, Lorenz KA, Bekelman DB, Brown-Johnson C, Lo N, Foglia MB, Lowery JS, Walling AM, Giannitrapani KF. Exploring expanded interdisciplinary roles in goals of care conversations in a national goals of care initiative: A qualitative approach. Palliat Med 2021; 35:1542-1552. [PMID: 34080488 DOI: 10.1177/02692163211020473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The United States Veterans Health Administration National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative throughout the Veterans Health Administration health care system in 2017. This policy encourages goals of care conversations, referring to conversations about patient's treatment and end-of-life wishes for life-sustaining treatments, among Veterans with serious illnesses. A key component of the initiative is expanding interdisciplinary provider roles in having goals of care conversations. AIM Use organizational role theory to explore medical center experiences with expanding interdisciplinary roles in the implementation of a goals of care initiative. DESIGN A qualitative thematic analysis of semi-structured interviews. SETTING/PARTICIPANTS Initial participants were recruited using purposive sampling of local medical center champions. Snowball sampling identified additional participants. Participants included thirty-one interdisciplinary providers from 12 geographically diverse initiative pilot and spread medical centers. RESULTS Five themes were identified. Expanding provider roles in goals of care conversations (1) involves organizational culture change; (2) is influenced by medical center leadership; (3) is supported by provider role readiness; (4) benefits from cross-disciplinary role agreement; and (5) can "overwhelm" providers. CONCLUSIONS Organizational role theory is a helpful framework for exploring interdisciplinary roles in a goals of care initiative. Support and recognition of provider role expansion in goals of care conversations was important for the adoption of a goals of care initiative. Actionable strategies, including multi-level leadership support and the use of interdisciplinary champions, facilitate role change and have potential to strengthen uptake of a goals of care initiative.
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Affiliation(s)
- Jessica E Ma
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health System, Durham, NC, USA
| | - Marie Haverfield
- Department of Communication Studies, San José State University, San José, CA, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Karl A Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - David B Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, CO, USA.,Center of Innovation for Veteran-Centered and Value Driven Care and Department of Medicine, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Natalie Lo
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Mary Beth Foglia
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA.,National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA
| | - Jill S Lowery
- National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Anne M Walling
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, West Los Angeles, CA, USA.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Karleen F Giannitrapani
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Baessler F, Zafar A, Ciprianidis A, Wagner FL, Klein SB, Schweizer S, Bartolovic M, Roesch-Ely D, Ditzen B, Nikendei C, Schultz JH. Analysis of risk communication teaching in psychosocial and other medical departments. MEDICAL EDUCATION ONLINE 2020; 25:1746014. [PMID: 32249706 PMCID: PMC7170276 DOI: 10.1080/10872981.2020.1746014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Aims: Teaching students about risk communication is an important aspect at medical schools given the growing importance of informed consent in healthcare. This observational study analyzes the quality of teaching content on risk communication and biostatistics at a medical school.Methods: Based on the concept of curriculum mapping, purpose-designed questionnaires were used via participant observers to record the frequency, characteristics and context of risk communication employed by lecturers during teaching sessions for one semester. The data was analyzed quantitatively and descriptively.Results: Teaching about risk communication was observed in 24.4% (n = 95 of 390) sessions. Prevalence varied significantly among different departments with dermatology having the highest rate (67.9%) but lesser in-depth teaching than medical psychology where risk communication concepts were discussed on a higher scale in 61.4% sessions. Relevant statistical values were not mentioned at all in 69% of these 95 sessions and clinical contexts were used rarely (55.8%). Supplementary teaching material was provided in 50.5% sessions while students asked questions in 18.9% sessions.Conclusions: Students are infrequently taught about communicating risks. When they are, the teaching does not include the mention of core biostatistics values nor does the teaching involve methods for demonstrating risk communication.
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Affiliation(s)
- Franziska Baessler
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
- CONTACT Franziska Baessler Department for General Internal and Psychosomatic Medicine, Centre for Psychosocial Medicine, Heidelberg University Hospital,Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Ali Zafar
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Anja Ciprianidis
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Fabienne Louise Wagner
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Sonja Bettina Klein
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Sophie Schweizer
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Heidelberg, Germany
| | - Marina Bartolovic
- Department of General Adult Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
| | - Daniela Roesch-Ely
- Department of General Adult Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
| | - Beate Ditzen
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Nikendei
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Jobst-Hendrik Schultz
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
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MacKenzie AR, Lasota M. Bringing Life to Death: The Need for Honest, Compassionate, and Effective End-of-Life Conversations. Am Soc Clin Oncol Educ Book 2020; 40:1-9. [PMID: 32207670 DOI: 10.1200/edbk_279767] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Conversations about death and dying are a crucial part of all medical care and are particularly relevant in the field of oncology. Patients express a desire to have discussions about goals of care, and many patients have thought about their end-of-life (EOL) wishes but have not had an opportunity to openly talk with care providers about this. Deficiencies in medical training, lack of confidence, limited time, and cultural barriers all contribute to the paucity of these important discussions. Although physicians are often expected to lead these conversations, nurses and nurse practitioners also play a vital role in the identification of opportunities to address EOL goals and should be a resource for the care team in facilitating EOL conversations at all points on the care continuum. Public engagement is paramount in normalizing conversations about death and dying, and the health care system needs to partner with public health agencies and private groups to open dialogues about EOL. Providers at all levels need improved education in having these difficult but essential conversations.
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Affiliation(s)
- Amy R MacKenzie
- Thomas Jefferson University, Sidney Kimmel Cancer Center, Philadelphia, PA
| | - Michelle Lasota
- Thomas Jefferson University, Sidney Kimmel Cancer Center, Philadelphia, PA
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10
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Baessler F, Weidlich J, Schweizer S, Ciprianidis A, Bartolovic M, Zafar A, Wolf M, Wagner FL, Baumann TC, Mihaljevic AL, Ditzen B, Roesch-Ely D, Nikendei C, Schultz JH. What and how are students taught about communicating risks to patients? Analysis of a medical curriculum. PLoS One 2020; 15:e0233682. [PMID: 32470064 PMCID: PMC7259606 DOI: 10.1371/journal.pone.0233682] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 05/11/2020] [Indexed: 11/18/2022] Open
Abstract
Background Communication is a core competence in medical care. Failure of physicians to properly communicate inherent risks of medical interventions has been linked with inadequate training at school. This study analyses a medical curriculum for assessing the content and quality of teaching risk communication to students. Methods A checklist based on the national guidelines of core competencies on risk communication required of physicians was developed. Participant observers surveyed all teaching sessions at a medical school during a semester to record the frequency, characteristics and clinical context used by lectures during classes. Data were analyzed using statistical and descriptive methods to determine the prevalence and quality of teaching content. Results 231 teaching sessions were surveyed. The inter-rater reliability was 81%. Lecturers mentioned topics of risk communication in 61.5% of teaching sessions (83.7% in surgery, 43.3% in internal medicine) but core biostatistics concepts were not discussed in more than 80% of these sessions. Important topics such as patient safety and preventable diseases were underrepresented. Risk communication was mainly taught in large-group, theoretical sessions and rarely with supplementary teaching material (7.4%). Students asked questions in 15.2% of courses, more often in surgery classes than in internal medicine. Conclusion Statistical and clinical topics relevant for teaching risk communication to medical students are not only underrepresented but also minimally explained by lecturers. Supplementary material on risk communication is rarely provided to students during classes. High-resource demanding, small-group teaching formats are not necessarily interactive as students ask few questions.
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Affiliation(s)
- Franziska Baessler
- Department of General, Internal and Psychosomatic Medicine, Center for Psychosocial Medicine, Heidelberg University Hospital, Heidelberg, Germany
- * E-mail:
| | - Joshua Weidlich
- Department of General, Internal and Psychosomatic Medicine, Center for Psychosocial Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Sophie Schweizer
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Heidelberg, Germany
| | - Anja Ciprianidis
- Department of General, Internal and Psychosomatic Medicine, Center for Psychosocial Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Marina Bartolovic
- Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Ali Zafar
- Department of General, Internal and Psychosomatic Medicine, Center for Psychosocial Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Wolf
- Department of General, Internal and Psychosomatic Medicine, Center for Psychosocial Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Fabienne Louise Wagner
- Department of General, Internal and Psychosomatic Medicine, Center for Psychosocial Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Tabea Chiara Baumann
- Department of General, Internal and Psychosomatic Medicine, Center for Psychosocial Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - André L. Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Beate Ditzen
- Institute of Medical Psychology, Heidelberg University Hospital, Heidelberg, Germany
| | - Daniela Roesch-Ely
- Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Nikendei
- Department of General, Internal and Psychosomatic Medicine, Center for Psychosocial Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Jobst-Hendrik Schultz
- Department of General, Internal and Psychosomatic Medicine, Center for Psychosocial Medicine, Heidelberg University Hospital, Heidelberg, Germany
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Khandelwal N, Long AC, Lee RY, McDermott CL, Engelberg RA, Curtis JR. Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals. THE LANCET RESPIRATORY MEDICINE 2019; 7:613-625. [PMID: 31122895 DOI: 10.1016/s2213-2600(19)30170-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.
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Affiliation(s)
- Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA.
| | - Ann C Long
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Cara L McDermott
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
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Lefkowits C, Bevis K, Carey EC, Sheeder J, Arnold RM, Podgurski L. Gynecologic oncology providers endorse practice-changing impact of communication skills training. Gynecol Oncol 2019; 153:633-638. [PMID: 30979590 DOI: 10.1016/j.ygyno.2019.03.242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/13/2019] [Accepted: 03/16/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Effective communication improves patient outcomes and is crucial to good patient care. Communication skills training (CST) has been shown to improve communication skills in non-gynecologic oncology specialties. We sought to develop and test CST for gynecologic oncology (GO) providers. METHODS We developed and conducted a two-day CST workshop with an interprofessional group of 20 GO providers over two years. Participants were surveyed pre-workshop, immediately post-workshop and one month post-workshop regarding self-assessed preparedness to handle challenging communication tasks, workshop evaluation and impact on practice. McNemar's tests were used for pre-post comparisons. RESULTS Of 12 challenging communication tasks assessed, all participants reported improvement in at least one, with a median of 10. The proportion of participants feeling more than "somewhat prepared" improved significantly for all communication tasks assessed (p < 0.05); improvement was sustained one month later. One month post-workshop, 86% reported thinking about what they had been taught at least weekly and 93% reported encountering situations where they used their CST skills at least weekly. Rates of reported practice-changing impact were >75% for each communication skill. All participants rated the CST educational quality very good or excellent and strongly agreed it should be required of all GO clinicians. CONCLUSIONS Participants felt the workshop provided high-quality, practice-changing education. As a result of the workshop, participants reported statistically significant, sustained improvement in preparedness to handle challenging communication tasks. CST for GO providers is feasible, with high rates of perceived effectiveness and impact on clinical practice. CST workshops should be integrated into GO training.
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Affiliation(s)
- Carolyn Lefkowits
- Department of Obstetrics & Gynecologic, Division of Gynecologic Oncology, University of Colorado Denver, Aurora, CO, United States of America; Department of Medicine, University of Colorado Denver, Aurora, CO, United States of America.
| | - Kerri Bevis
- Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Elise C Carey
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Jeanelle Sheeder
- Department of Obstetrics & Gynecology, Division of Family Planning, University of Colorado Denver, Aurora, CO, United States of America
| | - Robert M Arnold
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care & Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Lisa Podgurski
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care & Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
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Tan WS, Car J, Lall P, Low CK, Ho AHY. Implementing Advance Care Planning in Acute Hospitals: Leading the Transformation of Norms. J Am Geriatr Soc 2019; 67:1278-1285. [PMID: 30854643 DOI: 10.1111/jgs.15857] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/17/2019] [Accepted: 02/04/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite being simply defined as a process to further one's understanding about future medical care, the process of implementing advance care planning (ACP) within acute hospital settings can be complex. AIM We describe different ACP service models adopted in Singapore, and the facilitators for, and barriers to, its effective implementation. DESIGN Qualitative focus group study with thematic analysis. SETTINGS/PARTICIPANTS We purposefully sampled four stakeholder groups involved in the implementation of ACP. Our sample included 63 participants, 12 physicians, 15 nurses, 24 medical social workers, and 12 ACP coordinators from seven public hospitals and one specialist center. RESULTS We describe three different acute-care models adopted in Singapore, differentiated by leadership approach, target population, delivery process, and job roles. Our results revealed nine themes, organized into four categories, including: (1) hospital culture (curative norms, absence of preference-supportive culture), (2) organizational priority and leadership (low priority on hospital agenda, inappropriate leadership), (3) goals and distinction (lack of shared purpose and goals, no clear differentiation from existing practices), and (4) work practices (pigeonholing of ACP practice, inappropriate resourcing, accountability and feedback). CONCLUSION We learned that to implement ACP effectively in an acute-care setting, there needs to be a cultural and behavioral transformation, led by committed and empowered leaders. Organizations that can create a shared purpose built on an ethos of honoring patients' preferences, and support this with systematic processes and adequate resourcing, will be more equipped to implement ACP effectively.
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Affiliation(s)
- Woan Shin Tan
- Institute for Health Technologies, Interdisciplinary Graduate School, Nanyang Technological University, Singapore, Singapore.,Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Health Services and Outcomes Research Department, National Healthcare Group, Singapore, Singapore
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Global Digital Health Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Priya Lall
- School of Geography, Queen Mary University of London, London, United Kingdom
| | - Chan Kee Low
- Economics Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore
| | - Andy Hau Yan Ho
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Psychology Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore.,Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
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