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Harrison MB, Morrissey DL, Dalrymple WA, D'Abreu A, Daly FN. Primary Palliative Care in Huntington's Disease. Mov Disord Clin Pract 2022; 10:55-63. [PMID: 36698999 PMCID: PMC9847290 DOI: 10.1002/mdc3.13589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 09/12/2022] [Accepted: 09/23/2022] [Indexed: 01/28/2023] Open
Abstract
Background Palliative care practices, including communication about patient-centered goals of care and advance care planning (ACP), have the potential to enhance care throughout the course of Huntington's disease (HD) and related disorders. The goal of our project was to develop a pilot program that integrates primary palliative care practices with interdisciplinary care for HD. Objectives (1) To train HD team members to facilitate goals of care and ACP conversations at all stages of HD; (2) To create materials for care planning in HD focused on patient-centered goals of care and health-related quality of life; and (3) To modify clinic workflow to include goals of care and ACP discussions. Methods We defined planning domains to expand care planning beyond end-of-life concerns. We created a patient and family guide to advance care planning in HD. We conducted VitalTalk communications training with the HD team. We modified the interdisciplinary clinic workflow to include ACP and developed an EMR template for documentation. Results After communication training, more team members felt well prepared to discuss serious news (12.5% to 50%) and manage difficult conversations (25% to 62.5%). The proportion of clinic visits including advance care planning discussions increased from 12.5% to 30.6% during the pilot phase. Conclusions Provision of primary palliative care for HD in an interdisciplinary clinic is feasible. Integration of palliative care practices into HD specialty care requires additional training and modification of clinic operations.
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Affiliation(s)
| | - Dana L. Morrissey
- Department of NeurologyUniversity of VirginiaCharlottesvilleVirginiaUSA
| | - W. Alex Dalrymple
- Department of NeurologyUniversity of VirginiaCharlottesvilleVirginiaUSA
| | - Anelyssa D'Abreu
- Department of NeurologyUniversity of VirginiaCharlottesvilleVirginiaUSA
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2
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Perera N, Gold M, O'Driscoll L, Katz NT. Goals of Care Discussions Over the Course of a Patient's End of Life Admission: A Retrospective Study. Am J Hosp Palliat Care 2021; 39:652-658. [PMID: 34355578 DOI: 10.1177/10499091211035322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND As deaths in hospitals increase, clear discussions regarding resuscitation status and treatment limitations, referred to as goals of care (GOC), are vital. GOC may need revision as disease and patient priorities change over time. There is limited data about who is involved in GOC discussions, and how this changes as patients deteriorate in hospital. AIMS To review the timing and clinicians involved in GOC discussions for a cohort of patients who died in hospital. METHODS Retrospective observational audit of 80 consecutive end of life admissions between March 11th and April 9th, 2019. RESULTS Of 80 patients, 75 (93.6%) had GOC recorded during their admission, about half for ward-based non-burdensome symptom management or end-of-life care. GOC were revised in 68.0% of cases. Medical staff involved in initial versus final GOC discussions included home team junior doctor (54.7% versus 72.5%), home team consultant (37.3% versus 56.9%) and ICU doctor (16.0% versus 21.6%). For initial versus final GOC decisions, patients were involved in 34.7% versus 31.4%, and family in 53.3% versus 86.3%. Dying was documented for 92.0% of patients and this was documented to have been communicated to the family and patient in 98.6% and 19.5% of cases respectively. CONCLUSIONS As patients deteriorated, family and senior clinician involvement in GOC discussions increased, but patient involvement did not. Junior doctors were most heavily involved in discussions. We advocate for further GOC training and modeling to enhance junior doctors' confidence and competence in conducting and involving patients and families in GOC conversations.
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Affiliation(s)
- Natalie Perera
- Palliative Care Service, 5392Alfred Health, Melbourne, Victoria, Australia
| | - Michelle Gold
- Palliative Care Service, 5392Alfred Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Lisa O'Driscoll
- Advance Care Planning and Improving End of Life Care, 5392Alfred Health, Melbourne, Victoria, Australia
| | - Naomi T Katz
- Palliative Care Service, 5392Alfred Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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3
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Bartlett S, Fettig LP, Baenziger PH, DiOrio EN, Herget KM, D'Cruz L, Coughlin JR, Lake M, Truong A, Comer AR. Indiana Medical Resident's Knowledge of Surrogate Decision Making Laws. INTERNATIONAL QUARTERLY OF COMMUNITY HEALTH EDUCATION 2021; 42:272684X211004737. [PMID: 33752546 DOI: 10.1177/0272684x211004737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION During the care of incapacitated patients, physicians, and medical residents discuss treatment options and gain consent to treat through healthcare surrogates. The purpose of this study is to ascertain medical residents' knowledge of healthcare consent laws, application during clinical practice, and appraise the education residents received regarding surrogate decision making laws. METHODS Beginning in February of 2018, 35 of 113 medical residents working with patients within Indiana completed a survey. The survey explored medical residents' knowledge of health care surrogate consent laws utilized in Indiana hospitals and Veterans Affairs (VA) hospitals via clinical vignettes. RESULTS Only 22.9% of medical residents knew the default state law in Indiana did not have a hierarchy for settling disputes among surrogates. Medical residents correctly identified which family members could participate in medical decisions 86% of the time. Under the Veterans Affairs surrogate law, medical residents correctly identified appropriate family members or friends 50% of the time and incorrectly acknowledged the chief decision makers during a dispute 30% of the time. All medical residents report only having little or some knowledge of surrogate decision making laws with only 43% having remembered receiving surrogate decision making training during their residency. CONCLUSIONS These findings demonstrate that medical residents lack understanding of surrogate decision making laws. In order to ensure medical decisions are made by the appropriate surrogates and patient autonomy is upheld, an educational intervention is required to train medical residents about surrogate decision making laws and how they are used in clinical practice.
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Affiliation(s)
- Stephanie Bartlett
- Indiana University School of Health and Human Sciences, Indianapolis, Indiana, United States
| | - Lyle P Fettig
- Indiana University School of Medicine, Eskenazi Health, Indianapolis, Indiana, United States
| | - Peter H Baenziger
- Ascension's Peyton Manning Children's Hospital, Indianapolis, Indiana, United States
| | | | - Kayla M Herget
- St. Vincent Hospital, Indianapolis, Indiana, United States
| | - Lynn D'Cruz
- Indiana University School of Health and Human Sciences, Indianapolis, Indiana, United States
| | - Johanna R Coughlin
- Indiana University Health, Indianapolis, Indiana, United States
- Witham Hospital, Lebanon, Indiana, United States
| | - Mikaela Lake
- Lake Erie College of Osteopathic Medicine, Bradenton, Florida, United States
| | - Amy Truong
- Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, United States
| | - Amber R Comer
- Health Sciences, Indiana University, Indianapolis, Indiana, United States
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4
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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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5
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Zaeh SE, Hayes MM, Eakin MN, Rand CS, Turnbull AE. Housestaff perceptions on training and discussing the Maryland Orders for Life Sustaining Treatment Form (MOLST). PLoS One 2020; 15:e0234973. [PMID: 32559244 PMCID: PMC7304571 DOI: 10.1371/journal.pone.0234973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 06/06/2020] [Indexed: 11/18/2022] Open
Abstract
Background On-line tutorials are being increasingly used in medical education, including in teaching housestaff skills regarding end of life care. Recently an on-line tutorial incorporating interactive clinical vignettes and communication skills was used to prepare housestaff at Johns Hopkins Hospital to use the Maryland Orders for Life Sustaining Treatment (MOLST) form, which documents patient preferences regarding end of life care. 40% of housestaff who viewed the module felt less than comfortable discussing choices on the MOLST with patients. We sought to understand factors beyond knowledge that contributed to housestaff discomfort in MOLST discussions despite successfully completing an on-line tutorial. Methods We conducted semi-structured telephone interviews with 18 housestaff who completed the on-line MOLST training module. Housestaff participants demonstrated good knowledge of legal and regulatory issues related to the MOLST compared to their peers, but reported feeling less than comfortable discussing the MOLST with patients. Transcripts of interviews were coded using thematic analysis to describe barriers to using the MOLST and suggestions for improving housestaff education about end of life care discussions. Results Qualitative analysis showed three major factors contributing to lack of housestaff comfort completing the MOLST form: [1] physician barriers to completion of the MOLST, [2] perceived patient barriers to completion of the MOLST, and [3] design characteristics of the MOLST form. Housestaff recommended a number of adaptations for improvement, including in-person training to improve their skills conducting conversations regarding end of life preferences with patients. Conclusions Some housestaff who scored highly on knowledge tests after completing a formal on-line curriculum on the MOLST form reported barriers to using a mandated form despite receiving training. On-line modules may be insufficient for teaching communication skills to housestaff. Additional training opportunities including in-person training mechanisms should be incorporated into housestaff communication skills training related to end of life care.
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Affiliation(s)
- Sandra E. Zaeh
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
| | - Margaret M. Hayes
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Michelle N. Eakin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Cynthia S. Rand
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Alison E. Turnbull
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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6
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Harrington AW, Oliveira KD, Lui FY, Maerz LL. Resident Education in End-of-Life Communication and Management: Assessing Comfort Level to Enhance Competence and Confidence. JOURNAL OF SURGICAL EDUCATION 2020; 77:300-308. [PMID: 31780426 DOI: 10.1016/j.jsurg.2019.11.003] [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] [Received: 05/08/2019] [Revised: 10/24/2019] [Accepted: 11/03/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Our primary objective was to understand residents' baseline comfort with end-of-life (EOL) communication and management and to compare this with their comfort after completion of their surgical intensive care unit (SICU) rotation. We also evaluated the association between prior training with perceived level of comfort with EOL issues, and whether the resident believed in the concept of a "better death." DESIGN, SETTING, PARTICIPANTS As a quality improvement initiative, we conducted surveys of trainees before and after their rotation in the Yale New Haven Hospital SICU. Prerotation and postrotation surveys were administered to all residents who rotated during the 2016-2017 academic year and the first half of 2017-2018. The survey consisted of 34 questions querying residents on their level of training in EOL care, their comfort with management and discussions in different EOL domains, and their beliefs about what measures would have improved their ability to provide EOL care. Residents surveyed were from general surgery, emergency medicine, or anesthesia departments. RESULTS AND CONCLUSIONS Our study demonstrates that there is a significant correlation between resident comfort with EOL communication and experience providing EOL care. However, concepts in medicolegal aspects of palliative care could be taught through formal didactics, and structured training may allow residents the opportunity to reflect on the importance of a "better death."
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Affiliation(s)
| | - Kristin D Oliveira
- Yale School of Medicine, Department of Surgery, Section of General Surgery, Trauma & Surgical Critical Care, New Haven, Connecticut
| | - Felix Y Lui
- Yale School of Medicine, Department of Surgery, Section of General Surgery, Trauma & Surgical Critical Care, New Haven, Connecticut
| | - Linda L Maerz
- Yale School of Medicine, Department of Surgery, Section of General Surgery, Trauma & Surgical Critical Care, New Haven, Connecticut
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7
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Reddy SK, Tanco K, Yennu S, Liu DD, Williams JL, Wolff R, Bruera E. Integration of a Mandatory Palliative Care Education Into Hematology-Oncology Fellowship Training in a Comprehensive Cancer Center: A Survey of Hematology Oncology Fellows. J Oncol Pract 2019; 15:e934-e941. [PMID: 31268810 DOI: 10.1200/jop.19.00056] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The primary aim of this study was to determine the attitudes and beliefs of hematology and medical oncology (HMO) fellows regarding palliative care (PC) after they completed a 4-week mandatory PC rotation. METHODS The PC rotation included a 4-week standardized curriculum covering all PC domains. HMO fellows were provided educational materials and attended all didactic sessions. All had clinical rotation in an acute PC unit and an outpatient clinic. All HMO fellows from 2004 to 2017 were asked to complete a 32-item survey on oncology trainee perception of PC. RESULTS Of 105 HMO fellows, 77 (73%) completed the survey. HMO fellows reported that PC rotation improved assessment and management of symptoms (98%); opioid prescription (89%), opioid rotation (78%), and identification of opioid adverse effects (87%); communication with patients and families (91%), including advance care planning discussion (88%) and do-not-resuscitate discussion (88%); and they reported comfort with discussing ethical issues (74%). Participants reported improvement in knowledge of symptom assessment and management (n = 76; 98%) as compared with efficacy in ethics (n = 57 [74%]; P = .0001) and for coping with stress of terminal illness (n = 45 [58%]; P = .0001). The PC rotation educational experience was considered either far better or better (53%) or the same (45%) as other oncology rotations. Most respondents (98%) would recommend PC rotations to other HMO fellows, and 95% felt rotation should be mandatory. CONCLUSION HMO fellows reported PC rotation improved their attitudes and knowledge in all PC domains. PC rotation was considered better than other oncology rotations and should be mandatory.
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Affiliation(s)
- Suresh K Reddy
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Kimberson Tanco
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Sriram Yennu
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Diane D Liu
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | - Robert Wolff
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- The University of Texas, MD Anderson Cancer Center, Houston, TX
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8
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Moyer KM, Morrison LJ, Encandela J, Kennedy C, Ellman MS. A New Competency-Based Instrument to Assess Resident Knowledge and Self-Efficacy in Primary Palliative Care. Am J Hosp Palliat Care 2019; 37:117-122. [PMID: 31213089 DOI: 10.1177/1049909119855612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CONTEXT There is a need to improve both primary palliative care (PPC) education and its assessment in graduate medical education (GME). We developed an instrument based on published palliative care (PC) competencies to assess resident competency and educational interventions. OBJECTIVES To describe the development and psychometric properties of a novel, competency-based instrument to measure resident knowledge and self-efficacy in PPC. METHODS We created a 2-part instrument comprised of a knowledge test (KT) and a self-efficacy inventory (SEI) addressing 18 consensus, core PC resident competencies across 5 domains: pain and symptom management; communication; psychosocial, spiritual, and cultural aspects of care; terminal care and bereavement; and PC principles and practice. The instrument was distributed to 341 internal medicine residents during academic years 2015 to 2016 and 2016 to 2017. A standard item analysis was performed on the KT. Internal consistency (Cronbach α) and variable relationships (factor analysis) were measured for the SEI. RESULTS One hundred forty-four residents completed the survey (42% response). For 15 KT items, difficulty ranged from 0.17 to 0.98, with 7 items ranging 0.20 to 0.80 (typical optimum difficulty); discrimination ranged from 0.03 to 0.60 with 10 items ≥0.27 (good to very good discrimination). Cronbach α was 0.954 for 35 SEI items. Factor analysis of combined 2015 to 2016 items yielded 4 factors explaining the majority of variance for the entire set of variables. CONCLUSION Our instrument demonstrates promising psychometric properties and reliability in probing the constructs of PC and can be further utilized in PC GME research to assess learners and evaluate PPC educational interventions.
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Affiliation(s)
- Kristen M Moyer
- Advanced Illness Management Team, Departments of Anesthesia and Internal Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Laura J Morrison
- Section of Geriatrics, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - John Encandela
- Department of Psychiatry and Teaching and Learning Center, Yale School of Medicine, New Haven, CT, USA
| | - Catherine Kennedy
- Teaching and Learning Center, Yale School of Medicine, New Haven, CT, USA
| | - Matthew S Ellman
- Section of General Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
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9
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Piscitello GM, Parham WM, Huber MT, Siegler M, Parker WF. The Timing of Family Meetings in the Medical Intensive Care Unit. Am J Hosp Palliat Care 2019; 36:1049-1056. [PMID: 30983374 DOI: 10.1177/1049909119843133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Family meetings in the medical intensive care unit can improve outcomes. Little is known about when meetings occur in practice. We aimed to determine the time from admission to family meetings in the medical intensive care unit and assess the relationship of meetings with mortality. METHODS We performed a prospective cohort study of critically ill adult patients admitted to the medical intensive care unit at an urban academic medical center. Using manual chart review, the primary outcome was any attempt at holding a family meeting within 72 hours of admission. Competing risk models estimated the time from admission to family meeting and to patient death or discharge. RESULTS Of the 131 patients who met inclusion criteria in the 12-month study period, the median time from admission to family meeting was 4 days. Fewer than half of patients had a documented family meeting within 72 hours of admission (n = 60/131, 46%), with substantial interphysician variability in meeting rates ranging from 28% to 63%. Patients with family meetings within 72 hours were 30 times more likely to die within 72 hours (32% vs 1%, P < .001). Of the 55 patients who died in the intensive care unit, 27 (49%) had their first family meeting within 1 day of death. CONCLUSIONS Family meetings occur considerably later than 72 hours and are often held in close proximity to a patient's death. This suggests for some physicians, family meetings may primarily be used to negotiate withdrawal of life support rather than to support the patient and family.
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Affiliation(s)
- Gina M Piscitello
- 1 Department of Medicine, University of Chicago, Chicago, IL, USA.,2 MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
| | - William M Parham
- 3 Abbott Northwestern Hospital Critical Care Medicine, Minneapolis, MN, USA
| | - Michael T Huber
- 2 MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA.,4 Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Mark Siegler
- 1 Department of Medicine, University of Chicago, Chicago, IL, USA.,2 MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
| | - William F Parker
- 1 Department of Medicine, University of Chicago, Chicago, IL, USA.,2 MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
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Swinney R, Yin L, Lee A, Rubin D, Anderson C. The Role of Support Staff in Pediatric Palliative Care: Their Perceptions, Training, and Available Resources. J Palliat Care 2019. [DOI: 10.1177/082585970702300107] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pediatric palliative care requires the orchestrated efforts of a multidisciplinary care team of medical staff, nursing, psychosocial staff, and other healthcare professionals. Augmenting this team are support staff including financial counsellors, volunteers, secretaries, and others not involved in the direct administration of medical services. Prior research in palliative care has studied the perceptions, training, and professional resources of medical staff and social workers, but neglected to investigate such factors in support staff. Our study examined the effect of involvement in end-of-life pediatric care on support staff. We found this community to consist of a heterogeneous population of hospital employees, who develop numerous, substantial, direct interactions with dying children and their families. They indicated that such experiences had caused some adverse outcomes in their lives, and that few felt they had sufficient knowledge or training in palliative care. Our respondents voiced noteworthy opinions on symptom control, cultural issues, and spirituality pertinent to pediatric palliative care. Support staff play a key role in the palliative care team; research and resources need to be directed to educating, training, and supporting them.
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Affiliation(s)
- Ryan Swinney
- Keck School of Medicine at the University of Southern California, Los Angeles, California
| | - Lu Yin
- Department of Emergency Medicine, Brooklyn Hospital, Brooklyn, New York
| | - Andrew Lee
- Department of Otolaryngology, University of California—Davis Medical Center, Sacramento, California
| | - David Rubin
- Keck School of Medicine at the University of Southern California, Los Angeles, California
| | - Clarke Anderson
- Department of Pediatric Oncology, City of Hope, Duarte, California, USA
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11
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Senthil K, Serwint JR, Dawood FS. Patient End-of-Life Experiences for Pediatric Trainees: Spanning the Educational Continuum. Clin Pediatr (Phila) 2016; 55:811-8. [PMID: 26896342 DOI: 10.1177/0009922816631513] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background End-of-life care for a child is an emotionally charged experience for pediatric trainees. Objectives Describe the progression of medical trainee experiences with end-of-life care and determine personal/professional experiences that facilitated integration of experiences. Methods Medical students (MS4) and pediatric residents (PL-1-3) completed a 30-question survey about experiences with patient deaths and integration of these experiences. Results A total of 307 of 404 residents (76%) participated. Mean number of deaths ranged from 3.0 to 6.5 in the prior 12 months, and the most common location was neonatal intensive care unit or pediatric intensive care unit. In total, 18% to 27% experienced a death in their personal life. Between 26% and 41% of the residents made contact with a family after death, and 15% to 35% attended a funeral. Characteristics of good deaths included good communication and discussion of end-of-life issues. Conclusions Trainees experienced patient deaths along the educational continuum. These findings have implications for the optimal timing and method of end-of-life care education.
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Affiliation(s)
- Kumaran Senthil
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Janet R Serwint
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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12
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Wong A, Reddy A, Williams JL, Wu J, Liu D, Bruera E, Wong A, Reddy A, Williams JL, Wu J, Liu D, Bruera E. ReCAP: Attitudes, Beliefs, and Awareness of Graduate Medical Education Trainees Regarding Palliative Care at a Comprehensive Cancer Center. J Oncol Pract 2016; 12:149-50; e127-37. [PMID: 26787756 PMCID: PMC5702790 DOI: 10.1200/jop.2015.006619] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Palliative care (PC) training and integration with oncology care remain suboptimal. Current attitudes and beliefs of the oncology trainees regarding PC are not fully known. This study was undertaken in an attempt to address this issue. PARTICIPANTS AND METHODS We conducted a survey to determine awareness of PC among graduate medical trainees at a comprehensive cancer center with an established PC program. One hundred seventy oncology trainees who completed$9 months of training in medical, surgical, gynecologic, and radiation oncology fellowships and residency programs during the 2013 academic year completed an online questionnaire. Descriptive, univariable, and multivariable analyses were performed. RESULTS The response rate was 78% (132 of 170 trainees); 10 trainees without hands-on patient care were excluded. Medical (53 of 60 [88%]), gynecologic (six of six [100%]), and radiation oncology (20 of 20 [100%]) trainees reported more awareness of PC compared with surgical oncology (22 of 36 [61%]) trainees (P = .001). One hundred twelve of 122 (92%) perceived PC as beneficial to patients and families. One hundred eight of 122 (89%) perceived that PC can reduce health care costs, 78 (64%) believed that PC can increase survival, and 90 (74%) would consult PC for a patient with newly diagnosed cancer with symptoms. Eighty-two trainees (67%) believed a mandatory PC rotation is important. Trainees with previous exposure to PC rotations were more aware of the role of PC services than were trainees without PC rotation (96% [46 of 48] v 74% [55 of 74]; P = .005, respectively). CONCLUSION Surgical trainees and trainees without previous PC rotation had significantly less awareness of PC. Overall, trainees perceived PC as beneficial to patients and capable of reducing costs while increasing survival; they also supported early PC referrals and endorsed a mandatory PC rotation.
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Affiliation(s)
| | - Akhila Reddy
- The University of Texas MD Anderson Cancer Center
| | | | - Jimin Wu
- The University of Texas MD Anderson Cancer Center
| | - Diane Liu
- The University of Texas MD Anderson Cancer Center
| | | | - Angelique Wong
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Akhila Reddy
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Jimin Wu
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Diane Liu
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- The University of Texas MD Anderson Cancer Center, Houston, TX.
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13
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Abstract
RATIONALE The Accreditation Council for Graduate Medical Education requires physicians training in pulmonary and critical care medicine to demonstrate competency in interpersonal communication. Studies have shown that residency training is often insufficient to prepare physicians to provide end-of-life care and facilitate patient and family decision-making. Poor communication in the intensive care unit (ICU) can adversely affect outcomes for critically ill patients and their family members. Despite this, communication training curricula in pulmonary and critical care medicine are largely absent in the published literature. OBJECTIVES We evaluated the effectiveness of a communication skills curriculum during the first year of a pulmonary and critical care medicine fellowship using a family meeting checklist to provide formative feedback to fellows during ICU rotations. We hypothesized that fellows would demonstrate increased competence and confidence in the behavioral skills necessary for facilitating family meetings. METHODS We evaluated a 12-month communication skills curriculum using a pre-post, quasiexperimental design. Subjects for this study included 11 first-year fellows who participated in the new curriculum (intervention group) and a historical control group of five fellows who had completed no formal communication curriculum. Performance of communication skills and self-confidence in family meetings were assessed for the intervention group before and after the curriculum. The control group was assessed once at the beginning of their second year of fellowship. RESULTS Fellows in the intervention group demonstrated significantly improved communication skills as evaluated by two psychologists using the Family Meeting Behavioral Skills Checklist, with an increase in total observed skills from 51 to 65% (P ≤ 0.01; Cohen's D effect size [es], 1.13). Their performance was also rated significantly higher when compared with the historical control group, who demonstrated only 49% of observed skills (P ≤ 0.01; es, 1.55). Fellows in the intervention group also showed significantly improved self-confidence scores upon completion of the curriculum, with an increase from 77 to 89% (P ≤ 0.01; es, 0.87) upon completion of the curriculum CONCLUSIONS A structured curriculum that includes abundant opportunities for fellows to practice and receive feedback using a behavioral checklist during their ICU rotations helps to develop physicians with advanced communication skills.
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Sawatzky R, Porterfield P, Lee J, Dixon D, Lounsbury K, Pesut B, Roberts D, Tayler C, Voth J, Stajduhar K. Conceptual foundations of a palliative approach: a knowledge synthesis. BMC Palliat Care 2016; 15:5. [PMID: 26772180 PMCID: PMC4715271 DOI: 10.1186/s12904-016-0076-9] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 01/06/2016] [Indexed: 12/31/2022] Open
Abstract
Background Much of what we understand about the design of healthcare systems to support care of the dying comes from our experiences with providing palliative care for dying cancer patients. It is increasingly recognized that in addition to cancer, high quality end of life care should be an integral part of care that is provided for those with other advancing chronic life-limiting conditions. A “palliative approach” has been articulated as one way of conceptualizing this care. However, there is a lack of conceptual clarity regarding the essential characteristics of a palliative approach to care. The goal of this research was to delineate the key characteristics of a palliative approach found in the empiric literature in order to establish conceptual clarity. Methods We conducted a knowledge synthesis of empirical peer-reviewed literature. Search terms pertaining to “palliative care” and “chronic life-limiting conditions” were identified. A comprehensive database search of 11 research databases for the intersection of these terms yielded 190,204 documents. A subsequent computer-assisted approach using statistical predictive classification methods was used to identify relevant documents, resulting in a final yield of 91 studies. Narrative synthesis methods and thematic analysis were used to then identify and conceptualize key characteristics of a palliative approach. Results The following three overarching themes were conceptualized to delineate a palliative approach: (1) upstream orientation towards the needs of people who have life-limiting conditions and their families, (2) adaptation of palliative care knowledge and expertise, (3) operationalization of a palliative approach through integration into systems and models of care that do not specialize in palliative care. Conclusion Our findings provide much needed conceptual clarity regarding a palliative approach. Such clarity is of fundamental importance for the development of healthcare systems that facilitate the integration of a palliative approach in the care of people who have chronic life-limiting conditions.
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Affiliation(s)
- Richard Sawatzky
- School of Nursing, Trinity Western University, 7600 Glover Road, Langley, BC, V2Y 1Y1, Canada.
| | - Pat Porterfield
- School of Nursing, University of British Columbia, T-201-2211 Westbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - Joyce Lee
- School of Nursing, Trinity Western University, 7600 Glover Road, Langley, BC, V2Y 1Y1, Canada
| | - Duncan Dixon
- School of Nursing, Trinity Western University, 7600 Glover Road, Langley, BC, V2Y 1Y1, Canada
| | - Kathleen Lounsbury
- School of Nursing, Trinity Western University, 7600 Glover Road, Langley, BC, V2Y 1Y1, Canada
| | - Barbara Pesut
- School of Nursing, University of British Columbia, 1147 Research Road, Kelowna, BC, V1V 1V7, Canada
| | - Della Roberts
- Fraser Health, Delta Hospital, Hospice Palliative Care, 5800 Mountain View Blvd, Delta, BC, V4K 3V6, Canada
| | - Carolyn Tayler
- Fraser Health, Suite 400-Central City Tower, 13450 102nd Avenue, Surrey, BC, V3T 0H1, Canada
| | - James Voth
- Intogrey Research and Development Inc., 300-34334 Forrest Terrace, Abbotsford, BC, V2S 1G7, Canada
| | - Kelli Stajduhar
- School of Nursing, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada
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Einstein DJ, Einstein KL, Mathew P. Dying for Advice: Code Status Discussions between Resident Physicians and Patients with Advanced Cancer—A National Survey. J Palliat Med 2015; 18:535-41. [DOI: 10.1089/jpm.2014.0373] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- David J. Einstein
- Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
- Division of Hematology & Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Paul Mathew
- Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
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[Pediatric palliative care: a national survey of French pediatric residents' knowledge, education, and clinical experience]. Arch Pediatr 2014; 21:834-44. [PMID: 24993148 DOI: 10.1016/j.arcped.2014.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 03/07/2014] [Accepted: 05/13/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND The need for educational training of healthcare professionals in palliative care is an important issue. Training and practice of pediatric residents in the field of pediatric palliative care (PPC) has never been assessed, although the organization of the medical curriculum in France is currently being revised. MATERIALS AND METHODS This study presents a national survey of pediatric residents, using a computerized anonymous questionnaire. Four different areas were studied: epidemiological data, theoretical and practical knowledge, education, and clinical experience in PPC. RESULTS The response rate was 39% (n=365/927). Whatever their age or regional location, 25% of residents did not know any details of the French law concerning patients' rights and the end of life. Experience with PPC starts very early since 77% of the first-year pediatric residents experienced at least one child in a palliative care and/or end-of-life situation. During their entire residency, 87% of the residents had experience with PPC and nearly all (96%) end-of-life care. Furthermore, 76% had participated in announcing palliative care (cancer, ICU, etc.) or a serious illness, and 45% had met and discussed with bereaved parents. Furthermore, while 97% of the pediatric residents received training in adult palliative care, mainly before their residency, only 60% received specific PPC training. DISCUSSION AND CONCLUSION Ninety-six percent of all French pediatric residents encountered a PPC situation during their residency. That 77% of them had experienced PPC during their first year of residency shows the importance of early training in PPC for pediatric residents. Furthermore, this study points out that there is a significant lack in PPC training since 40% of all residents in the study received no specific PPC training. Progress in education remains insufficient in the dissemination of knowledge on the legal framework and concepts of palliative medicine: while the medical curriculum is being revised, we suggest that training in medical ethics and PPC should be introduced very early and systematically.
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Kottewar SA, Bearelly D, Bearelly S, Johnson ED, Fleming DA. Residents' End-of-Life Training Experience: A Literature Review of Interventions. J Palliat Med 2014; 17:725-32. [DOI: 10.1089/jpm.2013.0353] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Saket A. Kottewar
- Department of Medicine, University of Missouri School of Medicine, Columbia, Missouri
| | - Dilip Bearelly
- Division of Gastroenterology, University of Missouri School of Medicine, Columbia, Missouri
| | - Smith Bearelly
- Department of Medicine, University of Missouri School of Medicine, Columbia, Missouri
| | - E. Diane Johnson
- Information Services and Resources, J. Otto Lottes Health Sciences Library, University of Missouri School of Medicine, Columbia, Missouri
| | - David A. Fleming
- Department of Medicine, University of Missouri School of Medicine, Columbia, Missouri
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Schoenborn NL, Cheng MJ, Christmas C. A memorial service to provide reflection on patient death during residency. J Grad Med Educ 2013; 5:686-8. [PMID: 24455025 PMCID: PMC3886475 DOI: 10.4300/jgme-d-12-00322.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 07/16/2013] [Accepted: 07/30/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Patient death can be emotionally and psychologically stressful for clinicians, particularly clinicians in training. OBJECTIVE We describe an annual memorial service as a novel approach to help internal medicine residents cope with and reflect on the experiences of patient death. METHODS We created a memorial service in 2010 for patients who had died under the care of the internal medicine residents in our institution. Residents, medical students, and medicine faculty attended the 1-hour service. The memorial service was repeated in 2011, and a 10-question survey was sent to evaluate its impact. RESULTS Twenty-two participants in either the 2010 or 2011 memorial service responded to the survey. Most of the respondents thought that reflection on patient death was important (95%) and that the memorial service was helpful in facilitating such reflection and bringing closure (95%). CONCLUSIONS An annual memorial service helps trainees cope with the emotional impact of patient death. It can be easily adopted by other residency programs. The long-term impact of this experience on trainees' well-being and professional development is unknown.
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Tung EE, Wieland ML, Verdoorn BP, Mauck KF, Post JA, Thomas MR, Bundrick JB, Jaeger TM, Cha SS, Thomas KG. Improved Resident Physician Confidence With Advance Care Planning After an Ambulatory Clinic Intervention. Am J Hosp Palliat Care 2013; 31:275-80. [DOI: 10.1177/1049909113485636] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Many primary care providers feel uncomfortable discussing end-of-life care. The aim of this intervention was to assess internal medicine residents’ advance care planning (ACP) practices and improve residents’ ACP confidence. Residents participated in a facilitated ACP quality improvement workshop, which included an interactive presentation and chart audit of their own patients. Pre- and postintervention surveys assessed resident ACP-related confidence. Only 24% of the audited patients had an advance directive (AD), and 28% of the ACP-documentation was of no clinical utility. Terminally ill patients (odds ratio 2.8, P < .001) were more likely to have an AD. Patients requiring an interpreter were less likely to have participated in ACP. Residents reported significantly improved confidence with ACP and identified important training gaps. Future studies examining the impact on ACP quality are needed.
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Affiliation(s)
- Ericka E. Tung
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark L. Wieland
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brandon P. Verdoorn
- Internal Medicine Residency Program, Mayo Graduate School of Medicine, College of Medicine, Mayo Clinic, Rochester, MN, USA
- Hematology and Oncology Fellowship Program, University of Colorado Health Sciences Center, Denver, CO, USA
| | - Karen F. Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jason A. Post
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Matthew R. Thomas
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - John B. Bundrick
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Thomas M. Jaeger
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephen S. Cha
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Kris G. Thomas
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Abstract
The interactions and observations of residents speaking with patients and family members about end-of-life decisions indicated a need for more empathy. Nursing and medical students have been called to learn and work together so they can work more effectively. A review of the evidence on interdisciplinary education of residents concerning end-of-life care and communicating with patients and their family members was the inspiration for this study. This article applies evidence related to interdisciplinary education in critical care settings. This pilot project was a collaboration of medical education between a critical care service in a public hospital and baccalaureate nursing students assisting family members in making end-of-life decisions. As nursing students, we were able to effectively present content on end-of-life decision making to medical residents.
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Reckrey JM, Diane McKee M, Sanders JJ, Lipman HI. Resident Physician Interactions with Surrogate Decision-Makers: The Resident Experience. J Am Geriatr Soc 2011; 59:2341-6. [DOI: 10.1111/j.1532-5415.2011.03728.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jennifer M. Reckrey
- Brookdale Department of Geriatrics and Palliative Medicine; Mount Sinai School of Medicine; New York; New York
| | - M. Diane McKee
- Department of Family and Social Medicine; Albert Einstein College of Medicine; Bronx; New York
| | - Justin J. Sanders
- Department of Family and Social Medicine; Montefiore Medical Center; Bronx; New York
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22
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Meo N, Hwang U, Morrison RS. Resident perceptions of palliative care training in the emergency department. J Palliat Med 2011; 14:548-55. [PMID: 21291326 PMCID: PMC3089743 DOI: 10.1089/jpm.2010.0343] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2010] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To characterize the level of formal training and perceived educational needs in palliative care of emergency medicine (EM) residents. METHODS This descriptive study used a 16-question survey administered at weekly resident didactic sessions in 2008 to EM residency programs in New York City. Survey items asked residents to: (1) respond to Likert-scaled statements about the role of palliative care in the emergency department (ED); (2) quantify their level of formal training and personal comfort in symptom management, discussion of bad news and prognosis, legal issues, and withdrawing/withholding therapy; and (3) express their interest in future palliative care training. RESULTS Of 228 total residents, 159 (70%) completed the survey. Of those surveyed, 50% completed some palliative care training before residency; 71.1% agreed or strongly agreed that palliative care was an important competence for an EM physician. However, only 24.3% reported having a "clear idea of the role of palliative care in EM." The highest self-reported level of formal training was in the area of advanced directives or legal issues at the end of life; the lowest levels were in areas of patient management at the end of life. The highest level of self-reported comfort was in giving bad news and the lowest was in withholding/withdrawing therapy. A slight majority of residents (54%) showed positive interest in receiving future training in palliative care. CONCLUSIONS New York City EM residents reported palliative care as an important competency for emergency medicine physicians, yet also reported low levels of formal training in palliative care. The majority of residents surveyed favored additional training.
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Affiliation(s)
- Nicholas Meo
- Brookdale Department of Geriatrics and Palliative Care, Mount Sinai School of Medicine, New York, New York
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York
| | - Ula Hwang
- Brookdale Department of Geriatrics and Palliative Care, Mount Sinai School of Medicine, New York, New York
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York
- Research Enhancement Award Program (REAP) and Geriatric Research, Education and Clinical Center (GRECC), James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - R. Sean Morrison
- Brookdale Department of Geriatrics and Palliative Care, Mount Sinai School of Medicine, New York, New York
- Research Enhancement Award Program (REAP) and Geriatric Research, Education and Clinical Center (GRECC), James J. Peters Veterans Affairs Medical Center, Bronx, New York
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Dow LA, Matsuyama RK, Ramakrishnan V, Kuhn L, Lamont EB, Lyckholm L, Smith TJ. Paradoxes in advance care planning: the complex relationship of oncology patients, their physicians, and advance medical directives. J Clin Oncol 2009; 28:299-304. [PMID: 19933909 DOI: 10.1200/jco.2009.24.6397] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Many seriously ill patients with cancer do not discuss prognosis or advance directives (ADs), which may lead to inappropriate and/or unwanted aggressive care at the end of life. Ten years ago, patients with cancer said they would not like to discuss ADs with their oncologist but would be willing to discuss them with an admitting physician. We assessed whether this point of view still held. PATIENTS AND METHODS Semi-structured interviews were conducted with 75 consecutively admitted patients with cancer in the cancer inpatient service. RESULTS Of those enrolled, 41% (31 of 75) had an AD. Nearly all (87%, 65 of 75) thought it acceptable to discuss ADs with the admitting physician with whom they had no prior relationship, and 95% (62 of 65) thought that discussing AD issues was very or somewhat important. Only 7% (5 of 75) had discussed ADs with their oncologist, and only 23% (16 of 70) would like to discuss ADs with their oncologist. When specifically asked which physician they would choose, 48% (36 of 75) of patients would prefer their oncologist, and 35% (26 of 75) would prefer their primary care physician. CONCLUSION Fewer than half of seriously ill patients with cancer admitted to an oncology service have an AD. Only 23% (16 of 70) would like to discuss their ADs with their oncologist but nearly all supported a policy of discussing ADs with their admitting physician. However, fully 48% (36 of 75) actually preferred to discuss advance directives with their oncologist if AD discussion was necessary. We must educate patients on why communicating their ADs is beneficial and train primary care physicians, house staff, hospitalists, and oncologists to initiate these difficult discussions.
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Affiliation(s)
- Lindsay A Dow
- School of Medicine and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA 23298-0230, USA
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Billings ME, Curtis JR, Engelberg RA. Medicine residents' self-perceived competence in end-of-life care. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2009; 84:1533-9. [PMID: 19858811 PMCID: PMC5847268 DOI: 10.1097/acm.0b013e3181bbb490] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
PURPOSE Internal medicine residents frequently provide end-of-life care, yet feel inadequately trained and uncomfortable providing this care, despite efforts to improve end-of-life care curricula. Understanding how residents' experiences and attitudes affect their perceived competence in providing end-of-life care is important for targeting educational interventions. METHOD Medicine residents (74) at the University of Washington and Medical University of South Carolina enrolled in a trial investigating the efficacy of a communication skills intervention to improve end-of-life care. On entry to the study in the fall of 2007, residents completed a questionnaire assessing their prior experiences, attitudes, and perceived competence with end-of-life care. Multivariate regression analysis was performed to assess whether attitudes and experiences with end-of-life care were associated with perceived competence, controlling for gender, race/ethnicity, training year, training site, and personal experience with death of a loved one. RESULTS Residents had substantial experience providing end-of-life care. In an adjusted multivariate model including attitudes and clinical experience in end-of-life care as predictors, only clinical experience providing end-of-life care was associated with self-perceived competence (P=.015). CONCLUSIONS Residents with more clinical experience during training had greater self-perceived competence providing end-of-life care. Increasing the quantity and quality of the end-of-life care experiences during residency with appropriate supervision and role modeling may lead to enhanced skill development and improve the quality of end-of-life care. The results suggest that cultivating bedside learning opportunities during residency is an appropriate focus for educational interventions in end-of-life care education.
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Affiliation(s)
- Martha E Billings
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington 98104, USA.
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Tung EE, North F. Advance care planning in the primary care setting: a comparison of attending staff and resident barriers. Am J Hosp Palliat Care 2009; 26:456-63. [PMID: 19648573 DOI: 10.1177/1049909109341871] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Advance directive completion rates remain poor in the ambulatory setting. The purpose of this study was to explore and contrast staff provider and resident physicians' experiences with advance care planning (ACP) and to identify barriers to this process in the primary care setting. A 17-item survey was administered to staff primary care providers and categorical internal medicine residents. Staff providers were more likely to discuss ACP after prompting from patients' family members (P < .02) or after a change in health status (P < .02) and were more likely to believe that non-physician members of the care team should counsel patients about ACP. The majority of respondents cited system-based barriers as major obstacles to ACP. Strategies aimed at systematizing the ACP process for both patients and providers are needed.
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Affiliation(s)
- Ericka E Tung
- Division Primary Care Internal Medicine, Mayo Clinic, 200 First St, Rochester, MN 55902, USA.
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Abstract
Patient and family-centred care (PFCC) is an approach to health care that recognizes the integral role of the family and encourages mutually beneficial collaboration between the patient, family and health care professionals. Specific to the pediatric population, the literature indicates that the majority of families wish to be present for all aspects of their child's care and be involved in medical decision-making. Families who are provided with PFCC are more satisfied with their care. Integration of these processes is an essential component of quality care. This article reviews the principles of PFCC and their applicability to the pediatric patient in the emergency department; and it discusses a model for integrating PFCC that is modifiable based on existing resources.
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Sheetz MJ, Bowman MAS. Pediatric Palliative Care: An Assessment of Physicians' Confidence in Skills, Desire for Training, and Willingness to Refer for End-of-Life Care. Am J Hosp Palliat Care 2008; 25:100-5. [PMID: 18445861 DOI: 10.1177/1049909107312592] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study determines the confidence levels of physicians in providing components of pediatric palliative care and identifies their willingness to obtain training and to make palliative care referrals. Surveys were mailed to all physicians at Primary Children's Medical Center. The survey instrument includes 3 demographic items, 9 items designed to assess physician confidence in core palliative care skills, and 4 items designed to assess what steps physicians would be likely to take to assure that patients receive palliative care. Physicians were asked to rate their confidence levels to provide palliative care components on a 4-point scale for each of the items. Five hundred ninety-seven surveys were mailed, with 323 usable surveys returned. The proportion of physicians who rate their ability to provide palliative care as “confident” or “very confident” ranges from 74% for giving difficult news to families to 23% for managing end-of-life symptoms. Thirty-six percent of the physicians say they would be “likely” or “very likely” to attend training to improve their ability to provide palliative care to children. Eighty-six percent would be “likely” or “very likely” to refer for a palliative care consult and 91% to a home health agency or hospice. There is wide variation in the confidence levels of physicians to provide the core components of palliative care. Few are interested in obtaining additional training, but most are willing to obtain consultation or to refer to a palliative care service. These results argue in favor of hospital-based palliative care teams and for specialty training and certification in pediatric palliative care.
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Affiliation(s)
- M. Joan Sheetz
- Rainbow Kids Pediatric Palliative Care Program, Primary Children's Medical Center, Salt Lake City, Utah
| | - Mary-Ann Sontag Bowman
- Rainbow Kids Pediatric Palliative Care Program, Primary Children's Medical Center, Salt Lake City, Utah
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Deep KS, Green SF, Griffith CH, Wilson JF. Medical residents' perspectives on discussions of advanced directives: can prior experience affect how they approach patients? J Palliat Med 2007; 10:712-20. [PMID: 17592983 DOI: 10.1089/jpm.2006.0220] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Resident physicians are inadequately taught how to communicate with patients about end-of-life decision making. Their beliefs about resuscitation and prior experiences with end-of-life care may impact the manner in which they approach patients. OBJECTIVE To explore residents' perceptions of end-of-life discussions, determine the features they find most important, and discern the challenges they face in this process. METHODS Internal medicine residents were surveyed about their experiences discussing resuscitation with patients including perceptions of patient understanding, outcomes of resuscitation, and regret about attempting to resuscitate patients. They were asked what features of these discussions are most important and which are the most challenging. Qualitative content analysis was used to examine the responses to open-ended questions. RESULTS Fifty-five residents completed the survey. Residents reported rarely feeling satisfied with the results of these discussions and disagreed with the decision for resuscitation numerous times. They perceive that few patients and families understand resuscitation. In their description of important features, they focus on the content of the discussion rather than the process, with the most common responses centering on a description of resuscitation. In contrast, the greatest challenge they identify is dealing with the emotional aspects of the discussion. CONCLUSIONS Residents report internal conflict about their experiences discussing resuscitation with patients. Their approach to these discussions focuses on resuscitation itself with less attention paid to processes that might improve patient decision making. The challenges they describe may be overcome with improved education about end-of-life communication.
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Affiliation(s)
- Kristy S Deep
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky 40536, USA.
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Bowen JL, Salerno SM, Chamberlain JK, Eckstrom E, Chen HL, Brandenburg S. Changing habits of practice. Transforming internal medicine residency education in ambulatory settings. J Gen Intern Med 2005; 20:1181-7. [PMID: 16423112 PMCID: PMC1490278 DOI: 10.1111/j.1525-1497.2005.0248.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2005] [Revised: 07/26/2005] [Accepted: 07/26/2005] [Indexed: 11/30/2022]
Abstract
PURPOSE The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change. METHODS The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance. RESULTS Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education. CONCLUSION This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident's level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.
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Affiliation(s)
- Judith L Bowen
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, OR 97239-3098, USA.
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Gorman TE, Ahern SP, Wiseman J, Skrobik Y. Residents' end-of-life decision making with adult hospitalized patients: a review of the literature. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2005; 80:622-33. [PMID: 15980078 DOI: 10.1097/00001888-200507000-00004] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
PURPOSE The authors performed a structured literature review to understand residents' experiences with end-of-life (EOL) decision making with adult hospitalized patients, specifically regarding decisions to withhold or withdraw advanced life-support measures. METHOD An Ovid-based strategy was used to search Medline, ERIC, PsychINFO, and CINHAL databases for articles published between 1966 and February 2005, combining the domains of "resuscitation orders," "decision making," and "internship and residency." All quantitative and qualitative studies examining residents' EOL decision making with adult hospitalized patients were included. The authors developed and applied a scoring system for relevance and quality, performed data abstraction and quality assessment independently and in duplicate, then met to collate findings and identify factors in residents' EOL decision making. RESULTS The searches yielded 884 articles, of which 26 were included. Variable methodologies precluded meta-analysis. In these studies, residents felt unprepared to handle patient EOL decision making, although exposure to EOL discussions helped them gain confidence. Residents' attitudes, skills, and knowledge were key determinants of whether EOL decisions were addressed. Many misinterpreted the terms "DNR" and "futility." Residents' understanding of the patient EOL decision-making process could be extremely variable, and their do-not-resuscitate discussions suboptimal. Residents' lived practice experience of the patient EOL decision-making process was often at odds with what they were taught in formal curricula. CONCLUSIONS Educational strategies aimed at changing residents' knowledge, skills and attitude should address the hidden curriculum for the patient EOL decision-making process that is part of the experienced culture of every day practice. Future studies of this experienced culture would inform specific educational interventions.
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Corke CF, Stow PJ, Green DT, Agar JW, Henry MJ. How doctors discuss major interventions with high risk patients: an observational study. BMJ 2005; 330:182. [PMID: 15564228 PMCID: PMC544994 DOI: 10.1136/bmj.38293.435069.de] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the difficulties doctors face in discussing treatment options with patients with acute, life threatening illness and major comorbidities. DESIGN Observational study of doctor-patient interviews based on a standardised clinical scenario involving high risk surgery in a hypothetical patient (played by an actor) with serious comorbidities. PARTICIPANTS 30 trainee doctors 3-5 years after graduation. MAIN OUTCOME MEASURES Adequacy of coverage of various aspects was scored from 3 (good) to 0 (not discussed). RESULTS The medical situation was considered to be well described (median score 2.7 (interquartile range 2.1-3.0)), whereas the patient's functional status, values, and fears were poorly or minimally addressed (scores 0.5 (0.0-1.0), 0.5 (0.0-1.0), and 0.0 (0.0-1.5), respectively; all P < 0.001 v score for describing the medical situation). Twenty nine of the doctors indicated that they wished to include the patient's family in the discussion, but none identified a preferred surrogate decision maker. Six doctors suggested that the patient alone should speak with his family to reach a decision without the doctor being present. The doctors were reluctant to give advice, despite it being directly requested: two doctors stated that a doctor could not give advice, while 17 simply restated the medical risks, without advocating any particular course. Of the 11 who did offer advice, eight advocated intervention. CONCLUSIONS Doctors focused on technical medical issues and placed much less emphasis on patient issues such as functional status, values, wishes, and fears. This limits doctors' ability to offer suitable advice about treatment options. Doctors need to improve their communication skills in this difficult but common clinical situation.
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Affiliation(s)
- C F Corke
- Intensive Care Unit, Geelong Hospital, Barwon Health, Geelong, Victoria, Australia 3220.
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