Medicine residents' self-perceived competence in end-of-life care

The effect of combined training (theoretical-practical) of palliative care on perceived self-efficacy of nursing students

BACKGROUND

Nurses and researchers emphasize the importance of adding educational content of palliative care to nursing curricula in Iran as a means to improve the quality of care at the end of life and self-efficacy is considered as an important determinant in palliative care nursing. However, undergraduate nursing students are not sufficiently trained to achieve the qualifications required in palliative care. The aim of this study was to determine the effect of combined training (theoretical-practical) of palliative care on the perceived self-efficacy of nursing students.

METHODS

This is a semi-experimental study with a pretest-posttest design. Sampling was nonrandomized with convenience method and included 23 seventh-semester students. The intervention consisted of palliative care training for ten theoretical sessions and three practical sessions. Data were collected using demographic and the perceived self-efficacy questionnaires completed before and after the intervention. Data were then analyzed in the statistical SPSS 23 software using descriptive and analytical statistics.

RESULTS

The mean age of the samples was 22.78 (SD1.17). Most of the participants were male (56.5%) and single(91.3%). The findings showed that, perceived self-efficacy, psycho-social support and symptom management improved significantly after the intervention (p<0.05).

CONCLUSION

Palliative care training can increase the nursing students perceived self-efficacy. Since nursing students are the future nurses of the care system, therefore, managers and planners can take a step towards improving the quality of nursing care by using palliative care training programs. Since nursing students will be future nurses in health care system, therefore, managers and planners can take steps to improve the quality of nursing care by using palliative care education programs.

The Presence of Implantable Cardioverter Defibrillators is Rarely Addressed During Code Status Change

Background: Implantable Cardioverter Defibrillators (ICDs) are used to prevent sudden cardiac death, but they may provide unwanted shocks during end-of-life care. We aimed to study the frequency at which Do Not Resuscitate (DNR) discussions address ICD preferences in high-risk patients. Methods: A retrospective chart review was performed on patient hospitalizations with the presence of an ICD, a change in code status to DNR, and a subsequent death during that hospitalization. Data collected included demographics, significant comorbidities, if and when ICD was discussed, and who performed code status discussions, and were analyzed for statistical significance. Results: 129 patients met study criteria, and 110 patients (85.3%) did not have a documented discussion addressing ICD deactivation. There were no statistically significant differences in patient characteristics between patients with ICD addressed or not addressed, nor were there differences noted between discussions performed by residents vs staff or with the presence of cardiology, critical care status, or with palliative care consultation. It was noted that specifically discussing intubation or cardioversion was associated with the discussion of ICD deactivation. Conclusion: ICD discussions were rarely documented in our high-risk population, highlighting a potential need for better in-chart visibility of ICDs and for focused education of clinicians who care for these patients at end of life.

Measuring palliative care self-efficacy of intellectual and developmental disability staff using Rasch models

OBJECTIVES

The objectives of this study were to evaluate the psychometric properties of a palliative care self-efficacy instrument developed for intellectual and developmental disability (IDD) staff using Rasch analysis and assess the change in palliative care self-efficacy between 2 time points using Rasch analysis of stacked data.

METHODS

Staff from 4 nonprofit IDD services organizations in a US Midwestern state (n = 98) answered 11 questions with Likert-style responses at baseline and 1-month follow-up post training. Rasch analysis was performed to examine rating scale structure, unidimensionality, local independence, overall model fit, person and item reliability and separation, targeting, individual item and personal fit, differential item functioning (DIF), and change in palliative care self-efficacy between 2 time points.

RESULTS

The rating scale structure improved when 5 response categories were collapsed to 3. With the revised 3 response categories, the instrument demonstrated good psychometric properties. Principal components analysis of Rasch residuals supported the assumption of unidimensionality. Model fit statistics indicated an excellent fit of the data to the Rasch model. The instrument demonstrated good person and item reliability and separation. Gender-related DIF was found in 1 item, and work tenure-related DIF in 3 items. Overall palliative care self-efficacy improved between 2 time points.

SIGNIFICANCE OF RESULTS

Rasch analysis allowed for a more thorough examination of this palliative care self-efficacy instrument than classical test theory and provided information on rating scale structure, targeting, DIF, and individual persons and items. These recommendations can improve this instrument for research and practical contexts.

Voices of the Future: Junior Physicians' Experiences of Discussing Life-Sustaining Treatments With Hospitalized Patients

OBJECTIVES

Life-sustaining treatments (LST) aim to prolong life without reversing the underlying medical condition. Being associated with a high risk of developing unwanted adverse outcomes, decisions about LST are routinely discussed with patients at hospital admission, particularly when it comes to cardiopulmonary resuscitation. Physicians may encounter many challenges when enforcing shared decision-making in this domain. In this study, we map out how junior physicians in Southern Switzerland refer to their experiences when conducting LST discussions with hospitalized patients and their learning strategies related to this.

METHODS

In this qualitative exploratory study, we conducted semi-directive interviews with junior physicians working at the regional public hospital in Southern Switzerland and analyzed them with an inductive thematic analysis.

RESULTS

Nine physicians participated. We identified 3 themes: emotional burden, learning strategies and practices for conducting discussions. Participants reported feeling unprepared and often distressed when discussing LST with patients. Factors associated with emotional burden were related to the context and to how physicians developed and managed their emotions. Participants signaled having received insufficient education to prepare for discussing LST. They reported learning to discuss LST essentially through trial and error but particularly appreciated the possibility of mentoring and experiential training. Explanations that physicians gave about LST took into account patients' frequent misconceptions. Physicians reported feeling under pressure to ensure that decisions documented were medically indicated and being more at ease when patients decided by themselves to limit treatments. Communication was deemed as an important skill.

CONCLUSIONS

Junior physicians experienced conducting LST discussions as challenging and felt caught between advocating for medically relevant decisions and respecting patients' autonomy. Participants reported a substantive emotional burden and feeling unprepared for this task, essentially because of a lack of adequate training. Interventions aiming to ameliorate junior physicians' competency in discussing LST can positively affect their personal experiences and decisional outcomes.

Delphi-endorsed Communication Skills Clinicians Need to Care for Hospitalized Incapacitated Patients

Background

Objective

Methods

Results

Conclusion

The State of the Do-Not-Resuscitate Order in a Pediatric Intensive Care Unit in the Middle East: A Retrospective Study

OBJECTIVES

The Do-Not-Resuscitate (DNR) order is part of most hospitals' policies on the process of making and communicating decisions about a patient's resuscitation status. Yet it has not become a part of our society's ritual of dying in the Middle East especially among children. Given the diversity of pediatric patients, the DNR order continues to represent a challenge to all parties involved in the care of children including the medical team and the family.

METHODS

This was a retrospective review of the medical charts of patients who had died in the pediatric intensive care unit (PICU) of a tertiary academic institution in Beirut, Lebanon within the period of January 2012 and December 2017.

RESULTS

Eighty-two charts were extracted, 79 were included in the analysis. Three were excluded as one patient had died in the Emergency Department (ED) and 2 charts were incomplete. Most patients were male, Lebanese, and from Muslim families. These patients clinically presented with primary cardiac and oncological diseases or were admitted from the ED with respiratory distress or from the operating room for post-operative management. The primary cause of death was multiorgan failure and cardiac arrest. Only 34% of families had agreed to a DNR order prior to death and 10% suggested "soft" resuscitation. Most discussions were held in the presence of the parents, the PICU team and the patient's primary physician.

CONCLUSIONS

The DNR order presents one of the most difficult challenges for all care providers involved, especially within a culturally conservative setting such as Lebanon. As the numbers suggest, it is difficult for parents to reach the decision to completely withhold resuscitative measures for pediatric patients, instead opting for "soft" resuscitations like administering epinephrine without chest compressions.

Difficulties Facing Junior Physicians and Solutions Toward Delivering End-of-Life Care for Patients with Cancer: A Nationwide Survey in Japan

BACKGROUND

Junior physicians' perceived difficulty in end-of-life care of patients with cancer has not been structurally investigated; therefore, current challenges and solutions in this area remain unknown.

OBJECTIVES

To identify some difficulties junior physicians face in delivering end-of-life care for patients with cancer and to clarify the support required to reduce these difficulties.

DESIGN

A nationwide survey was conducted in over 300 institutions selected randomly from 1037 clinical training hospitals in Japan.

PARTICIPANTS

From each of these institutions, two resident physicians of postgraduate year (PGY) 1 or 2, two clinical fellows of PGY 3-5, and an attending physician were requested to respond to the survey.

MEASUREMENTS

The survey investigated issues regarding end-of-life care using the palliative care difficulties scale with two additional domains ("discussion about end-of-life care" and "death pronouncement"). Items related to potential solutions for alleviating the difficulties as well were investigated.

RESULTS

A total of 198 resident physicians, 134 clinical fellows, and 96 attending physicians responded to the survey (response rate: 33.0%, 22.3%, and 32.0%). The results revealed that junior physicians face difficulties within specific domains of end-of-life care. The most challenging domain comprised communication and end-of-life discussion with patients and family members, symptom alleviation, and death pronouncement. The most favored supportive measure for alleviating these difficulties was mentorship, rather than educational opportunities or resources regarding end-of-life care.

CONCLUSION

The findings of this study reveal the need for further effort to enrich the mentorship and support systems for junior physicians delivering end-of-life care.

Improving the Care of Patients With Serious Illness: What Are the Palliative Care Education Needs of Internal Medicine Residents?

BACKGROUND

Hospitalized patients with serious illness have significant symptom burden and face complex medical decisions that often require goals of care discussions. Given the shortage of specialty palliative care providers, there is a pressing need to improve the palliative care skills of internal medicine (IM) residents, who have a central role in the care of seriously ill patients hospitalized at academic medical centers.

METHODS

We conducted an anonymous survey of IM residents at a large, urban, academic medical center to identify which aspects of palliative care trainees find most important and their knowledge gaps in palliative care. The survey measured trainees' self-assessed degree of importance and knowledge of core palliative care skills and evaluated frequency of completing advance care planning documentation.

RESULTS

Overall, 51 (23%) IM residents completed the survey. The majority of trainees considered multiple palliative care skills to be "very important/important": symptom management, prognostication, introducing the palliative care approach, discussing code status, and breaking serious news. Across these same skills, trainees reported variable levels of knowledge. In our sample, trainees reported completing healthcare proxy forms and Medical Orders for Life-Sustaining Treatment infrequently.

CONCLUSIONS

IM trainees rated core palliative care skills as important to their practice. Yet, they reported knowledge gaps across multiple core palliative care skills that should be addressed given their role as frontline providers for patients with serious illness.

Goals of Care Discussions Over the Course of a Patient's End of Life Admission: A Retrospective Study

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.

Adapting Existing Resources for Serious Illness Communication Skills Training for Internal Medicine Residents

OBJECTIVES

Goals of care discussions are a vital component of patient care, but Internal Medicine residents receive limited training in these skills. Existing curricula often require simulated patients or faculty development, limiting implementation in many residency programs. Thus, we developed and implemented a curriculum leveraging existing educational resources with the goal of improving resident attitudes and confidence in conducting goals of care discussions in training settings.

METHODS

We developed cases and a detailed faculty guide for small-group discussion with three exercises to standardize the learner experience and minimize the need for faculty development. Exercises introduced established communication skill frameworks including SPIKES (setting, perception, invitation, knowledge, empathy, summary) and REMAP (reframe, emotion, map, align, propose a plan) for how to break bad news, respond to strong emotions, and conduct a goals of care discussion. Participants were 163 Internal Medicine postgraduate year 1, -2, and -3 residents at a large urban academic institution, where residency-wide curriculum is delivered in weekly half-day didactic sessions during the course of 5 weeks. Primary outcomes were resident self-reported confidence with goals of care communication skills.

RESULTS

A total of 109 (response rate 67%) of residents reported improvement in overall confidence in goals of care discussion skills (3.6 ± 0.9 vs 4.1 ± 0.6, P < 0.001), responding to emotions (3.5 ± 0.9 vs 3.9 ± 0.6, P = 0.004), making care recommendations (3.5 ± 1.0 vs 3.9 ± 0.7, P < 0.001), and quickly conducting a code status discussion (3.6 ± 1.0 vs 4.0 ± 0.7, P < 0.001). Residents also expressed an increased desire for supervision and feedback to further develop these skills.

CONCLUSIONS

This goals of care communication curriculum improves resident confidence and requires minimal resources. It may be ideal for programs that have limited access to simulated patients and/or faculty trained in communication skill simulation, but desire enhanced education on this important aspect of patient-doctor communication and high-quality patient care. Future studies measuring clinical outcomes and changes in learner behavior as a result of this intervention are needed. Ongoing observation and feedback on these skills will be important to solidify learning and sustain impact.

"Doing" healthcare at end-of-life: Identity tensions, negotiations, and conflicts

Observing how healthcare providers deal with death and dying, in terms of "doing" identity, allows us to explore how they cope with patient end-of-life (EOL) and highlights how the professional identity breaks down while managing patient death and dying. We conducted a digital ethnography of a publicly-accessible online forum for healthcare professionals. Providers' personal experiences with patient death and dying were interpreted through internalized values associated with their professional identity, which when dealing with EOL are challenged and must be negotiated. Training and support are needed to better equip providers with the skills and tools needed at EOL.

Difficulties Doctors Experience during Life-Sustaining Treatment Discussion after Enactment of the Life-Sustaining Treatment Decisions Act: A Cross-Sectional Study

Purpose

This study aimed to investigate difficulties doctors experience during life-sustaining treatment (LST) discussion with seriously ill patients and their families after enactment of the LST Decisions Act in February 2018.

Materials and Methods

A cross-sectional survey was conducted in a tertiary hospital in the Republic of Korea in August 2019. Six hundred eighty-six doctors who care for seriously ill patients were given a structured questionnaire, and difficulties during the discussion were examined.

Results

One hundred thirty-two doctors completed the questionnaire. Eighty-five percent answered they treat cancer patients. Most (86.4%) experienced considerable difficulties during LST discussions (mean score, 7.4±1.6/10). The two most common difficulties were communication with patients and family and determining when to discuss LST. Two-thirds of doctors found direct discussions with the patient difficult and said they would initiate LST discussions only with family. LST discussions were actually initiated later than considered appropriate. When medically assessing whether the patient is imminently dying, 56% of doctors experienced disagreements with other doctors, which could affect their decisions.

Conclusion

This study found that most doctors experienced serious difficulties regarding communication with patients and family and medical assessment of dying process during LST discussions. To alleviate these difficulties, further institutional support is needed to improve the LST discussion between doctors, patients, and family.

Knowledge and confidence of junior medical doctors in discussing and documenting resuscitation plans: A cross-sectional survey

BACKGROUND

A Resuscitation Plan is a medically authorised order to use or withhold resuscitation interventions. Absence of appropriate resuscitation orders exposes patients to the risk of invasive medical interventions that may be of questionable benefit depending on individual circumstances.

AIMS

To describe among junior doctors: (1) self-reported confidence discussing and completing resuscitation plans; (2) knowledge of resuscitation policy including whether resuscitation plans are legally enforceable and key triggers for completion; and (3) the factors associated with higher knowledge of triggers for completing resuscitation plans.

METHODS

A cross-sectional survey was conducted at five hospitals. Junior doctors on clinical rotation were approached at scheduled training sessions, before or after ward rounds, or at change of rotation orientation days and provided with a pen-and-paper survey.

RESULTS

A total of 118 junior doctors participated. Most felt confident discussing (79%, n = 92) and documenting (87%, n = 102) resuscitation plans with patients. However, only 45% of doctors (n = 52) correctly identified that resuscitation plans are legally enforceable medical orders. On average, doctors correctly identified 6.8 (SD = 1.8) out of 10 triggers for completing a resuscitation plan. Doctors aged >30 years were four times more likely to have high knowledge of triggers for completing resuscitation plans (OR 4.28 (95% CI 1.54 to 11.89), p = 0.0053).

CONCLUSION

Most junior doctors feel confident discussing and documenting resuscitation plans. There is a need to improve knowledge about legal obligations to follow completed resuscitation plans, and about when resuscitation plans should be completed to ensure they are completed with patients who are most at risk. This article is protected by copyright. All rights reserved.

Hospice Patient Care Goals and Medical Students' Perceptions: Evidence of a Generation Gap?

BACKGROUND

The ability to perceive care goals of the dying may be an indicator of future quality patient-centered care. Research conducted on end-of-life goals indicates discrepancies between patients and physicians.

OBJECTIVE

The aim of this study is to compare end-of-life care goals of hospice patients and medical student perceptions of patient care goals.

DESIGN

Hospice patients and medical students were surveyed on their care goals and perceptions, respectively, using an 11-item survey of goals previously identified in palliative care literature. Medical student empathy was measured using the Interpersonal Reactivity Index.

SETTINGS/PARTICIPANTS

Eighty hospice patients and 176 medical students (97 first-year and 79 third-year) in a New York State medical school.

RESULTS

Medical students ranked 7 of the 11 care goals differently than hospice patients: not being a burden to family (p < .001), time with family and friends (p = .002), being at peace with God (p < .001), dying at home (p = .004), feeling that life was meaningful (p < .001), living as long as possible (p < .001), and resolving conflicts (p < .001). Third-year students were less successful than first-year students in perceiving patient care goals of hospice patients. No significant differences in medical student empathy were found based on student year.

CONCLUSIONS

Medical students, while empathetic, were generally unsuccessful in perceiving end-of-life care goals of hospice patients in the psychosocial and spiritual domains. Differences impeding the ability of medical students to understand these care goals may be generationally based. Increased age awareness and sensitivity may improve future end-of-life care discussions. Overall, there is a need to recognize the greater dimensionality of the dying in order to provide the most complete patient-centered care.

Provision of palliative care in National Cancer Grid treatment centres in India: a cross-sectional gap analysis survey

OBJECTIVES

This study aimed to identify gaps in palliative care (PC) provision across the National Cancer Grid (NCG) centres in India.

METHODS

We performed a cross-sectional validated web-based survey on 102 NCG cancer centres (Nov '17 to April '18). The survey questionnaire had seven sections collecting data relating to the capacity to provide cancer care and PC, drug availability for pain and symptom control, education, advocacy, and quality assurance activities for PC.

RESULTS

Eighty-nine NCG centres responded for this study-72.5% of centres had doctors with generalist PC training, whereas 34.1% of centres had full-time PC physicians; 53.8% had nurses with 6 weeks of PC training; 68.1% of the centres have an outpatient PC and 66.3% have the facility to provide inpatient PC; 38.5% of centres offer home-based PC services; 44% of the centres make a hospice referral and 68.1% of the centres offer concurrent cancer therapy alongside PC. Among the centres, 84.3% have a licence to procure, store and dispense opioids, but only 77.5% have an uninterrupted supply of oral morphine for patients; 61.5% centres have no dedicated funds for PC, 23.1% centres have no support from hospital administration, staff shortage-69.2% have no social workers, 60.4% have no counsellors and 76.9% have no volunteers. Although end-of-life care is recognised, there is a lack of institutional policy. Very few centres take part in quality control measures.

CONCLUSIONS

The majority of the NCG centres have the facilities to provide PC but suffer from poor implementation of existing policies, funding and human resources.

Self-assessment of Skills by Surgeons and Anesthesiologists After a Trauma Surgery Masterclass

BACKGROUND

In the Netherlands, each year a three-day international multidisciplinary trauma masterclass is organized to provide the knowledge and skills needed to care for critically injured trauma patients. This study was designed to longitudinally evaluate the effect of the course on participant's self-assessment of their own ability and confidence to perform general and specific skills.

METHODS

Between 2013 and 2016, all participants were invited to complete a questionnaire before and during follow-up. Participants were asked to self-assess their level of confidence to perform general skills (communication, teamwork, leadership) and specific skills. Mean scores were calculated, and mixed models were used to evaluate correlation.

RESULTS

We asked 265 participants to participate. Response rate was 64% for the pre-questionnaire, 63% for the post-questionnaire and for 3 months, 1 year and 2 years, respectively, 40%, 30%, 20%. The surgical group showed a statistically significant increase in self-assessed confidence for general skills (3.82-4.20) and specific technical skills (3.01-3.83; p < 0.001). In the anesthetic group, self-assessed confidence increased significantly in general skills (3.72-4.26) and specific technical skills (3.33-4.08; p < 0.001). For both groups statistical significance remained during follow-up.

CONCLUSIONS

This study demonstrated a sustained positive effect of a dedicated multidisciplinary trauma training curriculum on participant's self-assessed confidence to perform both general and specific technical skills necessary for the care of injured patients. Given the known association between confidence and competence, these findings provide evidence that dedicated trauma training curricula can provide positive lasting results.

LEVEL OF EVIDENCE

This is a basic science paper and therefore does not require a level of evidence.

Association of Communication Interventions to Discuss Code Status With Patient Decisions for Do-Not-Resuscitate Orders: A Systematic Review and Meta-analysis

IMPORTANCE

Whether specific communication interventions to discuss code status alter patient decisions regarding do-not-resuscitate code status and knowledge about cardiopulmonary resuscitation (CPR) remains unclear.

OBJECTIVE

To conduct a systematic review and meta-analysis regarding the association of communication interventions with patient decisions and knowledge about CPR.

DATA SOURCES

PubMed, Embase, PsycINFO, and CINAHL were systematically searched from the inception of each database to November 19, 2018.

STUDY SELECTION

Randomized clinical trials focusing on interventions to facilitate code status discussions. Two independent reviewers performed the data extraction and assessed risk of bias using the Cochrane Risk of Bias Tool. Data were pooled using a fixed-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported.

DATA EXTRACTION AND SYNTHESIS

The study was performed according to the PRISMA guidelines.

MAIN OUTCOMES AND MEASURES

The primary outcome was patient preference for CPR, and the key secondary outcome was patient knowledge regarding life-sustaining treatment.

RESULTS

Fifteen randomized clinical trials (2405 patients) were included in the qualitative synthesis, 11 trials (1463 patients) were included for the quantitative synthesis of the primary end point, and 5 trials (652 patients) were included for the secondary end point. Communication interventions were significantly associated with a lower preference for CPR (390 of 727 [53.6%] vs 284 of 736 [38.6%]; RR, 0.70; 95% CI, 0.63-0.78). In a preplanned subgroup analysis, studies using resuscitation videos as decision aids compared with other interventions showed a stronger decrease in preference for life-sustaining treatment (RR, 0.56; 95% CI, 0.48-0.64 vs 1.03; 95% CI, 0.87-1.22; between-group heterogeneity P < .001). Also, a significant association was found between communication interventions and better patient knowledge (standardized mean difference, 0.55; 95% CI, 0.39-0.71).

CONCLUSIONS AND RELEVANCE

Communication interventions are associated with patient decisions regarding do-not-resuscitate code status and better patient knowledge and may thus improve code status discussions.

Development of a Standardized Communication Intervention Bundle for Use at a Medical Training Hospital Intensive Care Unit

How to cite this article: Pollard K, Wessman BT. Development of a Standardized Communication Intervention Bundle for Use at a Medical Training Hospital Intensive Care Unit. Indian J Crit Care Med 2019;23(5):234–235.

Michigan State University Veterinary Hospice Care: An Academic Hospice Practice 2011 to 2014

In 2011, Michigan State University College of Veterinary Medicine founded the second veterinary hospice in academic practice. This program was designed to meet the growing demand for veterinary end-of-life care in the community. Veterinary Hospice Care provided patients and their families palliative care services, through utilization of an interdisciplinary team, from the time of terminal diagnosis to the time of death. Families also received dedicated emotional support. As a direct result of the hospice care service, Michigan State University veterinary students as well as in-state technical college students received an increase in end-of-life care in the curriculum.

Are Health-Care Providers Well Prepared in Providing Optimal End-of-Life Care to Critically Ill Patients? A Cross-Sectional Study at a Tertiary Care Hospital in the United States

It is important for health-care providers to be comfortable in providing end-of-life (EOL) care to critically ill patients and realizing when continuing aggressive measures would be futile. Therefore, there is a need to understand health-care providers' self-perceived skills and barriers to providing optimum EOL care. A total of 660 health-care providers from medicine and surgery departments were asked via e-mail to complete an anonymous survey assessing their self-reported EOL care competencies, of which 238 responses were received. Our study identified several deficiencies in the self-reported EOL care competencies among health-care providers. Around 34% of the participants either disagreed (strongly disagree or disagree) or were neutral when asked whether they feel well prepared for delivering EOL care. Around 30% of the participants did not agree (agree and strongly agree) that they were well prepared to determine when to refer patients to hospice. 51% of the participants, did not agree (agree and strongly agree) that clear and accurate information is delivered by team members to patients/family. The most common barrier to providing EOL care in the intensive care unit was family not accepting the patient's poor prognosis. Nursing staff (registered nurse) had higher knowledge and attitudes mean competency scores than the medical staff. Attending physicians reported stronger knowledge competencies when compared to residents and fellows. More than half of the participants denied having received any previous training in EOL care. 82% of the participants agreed that training should be mandatory in this field. Most of the participants reported that the palliative care team is involved in EOL care when the patient is believed to be terminally ill. Apart from a need for a stronger training in the field of EOL care for health-care providers, the overall policies surrounding EOL and palliative care delivery require further evaluation and improvement to promote better outcomes in caring patients at the EOL.

[PKT - Palliative competence test for physicians : Design and validation of a questionnaire to assess knowledge and specific self-efficacy expectations of physicians in palliative care]

BACKGROUND

Providing end of life care for dying patients and those with life-threatening diseases is one of the core competences of physician. During the course of training all physicians should develop a sharpened perception of symptoms and acquire competence in the relief and therapy of pain.

OBJECTIVES

The Hospital of Saint John of God in Vienna, Austria, provides an educational program for residents concerning end of life care. Treatment of pain is one of the major topics. A questionnaire (PKT) was designed in order to evaluate the efficiency of this program.

MATERIAL AND METHODS

The Japanese PEACE questionnaire for assessing palliative knowledge of physicians was translated into German and the items checking specific self-efficacy expectations in palliative care in the Bonn palliative knowledge test (Bonner Palliativwissenstests) were transformed into physician duties. The new combination of 52 items was validated by testing groups of physicians with different levels of palliative education and experience.

RESULTS

The 37 physicians who had received palliative education scored better in the knowledge section than the 46 without palliative education: 21 vs. 16 correct answers out of 28 (p < 0.001). In these two groups we also found a differences in self-efficacy expectations in palliative care: 46 vs. 35 points out of 54 (p < 0.001). Having worked in a specialized palliative setting (n = 33) was associated with higher scores in palliative knowledge 23 vs. 16 points (p < 0.001) as well as in self-efficacy expectations 47 vs. 35 (p < 0.001).

CONCLUSION

The PKT is a German questionnaire that was validated to assess the efficiency of palliative education for physicians.

Self-Assessment of Teaching Skills Among Psychiatric Residents

OBJECTIVE

Psychiatry residency programs have increasingly emphasized the role of resident-as-teacher; however, little is known about resident self-perceptions of teaching skills. This study reports on psychiatry residents' self-perceived skills in teaching medical students and compares cohort ratings with anonymous medical student evaluations of residents as teachers at our large academic residency program.

METHODS

In May-June 2016, 84 residents in our program were surveyed using an anonymous, web-based survey, and this data was then compared to 3 years of aggregate data from anonymous student evaluations of resident teaching at our institution.

RESULTS

Forty-seven (47) residents responded to the survey (56% response rate). Residents reported self-perceived deficits in several specific teaching competencies. Medical students consistently rated residents higher with respect to teaching skills than residents rated themselves, and these data were highly statistically significant.

CONCLUSION

This study underscores the benefits of resident self-assessment in comparison to medical student evaluations of residents as teachers and this information can be used to inform training programs' resident-as-teacher curricula.

Self-confidence and knowledge of German ICU physicians in palliative care - a multicentre prospective study

Background

Little is known about ICU physicians’ self-confidence and knowledge related to palliative care. Our objective was to investigate self-confidence and knowledge of German ICU physicians related to palliative care, and to assess the impact of work experience, gender, specialty and additional certifications in pain or palliative medicine.

Methods

In a multicentre prospective observational study ICU physicians of ten hospitals were asked to rate their self-confidence and to complete a multiple choice questionnaire for the assessment of knowledge. Beyond descriptive statistics and non-parametric tests for group comparisons, linear regression analysis was used to assess the impact of independent variable on self-confidence and knowledge. Spearman‘s rank test was calculated.

Results

55% of answers in the knowledge test were correct and more than half of the participants rated themselves as “rather confident” or “confident”. Linear regression analysis revealed that an additional certificate in either pain or palliative medicine significantly increased both knowledge and self-confidence, but only 15 out of 137 participants had at least one of those certificates. Relation between self-confidence and the results of the knowledge test was weak (r = 0.270 in female) and very weak (r = −0.007 in male).

Conclusions

Although the questionnaire needs improvement according to the item analysis, it appears that, with respect to palliative care, ICU Physicians’ self-confidence is not related to their knowledge. An additional certificate in either pain or palliative medicine was positively correlated to both self-confidence and knowledge. However, only a minority of the participants were qualified through such a certificate.

Electronic supplementary material

The online version of this article (10.1186/s12904-017-0244-6) contains supplementary material, which is available to authorized users.

Refining the Frommelt Attitude Toward the Care of the Dying Scale (FATCOD-B) for medical students: A confirmatory factor analysis and Rasch validation study

OBJECTIVE

Given the increasing number of patients requiring palliative care and the need for more professionals who are able to provide care for the dying comfortably, assessment of medical attitudes toward end-of-life care is becoming a key aspect of medical education. The present study aimed to establish whether the Frommelt Attitude Toward the Care Of the Dying, Form B (FATCOD-B) meets current psychometric standards of validity for an assessment tool in medical education.

METHOD

The participants were 200 undergraduate medical students. Since in a previous study the FATCOD-B was found to have a weak structure due to poor item validity, a refined version was proposed and tested in the present study. Confirmatory factor analysis and the Rasch model were employed to assess its dimensionality and psychometric properties.

RESULTS

The construct measured by the FATCOD-B continues to be misspecified. The tool has a two-dimensional structure. The first is well-structured and demonstrates appreciable measurement and discriminant capabilities. The second has low validity because its measurement capabilities are based on weakly correlated items.

SIGNIFICANCE OF RESULTS

Our results suggest that the FATCOD-B measures a two-dimensional construct and that only its first dimension is a robust measurement tool for use in medical education to evaluate undergraduates' attitudes about caring for the dying.

Determinants of Patient-Oncologist Prognostic Discordance in Advanced Cancer

Importance

Patients with advanced cancer often report expectations for survival that differ from their oncologists' expectations. Whether patients know that their survival expectations differ from those of their oncologists remains unknown. This distinction is important because knowingly expressing differences of opinion is important for shared decision making, whereas patients not knowing that their understanding differs from that of their treating physician is a potential marker of inadequate communication.

Objective

To describe the prevalence, distribution, and proportion of prognostic discordance that is due to patients' knowingly vs unknowingly expressing an opinion that differs from that of their oncologist.

Design, Setting, and Participants

Cross-sectional study conducted at academic and community oncology practices in Rochester, New York, and Sacramento, California. The sample comprises 236 patients with advanced cancer and their 38 oncologists who participated in a randomized trial of an intervention to improve clinical communication. Participants were enrolled from August 2012 to June 2014 and followed up until October 2015.

Main Outcomes and Measures

We ascertained discordance by comparing patient and oncologist ratings of 2-year survival probability. For discordant pairs, we determined whether patients knew that their opinions differed from those of their oncologists by asking the patients to report how they believed their oncologists rated their 2-year survival.

Results

Among the 236 patients (mean [SD] age, 64.5 [11.4] years; 54% female), 161 patient-oncologist survival prognosis ratings (68%; 95% CI, 62%-75%) were discordant. Discordance was substantially more common among nonwhite patients compared with white patients (95% [95% CI, 86%-100%] vs 65% [95% CI, 58%-73%], respectively; P = .03). Among 161 discordant patients, 144 (89%) did not know that their opinions differed from that of their oncologists and nearly all of them (155 of 161 [96%]) were more optimistic than their oncologists.

Conclusions and Relevance

In this study, patient-oncologist discordance about survival prognosis was common and patients rarely knew that their opinions differed from those of their oncologists.

Necessary but not yet sufficient: a survey of aged residential care staff perceptions of palliative care communication, education and delivery

OBJECTIVES

Previous research has indicated that staff in aged residential care (ARC) may be unprepared for their role in palliative care provision. The need for palliative care knowledge among ARC staff has been characterised as 'pervasive'. Determining the palliative care education, communication and support needs of ARC clinical care staff is, therefore, of critical importance to the delivery of quality healthcare in this setting.

METHODS

A survey of clinical staff (n=431) in 52 ARC facilities in 1 urban district health board was conducted, using a paper-based questionnaire. Instruments included the 3-item Experiences with End of Life scale, developed measures of communication and support (13 items), support accessibility (12 items), and palliative care education (19 items).

RESULTS

Only 199 (46.2%) of staff participants reported undertaking palliative care education. Nurses were more likely to have engaged in palliative care education in comparison with healthcare assistants (HCAs) (χ²(1, N=387)=18.10, p=0.00). Participants (n=347) who wanted further education preferred an interactive, hands-on applied education (13.9%) in comparison to short topic-specific sessions/seminars (6.5%) or lecture-based courses (7.7%).

CONCLUSIONS

The study reveals an ongoing need for staff palliative care education. Results suggest the development of an integrated model of care which draws on both hospice and ARC staff expertise.

Physicians' and Nurse Practitioners' Level of Pessimism About End-of-Life Care During Training: Does It Change Over Time?

CONTEXT

An enhanced understanding of trainee attitudes about end-of-life care is needed to inform interventions to improve clinician communication about dying and death.

OBJECTIVES

To examine changes in trainee pessimism about end-of-life care over the course of one academic year and to explore predictors of pessimism among residents, fellows, and nurse practitioners.

METHODS

We used baseline and follow-up surveys completed by trainees during a randomized controlled trial of an intervention to improve clinician communication skills. Surveys addressed trainee feelings about end-of-life care. Latent variable modeling was used to identify indicators of trainee pessimism, and this pessimism construct was used to assess temporal changes in trainee attitudes about end-of-life care. We also examined predictors of trainee pessimism at baseline and follow-up. Data were available for 383 trainees from two training programs.

RESULTS

There was a significant decrease in pessimism between baseline and follow-up assessments. Age had a significant inverse effect on baseline pessimism, with older trainees being less pessimistic. There was a direct association of race/ethnicity on pessimism at follow-up, with greater pessimism among minority trainees (P = 0.028). The model suggests that between baseline and follow-up, pessimism among younger white non-Hispanic trainees decreased, whereas pessimism among younger trainees in racial/ethnic minorities increased over the same period.

CONCLUSION

Overall, trainee pessimism about end-of-life care decreases over time. Pessimism about end-of-life care among minority trainees may reflect the influence of culture on clinician attitudes about communication with seriously ill patients. Further research is needed to understand the evolution of trainee attitudes about end-of-life care during clinical training.

Palliative and end of life care communication as emerging priorities in postgraduate medical education

BACKGROUND

Reliance on surveys and qualitative studies of trainees to guide postgraduate education about palliative and end of life (EOL) communication may lead to gaps in the curriculum. We aimed to develop a deeper understanding of internal medicine trainees' educational needs for a palliative and EOL communication curriculum and how these needs could be met.

METHODS

Mixed methods, including a survey and focus groups with trainees, and interviews with clinical faculty and medical educators, were applied to develop a broader perspective on current experiences and needs for further education. Quantitative descriptive and thematic analyses were conducted.

RESULTS

Surveyed trainees were least confident and least satisfied with teaching in counseling about the emotional impact of emergencies and discussing organ donation. Direct observation with feedback, small group discussion, and viewing videos of personal consultations were perceived as effective, yet infrequently identified as instructional methods. Focus groups and interviews identified goals of care conversations as the highest educational priority, with education adapted to learner needs and accompanied by feedback and concurrent clinical and organizational support.

CONCLUSIONS

Our work expands on previous research describing needs for postgraduate education in palliative and EOL communication to include the importance of support, culture change, and faculty development, and provides insight into why such needs exist.

Internal Medicine Residents' Beliefs, Attitudes, and Experiences Relating to Palliative Care: A Qualitative Study

BACKGROUND

Internal medicine residents are frequently called upon to provide palliative care to hospitalized patients, but report feeling unprepared to do so effectively. Curricular development to enhance residents' palliative care skills and competencies requires an understanding of current beliefs, attitudes and learning priorities.

METHODS

We conducted a qualitative study consisting of semi-structured interviews with ten internal medicine residents to explore their understanding of and experiences with palliative care.

RESULTS

All of the residents interviewed had a sound theoretical understanding of palliative care, but faced many challenges in being able to provide care in practice. The challenges described by residents were system-related, patient-related and provider-related. They identified several priority areas for further learning, and discussed ways in which their current education in palliative care could be enhanced.

CONCLUSIONS

Our findings provide important insights to guide curricular development for internal medicine trainees. The top five learning priorities in palliative care that residents identified in our study were: 1) knowing how and when to initiate a palliative approach, 2) improving communication skills, 3) improving symptom management skills, 4) identifying available resources, and 5) understanding the importance of palliative care. Residents felt that their education in palliative care could be improved by having a mandatory rotation in palliative care, more frequent didactic teaching sessions, more case-based teaching from palliative care providers, opportunities to be directly observed, and increased support from palliative care providers after-hours.

A qualitative exploration of perceived key knowledge and skills in end-of-life care in dementia patients among medical, nursing, and pharmacy students

BACKGROUND

The steady increase in the number of people living and dying with dementia, coupled with the recent focus on quality of care, has highlighted the importance of dementia training for health care professionals. This exploratory study aimed to discover which skills health care students felt were important in providing quality end-of-life care to dementia patients.

METHODS

Ninety-four medicine, nursing, and pharmacy students participated in a larger study using open-ended and closed questions to explore attitudes related to caring for dementia patients at the end of life. This study looks at the student responses to an open-ended question regarding the skills and knowledge they believe are needed to provide end-of-life care to dementia patients. Individual responses were reviewed by the researchers, coded into key issues, and tabulated for frequency of occurrences and group differences.

RESULTS

Several common issues emerged: knowledge, patience, empathy, understanding, family involvement, compassion, medication knowledge, respect/patient autonomy, communication, quality of life, and patient education. Significant differences were observed among the participant groups on the following issues: Patience and understanding (pharmacy students mentioned these issues less frequently than medical and nursing students), compassion (medical students mentioned this issue more frequently than pharmacy students), and medication knowledge (pharmacy students mentioned this issue more frequently than medical and nursing students).

CONCLUSIONS

Different health care disciplines (in-training) value different skill sets for the provision of dementia care at the end-of-life. As health care education for dementia patients at the end of life is expanded, it will be important to understand which skills both patients and health care students value.

Evaluating Residents' Readiness to Elicit Advance Care Plans

BACKGROUND

Trainees are responsible for conducting advance care discussions but are often stressed by this role.

OBJECTIVE

We developed an instrument to determine whether residents could identify a clinical scenario that necessitated an examination of a patient's goals and preferences as they pertain to clinical care, and subsequently measured their readiness to engage in such discussions.

METHODS

Participants responded verbally to open-ended case presentations and completed survey items. We scored responses according to proximity to idealized answers.

RESULTS

The sample consisted of 44 internal medicine residents, 12 students, 5 hospitalists, and 3 palliative care attendings, all of whom volunteered for the study and participated in standard interviews. Residents had widely varying scores (range 0-12, maximum score of 15) on the scored open response items. For eliciting values, mean score increased with training, and students, trainees, and attending physicians had mean scores of 3.7, 5.7, and 8.7, respectively (P = .01). For recommending care, mean scores were 3.0, 6.5, and 9.3, respectively (P < .001). Scores were correlated closely with increasing clinical experience and inversely with self-reported stress when conducting a goals-of-care discussion. The Kuder-Richardson Formula 20 reliability for the instrument was 0.52. Interrater reliability for sections about eliciting and recommending care were 0.64 (P < .001) and 0.50 (P < .001), respectively. The 1-week test-retest reliability was 0.91 for open response items and 0.76 for Likert responses.

CONCLUSIONS

A verbally administered instrument can readily and rapidly characterize a trainee's readiness to participate in advance care planning with patients.

Patient Death Debriefing Sessions to Support Residents' Emotional Reactions to Patient Deaths

BACKGROUND

There is no standard way to help residents deal with the emotional impact of patient deaths. Most available curricula are time and resource intensive.

OBJECTIVE

We introduced "Patient Death Debriefing Sessions" into an inpatient medical oncology rotation at Memorial Sloan Kettering Cancer Center to provide a structured yet practical way to address residents' emotional reactions following the death of a patient. A questionnaire was used to evaluate the impact of these sessions.

METHODS

Patient Death Debriefing Sessions consist of a brief (~10 minutes), real-time (within 24-48 hours), consistent (following each death), attending physician-led debriefing that focuses on internal medicine residents' emotional reactions following patient deaths. Sessions were guided by a pocketcard tool and did not require faculty training. Residents completing a 4-week medical oncology rotation were surveyed before and after their rotation. Prerotation and postrotation mean differences were evaluated based on the number of sessions they participated in (0 to ≥ 3) using analyses of variance.

RESULTS

Ninety-one of 92 participants spanning all training levels completed questionnaires (99% response rate). Of these, 79 (87%) encountered a patient death and were included in the analyses. Overall, residents found debriefing sessions helpful, educational, and appreciated attending physician leadership. The number of debriefing sessions positively influenced residents' perception of received support.

CONCLUSIONS

This high-yield, novel pilot curriculum supported residents' emotional reactions to patient deaths and may foster communication with team members, including supervising attending physicians. This program is easily implemented and could be adapted for use in other clinical settings.

Communication About Advance Directives and End-of-Life Care Options Among Internal Medicine Residents

BACKGROUND

Despite increasing awareness about the importance of discussing end-of-life (EOL) care options with terminally ill patients and families, many physicians remain uncomfortable with these discussions.

OBJECTIVE

The objective of the study was to examine perceptions of and comfort with EOL care discussions among a group of internal medicine residents and the extent to which comfort with these discussions has improved over time.

METHODS

In 2013, internal medicine residents at a large academic medical center were asked to participate in an on-line survey that assessed their attitudes and experiences with discussing EOL care with terminally-ill patients. These results were compared to data from a similar survey residents in the same program completed in 2006.

RESULTS

Eighty-three (50%) residents completed the 2013 survey. About half (52%) felt strongly that they were able to have open, honest discussions with patients and families, while 71% felt conflicted about whether CPR was in the patient's best interest. About half (53%) felt strongly that it was okay for them to tell a patient/family member whether or not CPR was a good idea for them. Compared to 2006 respondents, the 2013 cohort felt they had more lectures about EOL communication, and had watched an attending have an EOL discussion more often.

CONCLUSIONS

Modest improvements were made over time in trainees' exposure to EOL discussions; however, many residents remain uncomfortable and conflicted with having EOL care discussions with their patients. More effective training approaches in EOL communication are needed to train the next generation of internists.

Advanced Care Directives: Overcoming the Obstacles

BACKGROUND

Advanced care directives (ACDs) and end-of-life discussions are important and typically difficult to initiate because of the sensitive nature of the topic and competing clinical priorities. Resident physicians need to have these conversations but often do not in their continuity clinics.

OBJECTIVE

We implemented a program to (1) increase physician opportunity to discuss end-of-life wishes with their patients, and (2) improve residents' confidence in leading discussions regarding ACDs.

INTERVENTION

A total of 95 residents in an academic outpatient internal medicine resident continuity clinic participated in a formalized curriculum (didactic sessions, simulations, and academic detailing). Clinic workflow alterations prompted the staff to question if patients had an ACD or living will, and then cued residents to discuss these issues with the patients if they did not.

RESULTS

Of the 77% of patients who were asked about ACDs, 74% had no ACD but were interested in discussing this topic. After our intervention, 65% (62 of 95) of our residents reported having at least 1 outpatient discussion with their patients. Residents reported increased confidence directing and discussing advanced care planning with older patients and conducting a family meeting (P < .01).

CONCLUSIONS

By delivering a formalized curriculum and creating a clinical environment that supports such discussions, resident physicians had more ACD discussions with their patients and reported increased confidence. When provided information and opportunity, patients consistently expressed interest in talking with their physician about their advanced care wishes.

Attitudes of Medical Students Toward the Care of the Dying in Relation to Personality Traits

Caring for dying patients requires specific attitudes. Medical students often feel unprepared to cope with issues related to end-of-life care. Little is known about the relationships between personality and attitudes toward the dying; consequently, it is difficult for medical educators to devise training that is best suited to prepare students for practicing palliative medicine. The study aimed to investigate the role of personality in predicting students’ attitudes toward the care of the dying. The study findings suggest a significant link between more self-directed and less harm-avoidant personality profiles and more developed attitudes toward the dying. Personality assessment in medical curricula is important, not merely to help teachers plan tailored training but also to foster in future doctors the propensity to develop a patient-centered practice.

Contending with advanced illness: patient and caregiver perspectives

CONTEXT

Despite improvements in end-of-life care, some unrelieved suffering persists for patients with advanced illness and their family members. Hospice and palliative care services can reduce suffering, but these services remain under-used.

OBJECTIVES

To investigate how patients with advanced illness and their primary caregivers experienced and responded to health care needs and decision making and how some dyads moved toward comfort-focused care.

METHODS

This was a qualitative study using the grounded theory method for sample selection, data collection, and analysis. Dyadic semi-structured interviews were audio-recorded and transcribed for analysis. Twenty-two participants, 12 patients and 10 family surrogates, provided 16 interviews for this study.

RESULTS

Participants engaged in a process of contending with advanced illness. The major phases comprising this process were suffering, struggling, and settling. Struggling included enduring the experience and fighting the illness. During the phase of settling, the focus shifted away from curative efforts and toward supportive care. Conditions that facilitated the movement into this phase included receiving clear and consistent information about the patient's health status, trusting health care providers, having attended to advance care planning in some form, and being aware of and able to acknowledge the terminal nature of the illness.

CONCLUSION

Findings from this pilot study offer a preliminary theoretical model to enhance the understanding of patient and family caregiver needs during advanced illness. Awareness of their perspective can inform the timing and content of clinicians' communication and interventions.

The Effects of an Early Observational Experience on Medical Students’ Attitudes Toward End-of-Life Care

End-of-life care is paramount in maintaining the quality of life of the terminally ill, protecting them from unnecessary treatment, and controlling costs incurred in their care. Training doctors to be effective end-of-life caregivers begins in medical school. A survey design was used to collect data from 166 first-year medical students before and after exposure to hospice or palliative care through an early clinical exposure program. Data demonstrated that students had a significant change in attitude scores after the observational experience ( P < .05). Providing students with the opportunity to observe and participate in end-of-life care has a positive effect on attitudes toward the care of dying persons. We recommend that direct exposure to end-of-life care practices be incorporated early in the medical school curriculum.

Interprofessional communication skills training for serious illness: evaluation of a small-group, simulated patient intervention

BACKGROUND

Communication with patients and families is an essential component of high-quality care in serious illness. Small-group skills training can result in new communication behaviors, but past studies have used facilitators with extensive experience, raising concerns this is not scalable.

OBJECTIVE

The objective was to investigate the effect of an experiential communication skills building workshop (Codetalk), led by newly trained facilitators, on internal medicine trainees' and nurse practitioner students' ability to communicate bad news and express empathy.

DESIGN

Trainees participated in Codetalk; skill improvement was evaluated through pre- and post- standardized patient (SP) encounters.

SETTING AND SUBJECTS

The subjects were internal medicine residents and nurse practitioner students at two universities.

INTERVENTION AND MEASUREMENTS

The study was carried out in anywhere from five to eight half-day sessions over a month. The first and last sessions included audiotaped trainee SP encounters coded for effective communication behaviors. The primary outcome was change in communication scores from pre-intervention to post-intervention. We also measured trainee characteristics to identify predictors of performance and change in performance over time.

RESULTS

We enrolled 145 trainees who completed pre- and post-intervention SP interviews-with participation rates of 52% for physicians and 14% for nurse practitioners. Trainees' scores improved in 8 of 11 coded behaviors (p<0.05). The only significant predictors of performance were having participated in the intervention (p<0.001) and study site (p<0.003). The only predictor of improvement in performance over time was participating in the intervention (p<0.001).

CONCLUSIONS

A communication skills intervention using newly trained facilitators was associated with improvement in trainees' skills in giving bad news and expressing empathy. Improvement in communication skills did not vary by trainee characteristics.

A cross-national cross-sectional survey of the attitudes and perceived competence of final-year medicine, nursing and pharmacy students in relation to end-of-life care in dementia

BACKGROUND

Little is known about the attitudes of healthcare professional students' perceived competence and confidence in treating those with dementia who are at the end of life.

AIM

To explore the attitudes of final year medical, nursing and pharmacy students towards people with dementia and to evaluate their perceived competence and confidence dealing with biomedical and psychosocial issues within the context of palliative care provision to patients with dementia.

DESIGN

Cross-sectional survey using a questionnaire.

SETTING/PARTICIPANTS

Final-year students in each profession from Queen's University Belfast (Northern Ireland) and the University of Iowa (USA) were recruited.

METHOD

Three versions of an online questionnaire (containing the Attitudes to Dementia Questionnaire and a series of questions on end-of-life care in dementia) were distributed.

RESULTS

A total of 368 responses were received (response rate 42.3%). All respondents reported positive attitudes towards people with dementia. US nursing students reported significantly more positive attitudes than the medical students of United States and Northern Ireland. Medical students were more likely to report low confidence in discussing non-medical aspects of dying, whereas nursing students were most likely to feel prepared and confident to do this. Medical and nursing students reported low confidence with aspects of medication-related care; however, data from the pharmacy samples of Northern Ireland and United States suggested that these students felt confident in advising other healthcare professionals on medication-related issues.

CONCLUSIONS

While healthcare students hold positive attitudes towards people with dementia, some clinical tasks remain challenging and further basic training may be of benefit.

Code status discussion skill retention in internal medicine residents: one-year follow-up

BACKGROUND

Communicating with patients about goals of care is an important skill for internal medicine residents. However, many trainees are not competent to perform a code status discussion (CSD). A multimodality intervention improved skills in a group of first-year residents in 2011. How long these acquired CSD skills are retained is unknown.

OBJECTIVE

To study CSD skill retention one year after a multimodality intervention.

DESIGN

This was a longitudinal cohort study.

SETTING/SUBJECTS

Thirty-eight second-year internal medicine residents in a university-affiliated internal medicine residency program participated in the study. Nineteen completed the intervention and 19 served as controls.

MEASUREMENTS

Mean CSD clinical skills examination (CSE) scores using an 18-item checklist were compared after the intervention (2011) and one year later (2012).

RESULTS

Intervention group residents performed significantly better than residents in the control group (71.9% (standard deviation [SD]=16.0%) versus 54.7% (SD=17.1%; p<0.001) at one-year follow-up. Intervention group residents retained their CSD skills at one year as performance was 75.1% in 2011 and 71.9% in 2012 (p=0.46). Control group residents did not develop additional CSD skills as 2011 checklist performance was 53.2% and 2012 performance was 54.7% (p=0.78).

CONCLUSIONS

CSD skills taught in a rigorous curriculum are retained at one-year follow-up. Residents in the control group did not acquire new CSD skills despite an additional year of training and clinical experience. Further study is needed to link improved CSD skills to better patient care quality.

Self-perceived competence among medical residents in skills needed to care for patients with advanced dementia versus metastatic cancer

To examine medical residents' perceived competence in caring for patients with dementia we conducted an online survey of all 120 second, third and fourth-year residents in Internal Medicine, Medicine/Pediatrics, and Family Medicine at University of Michigan. A structured survey elicited residents' training, experience, confidence, and perceived career needs for skills in estimating prognosis, symptom management, and communication in caring for patients with dementia, compared to patients with metastatic cancer. Among the 61 (51 %) respondents, a majority report lower confidence in assessing prognosis and eliciting treatment wishes in patients with dementia (vs. metastatic cancer), and in performing skills integral to the care of patients with dementia, including the ability to assess caregiver needs, decisional capacity, advise on place of care, and manage agitation, despite viewing these skills as important to their future careers. These findings support the need for enhanced education on optimal care of patients with advanced dementia.

Internal medicine trainee self-assessments of end-of-life communication skills do not predict assessments of patients, families, or clinician-evaluators

PURPOSE

To investigate the strength of association between trainees' self-assessments of the quality of their end-of-life communication skills and the assessments of their patients, patients' families, and clinician-evaluators.

METHODS

As part of a randomized trial, pre-intervention survey data were collected at two sites from internal medicine trainees and their patients, patients' families, and clinician-evaluators. In this observational analysis, comparisons using regression analysis were made between (1) trainees' scores on a scale of perceived competence at communication about end-of-life care and (2) patients', families', and clinician-evaluators' scores on a questionnaire on the quality of end-of-life communication (QOC). Secondary analyses were performed using topic-focused subscales of these measures.

RESULTS

Internal medicine trainees (143) were studied with both self-assessment and external assessments. No significant associations were found between trainee perceived competence scores and primary outcome measures (p>0.05). Of the 12 secondary subscale analyses, trainees' self-ratings were significantly associated with external assessments for only one comparison, but the association was in the opposite direction with increased trainee ratings being significantly associated with decreased family ratings on "treatment discussions." We also examined the correlation between ratings by patients, family, and clinician-evaluators, which showed significant correlations (p<0.05) for 7 of 18 comparisons (38.9%).

CONCLUSIONS

Trainee self-evaluations do not predict assessments by their patients, patients' families, or their clinician-evaluators regarding the quality of end-of-life communication. Although these results should be confirmed using the same measures across all raters, in the meantime efforts to improve communication about end-of-life care should consider outcomes other than physician self-assessment to determine intervention success.

A randomized trial to improve communication about end-of-life care among patients with COPD

OBJECTIVE

Patients with COPD consistently express a desire to discuss end-of-life care with clinicians, but these discussions rarely occur. We assessed whether an intervention using patient-specific feedback about preferences for discussing end-of-life care would improve the occurrence and quality of communication between patients with COPD and their clinicians.

METHODS

We performed a cluster-randomized trial of clinicians and patients from the outpatient clinics at the Veterans Affairs Puget Sound Health Care System. Using self-reported questionnaires, we assessed patients' preferences for communication, life-sustaining therapy, and experiences at the end of life. The intervention clinicians and patients received a one-page patient-specific feedback form, based on questionnaire responses, to stimulate conversations. The control group completed questionnaires but did not receive feedback. Patient-reported occurrence and quality of end-of-life communication (QOC) were assessed within 2 weeks of a targeted visit. Intention-to-treat regression analyses were performed with generalized estimating equations to account for clustering of patients within clinicians.

RESULTS

Ninety-two clinicians contributed 376 patients. Patients in the intervention arm reported nearly a threefold higher rate of discussions about end-of-life care (unadjusted, 30% vs 11%; P < .001). Baseline end-of-life communication was poor (intervention group QOC score, 23.3; 95% CI, 19.9-26.8; control QOC score, 19.2; 95% CI, 15.9-22.4). Patients in the intervention arm reported higher-quality end-of-life communication that was statistically significant, although the overall improvement was small (Cohen effect size, 0.21).

CONCLUSIONS

A one-page patient-specific feedback form about preferences for end-of-life care and communication improved the occurrence and quality of communication from patients' perspectives.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00106080; URL: www.clinicaltrials.gov.

Discussing religion and spirituality is an advanced communication skill: an exploratory structural equation model of physician trainee self-ratings

BACKGROUND

Communication about religious and spiritual issues is fundamental to palliative care, yet little empirical data exist to guide curricula in this area. The goal of this study was to develop an improved understanding of physicians' perspectives on their communication competence about religious and spiritual issues.

METHODS

We examined surveys of physician trainees (n=297) enrolled in an ongoing communication skills study at two medical centers in the northwestern and southeastern United States. Our primary outcome was self-assessed competence in discussing religion and spirituality. We used exploratory structural equation modeling (SEM) to develop measurement and full models for acquisition of self-assessed communication competencies.

RESULTS

Our measurement SEM identified two latent constructs that we label Basic and Intermediate Competence, composed of five self-assessed communication skills. The Basic Competence construct included overall satisfaction with palliative care skills and with discussing do not resuscitate (DNR) status. The Intermediate Competence construct included responding to inappropriate treatment requests, maintaining hope, and addressing fears about the end-of-life. Our full SEM model found that Basic Competence predicted Intermediate Competence and that Intermediate Competence predicted competence in religious and spiritual discussions. Years of clinical training directly influenced Basic Competence. Increased end-of-life discussions positively influenced Basic Competence and had a complex association with Intermediate Competence. Southeastern trainees perceived more competence in religious and spiritual discussions than northwestern trainees.

CONCLUSION

This study suggests that discussion of religious and spiritual issues is a communication skill that trainees consider more advanced than other commonly taught communication skills, such as discussing DNR orders.