Impact of a Simulation-Based Communication Workshop on Resident Preparedness for End-of-Life Communication in the Intensive Care Unit

Development of a measure of clinicians' self-efficacy for medical communication (SEMC)

OBJECTIVES

Studies of clinician-patient communication have used varied, ad hoc measures for communication efficacy. We developed and validated the Self-Efficacy for Medical Communication (SEMC) scale as a standard, quantitative measure of clinician-reported skills in communicating difficult news.

METHODS

Using evidence-based scale development guidelines, we created two 16-item forms of the SEMC, one assessing communication with patients and one assessing communication with families. Clinicians providing oncological care in four organisations were invited to participate and provided consent. Participant demographics, responses to the SEMC items and responses to convergent and discriminant measures (those expected to relate strongly and weakly to the SEMC) were collected online. We performed analyses to determine the convergent and discriminant validity of the SEMC as well as its reliability and factor structure.

RESULTS

Overall, 221 oncology clinicians (including physicians, residents, fellows, medical students, nurses, nurse practitioners and physician assistants) participated. The patient and family forms both demonstrated high internal consistency reliability (alpha=0.94 and 0.96, respectively) and were strongly correlated with one another (r=0.95, p<0.001). Exploratory factor analysis demonstrated that the SEMC measures a unitary construct (eigenvalue=9.0), and its higher mean correlation with convergent (r=0.46) than discriminant (r=0.22) measures further supported its validity.

CONCLUSIONS

Our findings support the SEMC's validity and reliability as a measure of clinician-rated communication skills regarding conducting difficult conversations with patients and families. It provides a useful standard tool for future research in oncology provider-patient serious illness communication.

Enhancing Oncologists' Comfort with Serious Illness Conversations: The Impact of Serious Illness Conversation Guide (SICG) Training

Providers oftentimes need to have difficult conversations with patients facing a poor prognosis. Research indicates that providers generally feel ill prepared for these conversations and that bad conversations may lead to more anxiety for patients. Communication skills development training programs have shown improvement in providers' skills. Our cancer center embarked on skills development training to help providers improve their skills and comfort in having serious illness conversations. During our phased approach, about 500 physicians and advanced practice providers in the Division of Oncology were trained for over a year. Their level of comfort with serious illness conversations was measured before and after the training by using both quantitative and qualitative methods. We found that mean and median comfort scores increased from pre-training to post-training. The findings suggest that the improved comfort and confidence observed among providers who undergo communications skills training can lead to better provider-patient communication, more patient-centered care, and improved patient satisfaction.

Evaluating surgeon communication of pancreatic cancer prognosis using the VitalTalk ADAPT framework

BACKGROUND AND OBJECTIVES

Few data exist to guide optimal communication practices for surgical oncologists. VitalTalk, an evidence-based communication skills training model for clinicians, offers the five-step ADAPT tool for discussing prognosis. This study aimed to characterize surgeon communication of pancreatic cancer prognosis using VitalTalk's ADAPT framework.

METHODS

Contemporaneous audio recordings from 12 initial surgeon-patient encounters for borderline resectable pancreatic cancer were transcribed. Directed qualitative content analysis based on ADAPT (Ask, Discover, Anticipate, Provide, and Track) was used to deductively code transcripts.

RESULTS

All encounters contained at least one ADAPT step while only one (8%) incorporated four or five steps. Surgeons provided prognostic information (Provide) in all but one encounter (92%); most was qualitative and clustered into themes: serious illness, surgical candidacy, prognostic ambiguity, and cancer recurrence. Surgeons elicited understanding (Ask), requested information preferences (Discover), anticipated ambivalence (Anticipate), and responded to emotion (Track) in a minority of encounters (25%-42%); of 15 patient emotional cues, six were not addressed by surgeons.

CONCLUSIONS

During an initial encounter for pancreatic cancer, surgeons focus heavily on providing information but omit critical prognostic communication steps. Future studies are needed to investigate if surgeon training in palliative care-based communication is feasible and impacts patient-perceived quality of communication.

Healthcare providers' communication experience in the pediatric intensive care unit: a phenomenological study

BACKGROUND

Healthcare providers must effectively communicate with other professionals, multidisciplinary teams, and parents of patients in pediatric intensive care units (PICUs) to improve outcomes in children and satisfaction levels of parents. Few studies have focused on healthcare providers' communication experiences, which are crucial for identifying current problems and suggesting future directions. This phenomenological study was conducted to address this gap.

METHODS

A qualitative study using online and face-to-face interviews was conducted from January to June 2021 by a trained researcher in PICUs of two tertiary hospitals. Participants were five physicians and four registered nurses who worked in the PICUs and had over five years of clinical experience. The interviews were audio recorded with the participant's consent and analyzed by the researchers using Colaizzi's seven-step method.

RESULTS

Healthcare providers' communication experiences revealed four categories: facing communication difficulties in PICUs, communication relying on individual competencies without established communication methods, positive and negative experiences gained through the communication process, and finding the most effective communication approach.

CONCLUSIONS

Without adequate support or a systematic training program, healthcare providers often have to overcome communication challenges on their own. Therefore, support and training programs should be developed to facilitate better communication in the future.

Implementation of a skills-based virtual communication curriculum for medical students interested in surgery

Background

Communication skills are essential to providing patient-centered care. The need for standardized communication skills training is at the forefront of medical school and residency education. We aimed to design and implement a curriculum teaching virtual communications skills to medical students. The purpose of this report is to describe our experience and to offer guidance for training programs developing similar curricula in the future.

Methods

The curriculum was presented in weekly modules over 5 weeks using Zoom technology. We focused on proven strategies for interacting with patients and other providers, adapted to a virtual platform. Skill levels during role-play were assessed by the Simulated Participants and students observing the simulation using the 14-item, physician specific Communication Assessment Tool (CAT). The primary outcome of the CAT is the percentage of "excellent" for each item ranked both years. Participants provided feedback on what worked well or how the module could be improved in open-ended responses.

Results

Twenty-eight and 25 students registered for the course in Year 1 and Year 2, respectively. Students' post-session confidence in their ability to perform target skills was statistically higher than their pre-session scores in most sessions. Modules with the lowest pre-session confidence for both years were "Disclosing a Medical Error" and "Responding to Patient Bias." The mean percentage of students receiving "excellent" scores on individual CAT items ranged from 5 to 73% over the course of both years. Verbal and written feedback in Year 1 provided direction for the curriculum developers to improve the course in Year 2.

Conclusions

Developing and implementing a new education curriculum is a complex process. We describe an intensive curriculum for medical students as we strive to allow students extra "clinical" time during COVID-related restriction. We believe continued focus on patient and family communication skills will enhance patient care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44186-022-00054-9.

Why did he say that? Teaching physicians-in-training how to recognize hidden emotions in end-of-life prognosis conversations: an autoethnography

Background: This article begins with two unconscionable end-of-life prognosis-related quotes from best-selling physician-author, Atul Gawande, and an unnamed doctor, asking: “Why did he say that?” The article then proceeds to answer this question by showing how physicians’ most common end-of-life communication blunders are rooted in their unexplored emotions. Healthcare’s only widespread communication training focused on examining the role of hidden emotions in influencing the flow of conversation is found in Spiritual Care’s “Verbatim” education modules. While the need for physicians’ emotional self-awareness for improved end-of-life communication has been identified in the literature, no one has explored how this need might be met by custom-tailoring Spiritual Care’s “Verbatim” education modules for physicians-in-training. Methods: This article utilizes the qualitative research method of autoethnography to grant physicians access to the content and power of Spiritual Care’s “Verbatim” education modules for identifying hidden emotions in clinical communication. Results: Using a profound personal example from the author’s firsthand experience of the suggested training tool, the “Verbatim” module is shown to grant revelatory self-knowledge and invaluable emotional intelligence. The same model then illuminates the physician cases. Conclusion: Spiritual Care’s “Verbatim” education modules address universal issues of clinical communication and emotional self-awareness that are applicable to physician-patient/family conversations surrounding end-of-life decision-making. Customizing these communication modules for physicians-in-training may help to address physicians’ emotionally-triggered conversational miscues in end-of-life prognosis communication. Existing programs for complementary end-of-life communication training are noted, and it is claimed that a combination of each of these models, together with the proposed module, may be ideal. It is also admitted that no form of education or training can ensure ethical communication. Therefore the ultimate solution is to supplement communication training with real-time, third-party support and accountability. This can be achieved by the "Doctor Body Cam" intervention protocol, introduced here: https://aquila.usm.edu/ojhe/vol17/iss1/7/.

Why did he say that? Teaching physicians-in-training how to recognize hidden emotions in end-of-life prognosis conversations: an autoethnography

Background : Intuitively accessible via WhyDidHeSayThat.com, this article begins with two unconscionable end-of-life prognosis-related quotes from best-selling physician-author, Atul Gawande, and an unnamed doctor, asking: "Why did he say that?" The article then proceeds to answer this question by showing how physicians' most common end-of-life communication blunders are rooted in their unexplored emotions. Healthcare's only widespread communication training focused on examining the role of hidden emotions in influencing the flow of conversation is found in Spiritual Care's "Verbatim" education modules. While the need for physicians' emotional self-awareness for improved end-of-life communication has been identified in the literature, no one has explored how this need might be met by custom-tailoring Spiritual Care's "Verbatim" education modules for physicians-in-training. Methods : This article utilizes the qualitative research method of autoethnography to grant physicians access to the content and power of Spiritual Care's "Verbatim" education modules for identifying hidden emotions in clinical communication. Results : Using a profound personal example from the author's firsthand experience of the suggested training tool, the "Verbatim" module is shown to grant revelatory self-knowledge and invaluable emotional intelligence. The same model then illuminates the physician cases. Conclusion : Spiritual Care's "Verbatim" education modules address universal issues of clinical communication and emotional self-awareness that are applicable to physician-patient/family conversations surrounding end-of-life decision-making. Customizing these communication modules for physicians-in-training may help to address physicians' emotionally-triggered conversational miscues in end-of-life prognosis communication. Existing programs for complementary end-of-life communication training are noted, and it is claimed that a combination of each of these models, together with the proposed module, may be ideal. It is also admitted that no form of education or training can ensure ethical communication. Therefore the ultimate solution is to supplement communication training with real-time, third-party support and accountability. This can be achieved by the "Doctor Body Cam" intervention protocol, accessible via DoctorBodyCam.com.

Why did he say that? Teaching physicians-in-training how to recognize hidden emotions in end-of-life prognosis conversations: an autoethnography

Background: Intuitively accessible via WhyDidHeSayThat.com, this article begins with two unconscionable end-of-life prognosis-related quotes from best-selling physician-author, Atul Gawande, and an unnamed doctor, asking: “Why did he say that?” The article then proceeds to answer this question by showing how physicians’ most common end-of-life communication blunders are rooted in their unexplored emotions. Healthcare’s only widespread conversation analysis training focused on examining the role of hidden emotions in influencing the flow of conversation is found in Spiritual Care’s “Verbatim” education modules. While the need for physicians’ emotional self-awareness for improved end-of-life communication has been identified in the literature, no one has explored how this need might be met by custom-tailoring Spiritual Care’s “Verbatim” education modules for physicians-in-training. Methods: This article utilizes the qualitative research method of autoethnography to grant physicians access to the content and power of Spiritual Care’s “Verbatim” education modules for conversation analysis and emotional intelligence.   Results: Using a profound personal example from the author’s firsthand experience of the suggested training tool, the “Verbatim” module is shown to grant revelatory self-knowledge and invaluable emotional intelligence. The same model then illuminates the physician cases. Conclusion: Spiritual Care’s “Verbatim” education modules address universal issues of clinical communication and emotional self-awareness that are applicable to physician-patient/family conversations surrounding end-of-life decision-making. Customizing these conversation analysis modules for physicians-in-training may help to address physicians’ emotionally-triggered conversational miscues in end-of-life prognosis communication. Existing programs for complementary end-of-life communication training are noted, and it is claimed that a combination of each of these models, together with the proposed module, may be ideal. It is also admitted that no form of education or training can ensure ethical communication. Therefore the ultimate solution is to supplement communication training with real-time, third-party support and accountability. This can be achieved by the "Doctor Body Cam" intervention protocol, accessible via DoctorBodyCam.com.

Serious illness conversations in pulmonary hypertension

Pulmonary arterial hypertension has evolved from a fatal disease with few treatment options to a chronic condition with improved survival. This improvement is possible through development of effective therapies as well as the expansion of risk stratification scores to assist clinical decision making. Despite improved disease control, quality of life, and overall prognosis, many challenges remain. The treatment itself is burdensome, with significant impact on quality of life. Many patients with pulmonary arterial hypertension still present with advanced, often end-stage disease. Increased use of mechanical circulatory support and catheter-based interventions have expanded use of extracorporeal life support and right ventricle assist devices. For these reasons as well as the long-term relationships pulmonary hypertension physicians have with patients and their families, navigating the course of the illness in a considered, proactive way is essential. Understanding individual goals and revisiting them as they change over time requires comfort with the conversation itself. There are many barriers and challenges to having effective, compassionate conversations in the clinical setting with time constraints being the most often cited. Compressed visits are necessarily focused on the clinical aspects, therapy and medication adherence and tolerance. Clinicians are sometimes wary of diminishing hope in the face of ongoing treatment. Having sufficient experience and comfort with these discussions can be empowering. In this paper, we discuss the challenges involved and propose a framework to assist in incorporating these discussions into clinical care.

Cultivating Empathy and Soft Skills Among Intensive Care Residents: Effects of a Mandatory, Simulation-Based, Experiential Training

Background

Communication with families is crucial in ICU care. However, only a few residency programs include communication and relationship training in their curricula. This study aimed to assess the impact of a communication-skill course on residents’ empathy and self-reported skills.

Material/Methods

A single-center, observational study was conducted. Since 2017, the 4^th-year residents of the Anaesthesia and Intensive Care School, University of Milan attended the mandatory “Program to Enhance Relational and Communication Skills in ICU (PERCS-ICU)”. PERCS-ICU lasted 10 hours and involved small groups of residents. The course was articulated around the simulation and debriefing of 3 difficult conversations with trained actors. Before and after the course, residents completed the Jefferson Scale of Empathy and a questionnaire measuring self-assessed preparation, communication skills, relational skills, confidence, anxiety, emotional awareness, management of emotions, and self-reflection when conducting difficult conversations. The quality and usefulness of the course and the case scenario were assessed on a 5-point Likert scales.

Results

Between 2017 and 2019, 6 PERCS-ICU courses were offered to 71 residents, 69 of whom completed the questionnaires. After the course, residents reported improvements in empathy (p<.05), preparation (p<.001), communication skills (p<.005), confidence (p<.001), self-reflection (p<.001), and emotional awareness (p<.001). Residents perceived the course as very useful (mean=4.79) and high-quality (mean=4.58). The case scenario appeared very realistic (mean=4.83) and extremely useful (mean=4.91). All residents recommended the course to other colleagues.

Conclusions

PERCS-ICU proved to be a well-received and effective course to improve residents’ empathy and some self-reported skills. The long-term effects remain to be investigated.

Physicians' Perceptions and Suggestions for the Adaptation of a US-Based Serious Illness Communication Training in a Non-US Culture: A Qualitative Study

CONTEXT

US-based serious illness communication training pedagogy has not been well studied outside of the United States.

OBJECTIVES

To explore the perception of a US-based, serious illness communication training pedagogy in a non-US culture and to identify aspects requiring cultural adaptations.

METHODS

In September 2019, we conducted a qualitative study using convenient sampling at two urban, academic medical centers in Tokyo, Japan. Semistructured interviews were conducted to Japanese physicians who participated in the four-hour VitalTalk training in Japanese. We explored six majored themes: 1) global impression of the training; 2) main goals from participation; 3) appropriateness of didactics; 4) role play experiences; 5) take away points from the training; and 6) changes in their own communication practice after the training. Interviews were transcribed, coded, and analyzed using phenomenological approach.

RESULTS

All 24 participants found the VitalTalk pedagogy novel and beneficial, stressing the importance of demonstrating empathy, reflecting on own skills, and recognizing the importance of feedback that emphasizes the use of specific words. Participants also pointed out that Japanese patients generally do not express their strong emotions explicitly.

CONCLUSION

Our study found empirical evidence that the VitalTalk pedagogy is perceived to be novel and beneficial in a non-US cultural setting. Cultural adaptations in expression and response to emotion may be required to maximize its efficacy in Japan. To meet the needs of clinical practice in Japan, further studies are needed to empirically test the suggested refinements for the VitalTalk pedagogy.

Simulation-Based Medical Education Improves Procedural Confidence in Core Invasive Procedures for Military Internal Medicine Residents

Introduction

The American Board of Internal Medicine (ABIM) requires that trainees receive procedural training for certification; however, Internal Medicine (IM) residents perform a variable number of procedures throughout residency training. This results in differences in confidence levels as well as procedural competence. For active-duty military trainees, this is especially problematic, as these procedural skills are often required during deployment soon after residency graduation. This deficit can be improved through standardized simulation-based training.

Methods

All internal medicine residents at our institution were invited to participate in a standardized simulation-based training program for core internal medicine procedures (lumbar puncture, arterial line, central line, thoracentesis, paracentesis, and arthrocentesis). Residents were asked to qualitatively rate their perceived procedural confidence using a Likert scale ranging from 1 (not at all confident) to 5 (extremely confident) in their ability to independently perform core internal medicine procedures prior to the simulation exercise. Experienced senior residents and internal medicine faculty instructed and supervised each resident as they performed the procedures. Following the simulation exercise, the residents repeated the survey and were asked to report whether or not they found the exercise useful. 

Results

Of the 96 residents invited to participate, 49 completed the pre-simulation questionnaire and 36 completed the post-simulation questionnaire. The cumulative mean Likert scale confidence rating for all procedures showed a statistically significant improvement post-simulation as compared to pre-simulation, including lumbar puncture (2.45±1.1 vs. 3.42±0.87, p<0.05), arterial line (2.48±1.06 vs. 3.39±1.04, p < 0.05), central line (2.86±1.08 vs. 3.5±1.02, p < 0.05), thoracentesis (2.67±1.10 vs. 3.64±0.83, p < 0.05), paracentesis (3.1±1.08 vs. 3.82±0.74, p < 0.05), and arthrocentesis (2.56±1.07 vs. 3.67±0.80, p < 0.05). All (36/36) trainees reported that they perceived the simulation exercise as valuable.

Conclusion

Internal medicine residents across all post-graduate year (PGY) levels at our institution lacked confidence to independently perform core internal medicine procedures. Utilizing simulation-based medical education as an adjunct to clinical training is well accepted by internal medicine trainees, and resulted in significantly improved procedural confidence. This intervention was well received by trainees and could feasibly be replicated at other active-duty military internal medicine residency programs to assist with readiness. Research is currently in progress to correlate in-situ competency and evaluate clinical outcomes of this improved confidence.

Clinical Tolerability and Safety of Tramadol in Hospitalized Patients

Tramadol is a schedule IV, monoaminergic and μ-opioid-receptor analgesic with unique pharmacology properties. Though it is well established and widely utilized, there is little guidance on tramadol's place in therapy, including tolerability, safety and monitoring guidelines. Retrospective chart review of 250 patients who received oral tramadol during their hospitalization from January 1, 2018 to December 31, 2018. Of the 250 patients, 10.8% had cancer as their primary diagnosis while 8.8% were admitted for hematologic reasons. 79.1% of patients had acute pain. Palliative care consult or ICU admission resulted in significant discontinuation of tramadol (p < 0.05 odds ratio 6.88, 2.39). There was no significant relationship of hypoglycemia when evaluating days on tramadol, total number of doses on tramadol, and MEDD start and end (p = 0.36, 0.88, 0.15, 0.23 consecutively). The longer that patients were on tramadol and the more doses they received during their inpatient stay, the greater risk of a severe drug-drug interaction (p < 0.05; R 0.29). In hospitalized patients, the risk of major and severe drug-drug interactions with tramadol increased with dose and duration. Hospital medicine, bone marrow transplant, and emergency medicine teams predominantly used tramadol.

Persistence of patient and family experiences of critical illness

OBJECTIVE

To investigate: (1) patient and family experiences with healthcare and the intensive care unit (ICU); (2) experiences during their critical illness; (3) communication and decision making during critical illness; (4) feelings about the ICU experience; (5) impact of the critical illness on their lives; and (6) concerns about their future after the ICU.

DESIGN

Four semistructured focus group interviews with former ICU patients and family members.

SETTINGS

Multicultural community group and local hospitals containing medical/surgical ICUs.

PARTICIPANTS

Patients and family who experienced a critical illness within the previous 10 years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Four separate focus groups each lasting a maximum of 150 min and consisting of a total of 21 participants were held. Focus groups were conducted using a semistructured script including six topics relating to the experience of critical illness that facilitated deduction and the sorting of data by thematic analysis into five predominant themes. The five main themes that emerged from the data were: (1) personalised stories of the critical illness; (2) communication and shared decision making, (3) adjustment to life after critical illness, (4) trust towards clinical team and relevance of cultural beliefs and (5) end-of-life decision making. Across themes, we observed a misalignment between the medical system and patient and family values and priorities.

CONCLUSIONS

The experience of critical illness of a diverse group of patients and families can remain vivid for years after ICU discharge. The identified themes reflect the strength of memory of such pivotal experiences and the importance of a narrative around those experiences. Clinicians need to be aware of the lasting effects of critical illness has on patients and families.

Hospice nurse identification of comfortable and difficult discussion topics: Associations among self-perceived communication effectiveness, nursing stress, life events, and burnout

OBJECTIVE

To assess hospice nurses' self-perceived communication effectiveness, identify comfortable and difficult discussion topics, and explore associations between self-perceived communication effectiveness, burnout, nursing stress, and life events.

METHODS

181 nurses completed self-report measures, then listed comfortable and/or difficult patient and caregiver discussion topics.

RESULTS

Nurses were generally experienced (median 9 years, range <1-46 as a registered nurse; median 3 years, range <1-23 as a hospice nurse), reporting overall Effective/Very Effective communication skills (85.6%); 70% desired more communication training. As nursing stress increased perceived overall communication effectiveness decreased (rs = -0.198; p 0.012). As burnout increased overall effectiveness (rs = -0.233; p 0.002) and effectiveness with difficult topics (rs = -0.225; p 0.003) decreased. Content analysis revealed 9 categories considered both comfortable and difficult to discuss; contextual comments provided fuller explanation (e.g. providing general information on the Dying Process was comfortable, discussing Dying process during patient death was difficult). Seven additional categories (e.g. Denial) were deemed uniquely difficult.

CONCLUSION

Hospice nurses perceive themselves as effective communicators, yet want additional training. Perceived communication effectiveness is associated with burnout and stress.

PRACTICE IMPLICATIONS

Communication training that focuses on contextually grounded topics identified by participants may optimize communication between hospice nurses, patients and caregivers.

A Simulated Approach to Fostering Competency in End-of-Life Care Among Pharmacy Students

Objective. To determine if pharmacy students participating in simulation-based scenarios reported fewer learning needs about the transition from acute to end-of-life (EOL) care compared to students participating in solely case-based scenario delivery. Methods. Four end-of-life cases were developed for both paper-based case study and simulation delivery. Pharmacy students on three distant campuses were exposed to the case study approach while four teams of nine to ten pharmacy students were exposed to simulated versions of the same cases. A validated questionnaire was administered before and after exposure to assess end-of-life care learning needs. Results were analyzed following a Bonferroni-adjustment for multiple testing. Results. The case study groups produced similar pre/post changes on the questionnaire. After results were pooled and compared to the simulation only group, significantly higher changes in pre/post scores were found for the simulation group. Conclusion. Pharmacy students exposed to simulated EOL scenarios experienced significantly reduced learning needs following the scenarios, unlike their classroom-based counterparts.

Patients' perspectives on dialysis decision-making and end-of-life care

BACKGROUND

Few studies have explored dialysis patients' perspectives on dialysis decision-making and end-of-life-care (EoLC) preferences. We surveyed a racially diverse cohort of maintenance dialysis patients in the Cleveland, OH, USA, metropolitan area.

MATERIALS AND METHODS

In this cross-sectional study, we administered a 41-item questionnaire to 450 adult chronic dialysis patients. Items assessed patients' knowledge of their kidney disease as well as their attitudes toward chronic kidney disease (CKD) treatment issues and EoLC issues.

RESULTS

The cohort included 67% Blacks, 27% Caucasians, 2.8% Hispanics, and 2.4% others. The response rate was 94% (423/450). Most patients considered it essential to obtain detailed information about their medical condition (80.6%) and prognosis (78.3%). Nearly 19% of respondents regretted their decision to start dialysis. 41% of patients would prefer treatment(s) aimed at relieving pain rather than prolonging life (30.5%), but a majority would want to be resuscitated (55.3%). Only 8.4% reported having a designated healthcare proxy, and 35.7% reported completing a living will. A significant percentage of patients wished to discuss their quality of life (71%), psychosocial and spiritual concerns (50.4%), and end-of-life issues (38%) with their nephrologist.

CONCLUSION

Most dialysis patients wish to have more frequent discussions about their disease, prognosis, and EoLC planning. Findings from this study can inform the design of future interventions.
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Feasibility and Effectiveness of a Mnemonic Approach to Teach Residents How to Assess Goals of Care

Background: Shared decision making is a collaborative process that allows patients, or their surrogates, and clinicians to make health care decisions together. There is an imperative to teach young physicians early in their training the importance of engaging in a shared decision-making process to define overall goals of care (GOC). The PERSON mnemonic proposes a structured format that allows providers to evaluate GOC across the spectrum of serious illnesses, outside of breaking bad news or end-of-life planning. Objectives: This study evaluated the utility of the PERSON mnemonic in training residents to have GOC with their patients, and investigated if these skills translated to the bedside with real patient encounters. Methods: First-year residents were divided into groups to participate in an in-depth education session. A pre-/postbaseline survey was administered immediately after the education intervention and approximately seven months later to assess retention and utility. Results: Thirty first-year residents were eligible for this study; 30 attended the educational sessions and completed the immediate baseline pre-/postsurvey and the seven-month follow-up survey, resulting in 100% retention rate throughout study. Residents found sustained utility in the mnemonic. It was significantly successful in increasing the knowledge and confidence level in exploring GOC. Patient-centered outcomes could not be analyzed due to low response rates and limited granularity of hospital-level data. Conclusion: The PERSON mnemonic is a feasible and useful format for teaching residents how to have a GOC discussion.

Pediatric-Oncology Simulation Training for Resident Education

Introduction

We sought to evaluate pediatric oncology simulations intended to improve pediatric residents' skills and comfort in caring for children with cancer.

Method

In a non-randomized trial, controls (the first three rotations) received a standard set of lectures, and the intervention arm received these lectures plus five simulation-training scenarios-fever/neutropenia, a new leukemia diagnosis, end-of-life care discussion, tumor lysis syndrome, and a mediastinal mass. All residents were tested after the rotation on the first three scenarios; management skills were evaluated independently by two raters. Before and after training, all residents completed an emotional-appraisal questionnaire evaluating each scenario as a perceived challenge or threat. Analysis of variance (ANOVA) measured differences by study arm in skills-checklist assessments and appraisals; repeated-measures ANOVA measured changes in emotional-appraisal scores.

Results

Forty-two residents (9 control, 33 intervention) participated. Inter-rater agreement for skills-checklist scores using average-measures intraclass correlation was high (0.847), and overall mean scores were significantly higher for the intervention than control group across both raters (P = 0.005). For all residents, perceived challenge increased in the end-of-life simulation, and perceived threat decreased in all three test scenarios. The intervention group, regardless of training year, evaluated the teaching scenarios favorably and felt that challenging oncology situations were addressed, skills were enhanced, and the simulations should be offered to other residents.

Conclusions

It was feasible to introduce residents to difficult pediatric oncology scenarios using simulation. The intervention group performed more skills than controls when tested, and perceive threat declined in all residents after their pediatric oncology rotation.

Intensity of End-of-Life Care for Patients with Hematologic Malignancies and the Role of Race/Ethnicity

BACKGROUND

Racial/ethnic minority patients with nonhematologic malignancies (non-HM) have lower rates of hospice care, advance directive use, and palliative care utilization than non-Hispanic white (NHW) patients. Less is known regarding racial/ethnic minority patients with hematologic malignancies (HM).

OBJECTIVES

To study hospital utilization among racial/ethnic minority patients with HM and compare end-of-life outcome measures to patients with non-HM.

METHODS

We performed a retrospective cohort study (2010-2015) using electronic health records from an integrated academic health center to study differences in hospital utilization patterns and documentation of advance care planning between patients with HM and non-HM. In the subgroup with hematologic malignancy, we examined outcomes associated with racial/ethnic minority status.

RESULTS

Among all patients in the last 30 days of life, those with HM had higher rates of inpatient care (odds ratio [OR], 1.96; 95% CI: 1.74-2.20; p < 0.001) and intensive care unit (ICU) care (OR, 3.50; 95% CI: 3.05-4.03; p < 0.001). Patients with HM were more likely to die in a hospital (OR, 2.75; 95% CI: 2.49-3.04; p < 0.001) than those with non-HM. Furthermore, during the last 30 days of life, among patients with HM, racial/ethnic minority patients were more likely to have more than one emergency room visit (OR, 6.81; 95% CI: 1.34-33.91; p = 0.02), 14+ days of inpatient care (OR, 1.60; 95% CI: 1.08-2.35; p = 0.02), longer stays in the ICU (OR, 1.26; 95% CI: 1.04-1.52; p = 0.02), and lower rates of advance directive documentation (OR, 0.60; 95% CI: 0.44-0.82; p < 0.01) than NHWs.

CONCLUSION

Our findings suggest that racial/ethnic minority patients with HM have higher utilization of care at the end-of-life and lower rates of advance directives compared with NHW patients.