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Abstract
The importance of integrated palliative care in surgical oncology has been established by high-level evidence demonstrating improved patient-centered outcomes. There has been substantial improvement in efforts to incorporate palliative medicine training into medical and surgical education over the last decade. However, although trainees may feel confident in managing patients at the end of life, they may not have the insight or proficiency to provide optimal palliative care. Surgeons and palliative care physicians should collaborate on methods to optimize palliative care education for both trainees and practicing surgeons. A growing number of palliative care resources are available to this end.
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Affiliation(s)
- Alexandra C Istl
- Division of Surgical Oncology, Johns Hopkins Hospital, Blalock 684, 600 North Wolfe Street, Baltimore, MD 21287, USA. https://twitter.com/AllyIstl
| | - Fabian M Johnston
- Division of Surgical Oncology, Johns Hopkins Hospital, Blalock 684, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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Yin S, Arkes HR, McCoy JP, Cohen ME, Mellers BA. Conflicting Goals Influence Physicians' Expressed Beliefs to Patients and Colleagues. Med Decis Making 2021; 41:505-514. [PMID: 33764191 DOI: 10.1177/0272989x211001841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Physicians who communicate their prognostic beliefs to patients must balance candor against other competing goals, such as preserving hope, acknowledging the uncertainty of medicine, or motivating patients to follow their treatment regimes. OBJECTIVE To explore possible differences between the beliefs physicians report as their own and those they express to patients and colleagues. DESIGN An online panel of 398 specialists in internal medicine who completed their medical degrees and practiced in the United States provided their estimated diagnostic accuracy and prognostic assessments for a randomly assigned case. In addition, they reported the diagnostic and prognostic assessments they would report to patients and colleagues more generally. Physicians answered questions about how and why their own beliefs differed from their expressed beliefs to patients and colleagues in the specific case and more generally in their practice. RESULTS When discussing beliefs about prognoses to patients and colleagues, most physicians expressed beliefs that differed from their own beliefs. Physicians were more likely to express greater optimism when talking to patients about poor prognoses than good prognoses. Physicians were also more likely to express greater uncertainty to patients when prognoses were poor than when they were good. The most common reasons for the differences between physicians' own beliefs and their expressed beliefs were preserving hope and acknowledging the inherent uncertainty of medicine. CONCLUSION To balance candor against other communicative goals, physicians tended to express beliefs that were more optimistic and contained greater uncertainty than the beliefs they said were their own, especially in discussions with patients whose prognoses were poor.
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Affiliation(s)
- Siyuan Yin
- Department of Marketing, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Hal R Arkes
- Department of Psychology, Ohio State University, Columbus, OH, USA.,The Harding Center for Risk Literacy, Berlin, Germany
| | - John P McCoy
- Department of Marketing, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Margot E Cohen
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Barbara A Mellers
- Department of Psychology and Department of Marketing, University of Pennsylvania, Philadelphia, PA, USA
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3
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Gilligan C, Brubacher SP, Powell MB. Assessing the training needs of medical students in patient information gathering. BMC MEDICAL EDUCATION 2020; 20:61. [PMID: 32122357 PMCID: PMC7053046 DOI: 10.1186/s12909-020-1975-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 02/20/2020] [Indexed: 05/17/2023]
Abstract
BACKGROUND Effective communication is at the heart of good medical practice but rates of error, patient complaints, and poor clinician job satisfaction are suggestive of room for improvement in this component of medical practice and education. METHODS We conducted semi-structured interviews with experienced clinicians (n = 19) and medical students (n = 20) to explore their experiences associated with teaching and learning clinical communication skills and identify targets for improvements to addressing these skills in medical curricula. RESULTS Interviews were thematically analysed and four key themes emerged; the importance of experience, the value of role-models, the structure of a consultation, and confidence. CONCLUSIONS The findings reinforce the need for improvement in teaching and learning communication skills in medicine, with particular opportunity to target approaches to teaching foundational skills which can establish a strong grounding before moving into more complex situations, thus preparing students for the flexibility required in medical interviewing. A second area of opportunity and need is in the engagement and training of clinicians as mentors and teachers, with the findings from both groups indicating that preparation for teaching and feedback is lacking. Medical programs can improve their teaching of communication skills and could learn from other fields s to identify applicable innovative approaches.
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Affiliation(s)
- Conor Gilligan
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - Sonja P Brubacher
- Centre for Investigative Interviewing, Griffith Criminology Institute, Griffith University, Mount Gravatt, Australia
| | - Martine B Powell
- Centre for Investigative Interviewing, Griffith Criminology Institute, Griffith University, Mount Gravatt, Australia
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5
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Abstract
While much attention has been directed at improving the quality of care at the end of life, few studies have examined what determines a good death in different individuals. We sought to identify common domains that characterize a good death in a diverse range of community-dwelling individuals, and to describe differences that might exist between minority and non-minority community-dwelling individuals’ views. Using data from 13 focus groups, we identified 10 domains that characterize the quality of the death experience: 1) physical comfort, 2) burdens on family, 3) location and environment, 4) presence of others, 5) concerns regarding prolongation of life, 6) communication, 7) completion and emotional health, 8) spiritual care, 9) cultural concerns, 10) individualization. Differences in minority compared to non-minority views were apparent within the domains of spiritual concerns, cultural concerns, and individualization. The findings may help in efforts to encourage more culturally sensitive and humane end-of-life care for both minority and non-minority individuals.
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Spagnoletti CL, Merriam S, Milberg L, Cohen WI, Arnold RM. Teaching Medical Educators How to Teach Communication Skills: More than a Decade of Experience. South Med J 2018; 111:246-253. [PMID: 29767213 DOI: 10.14423/smj.0000000000000801] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Although opportunities exist for medical educators to gain additional training in teaching, literature that describes how to teach educators to teach communication skills to trainees is limited. The authors developed and evaluated a faculty development course that uses didactics, demonstration, drills, and role-play in a small-group format. METHODS The course has been offered through the Institute for Clinical Research Education at the University of Pittsburgh for almost 15 years. Course effectiveness was evaluated with a survey of 62 clinicians who completed the course between 2003 and 2012. RESULTS The response rate was 85%. A total of 98% would recommend the course to a colleague and 98% indicated the course was effective at developing teaching techniques. Their use of standardized patients, teaching in small groups, and role-play increased as a result of participation in the course. A total of 70% went on to formally teach communication skills at various medical education levels. CONCLUSIONS This structured course effectively taught participants how to teach patient-doctor communication in both classroom and clinical settings. The majority put these techniques to use in formal settings. This course also provided educators with the skills necessary to meet the growing needs of training programs charged with teaching the next generation of providers to effectively communicate with patients. The description presented can serve as a framework for faculty development in teaching communication.
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Affiliation(s)
- Carla L Spagnoletti
- From the Departments of Medicine, Family Medicine, Pediatrics, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sarah Merriam
- From the Departments of Medicine, Family Medicine, Pediatrics, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Laurel Milberg
- From the Departments of Medicine, Family Medicine, Pediatrics, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - William I Cohen
- From the Departments of Medicine, Family Medicine, Pediatrics, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M Arnold
- From the Departments of Medicine, Family Medicine, Pediatrics, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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von Gunten CF, Twaddle M, Preodor M, Neely KJ, Martinez J, Lyons J. Evidence of improved knowledge and skills after an elective rotation in a hospice and palliative care program for internal medicine residents. Am J Hosp Palliat Care 2016; 22:195-203. [PMID: 15909782 DOI: 10.1177/104990910502200309] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There is compelling evidence that residents training in primary care need education in palliative care. Evidence for effective curricula is needed. The objective of this study was to test whether a clinical elective improves measures of knowledge and skill. Residents from three categorical training programs in internal medicine were recruited to an elective including clinical experiences in an acute hospital palliative care consultation service, on an acute hospice and palliative care unit, and in-home hospice care. A 25-question pre- and post-test and a videotaped interview with a standardized patient were used to assess communication skills and measure outcomes. Residents demonstrated a 10 percent improvement in knowledge after the four-week elective (p < 0.05). All residents demonstrated basic competency in communication skills at the end of the rotation. These results indicate that clinical rotation shows promise as an educational intervention to improve palliative care knowledge and skills in primary care residents. An important limitation of the study is that it is an elective; further studies with a required rotation and/or a control group are needed to confirm the findings.
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Affiliation(s)
- Charles F von Gunten
- Center for Palliative Studies, San Diego Hospice & Palliative Care, San Diego, California, USA
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Légaré F, O'Connor AM, Graham ID, Wells GA, Tremblay S. Impact of the Ottawa Decision Support Framework on the Agreement and the Difference between Patients' and Physicians' Decisional Conflict. Med Decis Making 2016; 26:373-90. [PMID: 16855126 DOI: 10.1177/0272989x06290492] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background. The Ottawa Decision Support Framework (ODSF) provides a process that facilitates shared decision making. Objective. To assess the impact of implementing the ODSF on the agreement and the difference between patients' and physicians' decisional conflict scores. Design. In total, 120 physicians and 903 patients enrolled in this before-and-after study. Implementation of the ODSF was composed of an interactive workshop, feedback, and a reminder at the point of care. The Decisional Conflict Scale (DCS) was completed by physicians and patients after a clinical encounter. Results. The intraclass correlation coefficient was–0.205 ± 0.096 (95% confidence interval [CI]= – 0.224 to –0.186) before implementing the ODSF and– 0.013 ± 0.114 (95% CI = – 0.036 to 0.009) after. At the patient level, the following factors were significantly associated with the difference between the patients' and physicians' DCS: unemployed (P = 0.023), implementing the ODSF (P = 0.008), high school degree (P = 0.04), male (P = 0.03), and unilateral role in decision making (P = 0.03). At the physician level, provincial committee (P = 0.001), national committee (P = 0.045), clinical site (P = 0.016), reluctance to share uncertainty (P = 0.023), and anxiety due to uncertainty (P = 0.017) were significantly associated with this outcome. Conclusion. After implementing the ODSF, there was less dissimilarity between patients' and physicians' DSC than expected by chance than before. Implementing the ODSF was also found to be associated with the difference between patients' and physicians' DSC. The physician level explained a significant amount of the variance in this outcome, thus emphasizing the importance of an intervention at this level.
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Affiliation(s)
- France Légaré
- Department of Family Medicine, Laval University, Hôpital St. François d'Assise, Québec, Canada.
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Finkelstein EA, Bilger M, Flynn TN, Malhotra C. Preferences for end-of-life care among community-dwelling older adults and patients with advanced cancer: A discrete choice experiment. Health Policy 2015; 119:1482-9. [DOI: 10.1016/j.healthpol.2015.09.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 05/19/2015] [Accepted: 09/04/2015] [Indexed: 11/30/2022]
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Dudley L, Gamble C, Allam A, Bell P, Buck D, Goodare H, Hanley B, Preston J, Walker A, Williamson P, Young B. A little more conversation please? Qualitative study of researchers' and patients' interview accounts of training for patient and public involvement in clinical trials. Trials 2015; 16:190. [PMID: 25928689 PMCID: PMC4410574 DOI: 10.1186/s13063-015-0667-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 03/20/2015] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Training in patient and public involvement (PPI) is recommended, yet little is known about what training is needed. We explored researchers' and PPI contributors' accounts of PPI activity and training to inform the design of PPI training for both parties. METHODS We used semi-structured qualitative interviews with researchers (chief investigators and trial managers) and PPI contributors, accessed through a cohort of clinical trials, which had been funded between 2006 and 2010. An analysis of transcripts of audio-recorded interviews drew on the constant comparative method. RESULTS We interviewed 31 researchers and 17 PPI contributors from 28 trials. Most researchers could see some value in PPI training for researchers, although just under half had received such training themselves, and some had concerns about the purpose and evidence base for PPI training. PPI contributors were evenly split in their perceptions of whether researchers needed training in PPI. Few PPI contributors had themselves received training for their roles. Many informants across all groups felt that training PPI contributors was unnecessary because they already possessed the skills needed. Informants were also concerned that training would professionalise PPI contributors, limiting their ability to provide an authentic patient perspective. However, informants welcomed informal induction 'conversations' to help contributors understand their roles and support them in voicing their opinions. Informants believed that PPI contributors should be confident, motivated, intelligent, focussed on helping others and have relevant experience. Researchers looked for these qualities when selecting contributors, and spoke of how finding 'the right' contributor was more important than accessing 'the right' training. CONCLUSIONS While informants were broadly receptive to PPI training for researchers, they expressed considerable reluctance to training PPI contributors. Providers of training will need to address these reservations. Our findings point to the importance of reconsidering how training is conceptualised, designed and promoted and of providing flexible, learning opportunities in ways that flow from researchers' and contributors' needs and preferences. We also identify some areas of training content and the need for further consideration to be given to the selection of PPI contributors and models for implementing PPI to ensure clinical trials benefit from a diversity of patient perspectives.
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Affiliation(s)
- Louise Dudley
- Department of Biostatistics, University of Liverpool, 1st floor Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
| | - Carrol Gamble
- Department of Biostatistics, University of Liverpool, 1st floor Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
| | - Alison Allam
- Department of Biostatistics, University of Liverpool, 1st floor Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
| | - Philip Bell
- Department of Biostatistics, University of Liverpool, 1st floor Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
| | - Deborah Buck
- Department of Biostatistics, University of Liverpool, 1st floor Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
| | - Heather Goodare
- Department of Biostatistics, University of Liverpool, 1st floor Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
| | - Bec Hanley
- TwoCan Associates, 59 Wickham Hill, Hurstpierpoint, Hassocks, BN6 9NR, UK.
| | - Jennifer Preston
- Department of Women's and Children's Health, Institute of Translational Medicine (Child Health), Alder Hey Children's NHS Foundation Trust, NIHR Clinical Research Network: Children, Coordinating Centre, University of Liverpool, Eaton Road, Liverpool, L12 2AP, UK.
| | - Alison Walker
- Department of Biostatistics, University of Liverpool, 1st floor Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
| | - Paula Williamson
- Department of Biostatistics, University of Liverpool, 1st floor Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
| | - Bridget Young
- Department of Psychological Sciences, University of Liverpool, Whelan Building, Liverpool, L69 3GB, UK.
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Cardiologist and cardiac surgeon view on decision-making in prosthetic aortic valve selection: does profession matter? Neth Heart J 2014; 22:336-43. [PMID: 24915773 PMCID: PMC4099434 DOI: 10.1007/s12471-014-0564-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Aims Assess and compare among Dutch cardiothoracic surgeons and cardiologists: opinion on (1) patient involvement, (2) conveying risk in aortic valve selection, and (3) aortic valve preferences. Methods and results A survey among 117 cardiothoracic surgeons and cardiologists was conducted. Group responses were compared using the Mann–Whitney U test. Most respondents agreed that patients should be involved in decision-making, with surgeons leaning more toward patient involvement (always: 83 % versus 50 % respectively; p < 0.01) than cardiologists. Most respondents found that ideally doctors and patients should decide together, with cardiologists leaning more toward taking the lead compared with surgeons (p < 0.01). Major risks of the therapeutic options were usually discussed with patients, and less common complications to a lesser extent. A wide variation in valve preference was noted with cardiologists leaning more toward mechanical prostheses, while surgeons more often preferred bioprostheses (p < 0.05). Conclusion Patient involvement and conveying risk in aortic valve selection is considered important by cardiologists and cardiothoracic surgeons. The medical profession influences attitude with regard to aortic valve selection and patient involvement, and preference for a valve substitute. The variation in valve preference suggests that in most patients both valve types are suitable and aortic valve selection may benefit from evidence-based informed shared decision-making.
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Detering K, Silvester W, Corke C, Milnes S, Fullam R, Lewis V, Renton J. Teaching general practitioners and doctors-in-training to discuss advance care planning: evaluation of a brief multimodality education programme. BMJ Support Palliat Care 2014; 4:313-21. [PMID: 24844586 DOI: 10.1136/bmjspcare-2013-000450] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Karen Detering
- Respecting Patient Choices, Austin Health, Heidelberg, Victoria, Australia
| | - William Silvester
- Respecting Patient Choices, Austin Health, Heidelberg, Victoria, Australia
| | - Charlie Corke
- Respecting Patient Choices, Barwon Health School of Medicine, Deakin University, Victoria, Australia
| | - Sharyn Milnes
- School of Medicine, Deakin University, Victoria, Australia
| | - Rachael Fullam
- Respecting Patient Choices, Austin Health, Heidelberg, Victoria, Australia
| | - Virginia Lewis
- Australian Institute for Primary Care and Ageing, La Trobe University, Melbourne, Victoria, Australia
| | - Jodie Renton
- Respecting Patient Choices, Austin Health, Heidelberg, Victoria, Australia
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Rocke DJ, Beumer HW, Taylor DH, Thomas S, Puscas L, Lee WT. Physician and Patient and Caregiver Health Attitudes and Their Effect on Medicare Resource Allocation for Patients With Advanced Cancer. JAMA Otolaryngol Head Neck Surg 2014; 140:497-503. [PMID: 24763550 DOI: 10.1001/jamaoto.2014.494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Physicians must participate in end-of-life discussions, but they understand poorly their patients' end-of-life values and preferences. A better understanding of these preferences and the effect of baseline attitudes will improve end-of-life discussions. OBJECTIVE To determine how baseline attitudes toward quality vs quantity of life affect end-of-life resource allocation. DESIGN, SETTING, AND PARTICIPANTS Otolaryngology-head and neck surgery (OHNS) physicians were recruited to use a validated online tool to create a Medicare health plan for advanced cancer patients. During the exercise, participants allocated a limited pool of resources among 15 benefit categories. These data were compared with preliminary data from patients with cancer and their caregivers obtained from a separate study using the same tool. Attitudes toward quality vs quantity of life were assessed for both physicians and patients and caregivers. INTERVENTIONS Participation in online assessment exercise. MAIN OUTCOMES AND MEASURES Medicare resource allocation. RESULTS Of 9120 OHNS physicians e-mailed, 767 participated. Data collected from this group were compared with data collected from 146 patients and 114 caregivers. Compared with patients and caregivers, OHNS physician allocations differed significantly in all 15 benefit categories except home care. When stratified by answers to 3 questions about baseline attitudes toward quality vs quantity of life, there were 3 categories in which allocations of patients and caregivers differed significantly from the group with the opposite attitude for at least 2 questions: other medical care (question 1, P < .001; question 2, P = .005), palliative care (question 1, P = .008; question 2, P = .006; question 3, P = .009), and treatment for cancer (questions 1 and 2, P < .001). In contrast, physician preferences showed significant differences in only 1, nonmatching category for each attitude question: cash (question 1, P = .02), drugs (question 2, P = .03), and home care (question 3, P = .048). CONCLUSIONS AND RELEVANCE Patients with cancer and their caregivers have different preferences from physicians. These preferences are, for these patients and their caregivers, affected by their baseline health attitudes, but physician preferences are not. Understanding the effect of baseline attitudes is important for effective end-of-life discussions.
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Affiliation(s)
- Daniel J Rocke
- Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Halton W Beumer
- Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina2now with Medical Corps, US Air Force, Joint Base Langley-Eustis, Virginia
| | - Donald H Taylor
- Duke Sanford School of Public Policy, Durham, North Carolina4Community and Family Medicine and Nursing, Duke University Medical Center, Durham, North Carolina
| | - Steven Thomas
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Liana Puscas
- Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Walter T Lee
- Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina6Section of Otolaryngology, Durham VA Medical Center, Durham, North Carolina
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Rocke DJ, Beumer HW, Thomas S, Lee WT. Effect of physician perspective on allocation of Medicare resources for patients with advanced cancer. Otolaryngol Head Neck Surg 2014; 150:792-800. [PMID: 24474714 DOI: 10.1177/0194599814520689] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess how physician perspective (perspective of patient vs perspective of physician) affects Medicare resource allocation for patients with advanced cancer and compare physician allocations with actual cancer patient and caregiver allocations. STUDY DESIGN Cross-sectional assessment. SETTING National assessment. SUBJECTS Otolaryngologists. METHODS Physicians used a validated tool to create a Medicare plan for patients with advanced cancer. Participants took the perspective of an advanced cancer patient and made resource allocations between 15 benefit categories (assessment 2, November/December 2012). Results were compared with data from a prior assessment made from a physician's perspective (assessment 1, February/March 2012) and with data from a separate study with patients with cancer and caregivers. RESULTS In total, 767 physicians completed assessment 1 and 237 completed assessment 2. Results were compared with 146 cancer patient and 114 caregiver assessments. Assessment 1 physician responses differed significantly from patients/caregivers in 14 categories (P < .05), while assessment 2 differed in 11. When comparing physician data, assessment 2 allocations differed significantly from assessment 1 in 7 categories. When these 7 categories were compared with patient/caregiver data, assessment 2 allocations in emotional care, drug coverage, and nursing facility categories were not significantly different. Assessment 1 allocations in cosmetic care, dental, home care, and primary care categories were more similar to patient/caregiver preferences, although all but home care were still significantly different. CONCLUSIONS Otolaryngology-head and neck surgery physician perspectives on end-of-life care differ significantly from cancer patient/caregiver perspectives, even when physicians take a patient's perspective when allocating resources. This demonstrates the challenges inherent in end-of-life discussions.
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Affiliation(s)
- Daniel J Rocke
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery (OHNS), Duke University Medical Center, Durham, North Carolina, USA
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Clayton JM, Adler JL, O'Callaghan A, Martin P, Hynson J, Butow PN, Laidsaar-Powell RC, Arnold RM, Tulsky JA, Back AL. Intensive communication skills teaching for specialist training in palliative medicine: development and evaluation of an experiential workshop. J Palliat Med 2012; 15:585-91. [PMID: 22433021 DOI: 10.1089/jpm.2011.0292] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Australasian Chapter of the Palliative Medicine (AChPM) Curriculum Development Group identified communication as a core skill that trainees in palliative medicine need to acquire, and proposed the development of a communication skills workshop that should become a compulsory part of training to achieve accreditation as a palliative medicine specialist in Australia and New Zealand. This paper describes the development and subsequent evaluation of this module. METHODS A three-day communication workshop was developed in collaboration with expert communication skills facilitators from the United States and Australia. The teaching consists of: (1) brief plenary presentations providing an evidence-based framework for communication and a demonstration of suggested strategies; (2) small group experiential learning providing opportunities to practice communication skills with clinically relevant simulated patients, self-appraisal, constructive feedback, and reflective exercises; and (3) accompanying course-specific written material. Participants completed de-identified questionnaires before, after, and three months following completion of the workshop. RESULTS Forty-one participants completed the training in two workshops held in 2008 and 2009. Participants said in their questionnaire responses that the training was useful, would be helpful for their communication with patients, and that they would recommend the training to others. Qualitative feedback was highly positive. Self-assessed confidence in communication skills significantly increased following the workshop (p<.001) and was sustained at three months (p<.001). CONCLUSION The training is highly valued by participants and increases confidence in communication skills. Facilitator training and capacity planning will be critical for the ongoing success of the communication workshop.
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Affiliation(s)
- Josephine M Clayton
- HammondCare Palliative and Supportive Care Service, Greenwich Hospital Sydney, Sydney, Australia.
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Age as a Deciding Factor in the Consideration of Futility for a Medical Intervention in Patients Among Internal Medicine Physicians in Two Practice Locations. J Am Med Dir Assoc 2010; 11:421-7. [DOI: 10.1016/j.jamda.2010.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 01/25/2010] [Accepted: 01/25/2010] [Indexed: 11/19/2022]
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Kaldjian LC, Curtis AE, Shinkunas LA, Cannon KT. Review Article: Goals of Care Toward the End of Life: A Structured Literature Review. Am J Hosp Palliat Care 2008; 25:501-11. [DOI: 10.1177/1049909108328256] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Goals of care are often mentioned as an important component of end-of-life discussions, but there are diverse assessments regarding the type and number of goals that should be considered. To address this lack of consensus, we searched MEDLINE (1967—2007) for relevant articles and identified the number, phrasing, and type of goals they addressed. An iterative process of categorization resulted in a list of 6 practical, comprehensive goals: (1) be cured, (2) live longer, (3) improve or maintain function/quality of life/ independence, (4) be comfortable, (5) achieve life goals, and (6) provide support for family/caregiver. These goals can be used to articulate goal-oriented frameworks to guide decision making toward the end of life and thereby harmonize patients' treatment choices with their values and medical conditions.
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Affiliation(s)
- Lauris C. Kaldjian
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center,
| | - Ann E. Curtis
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center
| | - Laura A. Shinkunas
- Program in Bioethics and Humanities, University of Iowa Carver College of Medicine
| | - Katrina T. Cannon
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center
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Torke AM, Alexander GC, Lantos J. Substituted judgment: the limitations of autonomy in surrogate decision making. J Gen Intern Med 2008; 23:1514-7. [PMID: 18618201 PMCID: PMC2518005 DOI: 10.1007/s11606-008-0688-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Revised: 04/30/2008] [Accepted: 05/21/2008] [Indexed: 11/29/2022]
Abstract
Substituted judgment is often invoked as a guide for decision making when a patient lacks decision making capacity and has no advance directive. Using substituted judgment, doctors and family members try to make the decision that the patient would have made if he or she were able to make decisions. However, empirical evidence suggests that the moral basis for substituted judgment is unsound. In spite of this, many physicians and bioethicists continue to rely on the notion of substituted judgment. Given compelling evidence that the use of substituted judgment has insurmountable flaws, other approaches should be considered. One approach provides limits on decision making using a best interest standard based on community norms. A second approach uses narrative techniques and focuses on each patient's dignity and individuality rather than his or her autonomy.
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Affiliation(s)
- Alexia M Torke
- Indiana University Center for Aging Research, Indianapolis, IN, USA.
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Forbes T, Goeman E, Stark Z, Hynson J, Forrester M. Discussing withdrawing and withholding of life-sustaining medical treatment in a tertiary paediatric hospital: a survey of clinician attitudes and practices. J Paediatr Child Health 2008; 44:392-8. [PMID: 18638330 DOI: 10.1111/j.1440-1754.2008.01351.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To better understand current attitudes and practices relating to discussions concerning the withholding and withdrawing of life-sustaining medical treatment (WWLSMT) among medical staff in the paediatric setting. METHODS An anonymous online survey of paediatricians (senior medical staff - SMS) and paediatric trainees (junior medical staff - JMS) likely to be involved in the care of children with life limiting illness. RESULTS A total of 162 responses were obtained (response rate 42%). SMS indicated feeling more comfortable with their abilities to discuss WWLSMT than JMS. Barriers to discussing WWLSMT were numerous and included clinician concerns about family readiness for the discussion, prognostic uncertainty, family disagreement with the treating team regarding the child's prognosis/diagnosis and concerns about how to manage family requests for treatments that are not perceived to be in the child's best interests. Fifty-eight per cent of JMS and 35.8% of SMS reported receiving no specific communication training regarding WWLSMT. Most learned through experience and by observing more senior colleagues. There was a high level of support for additional training in this area and for the provision of resources such as discussion guidelines and a structured form for documenting the outcomes WWLSMT discussions. CONCLUSION The majority of JMS feel less comfortable with their abilities to facilitate these discussions than their senior colleagues. The results of this study suggest that although confidence correlates with experience, junior and senior clinicians are eager to improve their skills through ongoing professional development and the provision of resources. The education needs of JMS and SMS appear to be different.
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Affiliation(s)
- Tom Forbes
- Royal Children's Hospital, Melbourne, Victoria, Australia
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Skrobik Y, Kavanagh BP. Scoring systems for the critically ill: use, misuse and abuse. Can J Anaesth 2006; 53:432-6. [PMID: 16636025 DOI: 10.1007/bf03022613] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Magauran CE, Brennan MJ. Patient-doctor communication and the importance of clarifying end-of-life decisions. Am J Hosp Palliat Care 2005; 22:335-6. [PMID: 16225352 DOI: 10.1177/104990910502200504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Claire E Magauran
- Internal Medicine Residency Program, Baystate Medical Center/Tufts University School of Medicine, Springfield, Massachusetts, USA
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Gorman TE, Ahern SP, Wiseman J, Skrobik Y. Residents' end-of-life decision making with adult hospitalized patients: a review of the literature. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2005; 80:622-33. [PMID: 15980078 DOI: 10.1097/00001888-200507000-00004] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
PURPOSE The authors performed a structured literature review to understand residents' experiences with end-of-life (EOL) decision making with adult hospitalized patients, specifically regarding decisions to withhold or withdraw advanced life-support measures. METHOD An Ovid-based strategy was used to search Medline, ERIC, PsychINFO, and CINHAL databases for articles published between 1966 and February 2005, combining the domains of "resuscitation orders," "decision making," and "internship and residency." All quantitative and qualitative studies examining residents' EOL decision making with adult hospitalized patients were included. The authors developed and applied a scoring system for relevance and quality, performed data abstraction and quality assessment independently and in duplicate, then met to collate findings and identify factors in residents' EOL decision making. RESULTS The searches yielded 884 articles, of which 26 were included. Variable methodologies precluded meta-analysis. In these studies, residents felt unprepared to handle patient EOL decision making, although exposure to EOL discussions helped them gain confidence. Residents' attitudes, skills, and knowledge were key determinants of whether EOL decisions were addressed. Many misinterpreted the terms "DNR" and "futility." Residents' understanding of the patient EOL decision-making process could be extremely variable, and their do-not-resuscitate discussions suboptimal. Residents' lived practice experience of the patient EOL decision-making process was often at odds with what they were taught in formal curricula. CONCLUSIONS Educational strategies aimed at changing residents' knowledge, skills and attitude should address the hidden curriculum for the patient EOL decision-making process that is part of the experienced culture of every day practice. Future studies of this experienced culture would inform specific educational interventions.
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Fairchild A, Kelly KL, Balogh A. In pursuit of an artful death: discussion of resuscitation status on an inpatient radiation oncology service. Support Care Cancer 2005; 13:842-9. [PMID: 15846524 DOI: 10.1007/s00520-005-0799-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2004] [Accepted: 02/16/2005] [Indexed: 10/25/2022]
Abstract
GOALS OF WORK Consensus has emerged among health practitioners, legal experts, clinical ethicists and the public that end-of-life decisions should be the shared responsibility of physicians and patients. In discussion of withholding cardiopulmonary resuscitation in cancer patients, however, opinion remains divided. We performed a quality assurance investigation on the use of the 'do-not-resuscitate' (DNR) order on an inpatient radiation oncology service to determine how often DNR orders are accompanied by a description of informed consent. PATIENTS AND METHODS Records of patients admitted 1 July to 31 December 2002 were identified and reviewed to determine the presence or absence of a DNR order. Circumstances surrounding the order, including evidence of informed consent, were determined. MAIN RESULTS The study population comprised 96 patients admitted 109 times. The median age was 64 years, and in 56.0% of admissions, the patient was female. In 26.8%, the patient had lung cancer. The intent of admission was curative in 53.2%, and palliative in 44.0%. DNR was recorded for 30.2% of patients, and there was evidence of informed consent in 41.4%. In 89.7% admission was with palliative intent. Nine patients (9.4%) experienced cardiac arrest; all were DNR at the time of their event. CONCLUSIONS While almost one-third of the patients on this inpatient radiation oncology service had documented DNR status, informed consent appeared to have been obtained in fewer than half. Patient involvement in resuscitative decisions should be an ethical obligation. Performed well, this may also allow for exploration of patients' needs at the end of life, to allow the pursuit of what Nuland terms an 'artful death'.
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Affiliation(s)
- Alysa Fairchild
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada, T6G 1Z2.
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Janse AJ, Gemke RJBJ, Uiterwaal CSPM, van der Tweel I, Kimpen JLL, Sinnema G. Quality of life: patients and doctors don't always agree: a meta-analysis. J Clin Epidemiol 2004; 57:653-61. [PMID: 15358393 DOI: 10.1016/j.jclinepi.2003.11.013] [Citation(s) in RCA: 219] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2003] [Indexed: 01/08/2023]
Abstract
OBJECTIVE In addition to traditional clinical markers, quality-of-life assessment can be helpful to estimate the well-being of patients. Discrepancies in perception of well-being between physicians and patients may interfere with the effectiveness of treatment. A systematic review and meta-analysis were performed to explore the (dis-)agreement in quality-of-life assessments between patients and physicians. STUDY DESIGN AND SETTING Data on the proportion agreement of paired observations were collected from Medline, Embase, Psychlit, and Social Abstracts. RESULTS Of the 1,316 articles found, six met the selection criteria, four studied the proportion agreement between children and physicians, and all six the proportion agreement between parents and physicians. None examined the magnitude of over- or underestimation by physicians. The agreement was lower in the more subjective domains (0.54-0.77) in comparison to the more objective domains (0.79-0.94). CONCLUSION Quality-of-life assessment should be integrated in clinical practice. During long-term treatment the perception of the patients' well-being by physicians and patients themselves can easily diverge from each other, resulting in misunderstandings about the treatment and its usefulness in relation to perceived quality of life, and may even become the base for noncompliance.
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Affiliation(s)
- A J Janse
- Department of Paediatrics, KB.03.023.3, Wilhelmina Children's Hospital, University Medical Centre Utrecht, P.O. Box 85090, 3508 AB, Utrecht, The Netherlands
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Yi MS, Luckhaupt S, Mrus JM, Tsevat J. Do medical house officers value the health of veterans differently from the health of non-veterans? Health Qual Life Outcomes 2004; 2:19. [PMID: 15070409 PMCID: PMC406418 DOI: 10.1186/1477-7525-2-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2004] [Accepted: 04/07/2004] [Indexed: 11/10/2022] Open
Abstract
Background Little information is available regarding medical residents' perceptions of patients' health-related quality of life. Patients cared for by residents have been shown to receive differing patterns of care at Veterans Affairs facilities than at community or university settings. We therefore examined: 1) how resident physicians value the health of patients; 2) whether values differ if the patient is described as a veteran; and 3) whether residency-associated variables impact values. Methods All medicine residents in a teaching hospital were asked to watch a digital video of an actor depicting a 72-year-old patient with mild-moderate congestive heart failure. Residents were randomized to 2 groups: in one group, the patient was described as a veteran of the Korean War, and in the other, he was referred to only as a male. The respondents assessed the patient's health state using 4 measures: rating scale (RS), time tradeoff (TTO), standard gamble (SG), and willingness to pay (WTP). We also ascertained residents' demographics, risk attitudes, residency program type, post-graduate year level, current rotation, experience in a Veterans Affairs hospital, and how many days it had been since they were last on call. We performed univariate and multivariable analyses using the RS, TTO, SG and WTP as dependent variables. Results Eighty-one residents (89.0% of eligible) participated, with 36 (44.4%) viewing the video of the veteran and 45 (55.6%) viewing the video of the non-veteran. Their mean (SD) age was 28.7 (3.1) years; 51.3% were female; and 67.5% were white. There were no differences in residents' characteristics or in RS, TTO, SG and WTP scores between the veteran and non-veteran groups. The mean RS score was 0.60 (0.14); the mean TTO score was 0.80 (0.20); the mean SG score was 0.91 (0.10); and the median (25th, 75th percentile) WTP was $10,000 ($7600, $20,000) per year. In multivariable analyses, being a resident in the categorical program was associated with assigning higher RS scores, but no residency-associated variables were associated with the TTO, SG or WTP scores. Conclusion Physicians in training appear not to be biased either in favor of or against military veterans when judging the value of a patient's health.
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Affiliation(s)
- Michael S Yi
- Department of Internal Medicine, Division of General Internal Medicine, Section of Outcomes Research, University of Cincinnati Medical Center, USA
- Center for Clinical Effectiveness, Institute for Health Policy and Health Services Research, University of Cincinnati Medical Center, USA
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, USA
| | - Sara Luckhaupt
- Department of Internal Medicine, Division of General Internal Medicine, Section of Outcomes Research, University of Cincinnati Medical Center, USA
| | - Joseph M Mrus
- Department of Internal Medicine, Division of General Internal Medicine, Section of Outcomes Research, University of Cincinnati Medical Center, USA
- Center for Clinical Effectiveness, Institute for Health Policy and Health Services Research, University of Cincinnati Medical Center, USA
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, USA
- HSR&D Service, Cincinnati Veterans Affairs Medical Center and Veterans Healthcare System of Ohio, Cincinnati, USA
| | - Joel Tsevat
- Department of Internal Medicine, Division of General Internal Medicine, Section of Outcomes Research, University of Cincinnati Medical Center, USA
- Center for Clinical Effectiveness, Institute for Health Policy and Health Services Research, University of Cincinnati Medical Center, USA
- HSR&D Service, Cincinnati Veterans Affairs Medical Center and Veterans Healthcare System of Ohio, Cincinnati, USA
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Engelberg RA. Commentary: observational studies and their importance in improving end-of-life care in the intensive care unit. J Crit Care 2003; 18:141-4. [PMID: 14626210 DOI: 10.1016/j.jcrc.2003.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Ruth A Engelberg
- Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, Washington Seatle, WA 98104-2499, USA.
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Von Gunten CF, Mullan PB, Harrity S, Diamant J, Heffernan E, Ikeda T, Roberts WL. Residents from five training programs report improvements in knowledge, attitudes and skills after a rotation with a hospice program. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2003; 18:68-72. [PMID: 12888378 DOI: 10.1207/s15430154jce1802_06] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND The faculty of the Center for Palliative Studies teach residents from 5 different primary care residency training programs who rotate at San Diego Hospice: 3 in Internal Medicine, 2 in Family Medicine. Residents participate in the care of patients in the inpatient care setting and make joint home visits with physicians and other team members. A series of 4 lectures on end-of-life care is given on Tuesday mornings: management of pain, other symptoms, interdisciplinary roles of chaplains, social workers, nurses, and grief/bereavement are discussed. In addition, there is a Tuesday noon conference that follows a journal club format. Because of scheduling, residents from some programs are not able to attend all lectures and conferences. METHODS A 27-item self-assessment evaluation tool was developed for administration to residents before and after their experience. A total of 65 evaluations for residents rotating in academic year 1997-98 and 1998-1999 were collated and analyzed. RESULTS When evaluated as a whole, residents noted significant improvements in their ability to assess and treat symptoms, to tell patient/family about the dying process and to care for dying patients at home (range in improvement from 26% to 67%, p < 0.05 using paired t-test). About half of the residents perceived that the content was not available elsewhere in their training. CONCLUSION We conclude that a single hospice rotation can effectively contribute to resident education in multiple programs.
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Affiliation(s)
- Charles F Von Gunten
- Center for Palliative Studies, San Diego Hospice and Palliative Care, San Diego, CA 92103, USA.
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Drought TS, Koenig BA. "Choice" in end-of-life decision making: researching fact or fiction? THE GERONTOLOGIST 2002; 42 Spec No 3:114-28. [PMID: 12415142 DOI: 10.1093/geront/42.suppl_3.114] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The contribution of bioethics to clinical care at the end of life (EOL) deserves critical scrutiny. We argue that researchers have rarely questioned the normative power of autonomy-based bioethics practices. Research on the ethical dimensions of EOL decision making has focused on an idealized discourse of patient "choice" that requires patients to embrace their dying to receive excellent palliative care. DESIGN AND METHODS Our critique is based on a comprehensive review of empirical research exploring bioethics practices at the EOL. In addition we will provide a brief review of our own ethnographic, longitudinal study of the decision-making experience of dying patients, their families, and their health care providers. RESULTS There is little or no empirical evidence to support the autonomy paradigm of patient "choice" in EOL decision making. What we found is that (a). prognostication at the EOL is problematic and resisted; (b). shared decision making is illusory, patients often resist advance care planning and hold other values more important than autonomy, and system characteristics are more determinative of EOL care than patient preferences; and (c). the incommensurability of medical and lay knowledge and values and the multifaceted and processual nature of patient and family decision making are at odds with the current EOL approach toward advance care planning. IMPLICATIONS It is exceedingly difficult to identify, study, and critique normative assumptions without creating them, reproducing them, or obliterating them in the process. However, a fuller account of the morally significant domains of end-of-life care is needed. Researchers and policy makers should heed what we have learned from empirical research on EOL care to develop more sensitive and supportive programs for care of the dying.
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Mullan PB, Weissman DE, Ambuel B, von Gunten C. End-of-life care education in internal medicine residency programs: an interinstitutional study. J Palliat Med 2002; 5:487-96. [PMID: 12353495 DOI: 10.1089/109662102760269724] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Integrating end-of-life care (EOL) education into medical residency programs requires knowledge of what programs currently teach and what residents learn. OBJECTIVE Evaluate EOL teaching content and practices in internal medicine residency programs and the EOL knowledge of their faculty and residents. DESIGN An interinstitutional pilot study. We examined patterns of EOL education, discerned from program directors' responses to structured surveys of institutional teaching and evaluation practices, and EOL knowledge, derived from the performance of faculty and residents on a 36-item knowledge examination. SUBJECTS Program directors, faculty, and residents at 32 accredited U.S. internal medicine residency programs. RESULTS Although all programs cited inclusion of some EOL education, expected EOL domains were not systematically taught or assessed. Pain assessment and treatment training was required in only 60% of programs. Even fewer programs required instruction on nonpain symptoms (<30%) or hospice and nonhospital care settings (22%). EOL assessment depends primarily on faculty's general ratings of residents' global competency; few programs use knowledge examinations or structured skill assessments. Directors identified barriers and support for improving education. On the knowledge examination, the mean score of residents increased across training levels (F = 21.7, p < .001), and the mean score of faculty was higher than residents' (57.6%: 48.9%, t = 51.6, p < .001). CONCLUSIONS Existing internal medicine residency education lacks training in critical EOL care domains. Residency programs need additional training for residents and teaching faculty in EOL content and skills, with assessment practices that demonstrate competencies have been acquired. Program directors perceive institutional support for making these changes.
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Ditillo BA. The emergence of palliative care: a new specialized field of medicine requiring an interdisciplinary approach. Crit Care Nurs Clin North Am 2002; 14:127-32. [PMID: 12038498 DOI: 10.1016/s0899-5885(01)00002-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Palliative care is a relatively new field of medicine. Physicians have traditionally been trained within a curative model of care. The SUPPORT study identified shortcomings in care for seriously ill and dying patients in American hospitals. As a result of the SUPPORT study, there is a fast growing movement in the United States that is working to improve end-of-life care. Palliative care offers a new meaningful focus for patients whose disease is not responsive to curative treatments and offers improvements in quality of life. The delivery of effective palliative care requires an interdisciplinary team approach in order to meet the complex needs of patients and families.
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Stevens L, Cook D, Guyatt G, Griffith L, Walter S, McMullin J. Education, ethics, and end-of-life decisions in the intensive care unit. Crit Care Med 2002; 30:290-6. [PMID: 11889295 DOI: 10.1097/00003246-200202000-00004] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the influence of education and clinical experience on residents' attitudes toward withdrawal of life support. DESIGN Self-administered survey. SETTING Four Canadian teaching hospitals. SUBJECTS Residents rotating through four intensive care units. MEASUREMENTS AND MAIN RESULTS The survey examined ethics education and experience regarding end-of-life care, importance of factors influencing withdrawal of life support, confidence in decisions, and recommendations for enhancing end-of-life education. The response rate was 83.9% (52 of 62). A minority of residents reported an appropriate amount of formal teaching on ethical principles (17.3%), patient-centered education (28.8%), and informal discussion (28.8%) before their intensive care unit rotation. During their rotation, most residents cared for patients in whom withdrawal of life support was considered. Although they usually attended family meetings, residents were never (34.6%) or rarely (42.3%) the primary discussant. Before the intensive care unit rotation, confidence in withdrawal decisions was related to male sex (p =.001) and previous patient-centered ethics education (p =.02). At the end of the intensive care unit rotation, only resident involvement in family meetings (p =.02) and being the primary discussant at such meetings (p =.01) were associated with confidence. After we adjusted for pre-rotation confidence in withdrawal of life support decision-making, the only predictor of post-rotation confidence was family meeting involvement (p <.001). Residents recommended more patient-centered discussion, observation of attending physicians discussing end-of-life issues, and opportunity to lead family meetings. CONCLUSIONS Experiential, case-based, patient-centered curricula are associated with resident confidence in withdrawal of life support decisions in the intensive care unit.
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Affiliation(s)
- Lesley Stevens
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Ditillo BA. Should there be a choice for cardiopulmonary resuscitation when death is expected? Revisiting an old idea whose time is yet to come. J Palliat Med 2002; 5:107-16. [PMID: 11839233 DOI: 10.1089/10966210252785079] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Since closed chest cardiac massage was introduced in 1960, the notion that cardiopulmonary resuscitation (CPR) attempts are not appropriate for all patients has been consistent. Over the years, leading authorities have clearly articulated that for patients who are dying irreversibly and expectedly medical decisions for do-not-resuscitate (DNR) orders should be made by physicians, because in such cases CPR attempts are not indicated. Physicians are not obligated to and should not offer or provide useless treatments, even in the name of patient autonomy. Despite this, physicians still seek and obtain patient or proxy consent when CPR is not indicated before writing a DNR order. Reasons include fear of legal repercussions/misconceptions, limited physician-patient relationships, time constraints, and institutional culture. End-of-life plans of care should be based on appropriate goals that focus on palliation and not on aggressive medical treatments that offer no benefit.
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Auerbach SM. Should patients have control over their own health care?: empirical evidence and research issues. Ann Behav Med 2001; 22:246-59. [PMID: 11126470 DOI: 10.1007/bf02895120] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Available research indicates that purported patient insufficiencies in ability to process information and make rational and reliable decisions have likely been overestimated. Furthermore, data indicate that nonscientific factors often play a role in physician decision-making and that physicians may not value different health outcomes in the same way as patients. Though the data on patient cognitive functioning are limited because of heavy reliance on patient responses in hypothetical versus actual decision-making situations, these findings lend credence to arguments that patients should have increased control over their own health care. Research on the effects of interventions designed to enhance patient control indicates that: (a) patients generally respond positively to increased information, but few studies have evaluated the effects of information as a precursor to decision-making; (b) the few studies using simple behavioral control interventions have shown generally positive effects on a range of patient outcomes; and (c) studies of decisional control (with breast cancer patients) have had experimental confounds which prohibit conclusions regarding effectiveness. Areas in greatest need of research include: (a) further exploration of the utility of noninvasive behavioral control interventions in different settings; (b) measuring the impact of control manipulations on patient perception of control as well as patient control-related behaviors; (c) matching patient differences in desire for control to experimental conditions and to physician differences in receptiveness to patient control; and (d) clinical trials in which patients facing critical decisions in trade-off situations are actually given a choice.
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Affiliation(s)
- S M Auerbach
- Department of Psychology, Box 842018, Virginia Commonwealth University, Richmond, VA 23284-2018, USA
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Rose JH, O'Toole EE, Dawson NV, Thomas C, Connors AF, Wenger N, Phillips RS, Hamel MB, Reding DT, Cohen HJ, Lynn J. Generalists and oncologists show similar care practices and outcomes for hospitalized late-stage cancer patients. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks for Treatment. Med Care 2000; 38:1103-18. [PMID: 11078051 DOI: 10.1097/00005650-200011000-00005] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this work was to identify similarities and differences in primary attending physicians' (generalists' versus oncologists') care practices and outcomes for seriously ill hospitalized patients with malignancy. DESIGN This was a prospective cohort study (SUPPORT project). SETTING Subjects were recruited from 5 US teaching hospitals; data were gathered from 1989 to 1994. SUBJECTS Included in the study was a matched sample of 642 hospitalized patients receiving care for non-small-cell lung cancer, colon cancer metastasized to the liver, or multiorgan system failure associated with malignancy with either a generalist or an oncologist as the primary attending physician. MEASUREMENTS Care practices and patient outcomes were determined from hospital records. Length of survival was identified with the National Death Index. Physicians' perceptions of patient's prognosis, preference for cardiopulmonary resuscitation (CPR), and length of relationship were assessed by interview. A propensity score for receiving care from an oncologist was constructed. After propensity-based matching of patients, practices and outcomes of oncologists' and generalists' patients were assessed through group comparison techniques. RESULTS Generalist and oncologist attendings showed comparable care practices, including the number of therapeutic interventions, eg, "rescue care" and chemotherapy, and the number of care topics discussed with patients/ families. Length of stay, discharge to supportive care, readmission, total hospital costs, and survival rates were similar. For both physician groups, perception of patients' wish for CPR was associated with rescue care (P < 0.03), and such care was related to higher hospital costs (P < 0.000). Poorer prognostic estimates predicted aggressiveness-of-care discussions by both types of physicians. Length of the patient-doctor relationship was associated with oncologists' care practices. More documented discussion about aggressiveness of care was related to higher hospital costs and shorter survival for patients in both physician groups (P < 0.001). CONCLUSIONS Generalists and oncologists showed similar care practices and outcomes for comparable hospitalized late-stage cancer patients. Physicians' perceptions about patients' preferences for CPR and prognosis influenced decision making and outcomes for patients in both physician groups. Length of relationship with patients was associated only with oncologists' care practices. Rescue care increased hospital costs but had no effect on patient survival. Future studies should compare physicians' palliative care as well as acute-care practices in both inpatient and ambulatory care settings. Patients' end-of-life quality and interchange between physician groups should also be documented and compared.
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Affiliation(s)
- J H Rose
- Department of Medicine-Geriatrics, Case Western Reserve University School of Medicine, Celeveland, Ohio 44120, USA.
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Weiss GL, Hite CA. The do-not-resuscitate decision: the context, process, and consequences of DNR orders. DEATH STUDIES 2000; 24:307-323. [PMID: 11010731 DOI: 10.1080/074811800200478] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
This study examines the process and consequences of an increasingly important element of the dying experience in American hospitals: the writing of a Do-Not-Resuscitate (DNR) order. The focus of the study is on the decision-making process and timing of the DNR decision, the impact of the DNR order on the dying experience, and the consequences of the DNR order for length of hospital stay and accrued medical charges. Patients with a DNR order are compared to those who were unsuccessfully coded. Data are obtained from a review and analysis of the medical charts and death monitor sheets of a sample of 249 persons who died in 1994 in a single teaching hospital. The study found physicians routinely discuss the DNR decision with patients and/or their surrogates (though patients are involved in the decision in only about one-third of cases) and that the decision is often made relatively early in the hospital stay. The dying experience of patients with a written DNR was different in significant ways from the experience of unsuccessfully-coded patients. Those with a DNR were more likely to remain in a single unit in the hospital and less likely to die in an intensive care unit or while connected to a ventilator. Consistent with other studies, however, average length of hospital stay and average medical charges were actually higher for the DNR patients. Implications of these differences between DNR and unsuccessfully-coded patients are discussed.
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Affiliation(s)
- G L Weiss
- Roanoke College, Salem, Virginia, USA.
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Covinsky KE, Fuller JD, Yaffe K, Johnston CB, Hamel MB, Lynn J, Teno JM, Phillips RS. Communication and decision-making in seriously ill patients: findings of the SUPPORT project. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Geriatr Soc 2000; 48:S187-93. [PMID: 10809474 DOI: 10.1111/j.1532-5415.2000.tb03131.x] [Citation(s) in RCA: 227] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) represents one of the largest and most comprehensive efforts to describe patient preferences in seriously ill patients, and to evaluate how effectively patient preferences are communicated. Our objective was to review findings from SUPPORT describing the communication of seriously ill patients' preferences for end-of-life care. METHODS We identified published reports from SUPPORT describing patient preferences and the communication of those preferences. We abstracted findings that addressed each of the following questions: What patient characteristics predict patient preferences for end of life care? How well do physicians, nurses, and surrogates understand their patients' preferences, and what variables are correlated with this understanding? Does increasing the documentation of existing advance directives result in care more consistent with patients' preferences? RESULTS Patients who are older, have cancer, are women, believe their prognoses are poor, and are more dependent in ADL function are less likely to want CPR. However, there is considerable variability and geographic variation in these preferences. Physician, nurse, and surrogate understanding of their patient's preferences is only moderately better than chance. Most patients do not discuss their preferences with their physicians, and only about half of patients who do not wish to receive CPR receive DNR orders. Factors other than the patients' preferences and prognoses, including the patient's age, the physician's specialty, and the geographic site of care were strong determinants of whether DNR orders were written. In SUPPORT patients, there was no evidence that increasing the rates of documentation of advance directives results in care that is more consistent with patients' preferences. CONCLUSIONS SUPPORT documents that physicians and surrogates are often unaware of seriously ill patients' preferences. The care provided to patients is often not consistent with their preferences and is often associated with factors other than preferences or prognoses. Improving these deficiencies in end-of-life care may require systematic change rather than simple interventions.
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Affiliation(s)
- K E Covinsky
- Division of Geriatrics, University of California San Francisco and San Francisco Veterans Affairs Medical Center, USA
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