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Pressimone C, Indralingam R, Metz CD, Levine AS. The Patient-Physician Relationship: Medical Students' Perceptions in a Novel Course. J Gen Intern Med 2024; 39:1492-1495. [PMID: 38600399 PMCID: PMC11169161 DOI: 10.1007/s11606-024-08759-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/01/2024] [Indexed: 04/12/2024]
Abstract
The patient-physician relationship, especially in the case of severely ill patients, is often fraught with anxiety, grief, and guilt in the physician who may come to feel that he or she has failed the patient and thereby becomes a "second victim." This notion was first explored in a 1973 publication (Artiss and Levine N Engl J Med 288(23):1210-4, 1973) that described a novel interactive seminar series for oncology fellows that had been designed to address and possibly remedy the frequent disquiet experienced by young physicians in this setting. Fifty years later, the medical student co-authors of this Perspective enrolled in an elective course that comprised a similar series of interactive seminars, now addressing the contemporary patient-physician relationship. The earlier paper was employed as a historical background, and the framework of the course then broadened such that the students considered the current environmental changes in medical practice (social, cultural, financial, legal, policy) that may be linked to the character of individual patient-physician relationships. This essay reports on the students' perception of such relationships, and on the environmental elements that may be helpful or harmful to the well-being of both patients and physicians.
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Affiliation(s)
| | | | | | - Arthur S Levine
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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2
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Salins N, Rao A, Dhyani VS, Prasad A, Mathew M, Damani A, Rao K, Nair S, Shanbhag V, Rao S, Iyer S, Gursahani R, Mani RK, Simha S. Palliative and end-of-life care practices for critically ill patients and their families in a peri-intensive care setting: A protocol for an umbrella review. Palliat Support Care 2024:1-8. [PMID: 38420705 DOI: 10.1017/s1478951524000130] [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: 03/02/2024]
Abstract
OBJECTIVES This umbrella review will summarize palliative and end-of-life care practices in peri-intensive care settings by reviewing systematic reviews in intensive care unit (ICU) settings. Evidence suggests that integrating palliative care into ICU management, initiating conversations about care goals, and providing psychological and emotional support can significantly enhance patient and family outcomes. METHODS The Joanna Briggs Institute (JBI) methodology for umbrella reviews will be followed. The search will be carried out from inception until 30 September 2023 in the following databases: Cochrane Library, SCOPUS, Web of Science, CINAHL Complete, Medline, EMBASE, and PsycINFO. Two reviewers will independently conduct screening, data extraction, and quality assessment, and to resolve conflicts, adding a third reviewer will facilitate the consensus-building process. The quality assessment will be carried out using the JBI Critical Appraisal Checklist. The review findings will be reported per the guidelines outlined in the Preferred Reporting Items for Overviews of Reviews statement. RESULTS This umbrella review seeks to inform future research and practice in critical care medicine, helping to ensure that end-of-life care interventions are optimized to meet the needs of critically ill patients and their families.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Arathi Rao
- Department of Health Policy, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vijay Shree Dhyani
- Evidence Synthesis Specialist, Kasturba Medical College, Manipal, Karnataka, India
| | - Ashmitha Prasad
- Department of Pallitaive Medicine, Karunashraya Bangalore Hospice Trust, Bangalore, India
| | - Mebin Mathew
- Department of Pallitaive Medicine, Karunashraya Bangalore Hospice Trust, Bangalore, India
| | - Anuja Damani
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Krithika Rao
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shreya Nair
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vishal Shanbhag
- Department of Critical Care Medicine, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shwethapriya Rao
- Department of Critical Care Medicine, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth University Medical College, Pune, India
| | - Roop Gursahani
- Department of Neurology, P D Hinduja Hospital, Mahim, Mumbai, India
| | - R K Mani
- Department of Critical care, Yashoda Super Speciality Hospitals, Ghaziabad, India
| | - Srinagesh Simha
- Department of Pallitaive Medicine, Karunashraya Bangalore Hospice Trust, Bangalore, India
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3
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Tamura Y, Nishiyama C, Takenouchi S, Sato R, Kiyohara K, Nin K. Development and Effectiveness of an End-of-Life Care Program for Faculty in the Critical Care Field: A Randomized Controlled Trial. J Hosp Palliat Nurs 2023; 25:178-187. [PMID: 37204851 DOI: 10.1097/njh.0000000000000951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
In Japan, end-of-life care education in the critical care field is still insufficient. Therefore, this study developed and verified the effectiveness of an end-of-life care program for faculty in the critical care field in Japan through a randomized controlled trial. The study was implemented from September 2016 to March 2017. Participants were 82 college teaching staff and nurses working in the critical care field. Six months after the program, data of 37 members (84.1%) of the intervention and 39 members (84.8%) [corrected] of the control group were analyzed. The results demonstrated that the primary end point-"confidence in teaching" 6 months after program completion-differed significantly between the 2 groups (2.5 [0.69] in the intervention group vs 1.8 [0.46] in the control group, P < .001). It is suggested that attending this program will give faculty in the field of critical care continued confidence in their end-of-life care teaching, as well as allow them to implement end-of-life care teaching in their field.
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Downar J, Hua M, Wunsch H. Palliative Care in the Intensive Care Unit: Past, Present, and Future. Crit Care Clin 2023; 39:529-539. [PMID: 37230554 DOI: 10.1016/j.ccc.2023.01.007] [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: 05/27/2023]
Abstract
In this article, the authors review the origins of palliative care within the critical care context and describe the evolution of symptom management, shared decision-making, and comfort-focused care in the ICU from the 1970s to the early 2000s. The authors also review the growth of interventional studies in the past 20 years and indicate areas for future study and quality improvement for end-of-life care among the critically ill.
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Affiliation(s)
- James Downar
- Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Rue Bruyere, Suite 268J, Ottawa K1N 5C8, Canada; Department of Critical Care, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON K1Y 4E9, Canada.
| | - May Hua
- Department of Anesthesiology, Columbia University, 622 West 168th Street, New York, NY 10032, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032, USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; Department of Anesthesiology and Pain Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, 2075 Bayview Avenue, Room D1.08, Toronto, Ontario M4N 3M5, Canada
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5
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Akkermans A, Prins S, Spijkers AS, Wagemans J, Labrie NHM, Willems DL, Schultz MJ, Cherpanath TGV, van Woensel JBM, van Heerde M, van Kaam AH, van de Loo M, Stiggelbout A, Smets EMA, de Vos MA. Argumentation in end-of-life conversations with families in Dutch intensive care units: a qualitative observational study. Intensive Care Med 2023; 49:421-433. [PMID: 37004524 PMCID: PMC10119246 DOI: 10.1007/s00134-023-07027-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/01/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE In intensive care units (ICUs), decisions about the continuation or discontinuation of life-sustaining treatment (LST) are made on a daily basis. Professional guidelines recommend an open exchange of standpoints and underlying arguments between doctors and families to arrive at the most appropriate decision. Yet, it is still largely unknown how doctors and families argue in real-life conversations. This study aimed to (1) identify which arguments doctors and families use in support of standpoints to continue or discontinue LST, (2) investigate how doctors and families structure their arguments, and (3) explore how their argumentative practices unfold during conversations. METHOD A qualitative inductive thematic analysis of 101 audio-recorded conversations between doctors and families. RESULTS Seventy-one doctors and the families of 36 patients from the neonatal, pediatric, and adult ICU (respectively, N-ICU, P-ICU, and A-ICU) of a large university-based hospital participated. In almost all conversations, doctors were the first to argue and families followed, thereby either countering the doctor's line of argumentation or substantiating it. Arguments put forward by doctors and families fell under one of ten main types. The types of arguments presented by families largely overlapped with those presented by doctors. A real exchange of arguments occurred in a minority of conversations and was generally quite brief in the sense that not all possible arguments were presented and then discussed together. CONCLUSION This study offers a detailed insight in the argumentation practices of doctors and families, which can help doctors to have a sharper eye for the arguments put forward by doctors and families and to offer room for true deliberation.
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Affiliation(s)
- Aranka Akkermans
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands.
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Sanne Prins
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Amber S Spijkers
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Jean Wagemans
- Department of Speech Communication, Argumentation Theory, and Rhetoric, University of Amsterdam, Amsterdam, The Netherlands
| | - Nanon H M Labrie
- Department of Language, Literature and Communication, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Dick L Willems
- Department of Ethics, Law and Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Thomas G V Cherpanath
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Job B M van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc van Heerde
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Moniek van de Loo
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anne Stiggelbout
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Mirjam A de Vos
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Sacco A, Tavecchia G, Ditali V, Garatti L, Villanova L, Colombo C, Viola G, Scavelli F, Varrenti M, Milani M, Morici N, Tavazzi G, Lissoni B, Forni L, Gorni G, Saporetti G, Oliva F. Effect of a quality-improvement intervention on end-of-life care in cardiac intensive care unit. Eur J Clin Invest 2023:e13982. [PMID: 36912206 DOI: 10.1111/eci.13982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/17/2023] [Accepted: 02/27/2023] [Indexed: 03/14/2023]
Affiliation(s)
- Alice Sacco
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giovanni Tavecchia
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Laura Garatti
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Luca Villanova
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claudia Colombo
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giovanna Viola
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesca Scavelli
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marisa Varrenti
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Martina Milani
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Nuccia Morici
- S. Maria Nascente-Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Guido Tavazzi
- Unit of Anaesthesia and Intensive Care, Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia Italy.,Department of Anaesthesia, Intensive Care and Pain Therapy, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Barbara Lissoni
- Clinical Psicology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Lorena Forni
- Comitato per l'Etica di Fine Vita, Milan, Italy.,School of Law, Università Milano-Bicocca, Milan, Italy
| | - Giovanna Gorni
- Palliative Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giorgia Saporetti
- Quality and Risk Management, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Oliva
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Orr S, Falk M, Elswick RK. Facing the Inevitable: Preparing Nurses to Deliver End-of-Life Care. J Hosp Palliat Nurs 2021; 23:462-468. [PMID: 34162790 DOI: 10.1097/njh.0000000000000780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Health care providers have an ethical obligation to reduce suffering during a patient's end of life (EOL), but few receive formal education on EOL care principles. The objective of this project was to determine the feasibility and potential benefits of an education initiative in which the principles of EOL care were taught to senior-level nursing students and practicing nurses. To assess feasibility, data regarding recruitment rates, retention rates, and implementation issues were collected. Workshop effectiveness was evaluated through use of the End-of-Life Nursing Education Consortium-Knowledge Assessment Test survey, which evaluates knowledge levels regarding EOL care principles. A mixed-effects linear model was used to test for changes from the preworkshop to postworkshop scores. Demographic information and satisfaction data were also collected. Nineteen students and 24 nurses participated (total N = 43). There was a statistically significant time difference (P = .0001), with the postworkshop scores being higher (43.5 ± 0.93) versus the preworkshop scores (41.2 ± 0.93). However, no statistically significant workshop date difference (P = .3146) emerged. Satisfaction data were positive. Retention for the second workshop was negatively affected by COVID-19. The unique needs of patients nearing their EOL are significant. This project describes the implementation and outcomes of an education initiative, focused on EOL care principles, that was both feasible and beneficial.
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Campbell EY, Lawson TG, Urban S, Vaughan L, Kamal AH, Jones CA, Higgins EA. Top Ten Tips Palliative Care Clinicians Should Know About Teaching Trainees How to Conduct a Family Meeting. J Palliat Med 2020; 24:267-272. [PMID: 33306932 DOI: 10.1089/jpm.2020.0687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The family meeting is an essential component of effective palliative care (PC); however, medical students and junior doctors-in-training often consider leading a family meeting to be a daunting task. The old "see one, do one, teach one" axiom should not apply in preparing trainees to conduct a family meeting. After a review of the literature on established PC curricula, trainee perceptions of their PC educational experiences, and documented educational interventions in preparing trainees to conduct a family meeting, we have compiled a list of 10 tips for clinical educators to consider in assisting their students to feel better equipped to conduct productive family meetings.
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Affiliation(s)
- Emily Young Campbell
- Department of Internal Medicine, Division of General Internal Medicine, Geriatrics and Palliative Care, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Theresa Gunter Lawson
- Department of Internal Medicine, South University College of Nursing and Public Health, Savannah, Georgia, USA
| | - Sophia Urban
- Department of Internal Medicine, Division of General Internal Medicine, Geriatrics and Palliative Care, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Leigh Vaughan
- Department of Internal Medicine, Division of General Internal Medicine, Geriatrics and Palliative Care, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Arif H Kamal
- Department of Internal Medicine, Division of Medical Oncology, Duke Cancer Institute, Duke Fuqua School of Business, Duke University, Durham, North Carolina, USA
| | - Christopher A Jones
- Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Elizabeth A Higgins
- Department of Internal Medicine, Division of General Internal Medicine, Geriatrics and Palliative Care, Medical University of South Carolina, Charleston, South Carolina, USA
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Arora S, Shaikh S, Karachi T, Vanniyasingam T, Centofanti J, Piquette D, Meade M, Boyle A, Woods A, Downar J, Cook D. End-of-Life Skills and Professionalism for Critical Care Residents in Training: The ESPRIT Survey. J Intensive Care Med 2020; 36:1272-1280. [PMID: 32912037 DOI: 10.1177/0885066620946316] [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: 11/17/2022]
Abstract
End-of-life (EOL) care is a key aspect of critical care medicine (CCM) training. The goal of this study was to survey CCM residents and program directors (PDs) across Canada to describe current EOL care education. Using a literature review, we created a self-administered survey encompassing 10 CCM national objectives of training to address: (1) curricular content and evaluation methods, (2) residents' preparedness to meet these objectives, and (3) opportunities for educational improvement. We performed pilot testing and clinical sensibility testing, then distributed it to all residents and PDs across the 13 Canadian CCM programs. Our response rate was 84.3% overall (77 [81.1%] for residents and 13 [100%] for PDs). Residents rated direct observation, informal advice, and self-reflection as both the top 3 most utilized and perceived most effective teaching modalities. Residents most commonly reported comfort with skills related to pain and symptom management (n = 67, 94.3%; score > 3 on 5-point Likert scale), and least commonly reported comfort with donation after cardiac death skills (n = 26-38; 44.8%-65.5%). Base specialty and time in CCM training were independently associated with comfort ratings for some, but not all, EOL skills. With respect to family meetings, residents infrequently received feedback; however, most PDs believed feedback on 6 to 10 meetings is required for competence. When PD perceptions of teaching effectiveness were compared with resident comfort ratings, differences were most apparent for skills related to pain and symptom management, cultural awareness, and ethical principles. By the end of their first subspecialty training year, PDs expect residents to be competent at most, but not all, EOL skills. In summary, trainees and programs rely on clinical activities to develop competency in EOL care, resulting in some educational gaps. Transitioning to competency-based medical education presents an opportunity to address some of these gaps, while other gaps will require more specific curricular intervention.
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Affiliation(s)
- Samantha Arora
- Department of Medicine, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sameer Shaikh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tim Karachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Thuva Vanniyasingam
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada.,Biostatistics Unit, St. Joseph's Hamilton Healthcare, Ontario, Canada
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Dominique Piquette
- Interdepartmental Division of Critical Care, University of Toronto, Ontario, Canada
| | - Maureen Meade
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anne Boyle
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anne Woods
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James Downar
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Critical Care, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Deborah Cook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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10
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Zaeh SE, Hayes MM, Eakin MN, Rand CS, Turnbull AE. Housestaff perceptions on training and discussing the Maryland Orders for Life Sustaining Treatment Form (MOLST). PLoS One 2020; 15:e0234973. [PMID: 32559244 PMCID: PMC7304571 DOI: 10.1371/journal.pone.0234973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 06/06/2020] [Indexed: 11/18/2022] Open
Abstract
Background On-line tutorials are being increasingly used in medical education, including in teaching housestaff skills regarding end of life care. Recently an on-line tutorial incorporating interactive clinical vignettes and communication skills was used to prepare housestaff at Johns Hopkins Hospital to use the Maryland Orders for Life Sustaining Treatment (MOLST) form, which documents patient preferences regarding end of life care. 40% of housestaff who viewed the module felt less than comfortable discussing choices on the MOLST with patients. We sought to understand factors beyond knowledge that contributed to housestaff discomfort in MOLST discussions despite successfully completing an on-line tutorial. Methods We conducted semi-structured telephone interviews with 18 housestaff who completed the on-line MOLST training module. Housestaff participants demonstrated good knowledge of legal and regulatory issues related to the MOLST compared to their peers, but reported feeling less than comfortable discussing the MOLST with patients. Transcripts of interviews were coded using thematic analysis to describe barriers to using the MOLST and suggestions for improving housestaff education about end of life care discussions. Results Qualitative analysis showed three major factors contributing to lack of housestaff comfort completing the MOLST form: [1] physician barriers to completion of the MOLST, [2] perceived patient barriers to completion of the MOLST, and [3] design characteristics of the MOLST form. Housestaff recommended a number of adaptations for improvement, including in-person training to improve their skills conducting conversations regarding end of life preferences with patients. Conclusions Some housestaff who scored highly on knowledge tests after completing a formal on-line curriculum on the MOLST form reported barriers to using a mandated form despite receiving training. On-line modules may be insufficient for teaching communication skills to housestaff. Additional training opportunities including in-person training mechanisms should be incorporated into housestaff communication skills training related to end of life care.
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Affiliation(s)
- Sandra E. Zaeh
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
| | - Margaret M. Hayes
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Michelle N. Eakin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Cynthia S. Rand
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Alison E. Turnbull
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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11
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Abstract
Patients undergoing cardiothoracic surgery face a small but significant mortality risk. Despite this, end-of-life care specific to this population has received little attention. This article examines current literature on end-of-life care in cardiothoracic surgery and in critical care. Recommendations for management at the end of life are made based on the available evidence.
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12
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End-of-life care content in postgraduate critical care nursing programs: Structured telephone interviews to evaluate content-informing practice. Aust Crit Care 2019; 33:181-186. [PMID: 31182250 DOI: 10.1016/j.aucc.2019.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/31/2019] [Accepted: 04/13/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The provision of end-of-life care remains a significant component of work for clinicians in critical care settings. Critical care nurses report that this area of practice receives limited attention in education and training. OBJECTIVES The objective of this study was to identify and describe the end-of-life care content in postgraduate critical care nursing programs in Australia. METHODS Using a descriptive exploratory research design, an Internet search was undertaken in August 2015, identifying 17 education providers offering postgraduate critical care nursing programs. Thirteen individuals agreed to participate in a structured telephone interview regarding end-of-life content in their postgraduate program. Descriptive statistics were calculated to summarise the data obtained. RESULTS Twelve participants reported that end-of-life care content was explicitly addressed in their postgraduate critical care nursing programs, yet variation in actual content areas covered was evident. The majority of programs addressed content related to organ donation (92%) and legal and ethical issues (77%). However, content least commonly identified as covered pertained to the work of the nurse in providing direct clinical care to the patient at the end of life and his or her family, including the physical changes experienced by the dying patient (31%), respiratory management encompassing withdrawal of ventilation and symptom management (23%), emotional support of family (23%), care of the body after death (23%), and the process of withdrawing life-sustaining treatment (15%). Participants (92%) agreed that end-of-life content was important in postgraduate critical care nursing programs, with 77% of participants agreeing that more time should be allocated to end-of-life content. CONCLUSIONS This study provides preliminary evidence of the variation in end-of-life content in postgraduate critical care nursing programs in Australia. Addressing gaps in end-of-life care content in formal education, including clinical care of the dying patient, is urgently needed to address the complexity of this phase of care that is so frequently provided in critical care units.
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