Development of a list of competencies and entrustable professional activities for resident physicians during death pronouncement: a modified Delphi study

Need for Improvement in Death Pronouncements in Palliative Care Units

Background

Death pronouncement is an important moment that can impact a family's bereavement process; however, necessary improvements in physicians' behavior during death pronouncement remain unclear.

Objectives

To explore whether the lack of certain behaviors by the physician was associated with a perceived need for improving death pronouncement for advanced cancer patients in palliative care units (PCUs).

Methods

This study was a secondary analysis of a nationwide multicenter questionnaire survey conducted in 2018 that targeted bereaved family members of cancer patients who died in PCUs. We performed univariate analysis to investigate the need to improve behavior toward death pronouncement. We performed bivariate analysis to investigate the relationship among the need for improvement in behavior toward death pronouncement, physician attribution (primary responsible physician, a member of the same team, and another physician), and nine specific behaviors.

Results

Four hundred twenty-two questionnaires (64.2%) were returned. We analyzed 356 responses and found that 32.5% perceived the need to improve death pronouncement. Lack of certain behaviors at death pronouncement, especially not explicitly explaining the cause of death to family members (odds ratio: 11.89, p < 0.001), were positively associated with the need for improvement. There were significant differences among the types of physician attribution regarding the need for improvement (primary responsible physician vs. a member of the same team vs. another physician [15.1% vs. 42.6% vs. 45.7%, p < 0.001]).

Conclusion

There was a significant positive association between the lack of certain behaviors toward death pronouncement and the need for improvement. The major lack of behavior toward death pronouncement was not explicitly explaining the cause of death to family members and not calling out to the patient before beginning the patient's examination.

Integrated immediate postmortem and acute bereavement care: Competency-based entrustable professional activities for nursing

BACKGROUND

Integrated immediate postmortem and acute bereavement care alleviates emotional distress due to losing a loved one; however, the provision of effective nursing care remains insufficient. Therefore, preparing nursing students with such skills is essential in end-of-life care education, and entrustable professional activities (EPAs) offer potential to address this gap.

OBJECTIVES

To establish EPAs concerning immediate postmortem and acute bereavement care with a seven-category description for EPAs, milestones, and assessment tools.

DESIGN

We used a modified Delphi method and four-step consensus-building approach to i) identifying the list of possible EPA items related to immediate postmortem and acute bereavement care based on a literature review and clinical experiences, ii) select an expert panel, iii) pool, review, and revise the EPAs, and iv) validate EPA quality using the Queen's EPA Quality rubric. Data analysis was performed via modes and quartile deviations.

RESULTS

The following four major EPA components were identified: i) cultural and religious ritual assessment; ii) death preparation; iii) postmortem care; and iv) acute bereavement care. Three essential competencies were identified as highly correlated: general clinical skills, communication and teamwork capabilities, and caring. Consensus was achieved after three survey rounds. A 100 % questionnaire response rate was obtained. In the third round, all items received 4 or 5 points from >95 % of the panel members and were found to meet the quartile deviation cutoff score of <0.6, indicating that a high consensus level was established. The average Queen's EPA Quality rubric score was 62.5, with an average item score of 4.46, which was higher than the cut-off score of 4.07. Three major parts of EPAs were developed: task descriptions, milestones, and the assessment tool.

CONCLUSION

The development of EPAs assessments concerning immediate postmortem and acute bereavement care may guide nursing curricula planning to bridge the gap between competencies and clinical practice.

Death Pronouncement: Preparing Incoming Residents for Duties When Life Ends

Introduction

Undergraduate Medical Education (UME) prepares future residents for many aspects of medical practice, but it is rarely all-inclusive. Death pronouncement (DP), a highly important aspect of clinical training for residents, seems to be inadequately addressed and taught in undergraduate institutions. Studies have indicated that most first-year residents received minimal DP training and felt unprepared for this duty. Despite being a challenging situation, a formal teaching course is not universally taught, with most institutions merely delivering point-of-care DP instruction to medical trainees provided by supervising faculty, senior residents, and nurses. Our primary objective was to provide formal education in Duties When Life Ends (DWLE), with the goal of enhancing familiarity, knowledge, and confidence in addressing the circumstances surrounding death for graduating medical students transitioning to residency.

Methods

As a part of a Transition to Residency (TTR) course for students entering nonsurgical specialties, we developed a curriculum to provide formal education to fourth-year medical students in DWLE that included a two-hour didactic session delivered virtually, followed by an in-person simulation session. The didactic session covered the history, processes of DP, death physical examination, identification of medical examiner (ME) case, education on how to deliver death news to family, information about autopsies and organ donation, distinction between the cause and mechanism of death, and documentation of death notes and certificates, as well as provider self-reflection and appropriate coping mechanisms for patient death.

In the 45-minute simulation, students were divided into small groups and given a case summary. During the first half, they performed a physical examination and a verbal pronouncement on cadavers, followed by an interactive small group session where students reviewed the case and worked to identify the cause of death, determine if the death was a medical examiner’s case, deliver death news to the family, and complete a death progress note and certificate. Pre- and post-session questionnaires were administered, assessing three components: process familiarity, knowledge, and confidence. Finally, participants assessed course usefulness and had a free response opportunity for comments and feedback. 

Results

Overall, 198 students participated in all sessions, with 182 completing both pre- and post-session questionnaires. Pre-survey revealed that 70% of participants reported witnessing DP previously, with only 20% being familiar with the process of DP and 6% with documentation. Following the intervention, a comparison of the pre- and post-course questionnaires assessing process familiarity, knowledge, and confidence using a five-point Likert scale demonstrated statistically significant improvement in the mean scores in all three domains, with reported course usefulness of 96%.

Conclusion

A DWLE curriculum, as a part of the TTR course, was effective in improving self-reported familiarity, knowledge, and confidence regarding physician duties associated with patient death. The curriculum was well received by students. The incorporation of DWLE curriculum into TTR courses allows for vital preparation and education in the duties related to patient death. This may make a stressful process somewhat less stressful and may aid future physicians in developing competence in conducting these final physician duties.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

PARTICIPANTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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