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Shah K, Janssen A, Donnelly C, Shaw T. Digital Educational Interventions for the Development of Advanced Care Planning Skills for Medical Practitioners: A Scoping Review. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2022; 43:181-187. [PMID: 36215159 DOI: 10.1097/ceh.0000000000000460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Medical practitioners are important facilitators of advanced care planning but are often reluctant to engage in these conversations with patients and their families. Barriers to participation can be addressed through medical education for medical practitioners. INTRODUCTION The primary objective was to examine the extent to which digital educational interventions are used to foster advanced care planning skills. Secondary objectives include understanding the acceptability of these interventions and whether electronic health records can be used to personalize learning. METHODS Online databases were used to identify relevant articles published from 2008 to 2021. Nine articles which evaluated the impact of digital learning for medical practitioners were selected. Studies eligible for inclusion in the review assessed changes in knowledge, attitudes, and practice regarding skills used in advanced care planning. RESULTS All publications used a pre-post study design with education delivered solely online. Only three studies focused on completing advance care plans or directives (33%). All but two studies recorded improvements in knowledge and/or attitudes toward planning (78%) while three studies recorded improvements in clinical practice (33%). The review suggests prior clinical or personal experiences could be used to personalize education. DISCUSSION The literature revealed that using digital education to develop advanced care planning skills is relatively unexplored despite the ability of this type of learning to improve professional knowledge and confidence. Digital devices can also improve access to relevant information at the point-of-care. Personalized interventions that incorporate prior clinical experiences, potentially extracted from health records, could be used to optimize outcomes.
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Affiliation(s)
- Kavisha Shah
- Ms. Shah: Research Assistant, The University of Sydney, Faculty of Medicine and Health, Sydney, Australia, and Sydney West Translational Cancer Research Centre, Sydney, Australia. Dr. Janssen: Senior Research Fellow, the University of Sydney, Faculty of Medicine and Health, Sydney, Australia. Mrs Donnelly: Senior Research Officer, PhD Candidate, The University of Sydney, Faculty of Medicine and Health, Sydney, Australia, and Sydney West Translational Cancer Research Centre, Sydney, Australia. Prof. Shaw: Director of Research in Implementation Science and Health (PhD, BSc), the University of Sydney, Faculty of Medicine and Health, Sydney, Australia
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Mirarchi F, Cammarata C, Cooney TE, Juhasz K, Terman SA. TRIAD IX: Can a Patient Testimonial Safely Help Ensure Prehospital Appropriate Critical Versus End-of-Life Care? J Patient Saf 2021; 17:458-466. [PMID: 28622155 DOI: 10.1097/pts.0000000000000387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The present study sought to assess the clarity of Physician Orders for Life-Sustaining Treatment (POLST) or Living Will (LW) documents alone or in combination with a video message/testimonial (VM). METHODS Emergency medical services (EMS) personnel responded to survey questions about the meaning of stand-alone POLST and LW documents and those used in conjunction with emergent care scenarios. Personnel were randomized to receive documents only or documents with VM. Questions sought a code status for each scenario and a resuscitation decision. Code status responses were analyzed for consensus (95% response rate), resuscitation responses for correct treatment decisions. RESULTS The survey response rate was 85%. Approximately half of emergency medical technician (EMT) respondents were EMT basic, and half EMT respondents were paramedic, with an average age of 42 years. Less than half had previous POLST/LW training averaging 2 hours. Consensus failed to be reached for stand-alone documents. For clinical scenarios, responses to POLST documents specifying do not resuscitate/comfort measures only or cardiopulmonary resuscitation/full treatment exceeded 80% for code status designation and correct resuscitation decisions. Other POLST resuscitation/treatment combinations showed more disparate responses, and most benefited from VM with changes in responses of 20% or more (P ≤ 0.025). Code status responses to LW-based scenarios evidenced a nonconsensus majority (79%-83%) that was significantly affected with VMs (≥12%, P ≤ 0.004); half evidenced large changes in resuscitation decisions (49%, P < 0.001). CONCLUSIONS Document clarity, judged by consensus response, was rarely evidenced. video message/testimonial seems to be a helpful aid to both POLST and LWs. Standardized education and training reveal opportunities to improve patient safety to ensure patient wishes.
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Affiliation(s)
| | | | - Timothy E Cooney
- From the Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
| | - Kristin Juhasz
- From the Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
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Pearse W, Saxon R, Plowman G, Hyde M, Oprescu F. Continuing Education Outcomes for Advance Care Planning: A Systematic Review of the Literature. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2021; 41:39-58. [PMID: 33433128 DOI: 10.1097/ceh.0000000000000323] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Advance care planning (ACP) is a process of considering future health and care needs for a time when a person may be unable to speak for themselves. Health professional continuing education programs have been proposed for facilitating patient participation in ACP; however, their impacts on participants, patient and clinical outcomes, and organizational approaches to ACP are not well understood. METHODS This systematic literature review examined interventional studies of education programs conducted with health professionals and care staff across a broad range of settings. Five electronic databases were searched up to June 2020, and a manual search of reference lists was conducted. The quality of studies was appraised by the first, second, and third authors. RESULTS Of the 7993 articles identified, 45 articles met the inclusion criteria. Program participants were predominantly medical, nursing, and social work staff, and students. Interventions were reported to improve participants' self-perceived confidence, knowledge, and skills; however, objectively measured improvements were limited. Multimodal programs that combined initial didactic teaching and role-play simulation tasks with additional activities were most effective in producing increased ACP activity in medical records. Evidence for improved clinical outcomes was limited. DISCUSSION Further studies that use rigorous methodological approaches would provide further evidence about what produces improved patient and clinical outcomes. Needs analyses and quality indicators could be considered to determine the most appropriate and effective education resources and monitor their impacts. The potential contribution of a broader range of health professionals and interprofessional learning approaches could be considered to ultimately improve patient care.
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Affiliation(s)
- Wendy Pearse
- Ms. Pearse: End of Life Care Project Manager, Nambour General Hospital, Sunshine Coast Hospital and Health Service, Queensland, Australia, and School of Health and Sports Sciences, University of the Sunshine Coast, Queensland, Australia. Dr. Saxon: Allied Health Data and Informatics, Advanced Speech Pathologist, Sunshine Coast University Hospital, Sunshine Coast Hospital and Health Service, Queensland, Australia. Dr. Plowman: Physician, Sunshine Coast University Hospital, Sunshine Coast Hospital and Health Service, Queensland, Australia. Dr. Hyde: Professor, School of Education, University of the Sunshine Coast, Queensland, Australia. Dr. Oprescu: Associate Professor, School of Health and Sport Sciences, University of the Sunshine Coast, Queensland, Australia
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Mirarchi F, Juhasz K, Cooney T, Desiderio D. TRIAD XI: Utilizing simulation to evaluate the living will and POLST ability to achieve goal concordant care when critically ill or at end-of-life-The Realistic Interpretation of Advance Directives. J Healthc Risk Manag 2020; 41:22-30. [PMID: 33301646 DOI: 10.1002/jhrm.21453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Utilize simulation to evaluate if living wills (LW) or POLST achieves goal concordant Care (GCC) in a medical crisis. METHODS Nurses and resident-physicians from a single center were randomized to a clinical scenario with a living will (LW), physician orders for life sustaining treatment (POLST) or no document. Primary outcomes were resuscitation decision and time to decision. Secondary outcome was the effect of education. RESULTS Total enrollment was 57 and less than 30% received prior training. Types of directives were linked to resuscitation decisions (P = .019). Participants randomized to "No Document" or POLST specifying "CPR" performed resuscitation. If a terminal condition presented with a POLST/ do not resuscitate-comfort measures only (DNR-CMO), 73% resuscitated. The LW or POLST specifying DNR combined with medical support resulted in resuscitations in 29% or more of the scenarios. Documents did not significantly affect median time-to-decision (P = .402) but decisions for "No Document" and POLST/CPR were at least 10 s less than other scenarios. Scenarios involving POLST DNR/Limited Treatment had the highest median time of 43 s. Prior training in LWs and POLST exerted a 10% improvement in decision making (P = .537). CONCLUSION GCC was not always achieved with a LW or POLST. This conclusion supports prior research identifying problems with the interpretation and discordance with LW's and POLST.
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Affiliation(s)
| | - Kristin Juhasz
- Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
| | - Timothy Cooney
- Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
| | - Daniel Desiderio
- Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
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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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Baker A, Speroni KG, Honigsberg H, Ruby D. Healthcare professionals' perceptions of life-sustaining treatment orders. Nursing 2020; 50:64-69. [PMID: 31977809 DOI: 10.1097/01.nurse.0000615132.39081.c1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Alyssa Baker
- At the University of Maryland Shore Regional Health in Easton, Md., Karen Gabel Speroni is chair of the Nursing Research Council; Dawn Ruby is a clinical coordinator; and Alyssa Baker is a transitional nurse navigator, as well as a clinical hospice nurse with Talbot Hospice. Hope Honigsberg is a family practice NP at University of Maryland Shore Medical Group
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Schilinski S, Hellier SD, Cline TW. Evaluation of an Electronically Delivered Learning Module Intended for Continuing Education of Practicing Registered Nurses: A Pretest–Posttest Longitudinal Study. J Contin Educ Nurs 2019; 50:331-336. [DOI: 10.3928/00220124-20190612-09] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 02/28/2019] [Indexed: 11/20/2022]
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Turnbull AE, Ning X, Rao A, Tao JJ, Needham DM. Demonstrating the impact of POLST forms on hospital care requires information not contained in state registries. PLoS One 2019; 14:e0217113. [PMID: 31211788 PMCID: PMC6581427 DOI: 10.1371/journal.pone.0217113] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/30/2019] [Indexed: 11/18/2022] Open
Abstract
Background Physician Orders for Life-Sustaining Treatment (POLST) programs have expanded rapidly, but evaluating their impact on hospital care is challenging. Objectives To demonstrate how careful study design can reveal POLST’s impact at hospital admission and why analyses of state registry data are unlikely to capture POLST’s effects. Design Prospective cohort study. Setting and participants Adult in-patients with Do Not Intubate and/or Do Not Resuscitate (DNR/I) orders in the electronic medical record at the time of discharge from Johns Hopkins Hospital over 18 months. For patients with unplanned readmissions within 30 days, records were reviewed to determine if a Maryland Medical Order for Life-Sustaining Treatment (MOLST) form was presented and for the time from readmission to a DNR/I order in the EMR. Analyses were stratified by whether patients could communicate or were accompanied by a proxy at readmission. Results Among 1,507 patients with DNR/I orders at discharge, 124 (8%) had unplanned readmissions, 112 (90%) could communicate or were accompanied by a proxy at readmission, and 12 (10%) could not communicate and were unaccompanied. For patients who were unaccompanied and could not communicate, MOLST significantly decreased the median time from readmission to DNR/I order (1.2 vs 27.1 hours, P = .001), but this association was greatly attenuated among patients who could communicate or were accompanied by a proxy (16.4 vs 25.4 hours P = .10). Conclusion Among patients who wanted to avoid intubation and/or CPR, MOLST forms were protective when the patient was unaccompanied by a healthcare proxy at admission and could not communicate. Fewer than 10% of patients met these criteria during unplanned readmissions, and state registry data does not allow this sub-population to be identified.
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Affiliation(s)
- Alison E. Turnbull
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Johns Hopkins University, Outcomes After Critical Illness and Surgery Group (OACIS), Baltimore, Maryland, United States of America
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Xuejuan Ning
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Anirudh Rao
- Medstar Washington Hospital, Washington, DC, United States of America
| | - Jessica J. Tao
- Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Dale M. Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Johns Hopkins University, Outcomes After Critical Illness and Surgery Group (OACIS), Baltimore, Maryland, United States of America
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, United States of America
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TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care. J Patient Saf 2017; 13:51-61. [PMID: 28198722 DOI: 10.1097/pts.0000000000000357] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE End-of-life interventions should be predicated on consensus understanding of patient wishes. Written documents are not always understood; adding a video testimonial/message (VM) might improve clarity. Goals of this study were to (1) determine baseline rates of consensus in assigning code status and resuscitation decisions in critically ill scenarios and (2) determine whether adding a VM increases consensus. METHODS We randomly assigned 2 web-based survey links to 1366 faculty and resident physicians at institutions with graduate medical education programs in emergency medicine, family practice, and internal medicine. Each survey asked for code status interpretation of stand-alone Physician Orders for Life-Sustaining Treatment (POLST) and living will (LW) documents in 9 scenarios. Respondents assigned code status and resuscitation decisions to each scenario. For 1 of 2 surveys, a VM was included to help clarify patient wishes. RESULTS Response rate was 54%, and most were male emergency physicians who lacked formal advanced planning document interpretation training. Consensus was not achievable for stand-alone POLST or LW documents (68%-78% noted "DNR"). Two of 9 scenarios attained consensus for code status (97%-98% responses) and treatment decisions (96%-99%). Adding a VM significantly changed code status responses by 9% to 62% (P ≤ 0.026) in 7 of 9 scenarios with 4 achieving consensus. Resuscitation responses changed by 7% to 57% (P ≤ 0.005) with 4 of 9 achieving consensus with VMs. CONCLUSIONS For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus.
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