Effect of Palliative Care Curriculum on Serious Illness Conversation Preparedness

Determining the Effects of Complex Education on Primary Care Nurse Practitioners' Self-efficacy in Advance Care Planning for Healthy Adults

Advance care planning is a process in which capable adults communicate their preferences for medical care in case of incapacitation. Regardless of health status, most adults are interested in advance care planning conversations and prefer providers to initiate these discussions. Primary care nurse practitioners are ideally positioned to lead these conversations but lack knowledge, confidence, and communication skills to do so. This project aimed to develop, implement, and evaluate an educational program for primary care nurse practitioners regarding leading advance care planning conversations with healthy adults. This evidence-based practice project used the Advance Care Planning Self-Efficacy Scale to measure primary care nurse practitioners' self-efficacy after completing a complex educational program. The educational program was developed based on a nationally recognized program incorporating didactic, observational, and role-play learning. The findings of this project indicated that providing complex education was an effective intervention immediately and after 3 months (P = .018 and P = .023, respectively). The results indicate that educating nurse practitioners is an effective intervention for increasing their self-efficacy in leading advance care planning conversations with healthy adults over 3 months, recommending additional intervention at least earlier than 6 months.

Internal Medicine Resident Barriers to Advance Care Planning in the Primary Care Continuity Clinic

Background: While primary care providers regularly engage in Advance Care Planning (ACP) conversations, it is not well known what challenges resident physicians face to achieving this core competency. Objectives: We aimed to assess resident perceptions of barriers and potential interventions to outpatient ACP. Methods: We distributed an electronic survey to Internal Medicine and Medicine-Psychiatry residents at our institution in 2022. Questions addressed outpatient ACP barriers and potential interventions in several domains: structural issues, personal knowledge, and communication skills. We reported results using descriptive statistics and Wilcoxon rank-sum tests, comparing responses by residency year (interns vs upperyears). Likert-scale responses were dichotomized to a "not at all or slightly" vs "moderate or extreme" barrier or helpful intervention. Results: Of 149 residents, 71 completed the survey (48%). Highest scoring barriers were structural, including 1) lack of clinic time (99%), 2) need to prioritize other medical problems (94%), and 3) lack of patient continuity (62%). Highest scoring interventions included the ability to schedule dedicated ACP visits with themselves (96%) or another clinician (82%). Interns were statistically significantly less confident in their ability to conduct ACP, and more likely to report lack of knowledge (i.e., not understanding ACP, patient prognosis, or how to complete paperwork, P < .05). Conclusions: Residents report significant structural barriers to outpatient ACP, including limitations in time, continuity, and competing medical priorities, that may warrant greater program attention to interventions such as clinic schedules and work-flow. Additional trainings may be most beneficial if targeted to the beginning of intern year.

Palliative Care Education in US Physical Medicine and Rehabilitation Residency Programs: Current Practices, Perceived Needs, and Barriers

Background: Physical medicine and rehabilitation (PM&R) clinicians commonly care for patients with serious illness/injury and would benefit from primary palliative care (PC) training. Objective: To assess current practices, attitudes, and barriers toward PC education among U.S. PM&R residencies. Design: This is a cross-sectional study utilizing an electronic 23-question survey. Setting/Subjects: Subjects were program leaders from U.S. PM&R residency programs. Results: Twenty-one programs responded (23% response). Only 14 (67%) offered PC education through lectures, elective rotations, or self-directed reading. Pain management, communication, and nonpain symptom management were identified as the most important PC domains for residents. Nineteen respondents (91%) felt residents would benefit from more PC education, but only five (24%) reported undergoing curricular change. Lack of faculty availability/expertise and teaching time were the most endorsed barriers. Conclusion: PC education is heterogeneous across PM&R programs despite its perceived value. PC and PM&R educators can collaborate to build faculty expertise and integrate PC principles into existing curricula.

An Educational Intervention to Enhance Palliative Care Training at HBCUs

CONTEXT

Primary palliative care training is important for clinicians at Historically Black Colleges and Universities (HBCUs) given the decreased access to specialty palliative care among Black patients and patients' preferences for race concordant care.

OBJECTIVES

To describe the impact of a palliative care educational intervention at two HBCUs.

METHODS

We administered a palliative care educational intervention in family and internal medicine residency programs at Morehouse School of Medicine and Howard University College of Medicine. Pre- and post-intervention surveys were sent to residents assessing attitudes toward their palliative care education and their perceived competency in specific palliative care domains. The results were analyzed using Chi-squared analysis.

RESULTS

A total of 105 of 191 (response rate 55%) residents completed pre-intervention surveys and 101 of 240 (42%) completed post-intervention surveys. Prior to the intervention, 50% of residents rated their overall preparedness in palliative care as a 7 or above (0-10 Likert scale); 78% (P < .01) of respondents reported ≥7/10 after the educational intervention. While post-intervention residents did not feel better prepared to treat symptoms, a higher percentage reported feeling well prepared to deliver bad news (41% post-intervention vs. 23% pre-intervention) and conduct a family meeting (44% post-intervention vs. 27% pre-intervention) (P < .05). Pre-intervention, 14% of residents felt their overall palliative care education was very good or excellent, while post-intervention ratings increased to 30% (P < .01).

CONCLUSION

Residents' confidence in their preparedness to provide palliative care, particularly in their communication skills increased after an intervention at two HBCUs.

Communication Training and Code Status Conversation Patterns Reported by Emergency Clinicians

CONTEXT

During acute health decompensations for seriously ill patients, emergency clinicians often determine the intensity end-of-life care. Little is known about how emergency clinicians conduct these conversations, especially among those who have received serious illness communication training.

OBJECTIVES

To determine the self-reported practice patterns of code status conversations by emergency clinicians with and without serious illness communication training.

METHODS

A cross-sectional survey was conducted among emergency clinicians with and without a recent evidence-based, serious illness communication training tailored for emergency clinicians. Emergency clinicians were included from two academic medical centers. A five-point Likert scale ("very unlikely" to "very likely" to ask) was used to assess the self-reported likelihood of asking about patients' preferences for medical procedures and patients' values and goals.

RESULTS

Among 161 respondents (71% response rate), 77 (48%) received the training. A total of 70% of emergency clinicians reported asking about procedure-based questions, and only 38% reported asking about patient's values regarding end-of-life care. For value-based questions, statistically significant differences were observed between emergency clinicians who underwent the training and those who did not in four of the seven questions asked (e.g., the higher odds of exploring the patient's life priorities [adjusted OR = 4.34, 95% CI = 1.95-9.65, P-value < 0.001]). No difference was observed in the self-reported rates of all procedure-based questions between the two groups.

CONCLUSION

Most emergency clinicians reported asking about procedure-based questions, and some asked about patient's value-based questions. Clinicians with recent serious illness communication training may ask more about some values and priorities.