Learning needs and perceived barriers and facilitators to end-of-life care: a survey of front-line nurses on acute medical wards

OBJECTIVES

Caring for dying hospitalised patients is a healthcare priority. Our objective was to understand the learning needs of front-line nurses on the general internal medicine (GIM) hospital wards, and perceived barriers to, and facilitators of, optimal end-of-life care.

METHODS

We developed an 85-item survey informed by the Theoretical Domains Framework and Capability-Opportunity-Motivation-Behaviour system. We included demographics and two main domains (knowledge and practice; delivering end-of-life care) with seven subsections. Nurses from four GIM wards and the nursing resource team completed this survey. We analysed and compared results overall, by Capability, Opportunity, and Motivation, and by survey domain. We considered items with median scores <4/7 barriers. We conducted an a priori subgroup analysis based on duration of practice (≤5 and >5 years).

RESULTS

Our response rate was 60.5% (144/238). 51% had been practising for >5 years; most respondents were female (93.1%). Nurses had similar scores on the knowledge (mean 76.0%; SD 11.6%) and delivering care (mean 74.5% (8.6%)) domains. Scores for items associated with Capability were higher than those associated with Opportunity (median (first, third quartiles) 78.6% (67.9%, 87.5%) vs 73.9% (66.0%, 81.8%); p=0.04). Nurses practising >5 years had significantly higher scores on all analyses. Barriers included engaging with families having strong emotional reactions, managing goals of care conflicts between patients and families, and staffing challenges on the ward. Additional requested resources included formal training, information binders and more staff. Opportunities for consideration include formalised on-the-job training, access to comprehensive information, including symptom management at the end of life, and debriefing sessions.

CONCLUSIONS

Front-line nurses reported an interest in learning more about end-of-life care and identified important barriers that are feasible to address. These results will inform specific knowledge translation strategies to build capacity among bedside nurses to enhance end-of-life care practices for dying patients on GIM wards.

Enhancing end of life care on general internal medical wards: the 3 Wishes Project

BACKGROUND

Initially developed in the intensive care unit (ICU) at St. Joseph's Healthcare Hamilton (SJHH) the 3 Wishes Project (3WP) provides personalized, compassionate care to dying patients and their families. The objective of this study was to develop and evaluate 3WP expansion strategies for patients cared for on General Internal Medicine (GIM) wards in our hospital.

METHODS

From January 2020-November 2021, we developed a phased, multicomponent approach for program expansion. We enrolled patients on the GIM wards who had a high probability of dying in hospital, then elicited, implemented, and documented wishes for them or their families. Data were analyzed descriptively.

RESULTS

From March 2020 to November 2020, we implemented staff education and engagement activities, created an Expansion Coordinator position, held strategic consultations, and offered enabling resources. From March 2020 to November 2021, we enrolled 62 patients and elicited 281 wishes (median [1^st, 3^rd quartiles] 4 [4, 5] wishes/patient). The most common wish categories were personalizing the environment (67 wishes, 24%), rituals and spiritual support (42 wishes, 15%), and facilitating connections (39 wishes, 14%). The median [1^st, 3^rd] cost/patient was $0 [0, $10.00] (range $0 to $86); 91% of wishes incurred no cost to the program.

CONCLUSIONS

The formal expansion of the 3WP on GIM wards has been successful despite COVID-19 pandemic disruptions. While there is still work ahead, these data suggest that implementing the 3WP on the GIM wards is feasible and affordable. Increased engagement of the clinical team during the pandemic suggests that it is positively received.

Mechanism(s) for age-related sex differences in diet-induced cardiomyopathy: role of RNA methylation

Background/Introduction

Age and sexual dimorphism contribute to the differential cardiometabolic dysfunctions associated with diet-induced obesity. However, the underlying mechanisms remain elusive. RNA modifications via RNA m6A methylation, is an emerging mediator of RNA stability, translation and localization responsible for regulation of multiple biological functions. RNA m6A modifications are regulated by “writers”, “erasers” and “readers”. The role of RNA methylation machinery genes in the heart is largely unexplored, and may provide insight into the influence of age and sex on cardiometabolic dysfunction.

Purpose

We aim to determine differential RNA methylation changes within the heart in a diet-induced cardiomyopathy mouse model, stratified according to age and sex.

Methods

Male and female C57BL/6 mice (6–8wk-old) were fed normal chow (NC) or high-fat/high-sucrose (HFHS) diet for 1 or 4 months. Echocardiographic measurements were performed at 1 and 4 months according to the American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines. At study endpoint, glucose and insulin tolerance testing was conducted by injecting mice intraperitoneally with 2g/kg glucose or 0.6U/kg insulin, and monitoring blood glucose levels over a 2 hour period. RNA from heart tissue was subjected to quantitative PCR for RNA methylation machinery genes (FTO, ALKBH5, METTL3, METTL4, METTL14, YTHDF1 and YTHDF2). PPIA was used to normalise qPCR data.

Results

Both male and female mice showed evidence of age- and diet-induced metabolic dysfunction, however, males and females showed markedly different metabolic impairments. For example, glucose tolerance was exacerbated by 4 months of HFHS diet in males but not females; and only females showed impaired insulin tolerance. Echocardiography showed that males had systolic (stoke volume, cardiac output) and diastolic (E/A ratio) dysfunction after 4 months of HFHS diet, while females were unperturbed. We identified that METTL3 and METTL14, the “writers” of m6A methylation, were consistently increased in male mouse hearts at 1 vs 4 months of age but were unchanged or decreased in females, irrespective of diet. Conversely, YTHDF1, a “reader”, was unchanged in male mouse hearts at 1 vs. 4 months of age but was significantly increased in female hearts.

Conclusion

Our study confirms that markedly different cardiometabolic impairments occur in male versus female mice in response to long-term HFHS diet. Despite significant metabolic impairment in both sexes, cardiac dysfunction was only evident in males. RNA methylation machinery genes were differentially expressed in mouse hearts according to age and sex, suggesting that RNA methylation may be involved in age-related sexual dimorphism in cardiometabolic impairments.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Heart Foundation

Use of Video Technology in End-of-Life Care for Hospitalized Patients During the COVID-19 Pandemic

BACKGROUND

Infection control protocols, including visitor restrictions, implemented during the COVID-19 pandemic threatened the ability to provide compassionate, family-centered care to patients dying in the hospital. In response, clinicians used videoconferencing technology to facilitate conversations between patients and their families.

OBJECTIVES

To understand clinicians' perspectives on using videoconferencing technology to adapt to pandemic policies when caring for dying patients.

METHODS

A qualitative descriptive study was conducted with 45 clinicians who provided end-of-life care to patients in 3 acute care units at an academically affiliated urban hospital in Canada during the first wave of the pandemic (March 2020-July 2020). A 3-step approach to conventional content analysis was used to code interview transcripts and construct overarching themes.

RESULTS

Clinicians used videoconferencing technology to try to bridge gaps in end-of-life care by facilitating connections with family. Many benefits ensued, but there were also some drawbacks. Despite the opportunity for connection offered by virtual visits, participants noted concerns about equitable access to videoconferencing technology and authenticity of technology-assisted interactions. Participants also offered recommendations for future use of videoconferencing technology both during and beyond the pandemic.

CONCLUSIONS

Clinician experiences can be used to inform policies and practices for using videoconferencing technology to provide high-quality end-of-life care in the future, including during public health crises.

Sacrifice and solidarity: a qualitative study of family experiences of death and bereavement in critical care settings during the pandemic

BACKGROUND

Pandemic-related restrictions are expected to continue to shape end-of-life care and impact the experiences of dying hospitalised patients and their families.

OBJECTIVE

To understand families' experiences of loss and bereavement during and after the death of their loved one amidst the SARS-CoV-2 (COVID-19) pandemic.

DESIGN

Qualitative descriptive study.

SETTING

Three acute care units in a Canadian tertiary care hospital.

PARTICIPANTS

Family members of 28 hospitalised patients who died from March-July 2020.

MAIN OUTCOME MEASURES

Qualitative semistructured interviews conducted 6-16 months after patient death inquired about family experiences before and beyond the death of their loved one and garnered suggestions to improve end-of-life care.

RESULTS

Pandemic restrictions had consequences for families of dying hospitalised patients. Most family members described an attitude of acquiescence, some framing their experience as a sacrifice made for the public good. Families appreciated how clinicians engendered trust in the name of social solidarity while trying to mitigate the negative impact of family separation. However, fears about the patient's experience of isolation and changes to postmortem rituals also created despair and contributed to long-lasting grief.

CONCLUSION

Profound loss and enduring grief were described by family members whose final connections to their loved one were constrained by pandemic circumstances. Families observed solidarity among clinical staff and experienced a sense of unity with staff, which alleviated some distress. Their suggestions to improve end-of-life care given pandemic restrictions included frequent, flexible communication, exceptions for family presence when safe, and targeted efforts to connect patients whose isolation is intensified by functional impairment or limited technological access.

TRIAL REGISTRATION NUMBER

NCT04602520; Results.

Adipose-targeted overexpression of mitochondrial-targeted catalase does not improve cardio-metabolic parameters in mice with diet-induced obesity

Background

Obesity is associated with significant cardio-metabolic complications. Adipokines, and cytokines released from adipose tissue (AT) stimulate excessive mitochondrial production of reactive oxygen species (ROS). ROS-mediated oxidative modifications is associated with development of insulin resistance and impaired cardiac function. We hypothesised that adipose-targeted overexpression of mitochondrial-targeted catalase (AT-mCAT) could lead to improvement in diet-induced cardio-metabolic dysfunction.

Methods/Results

mCAT (floxed) and AdipoQ-Cre mice were crossed to generate mice overexpressing catalase with a mitochondrial-targeting sequence predominantly in AT (AT-mCAT). Wild-type (WT) and AT-mCAT male mice were fed normal chow (NC) or high-fat/high-sucrose (HFHS) diet (36%fat/34%sucrose) for 4 months. At endpoint, echocardiography showed reduced cardiac output in all groups v WT NC (p&lt;0.05); reduced IVSd in AT-mCAT NC and HFHS groups v WT NC (p&lt;0.01); reduced left ventricular ejection fraction in AT-mCAT HFHS v WT NC (p&lt;0.05) and no differences in fractional shortening or E/A ratio between groups. Glucose tolerance tests (2g/kg) showed impairment in WT HFHS and AT-mCAT HFHS v WT NC (p&lt;0.01, p&lt;0.05 respectively). Triglyceride levels were increased in WT HFHS and AT-mCAT HFHS v WT NC (p&lt;0.05). Analysis of hypertrophic signalling in cardiac tissues by ELISA showed p-AKT/total Akt levels were decreased in AT-mCAT hearts regardless of diet (WT NC v AT-mCAT NC p&lt;0.01; WT HFHS v AT-mCAT HFHS p&lt;0.05).

Conclusion

Our results confirm previous findings that diet-induced obesity is a systemic condition. Targeting adipose tissue with mitochondrial catalase may not be adequate to prevent development of cardio-metabolic dysfunction. More systemic approaches may be required to combat obesity-induced cardio-metabolic impairment.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart Foundation of Australia

Colchicine and quality of life in patients with acute coronary syndromes: results from the COPS randomized trial

Background

Recent data suggest that colchicine may reduce cardiovascular events among patients presenting with acute coronary syndromes. This sub-study of the Australian COPS trial aimed to assess whether colchicine affects health status outcomes.

Methods

Health status was assessed at baseline and 12-months using the EuroQol-5 Dimension 5-level (EQ-5D-5L) score and the full 19-question Seattle Angina Questionnaire (SAQ). Data were available for 786 patients (388 randomized to colchicine, 398 to placebo).

Results

Baseline characteristics were well matched between groups; mean age was 60.1 (SD 14.8) years, and 20% were female. Baseline health status scores were impaired, and most parameters demonstrated significant improvement from baseline to 12-months (EQ-5D-5L Visual Analogue Score [VAS] 69.3 to 77.7; SAQ angina frequency score 83.0 to 95.3, both p&lt;0.001). No significant differences in adjusted mean score change among any of the EQ-5D-5L or SAQ dimensions were observed between treatment groups in either intention-to-treat or per-protocol analysis. There were borderline interactions in EQ-5D-5L scores for those with previous MI vs not, and in SAQ scores for those with obesity vs not. In categorical analysis using observed data, patients treated with colchicine were more likely to have clinically significant improvement in physical limitation score over the period (36% improved vs. 28%, P&lt;0.05). Baseline health status scores were not associated with the primary endpoint at 12 months.

Conclusions

Treatment with colchicine did not appear to affect change in measures of health status following acute coronary syndromes, but it did lead to a greater likelihood of improvement in physical limitation scores.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Peninsula Health, Monash University

Clinician Perspectives on Caring for Dying Patients During the Pandemic : A Mixed-Methods Study

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has affected the hospital experience for patients, visitors, and staff.

OBJECTIVE

To understand clinician perspectives on adaptations to end-of-life care for dying patients and their families during the pandemic.

DESIGN

Mixed-methods embedded study. (ClinicalTrials.gov: NCT04602520).

SETTING

3 acute care medical units in a tertiary care hospital from 16 March to 1 July 2020.

PARTICIPANTS

45 dying patients, 45 family members, and 45 clinicians.

INTERVENTION

During the pandemic, clinicians continued an existing practice of collating personal information about dying patients and "what matters most," eliciting wishes, and implementing acts of compassion.

MEASUREMENTS

Themes from semistructured clinician interviews that were summarized with representative quotations.

RESULTS

Many barriers to end-of-life care arose because of infection control practices that mandated visiting restrictions and personal protective equipment, with attendant practical and psychological consequences. During hospitalization, family visits inside or outside the patient's room were possible for 36 patients (80.0%); 13 patients (28.9%) had virtual visits with a relative or friend. At the time of death, 20 patients (44.4%) had a family member at the bedside. Clinicians endeavored to prevent unmarked deaths by adopting advocacy roles to "fill the gap" of absent family and by initiating new and established ways to connect patients and relatives.

LIMITATION

Absence of clinician symptom or wellness metrics; a single-center design.

CONCLUSION

Clinicians expressed their humanity through several intentional practices to preserve personalized, compassionate end-of-life care for dying hospitalized patients during the SARS-CoV-2 pandemic.

PRIMARY FUNDING SOURCE

Canadian Institutes of Health Research and Canadian Critical Care Trials Group Research Coordinator Fund.

Scale-up and sustainability of a personalized end-of-life care intervention: a longitudinal mixed-methods study

BACKGROUND

Scaling-up and sustaining healthcare interventions can be challenging. Our objective was to describe how the 3 Wishes Project (3WP), a personalized end-of-life intervention, was scaled-up and sustained in an intensive care unit (ICU).

METHODS

In a longitudinal mixed-methods study from January 12,013 - December 31, 2018, dying patients and families were invited to participate if the probability of patient death was > 95% or after a decision to withdraw life support. A research team member or bedside clinician learned more about each of the patients and their family, then elicited and implemented at least 3 personalized wishes for patients and/or family members. We used a qualitative descriptive approach to analyze interviews and focus groups conducted with 25 clinicians who cared for the enrolled patients. We used descriptive statistics to summarize patient, wish, and clinician characteristics, and analyzed outcome data in quarters using Statistical Process Control charts. The primary outcome was enrollment of terminally ill patients and respective families; the secondary outcome was the number of wishes per patient; tertiary outcomes included wish features and stakeholder involvement.

RESULTS

Both qualitative and quantitative analyses suggested a three-phase approach to the scale-up of this intervention during which 369 dying patients were enrolled, having 2039 terminal wishes implemented. From a research project to clinical program to an approach to practice, we documented a three-fold increase in enrolment with a five-fold increase in total wishes implemented, without a change in cost. Beginning as a study, the protocol provided structure; starting gradually enabled frontline staff to experience and recognize the value of acts of compassion for patients, families, and clinicians. The transition to a clinical program was marked by handover from the research staff to bedside staff, whereby project catalysts mentored project champions to create staff partnerships, and family engagement became more intentional. The final transition involved empowering staff to integrate the program as an approach to care, expanding it within and beyond the organization.

CONCLUSIONS

The 3WP is an end-of-life intervention which was implemented as a study, scaled-up into a clinical program, and sustained by becoming integrated into practice as an approach to care.

Global longitudinal strain and mechanical dispersion at rest in exercise stress echocardiography for detecting obstructive coronary artery disease: a pilot study

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Exercise stress echocardiography (ESE) is a commonly used investigation for risk stratification in coronary artery disease (CAD). The added value of resting indices such as Global Longitudinal Strain (GLS) and Mechanical Dispersion (MD) to detect obstructive CAD is not well established and would be of significant clinical benefit.

PURPOSE

To evaluate the diagnostic value of GLS and MD at rest and post-exercise during ESE to detect obstructive CAD, defined by angiographic stenosis &gt;70% in any major coronary artery.

METHODS

Retrospective cohort study of 80 consecutive patients who underwent ESE and had coronary angiography (invasive or CT) within 6 months. Retrospective speckle tracking strain analysis was performed on digitally archived video-loops, using vendor independent software. Data on demographics, medications, outcomes and ESE characteristics were collected and analysed.

RESULTS

In 49 (61.3%) patients with any CAD &gt;70%, GLS at rest was lower (-13.9% ± 4.2 vs -16.1% ± 5.2, p-value = 0.04), and MD at rest was higher (81ms ± 43 vs 58ms ± 28, p-value = 0.008), when compared to patients without CAD &gt;70%. GLS and MD measured post-exercise were not significantly different between groups. Ejection fraction (EF) and Wall Motion Score Index (WMSI) at rest and post-exercise were not significantly different between groups. A resting GLS cutpoint of -14% had a sensitivity and specificity of 57/68%, comparable to the development of new regional wall motion abnormalities (71/39%) and peak WMSI &gt;1.2 (59/48%). Additionally, in 39 (48.8%) patients who had &gt;70% stenosis in the left anterior descending (LAD) artery, LS in the LAD territory segments was lower (-16.2% ± 4.4 vs -18.3% ± 4.7, p-value = 0.04), when compared to patients without &gt;70% stenosis in the LAD artery.

CONCLUSION

Resting GLS was lower and MD higher in patients undergoing ESE, who have any CAD &gt;70% compared to patients who do not have any CAD &gt;70%. Resting GLS and MD may increase diagnostic accuracy during ESE to predict obstructive CAD. Further prospective studies evaluating the utility of resting indices to predict functionally significant CAD are required.

Experiences of Bereaved Family Members Receiving Commemorative Paintings: A Qualitative Study

IMPORTANCE

Although family members of patients who die in the intensive care unit commonly experience long-term psychological distress, end-of-life bereavement support programs for such relatives are uncommon. Whether art influences the grief experience of families is largely unexplored.

OBJECTIVE

To explore the influence of personalized paintings created to honor deceased critically ill patients on family members' bereavement experience.

DESIGN, SETTING, AND PARTICIPANTS

A qualitative descriptive analysis was conducted of semistructured interviews of grieving relatives who received a painting after the death of their loved one. The deceased patients were from a 21-bed medical-surgical intensive care unit. Eleven families were invited to receive a painting, of whom 1 family declined. A total of 22 family members of 10 patients who died in the intensive care unit were interviewed in the study between July 11, 2017, and May 19, 2019.

INTERVENTIONS

Patients were enrolled in an end-of-life care program that elicits and implements wishes of patients and their families to bring peace during the dying process. Selected families of 10 decedents were invited to receive a painting to honor their loved one 1 to 10 months after the patient's death. Using details about the patient's life story, the artist created individualized paintings to commemorate each patient.

MAIN OUTCOMES AND MEASURES

The experiences of family members receiving a personalized painting and its reported influence on their grieving experience.

RESULTS

The family members of 10 decedents (mean [SD] age, 60 [14] years; 5 women [50%]; 8 White patients [80%]) were interviewed. The central theme of art to facilitate healing was illustrated through the following domains: the cocreation process, painting narratives, postmortem connections, and legacy. The process of cocreating the paintings with the artist and family members involved reminiscing, storytelling, and creativity. Family members emphasized the role of art to facilitate healing, exemplified through connections with images portrayed that deeply resonated with memories of their loved one. Participants indicated that the paintings validated that the patient was remembered, helped families feel less alone during a time of grief, honored the loved one's life, and enhanced connections between family members and clinicians.

CONCLUSIONS AND RELEVANCE

This qualitative study's findings suggest that the creation of personalized paintings commemorating the lives of patients may help foster legacy and postmortem connections with clinicians and may help family members in their healing process.

Hospital leadership perspectives on the value of the 3 Wishes Project: a qualitative study

Background

Healthcare organisations are increasingly interested in improving the work life of their employees. By encouraging individualised acts of compassion for dying patients and their families, the 3 Wishes Project (3WP) has been shown to ease grief for both families and clinicians.

Purpose

The objective of this study was to explore the perspectives of hospital leaders on the value of the 3WP to the hospital and how decisions are made about which programmes to support.

Methods

We conducted semistructured interviews with 20 hospital leaders in four North American institutions. Transcripts were analysed using qualitative content analysis.

Results

Interviews with 12 clinical managers and 8 senior administrators identified the institutional value of the 3WP as improving patient and family experiences, enhancing staff morale, translating institutional mission and values into front-line practice, and creating positive public relations. Hospital leaders acknowledged potential resource challenges, including staff time, space to store supplies and funds to purchase items for some wishes. However, citing stories they had heard from families and staff, hospital leaders shared their view of how their decisions about the value of clinical programmes extend beyond quantifiable outcomes.

Conclusions

When reflecting on this personalised palliative care programme, hospital leaders described how inspiring narratives promoted institutional values in ways that are difficult to measure quantitatively. Leaders underscored the need to balance the value that a programme brings with the resources it requires, stating how different types of evidence influence their support of new programmes.

Trial registration number

NCT04147169.

Building organizational compassion among teams delivering end-of-life care in the intensive care unit: The 3 Wishes Project

BACKGROUND

The 3 Wishes Project is a semistructured program that improves the quality of care for patients dying in the intensive care unit by eliciting and implementing wishes. This simple intervention honors the legacy of patients and eases family grief, forging human connections between family members and clinicians.

AIM

To examine how the 3 Wishes Project enables collective patterns of compassion between patients, families, clinicians, and managerial leaders in the intensive care unit.

DESIGN

Using a qualitative descriptive approach, interviews and focus groups were used to collect data from family members of dying patients, clinicians, and institutional leaders. Unconstrained directed qualitative content analysis was performed using Organizational Compassion as the analytic framework.

SETTING/PARTICIPANTS

Four North American intensive care units, participants were 74 family members of dying patients, 72 frontline clinicians, and 20 managerial leaders.

RESULTS

The policies and processes of the 3 Wishes Project exemplify organizational compassion by supporting individuals in the intensive care unit to collectively notice, feel, and respond to suffering. As an intervention that enables and empowers clinicians to engage in acts of kindness to enhance end-of-life care, the 3 Wishes Project is particularly well situated to encourage collective responses to suffering and promote compassion between patients, family members, and clinicians.

CONCLUSIONS

Examining the 3 Wishes Project through the lens of organizational compassion reveals the potential of this program to cultivate the capacity for people to collectively notice, feel, and respond to suffering. Our data document multidirectional demonstrations of compassion between clinicians and family members, forging the type of human connections that may foster resilience.

End-of-Life Skills and Professionalism for Critical Care Residents in Training: The ESPRIT Survey

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.

Palliative care clinical rotations among undergraduate and postgraduate medical trainees in Canada: a descriptive study

BACKGROUND

The number of medical undergraduate and postgraduate students completing palliative care clinical rotations in Canadian medical schools is currently unknown. The aim of this study was to assess the proportion of Canadian medical trainees completing clinical rotations in palliative care and to determine whether changes took place between 2008 and 2018.

METHODS

In this descriptive study, all Canadian medical schools (n = 17) were invited to provide data at the undergraduate and postgraduate levels (2007/08-2015/16 and 2007/08-2017/18, respectively). Information collected included the number, type and length of palliative care clinical rotations offered and the total number of medical trainees or residents enrolled at each school.

RESULTS

All 17 Canadian medical schools responded to the request for information. At the undergraduate level, palliative care clinical rotations were not offered in 2 schools, mandatory in 2 and optional in 13. Three schools that offered optional rotations were unable to provide complete data and were therefore excluded from further analyses. In 2015/16, only 29.7% of undergraduate medical students completed palliative care clinical rotations, yet this was a significant improvement compared to 2011/12 (13.6%, p = 0.02). At the postgraduate level, on average, 57.9% of family medicine trainees completed such rotations between 2007/08 and 2016/17. During the same period, palliative care clinical rotations were completed by trainees in specialty or subspecialty programs in anesthesiology (34.2%), geriatric medicine (64.4%), internal medicine (30.9%), neurology (28.2%) and psychiatry (64.5%).

INTERPRETATION

Between 2008 and 2018, a large proportion of Canadian medical trainees graduated without the benefit of a clinical rotation in palliative care. Without dedicated clinical exposure to palliative care, many physicians will enter practice without vital palliative care competencies.

Compassionate End-of-Life Care: Mixed-Methods Multisite Evaluation of the 3 Wishes Project

BACKGROUND

The 3 Wishes Project (3WP) is an end-of-life program that aims to honor the dignity of dying patients by creating meaningful patient- and family-centered memories while promoting humanistic interprofessional care.

OBJECTIVE

To determine whether this palliative intervention could be successfully implemented-defined as demonstrating value, transferability, affordability, and sustainability-beyond the intensive care unit in which it was created.

DESIGN

Mixed-methods formative program evaluation. (ClinicalTrials.gov: NCT04147169).

SETTING

4 North American intensive care units.

PARTICIPANTS

Dying patients, their families, clinicians, hospital managers, and administrators.

INTERVENTION

Wishes from dying patients, family members, and clinicians were elicited and implemented.

MEASUREMENTS

Patient characteristics and processes of care; the number, type, and cost of each wish; and semistructured interviews and focus groups with family members, clinicians, and managers.

RESULTS

A total of 730 patients were enrolled, and 3407 wishes were elicited. Qualitative data were gathered from 75 family members, 72 clinicians, and 20 managers or hospital administrators. Value included intentional comforting of families as they honored the lives and legacies of their loved ones while inspiring compassionate clinical care. Factors promoting transferability included family appreciation and a collaborative intensive care unit culture committed to dignity-conserving end-of-life care. Staff participation evolved from passive support to professional agency. Program initiation required minimal investment for reusable materials; thereafter, the mean cost was $5.19 (SD, $17.14) per wish. Sustainability was demonstrated by the continuation of 3WP at each site after study completion.

LIMITATION

This descriptive formative evaluation describes tertiary care center-specific experiences rather than aiming for generalizability to all jurisdictions.

CONCLUSION

The 3WP is a transferrable, affordable, and sustainable program that provides value to dying patients, their families, clinicians, and institutions.

PRIMARY FUNDING SOURCE

Greenwall Foundation.

Single-shot frequency-resolved optical gating for retrieving the pulse shape of high energy picosecond pulses

Accurate characterization of laser pulses used in experiments is a crucial step to the analysis of their results. In this paper, a novel single-shot frequency-resolved optical gating (FROG) device is described, one that incorporates a dispersive element which allows it to fully characterize pulses up to 25 ps in duration with a 65 fs per pixel temporal resolution. A newly developed phase retrieval routine based on memetic algorithms is implemented and shown to circumvent the stagnation problem that often occurs with traditional FROG analysis programs when they encounter a local minimum.