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Pusa S, Baxter R, Andersson S, Fromme EK, Paladino J, Sandgren A. Core Competencies for Serious Illness Conversations: An Integrative Systematic Review. J Palliat Care 2024:8258597241245022. [PMID: 38557369 DOI: 10.1177/08258597241245022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Objective: The Serious Illness Care Program was developed to support goals and values discussions between seriously ill patients and their clinicians. The core competencies, that is, the essential clinical conversation skills that are described as requisite for effective serious illness conversations (SICs) in practice, have not yet been explicated. This integrative systematic review aimed to identify core competencies for SICs in the context of the Serious Illness Care Program. Methods: Articles published between January 2014 and March 2023 were identified in MEDLINE, PsycINFO, CINAHL, and PubMed databases. In total, 313 records underwent title and abstract screening, and 96 full-text articles were assessed for eligibility. The articles were critically appraised using the Joanna Briggs Institute Critical Appraisal Guidelines, and data were analyzed using thematic synthesis. Results: In total, 53 articles were included. Clinicians' core competencies for SICs were described in 3 themes: conversation resources, intrapersonal capabilities, and interpersonal capabilities. Conversation resources included using the conversation guide as a tool, together with applying appropriate communication skills to support better communication. Intrapersonal capabilities included calibrating one's own attitudes and mindset as well as confidence and self-assurance to engage in SICs. Interpersonal capabilities focused on the clinician's ability to interact with patients and family members to foster a mutually trusting relationship, including empathetic communication with attention and adherence to patient and family members views, goals, needs, and preferences. Conclusions: Clinicians need to efficiently combine conversation resources with intrapersonal and interpersonal skills to successfully conduct and interact in SICs.
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Affiliation(s)
- Susanna Pusa
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Rebecca Baxter
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Sofia Andersson
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Erik K Fromme
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joanna Paladino
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
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2
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Pottash M, Suguness A, Joseph L, Cuneo B, Woods C. Practicing Serious Illness Conversations in a Pulmonary Medicine Teaching Clinic. Am J Hosp Palliat Care 2024; 41:45-49. [PMID: 36802952 DOI: 10.1177/10499091231158763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Physician trainees in pulmonary medicine are not provided with supervised practice opportunities to gain confidence and skill in having serious illness conversations in the ambulatory setting. OBJECTIVE We incorporated a palliative medicine attending into an ambulatory pulmonology teaching clinic to provide supervised opportunities for serious illness conversations. METHODS Trainees in a pulmonary medicine teaching clinic requested supervision from a palliative medicine attending based on a set of evidence-based pulmonary-specific triggers that indicate advanced disease. Semi-structured interviews were conducted to determine the trainee's perceptions of the educational intervention. RESULTS The palliative medicine attending supervised 8 trainees in 58 patient encounters. The most common trigger for palliative medicine supervision was answering "no" to the "surprise question." At baseline, all trainees cited lack of time as the primary barrier to having serious illness conversations. Themes emerging from post-intervention semi-structured interviews included trainees learning that (1) patients are grateful to have conversations about the severity of their illness, (2) patients do not have a good sense of their prognosis, and (3) with improved skills, these conversations can be conducted efficiently. CONCLUSIONS Pulmonary medicine trainees were provided practice opportunities for having serious illness conversations under the supervision of the palliative medicine attending. These practice opportunities effected trainee perception on important barriers to further practice.
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Affiliation(s)
- Michael Pottash
- Division of Palliative Medicine, Department of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
| | - Arvind Suguness
- Case Western University School of Medicine, Cleveland, OH, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, MetroHealth Medical Center, Cleveland, OH, USA
| | - Lily Joseph
- Children's National Hospital, Washington, DC, USA
| | - Brian Cuneo
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Christian Woods
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
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3
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Mandel EI, Maloney FL, Pertsch NJ, Gass JD, Sanders JJ, Bernacki RE, Block SD. A Pilot Study of the Serious Illness Conversation Guide in a Dialysis Clinic. Am J Hosp Palliat Care 2023; 40:1106-1113. [PMID: 36708263 DOI: 10.1177/10499091221147303] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Clinician-led conversations about future care priorities occur infrequently with end-stage renal disease (ESRD) patients on dialysis. This was a pilot study of structured serious illness conversations using the Serious Illness Conversation Guide (SICG) in a single dialysis clinic to assess acceptability of the approach and explore conversation themes and potential outcomes among patients with ESRD. Twelve individuals with ESRD on dialysis from a single outpatient dialysis clinic participated in this study. Participants completed a baseline demographics survey, engaged in a clinician-led structured serious illness conversation, and completed an acceptability questionnaire. Conversations were recorded, transcribed and thematically analyzed. The average age of participants was 68.8 years. The conversations averaged 20:53 in length. Ten participants (83%) felt that the conversation was held at the right time in their clinical course and eleven participants (91%) felt that it was worthwhile. Most participants (73%) reported neutral feelings about clinician use of a printed guide. Eleven participants (91%) reported no change in anxiety about their illness following the conversation, and five participants (42%) reported that the conversation increased their hopefulness about future quality of life. Thematic analysis revealed common perspectives on dialysis including that participants view in-center hemodialysis as temporary, compartmentalize their kidney disease, perceive narrowed life experiences and opportunities, and believe dialysis is their only option. This pilot study suggests that clinician-led structured serious illness conversations may be acceptable to patients with ESRD on dialysis. The themes identified can inform future serious illness conversations with dialysis patients.
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Affiliation(s)
- Ernest I Mandel
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Francine L Maloney
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Nathan J Pertsch
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | - Justin J Sanders
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Rachelle E Bernacki
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Susan D Block
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Departments of Psychiatry and Medicine, Brigham and Women's Hospital, Boston, MA, USA
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4
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Mathis NJ, Maya H, Santoro A, Bartelstein M, Vaynrub M, Yang JT, Gillespie EF, Desai AV, Yerramilli D. A Worksheet to Facilitate Discussions of Values for Patients With Metastatic Cancer: A Pilot Study. J Pain Symptom Manage 2023; 66:242-247.e1. [PMID: 37302532 DOI: 10.1016/j.jpainsymman.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/17/2023] [Accepted: 06/04/2023] [Indexed: 06/13/2023]
Abstract
CONTEXT Individual goals and values should drive medical decision making for patients with serious illness. Unfortunately, clinicians' existing strategies to encourage reflection and communication regarding patients' personal values are generally time-consuming and limited in scope. OBJECTIVES Herein, we develop a novel intervention to facilitate at-home reflection and discussion about goals and values. We then conduct a pilot study of our intervention in a small population of patients with metastatic cancer. METHODS We first engaged former cancer patients and their families to adapt an existing serious illness communication guide to a worksheet format. We then distributed this adapted "Values Worksheet" to 28 patients with metastatic cancer. We surveyed participants about their perceptions of the Worksheet to assess its feasibility. RESULTS Of 30 patients approached, 28 agreed to participate. Seventeen participants completed the Values Worksheet, and of those 11 (65%) responded to the follow-up survey. Seven of eleven reported that the Values Worksheet was a good use of time, and nine of eleven would be likely to recommend it to other patients with cancer. Eight of ten reported mild distress, two of ten reported moderate to severe distress. CONCLUSION The Values Worksheet was a feasible way to facilitate at-home discussions of goals and values for select patients with metastatic cancer. Further research should focus on identifying which patients are most likely to benefit from the Values Worksheet, and should employ the Worksheet as one tool to facilitate reflection on the questions that arise around serious illness, as an adjunct to serious illness conversations with a physician.
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Affiliation(s)
- Noah J Mathis
- Department of Radiation Oncology (N.J.M., A.S., D.Y.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Hadley Maya
- Department of Surgery (H.M., M.B., M.V.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amanda Santoro
- Department of Radiation Oncology (N.J.M., A.S., D.Y.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Meredith Bartelstein
- Department of Surgery (H.M., M.B., M.V.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Max Vaynrub
- Department of Surgery (H.M., M.B., M.V.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jonathan T Yang
- Department of Radiation Oncology (J.T.Y., E.F.G.), University of Washington Medical Center, Seattle, Washington, USA
| | - Erin F Gillespie
- Department of Radiation Oncology (J.T.Y., E.F.G.), University of Washington Medical Center, Seattle, Washington, USA
| | - Anjali V Desai
- Department of Medicine (A.V.D.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Divya Yerramilli
- Department of Radiation Oncology (N.J.M., A.S., D.Y.), Memorial Sloan Kettering Cancer Center, New York, New York, USA.
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5
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Lee CW, Evans E, Vitous CA, Suwanabol PA. Living with uncertainty in surgery: integrating palliative care principles into conversations as a solution to patient and family, provider, and health system disquietude. Ann Palliat Med 2023; 12:16-20. [PMID: 36627852 DOI: 10.21037/apm-22-1332] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 12/22/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Christina W Lee
- University of British Columbia, North Vancouver, British Columbia, Canada
| | - Emily Evans
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - C Ann Vitous
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Gonella S, Di Giulio P, Berchialla P, Bo M, Cotogni P, Macchi G, Campagna S, Dimonte V. The Impact of Health and Social Care Professionals' Education on the Quality of Serious Illness Conversations in Nursing Homes: Study Protocol of a Quality Improvement Project. Int J Environ Res Public Health 2022; 20:725. [PMID: 36613049 PMCID: PMC9819581 DOI: 10.3390/ijerph20010725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/23/2022] [Accepted: 12/26/2022] [Indexed: 06/17/2023]
Abstract
Health and social care professionals (HCPs) who work in nursing homes (NHs) are increasingly required to sustain serious illness conversations about care goals and preferences. Although these conversations may also be challenging for experienced HCPs and the literature recognizes high-quality communication as key to providing patient-centered care, so far, no specific educational program has been developed for the NH setting to improve HCPs' communication skills. Our study aims to test the feasibility and potential effectiveness of an innovative, blended communication skills training program (Teach-to-Communicate) targeting the HCPs who work in NHs. This program includes classroom-based theory, experiential learning, and e-learning, and relies on interdisciplinary contexts and several didactic methods. The study consists of two phases: phase I is the development of written resources that employ focus group discussion involving field experts and external feedback from key stakeholders. Phase II consists of a multicenter, pilot, pre-post study with nested qualitative study. The Teach-to-Communicate training program is expected to enhance the quality of communication in NH and HCPs' confidence in sustaining serious illness conversations, reduce family carers' psycho-emotional burden and improve their satisfaction with the care received, and increase advance care planning documentation. Our protocol will provide insight for future researchers, healthcare providers, and policymakers and pave the way for blended educational approaches in the field of communication skills training.
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Affiliation(s)
- Silvia Gonella
- Direction of Health Professions, City of Health and Science University Hospital of Torino, Corso Bramante 88-90, 10126 Turin, Italy
- Department of Public Health and Pediatrics, University of Torino, via Santena 5 bis, 10126 Turin, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Torino, via Santena 5 bis, 10126 Turin, Italy
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Torino, via Santena 5 bis, 10126 Torino, Italy
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Torino, City of Health and Science University Hospital of Turin, Corso Bramante 88-90, 10126 Turin, Italy
| | - Paolo Cotogni
- Pain Management and Palliative Care, Department of Anesthesia, Intensive Care and Emergency, University of Torino, City of Health and Science University Hospital of Turin, Corso Bramante 88-90, 10126 Turin, Italy
| | - Giorgia Macchi
- Pain Management and Palliative Care, Department of Anesthesia, Intensive Care and Emergency, University of Torino, City of Health and Science University Hospital of Turin, Corso Bramante 88-90, 10126 Turin, Italy
| | - Sara Campagna
- Department of Public Health and Pediatrics, University of Torino, via Santena 5 bis, 10126 Turin, Italy
| | - Valerio Dimonte
- Direction of Health Professions, City of Health and Science University Hospital of Torino, Corso Bramante 88-90, 10126 Turin, Italy
- Department of Public Health and Pediatrics, University of Torino, via Santena 5 bis, 10126 Turin, Italy
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7
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Morberg Jämterud S, Sandgren A. Health care professionals' perceptions of factors influencing the process of identifying patients for serious illness conversations: A qualitative study. Palliat Med 2022; 36:1072-1079. [PMID: 35729752 PMCID: PMC9247430 DOI: 10.1177/02692163221102266] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Serious Illness Care Programme enables patients to receive care that is in accordance with their priorities. However, despite clarity about palliative care needs, many barriers to and difficulties in identifying patients for serious illness conversations remain. AIM To explore healthcare professionals' perceptions about factors influencing the process of identifying patients for serious illness conversations. DESIGN Qualitative design. A thematic analysis of observations and semi-structured interviews was used. SETTING/PARTICIPANTS Twelve observations at team meetings in which physicians and nurses discussed the process of identifying the patients for serious illness conversations were conducted at eight different clinics in two hospitals. Semi-structured interviews were conducted with three physicians and two nurses from five clinics. RESULTS Identifying the right patient and doing so at the right time were key to identifying patients for serious illness conversations. The continuity of relations and continuity over time could facilitate the identification process, while attitudes towards death and its relation to hope could hinder the process. CONCLUSIONS The process of identifying patients for serious illness conversations is complex and may not be captured only by generic tools such as the surprise question. It is crucial to address existential and ethical obstacles that can hinder the identification of patients for serious illness conversations.
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Affiliation(s)
- Sofia Morberg Jämterud
- Department of Thematic Studies, Linköping University, Linköping, Sweden.,Center for Collaborative Palliative Care, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
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8
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Baxter R, Fromme EK, Sandgren A. Patient Identification for Serious Illness Conversations: A Scoping Review. Int J Environ Res Public Health 2022; 19:4162. [PMID: 35409844 DOI: 10.3390/ijerph19074162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 02/04/2023]
Abstract
Serious illness conversations aim to align medical care and treatment with patients’ values, goals, priorities, and preferences. Timely and accurate identification of patients for serious illness conversations is essential; however, existent methods for patient identification in different settings and population groups have not been compared and contrasted. This study aimed to examine the current literature regarding patient identification for serious illness conversations within the context of the Serious Illness Care Program and/or the Serious Illness Conversation Guide. A scoping review was conducted using the Joanna Briggs Institute guidelines. A comprehensive search was undertaken in four databases for literature published between January 2014 and September 2021. In total, 39 articles met the criteria for inclusion. This review found that patients were primarily identified for serious illness conversations using clinical/diagnostic triggers, the ’surprise question’, or a combination of methods. A diverse assortment of clinicians and non-clinical resources were described in the identification process, including physicians, nurses, allied health staff, administrative staff, and automated algorithms. Facilitators and barriers to patient identification are elucidated. Future research should test the efficacy of adapted identification methods and explore how clinicians inform judgements surrounding patient identification.
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9
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Zehm A, Scott E, Schaefer KG, Nguyen PL, Jacobsen J. Improving Serious Illness Communication: Testing the Serious Illness Care Program with Trainees. J Pain Symptom Manage 2022; 63:e252-e259. [PMID: 34743012 DOI: 10.1016/j.jpainsymman.2021.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/19/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Early conversations about patients' goals and values improve care, but clinicians struggle to conduct them. The systems-based Serious Illness Care Program (SICP) helps clinicians have more, better, and earlier conversations. Central to this approach is a clinician conversation guide for patient encounters. While the SICP works for practicing clinicians, it has not been tested with medical trainees. INTERVENTION We adapted the SICP training to emphasize assessing prognostic awareness and responding to emotion. We developed a 2.5-hour SICP workshop for medical students and medical interns that included large- and small-group work, practice with an actor, and interdisciplinary clinician facilitators. We trained 81 students and 156 interns and obtained anonymous quantitative and qualitative feedback. OUTCOMES Eighty-six percent of students and 91% of residents rated the session as "very good" or "excellent" and >90% of all learners would either recommend this training or intended to apply this to their practice. Post-session learner confidence increased in all communication skills. Learners said the training provided a helpful framework and useful language for these conversations. Resident documentation of serious illness conversations in the medical record increased dramatically during the year following training commencement. CONCLUSIONS Grounded in principles of adult learning theory, this training was rated highly by trainees and resulted in demonstrable practice change. These early learners were more flexible and willing to try this approach than practicing clinicians who tend to resist or revert to old habits. A Guide represents a new paradigm for teaching communication skills and is valued by early learners.
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Affiliation(s)
- April Zehm
- Medical College of Wisconsin (A.Z.), Milwaukee, Wisconsin, USA.
| | - Erin Scott
- The Ohio State University College of Medicine (E.S.), Columbus, Ohio, USA
| | | | - Phuong L Nguyen
- Massachusetts General Hospital (P.L.N., J.J.), Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Harvard Medical School (K.G.S., J.J.), Boston, Massachusetts, USA; Massachusetts General Hospital (P.L.N., J.J.), Boston, Massachusetts, USA
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10
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Gramling R, Straton J, Ingersoll LT, Clarfeld LA, Hirsch L, Gramling CJ, Durieux BN, Rizzo DM, Eppstein MJ, Alexander SC. Epidemiology of Fear, Sadness, and Anger Expression in Palliative Care Conversations. J Pain Symptom Manage 2021; 61:246-253.e1. [PMID: 32822753 DOI: 10.1016/j.jpainsymman.2020.08.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Advancing the science of serious illness communication requires methods for measuring characteristics of conversations in large studies. Understanding which characteristics predict clinically important outcomes can help prioritize attention to scalable measure development. OBJECTIVES To understand whether audibly recognizable expressions of distressing emotion during palliative care serious illness conversations are associated with ratings of patient experience or six-month enrollment in hospice. METHODS We audiorecorded initial palliative care consultations involving 231 hospitalized people with advanced cancer at two large academic medical centers. We coded conversations for expressions of fear, anger, and sadness. We examined the distribution of these expressions and their association with pre/post ratings of feeling heard and understood and six-month hospice enrollment after the consultation. RESULTS Nearly six in 10 conversations included at least one audible expression of distressing emotion (59%; 137 of 231). Among conversations with such an expression, fear was the most prevalent (72%; 98 of 137) followed by sadness (50%; 69 of 137) and anger (45%; 62 of 137). Anger expression was associated with more disease-focused end-of-life treatment preferences, pre/post consultation improvement in feeling heard and understood and lower six-month hospice enrollment. Fear was strongly associated with preconsultation patient ratings of shorter survival expectations. Sadness did not exhibit strong association with patient descriptors or outcomes. CONCLUSION Fear, anger, and sadness are commonly expressed in hospital-based palliative care consultations with people who have advanced cancer. Anger is an epidemiologically useful predictor of important clinical outcomes.
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Affiliation(s)
- Robert Gramling
- Department of Family Medicine, University of Vermont, Burlington, VT, USA.
| | | | - Lukas T Ingersoll
- Department of Public Health, Purdue University, West Lafayette, IN, USA
| | | | | | | | | | - Donna M Rizzo
- Department of Civil & Environmental Engineering, University of Vermont, Burlington, VT, USA
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11
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Foglia MB, Cohen JH, Batten A, Alfandre D. An Exploratory Study of Goals of Care Conversations Initiated with Seriously Ill Veterans in the Emergency Room. J Palliat Med 2020; 24:873-878. [PMID: 33170071 DOI: 10.1089/jpm.2020.0401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Emergency department (ED) visits are common for older patients with chronic, life-limiting illnesses and may offer a valuable opportunity for clinicians to initiate proactive goals of care conversations (GoCC) to ensure end-of-life care that aligns with the patients' values, goals, and preferences. Objectives: The purpose of this study is to assess whether GoCC are occurring with patients in Department of Veteran Affairs (VA) EDs, to characterize these patients' goals of care and life-sustaining treatment (LST) decisions, and to examine the extent to which palliative or hospice consultations occur following the ED visit. Design: We conducted a cross-sectional retrospective study using health record data. Settings/Subjects: A total of 10,780 patients receiving care in VA, whose first GoCC occurred during an ED visit. Results: Of the patients in the study, approximately half were at least 70 years of age, three-quarters were white, and half had multiple serious disease comorbidities. The percentage of patients who desired cardiopulmonary resuscitation was lower among the highest risk (i.e., of hospitalization and death) patients (64% vs. 51%). The percentage of patients wanting other LSTs (e.g., mechanical ventilation) was higher among the lowest risk patients; and the percentage of patients requesting limits to LSTs was highest among higher risk patients. Eighteen percent of patients had a palliative or hospice care consult within three months of their ED visit. Conclusions: In this study, we verified that GoCC are being initiated in the ED with Veterans at differing stages in their illness trajectory and that higher proportions of higher risk patients preferred to limit LSTs.
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Affiliation(s)
- Mary Beth Foglia
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jennifer H Cohen
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA.,Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Adam Batten
- Seattle Institute for Biomedical and Clinical Research, Seattle, Washington, USA
| | - David Alfandre
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA.,Department of Population Health, New York University School of Medicine, New York, New York, USA
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12
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Horowitz RK, Hogan LA, Carroll T. MVP-Medical Situation, Values, and Plan: A Memorable and Useful Model for All Serious Illness Conversations. J Pain Symptom Manage 2020; 60:1059-1065. [PMID: 32738279 PMCID: PMC7390732 DOI: 10.1016/j.jpainsymman.2020.07.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Robert K Horowitz
- Division of Palliative Care, University of Rochester Medicine, Rochester, New York, USA.
| | - Laura A Hogan
- Division of Palliative Care, University of Rochester Medicine, Rochester, New York, USA
| | - Thomas Carroll
- Division of Palliative Care, University of Rochester Medicine, Rochester, New York, USA
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