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Sanders JJ, Benotti E, Jaramillo C, Sihlongonyane B, Downey N, Mitchell S, Sterba KR, Carey EC, Meier D, Mohta NS, Fromme E, Paladino J. Implementing the Serious Illness Care Program in Safety Net Health Systems: a qualitative study. J Pain Symptom Manage 2024:S0885-3924(24)00787-5. [PMID: 38815729 DOI: 10.1016/j.jpainsymman.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/03/2024] [Accepted: 05/14/2024] [Indexed: 06/01/2024]
Abstract
CONTEXT Interventions to improve the quality of care for people affected by serious illness commonly fail to reach patients from marginalized and underserved communities, which include those characterized by racialized or indigenous identity, sexual and gender minority status, and rural living. Interventions to improve care through serious illness conversations have demonstrated benefit, but little is known about their implementation in health systems that predominantly serve these patient groups. OBJECTIVES The study aimed to understand factors influencing implementation of a serious illness communication-focused intervention - the Serious Illness Care Program - in health systems who primarily provide care to marginalized and underserved communities. METHODS Qualitative interviews (16) and focus groups (3) were conducted with 19 interdisciplinary team members from six geographically diverse U.S. healthcare systems. Using a template analysis approach, investigators coded data inductively and deductively to identify themes. RESULTS Three themes emerged: patient factors, intervention elements, and health system contextual factors. Participants highlighted mission-driven efforts, creativity, interprofessional practice, and trainees as enablers of success. They identified weaknesses in the intervention's communication tool - the Serious Illness Conversation Guide guide, - as barriers to implementation of conversations. Resource constraints, socio-economic vulnerability, and mistrust in the health system were seen as additional barriers. CONCLUSIONS Health systems that provide care to underserved and marginalized communities face unique challenges implementing the Serious Illness Care Program. They also possess assets, some unique to these settings, that support program adoption. Findings suggest that implementation of similar programs in low-resource healthcare settings may help address unmet needs among marginalized populations.
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Affiliation(s)
- Justin J Sanders
- Ariadne Labs, Boston, MA; McGill University, Montreal, QC, Canada.
| | | | | | | | | | | | | | | | | | - Namita S Mohta
- Ariadne Labs, Boston, MA; Harvard Medical School; Brigham and Women's Hospital, Boston, MA
| | - Erik Fromme
- Ariadne Labs, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School
| | - Joanna Paladino
- Ariadne Labs, Boston, MA; Harvard Medical School; Massachusetts General Hospital, Boston, MA
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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] [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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Baxter R, Pusa S, Andersson S, Fromme EK, Paladino J, Sandgren A. Core elements of serious illness conversations: an integrative systematic review. BMJ Support Palliat Care 2024:spcare-2023-004163. [PMID: 37369576 DOI: 10.1136/spcare-2023-004163] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Ariadne Labs' Serious Illness Care Program (SICP), inclusive of the Serious Illness Conversation Guide (SICG), has been adapted for use in a variety of settings and among diverse population groups. Explicating the core elements of serious illness conversations could support the inclusion or exclusion of certain components in future iterations of the programme and the guide. AIM This integrative systematic review aimed to identify and describe core elements of serious illness conversations in relation to the SICP and/or SICG. DESIGN Literature published between 1 January 2014 and 20 March 2023 was searched in MEDLINE, PsycINFO, CINAHL and PubMed. All articles were evaluated using the Joanna Briggs Institute Critical Appraisal Guidelines. Data were analysed with thematic synthesis. RESULTS A total of 64 articles met the inclusion criteria. Three themes were revealed: (1) serious illness conversations serve different functions that are reflected in how they are conveyed; (2) serious illness conversations endeavour to discover what matters to patients and (3) serious illness conversations seek to align what patients want in their life and care. CONCLUSIONS Core elements of serious illness conversations included explicating the intention, framing, expectations and directions for the conversation. This encompassed discussing current and possible trajectories with a view towards uncovering matters of importance to the patient as a person. Preferences and priorities could be used to inform future preparation and recommendations. Serious illness conversation elements could be adapted and altered depending on the intended purpose of the conversation.
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Affiliation(s)
- Rebecca Baxter
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Susanna Pusa
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Sofia Andersson
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Erik K Fromme
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, 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-Vaxjo Campus, Vaxjo, Sweden
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Lavecchia M, Myers J, Bainbridge D, Incardona N, Levine O, Steinberg L, Schep D, Vautour J, Kumar SJ, Seow H. Education modalities for serious illness communication training: A scoping review on the impact on clinician behavior and patient outcomes. Palliat Med 2024; 38:170-183. [PMID: 37424275 PMCID: PMC10865772 DOI: 10.1177/02692163231186180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
BACKGROUND Several clinician training interventions have been developed in the past decade to address serious illness communication. While numerous studies report on clinician attitudes and confidence, little is reported on individual education modalities and their impact on actual behavior change and patient outcomes. AIM To examine what is known about the education modalities used in serious illness communication training and their impact on clinician behaviors and patient outcomes. DESIGN A scoping review using the Joanna Briggs Methods Manual for Scoping Reviews was conducted to examine studies measuring clinician behaviors or patient outcomes. DATA SOURCES Ovid MEDLINE and EMBASE databases were searched for English-language studies published between January 2011 and March 2023. RESULTS The search identified 1317 articles: 76 met inclusion criteria describing 64 unique interventions. Common education modalities used were: single workshop (n = 29), multiple workshops (n = 11), single workshop with coaching (n = 7), and multiple workshops with coaching (n = 5); though they were inconsistently structured. Studies reporting improved clinician skills tended to be in simulation settings with neither clinical practice nor patient outcomes explored. While some studies reported behavior changes or improved patient outcomes, they did not necessarily confirm improvements in clinician skills. As multiple modalities were commonly used and often embedded within quality improvement initiatives, the impact of individual modalities could not be determined. CONCLUSION This scoping review of serious illness communication interventions found heterogeneity among education modalities used and limited evidence supporting their effectiveness in impacting patient-centered outcomes and long-term clinician skill acquisition. Well-defined educational modalities and consistent measures of behavior change and standard patient-centered outcomes are needed.
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Affiliation(s)
- Melissa Lavecchia
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada
| | - Jeff Myers
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Daryl Bainbridge
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Nadia Incardona
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Oren Levine
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Leah Steinberg
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel Schep
- Division of Radiation Oncology, Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Joanna Vautour
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, ON, Canada
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Rao V, Linsky S, Knobf MT. Perspectives of Patients With Relapsed and Refractory Acute Myeloid Leukemia and High-Risk Myelodysplastic Syndrome on Patient-Clinician Communication About Prognosis and the Future. Palliat Med Rep 2024; 5:53-62. [PMID: 38249836 PMCID: PMC10797310 DOI: 10.1089/pmr.2023.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 01/23/2024] Open
Abstract
Background Patients with acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS) experience unpredictable disease trajectories and high prognostic uncertainty, which serve as barriers to patient-clinician communication about prognosis and their values and preferences for the future in the event of worsening health. Little is known about patients' day-to-day lived experiences and how this shapes their willingness to engage in such conversations. Objectives To explore participant perspectives on living with their illness and patient-clinician communication about prognosis and the future. Design This is a qualitative study using semi-structured interviews. Setting/Subjects Patients with relapsed and refractory (R/R) AML and high-risk MDS from a northeastern U.S. cancer center. Data Collection Interviews were transcribed verbatim and thematic analysis was used to generate findings. Results Of the 14 participants, the mean age was 66 years, 79% were men, 93% were White, married, and had AML. The overarching theme that describes the experience was "Taking One Day at a Time" in a Fog of Uncertainty. Uncertainty was a universal perception related to the challenges for clinicians to predict prognosis. To cope with uncertainty, most participants tried to focus on the present and maintain normality in everyday life. Participants valued encouragement and positivity in patient-clinician communication, however, the majority were not ready to discuss prognosis and the future in the event of worsening health. Of note, 7 of 14 participants died within three months after the interview. Conclusions These data describe a unique perspective of patients with R/R AML and high-risk MDS that clinicians could use to enhance communication strategies.
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Affiliation(s)
- Vinay Rao
- Division of Palliative Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sarah Linsky
- School of Nursing, Yale University, Orange, Connecticut, USA
| | - M. Tish Knobf
- School of Nursing, Yale University, Orange, Connecticut, USA
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Andersson S, Granat L, Baxter R, Reimertz H, Modéus C, Pusa S, Sandgren A. Translation, Adaptation, and Validation of the Swedish Serious Illness Conversation Guide. J Palliat Care 2024; 39:21-28. [PMID: 37886797 PMCID: PMC10687820 DOI: 10.1177/08258597231210136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Objective: To translate and adapt the Serious Illness Conversation Guide for use within the Swedish healthcare setting and examine the validity and acceptability of the Swedish Serious Illness Conversation Guide. Methods: Three rounds of cognitive interviews were conducted (T1-3); patients (T1 n = 11; T2 n = 10; T3 n = 8), family members (T1 n = 5; T2 n = 2; T3 n = 2), and healthcare professionals (T1 n = 6; T2 n = 6; T3 n = 5). The guide was iteratively adapted based on interview feedback, clinical experience, and the literature. The guide was tested on training days with physicians and nurses. Results: The Swedish Serious Illness Conversation Guide was found to be useful in supporting serious illness conversations. Clinicians reported that some questions were emotionally challenging. Explicit questions about prognosis and timing were excluded. Instead, the dual approach of "hoping for the best and preparing for the worst" was used to explore patients' thoughts about the future. Conclusions: Patients, family members, and healthcare professionals found the Swedish Serious Illness Conversation Guide to be appropriate, sensitive, and responsive to their needs. The Swedish Serious Illness Conversation Guide may facilitate a more health-promoting approach to serious illness conversations. Further research is needed to understand the impact of these conversations on person-centered and goal-concordant care.
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Affiliation(s)
- Sofia Andersson
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Sweden
| | - Lisa Granat
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Rebecca Baxter
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Sweden
| | - Helene Reimertz
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Unit of Palliative Care, Region Kronoberg, Växjö, Sweden
| | - Carina Modéus
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Unit of Palliative Care, Region Kronoberg, Växjö, Sweden
| | - Susanna Pusa
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Sweden
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
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Sullivan SS, Mann CM, Wittenberg E. Communication Openings: A Novel Approach for Serious Illness Communication in Homecare. J Gerontol Nurs 2023; 49:33-41. [PMID: 37906048 DOI: 10.3928/00989134-20231011-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Serious illness communication in homecare about hospice and/or palliative care transitions is lacking due to clinical culture. The purpose of the current study was to understand communication openings using COMFORT™, a palliative care communication model used to train nurses. Qualitative, focus group interviews with 31 homecare nurses were conducted. Data were transcribed verbatim and thematically analyzed using NVivo software, followed by hand-sorting. Four themes for communication openings for initiating discussions about potential hospice and/or palliative care transitions were identified: Organizational Openings (homecare appropriateness, eligibility requirements, and staffing); Patient Openings (patient physical decline, psychosocial changes, safety concerns, and denying/stopping care); Caregiver Openings (caregiver physical changes and patient readiness); and Nurse Openings (need for hospice, checking for prognosis understanding, increasing interprofessional care needs, and providing end-of-life care). This study extends the concept of communication openings in the COMFORT model. Further development of communication openings as part of COMFORT communication is needed in educational and intervention research. [Journal of Gerontological Nursing, 49(11), 33-41.].
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Salas A, Boanca K, Purdy J, De Lima B, Peterson M, Nerness R, Eckstrom E, Kwon A. Resident-led research: a quality improvement project to improve serious illness conversations. GERONTOLOGY & GERIATRICS EDUCATION 2023:1-6. [PMID: 37561638 DOI: 10.1080/02701960.2023.2246406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Skilled conversations regarding end-of-life (EOL) care reduce emotional suffering and increase goal-concordant care. The Ariadne Labs Serious Illness Conversation (SIC) framework is an effective tool for improving EOL communication, but research is lacking on use with resident physicians. This study led by internal medicine residents tested the feasibility and acceptability of training peers in SIC. In 2021, three resident project leaders recruited first and second year internal medicine residents at a single tertiary academic center to receive extracurricular training on the Ariadne Labs SIC Guide. Baseline and post-training surveys were conducted to determine attitudes, barriers, and confidence related to EOL discussions. Initial recruitment efforts were unsuccessful but participation increased from zero to seven after residency administrators approved protected time for SIC training. Six residents (85.7%) completed baseline and post-training surveys. Residents identified lack of time as the key barrier to initiating SIC. Self-reported comfort discussing EOL care and documenting the conversations improved after training. Both resident researchers and participants reported SIC training was valuable and successful. Institutional support with dedicated buy-in, strong faculty mentorship, and committed resident leaders all contribute to successfully implementing a resident-led project.
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Affiliation(s)
- Arinea Salas
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - KerriAnn Boanca
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Johanna Purdy
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Bryanna De Lima
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Mara Peterson
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Reed Nerness
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Elizabeth Eckstrom
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Amy Kwon
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
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Vergo MT, Cullinan A, Wilson M, Wasp G, Foster-Johnson L, Arnold RM. Low-Cost, Low-Resource Training Model to Enhance and Sustain Serious Illness Conversation Skills for Internal Medicine Residents. J Palliat Med 2022; 25:1708-1714. [PMID: 36036825 DOI: 10.1089/jpm.2022.0247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Funding and limited resources are barriers to required training of residents in serious illness conversation (SIC) skills. Objectives: To examine the effectiveness of a low-cost, low-resource (LCLR) SIC training embedded within a required palliative care rotation. Design: Pre-post prospective cohort study design. Setting/Subjects: Second year internal medicine (IM) residents received an LCLR three-hour training in the SIC Guide (SICG) with a single-faculty member and paired-participant practice replacing actors during a required two-week palliative medicine rotation. Measures: SIC competence checklist measured within simulated patient encounters longitudinally. Results: Twenty resident average SIC checklist scores improved from 11 (95% confidence interval [CI] 9-13) at the beginning of rotation to 19 (95% CI 17-20) at the end of rotation and 18 (95% CI 16-20) at six months after the rotation. Conclusions: LCLR SIC training for IM residents significantly increased the sustained use of basic SIC skills, but was less effective for more complex skills.
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Affiliation(s)
- Maxwell T Vergo
- Section of Palliative Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Amelia Cullinan
- Section of Palliative Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Matthew Wilson
- Section of Palliative Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Garrett Wasp
- Section of Hematology-Oncology, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Lynn Foster-Johnson
- Department of Medical Education, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC) and UPMC Health System, Palliative and Supportive Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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