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Sun AH, Ménard A, Farrell E, Filip A, Katz A, Orosz Z, Hsu AT. Perceptions of Palliative and End-Of-Life Care Capacity Among Frontline Staff and Administrators in Long-Term Care Homes During the COVID-19 Pandemic in Ontario, Canada: A Mixed-Methods Evaluation. J Am Med Dir Assoc 2023; 24:1586-1593. [PMID: 37488030 PMCID: PMC10293894 DOI: 10.1016/j.jamda.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 05/18/2023] [Accepted: 06/12/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVES The COVID-19 pandemic has greatly affected the morbidity and mortality of residents in long-term care (LTC) homes. However, not much is known about its impact on staff's perception of their capacity to provide palliative and end-of-life (EOL) care for LTC residents over the course of the pandemic. We investigated changes in self-reported confidence among LTC workers and their experience in providing palliative and EOL care to residents before and during the COVID-19 pandemic. DESIGN Mixed-methods evaluation using a survey (n = 19) and semistructured interviews (n = 28). SETTING AND PARTICIPANTS Frontline workers from 9 LTC homes who participated in Communication at End-of-Life Program in Ontario, Canada, between August 2019 and March 2020. METHODS The survey captured LTC staff's confidence level, including attitudes toward death and dying; relationships with residents and families; and participation in palliative and EOL care. The interviews identified facilitators and barriers to providing palliative and EOL care during the pandemic. RESULTS The COVID-19 pandemic negatively impacted frontline LTC staff's confidence in their role as palliative care providers. Participants also reported notable challenges to providing resident-centered palliative and EOL care. Specifically, visitation restriction has led to increased loneliness and isolation of residents and impeded staff's ability to build supportive relationships with families. Furthermore, staffing shortages due to the single-site work restriction and illness increased workload. Psychological stress caused by a fear of COVID-19 infection and transmission also hindered staff's capacity to provide good palliative and EOL care. CONCLUSIONS AND IMPLICATIONS Frontline LTC staff-even those who felt competent in their knowledge and skills in providing palliative and EOL care after receiving training-reported notable difficulties in providing resident-centered palliative and EOL care during the COVID-19 pandemic.
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Affiliation(s)
- Annie H Sun
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ontario Centres for Learning, Research and Innovation in Long-Term Care at Bruyère, Ottawa, Ontario, Canada
| | - Alixe Ménard
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Emily Farrell
- Ontario Centres for Learning, Research and Innovation in Long-Term Care at Bruyère, Ottawa, Ontario, Canada
| | - Angelina Filip
- Ontario Centres for Learning, Research and Innovation in Long-Term Care at Bruyère, Ottawa, Ontario, Canada
| | - Andrea Katz
- Ontario Centres for Learning, Research and Innovation in Long-Term Care at Bruyère, Ottawa, Ontario, Canada
| | - Zsofia Orosz
- Ontario Centres for Learning, Research and Innovation in Long-Term Care at Bruyère, Ottawa, Ontario, Canada
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ontario Centres for Learning, Research and Innovation in Long-Term Care at Bruyère, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Sun AH, Crick M, Orosz Z, Hsu AT. An Evaluation of the Communication at End-of-Life Education Program for Personal Support Workers in Long-Term Care. J Palliat Med 2021; 25:89-96. [PMID: 34403594 DOI: 10.1089/jpm.2021.0054] [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: 11/12/2022] Open
Abstract
Background: Communication skills are crucial for personal support workers (PSWs) to foster therapeutic relationships with the residents and their families in the long-term care (LTC) setting. Aim: To evaluate the impact of the Communication at End-of-Life (CEoL) Education Program on the competency and confidence of PSWs working in LTC to communicate about palliative and end-of-life care, and factors affecting their involvement in palliative and end-of-life care. Setting/Participants: PSWs from 35 LTC homes in Ontario, Canada, who participated in the CEoL Education Program between January and March 2019. Design: Mixed-methods evaluation using pre- (n = 178) and post-workshop (n = 113) surveys capturing the attitudes and beliefs toward death and dying; relationships with residents and families; and PSWs' participation in end-of-life care. Follow-up interviews were conducted between February and March 2019 with 21 PSWs to examine facilitators and barriers that affected their confidence in engaging in palliative care. Results: We observed significant improvements in all three domains, with the greatest increase (11%, p < 0.001) in the proportion of participants who responded "Often" or "Always" in the participation in end-of-life care domain. Specifically, we observed PSWs' elevated confidence in speaking with families of the residents about end-of-life, discussing goals and plans with the residents, and realizing that a "good death" is possible. Time constraints and staff shortages were recurrent themes that hindered many participants' ability to provide resident-centered care. Conclusions: This evaluation demonstrates that CEoL Education Program was associated with improved PSW competency and confidence in supporting palliative and end-of-life care in LTC settings.
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Affiliation(s)
- Annie H Sun
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Ontario Centers for Learning, Research, and Innovation in Long-Term Care at Bruyère, Ottawa, Ontario, Canada
| | - Michelle Crick
- Ontario Centers for Learning, Research, and Innovation in Long-Term Care at Bruyère, Ottawa, Ontario, Canada
| | - Zsofia Orosz
- Ontario Centers for Learning, Research, and Innovation in Long-Term Care at Bruyère, Ottawa, Ontario, Canada
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Palathra BC, Kawai F, Oromendia C, Bushan A, Patel Y, Morris J, Pan CX. To Code or Not To Code: Teaching Multidisciplinary Clinicians to Conduct Code Status Discussions. J Palliat Med 2019; 22:566-571. [PMID: 30615558 DOI: 10.1089/jpm.2018.0362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Code status discussions (CSDs) can be challenging for many clinicians. Barriers associated with them include lack of education, comfort level, and experience. Objective: To conduct an educational intervention to improve knowledge and communication approaches related to CSDs. Design: A cross-sectional multidisciplinary educational intervention was conducted over one year consisting of an interactive presentation, live role-play, and pre- and post-intervention tests to measure impact of the formal training. Evaluations and comments were also collected. Setting/Subjects: Attending physicians, nurses, residents, fellows, and physician assistants (PAs) at an urban community teaching hospital of 500 beds serving an ethnically diverse population. Measurements: Data from pre- and post-intervention tests evaluating knowledge and communication approach regarding CSDs were collected. Participants completed a qualitative evaluation of the program. Results: There were 165 participants: 29 attending physicians, 26 residents, 17 fellows, 18 PAs, and 75 nurses. All (100%) completed the pre-intervention test and 154 (93.3%) completed the post-intervention test. There was an overall improvement in scores, 43.8% pre-intervention to 75.6% post-intervention (p-values <0.005). Attending physicians and fellows had the highest pre-intervention scores, while nurses and PAs had the lowest. Most participants (97%) reported they learned new information and 91% stated they would change patient management. Conclusions: Our study found that a brief educational intervention with multipronged teaching tools improved knowledge concerning CSDs. Participants felt it provided new insights and would change their practice. This study contributes to the literature by examining CSD training across different disciplines, allowing for cross-group comparisons. Future studies should try to correlate educational interventions and clinician knowledge with clinical practice outcomes.
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Affiliation(s)
- Brigit C Palathra
- 1 Division of Geriatrics and Palliative Care, NewYork-Presbyterian Queens, Flushing, New York
| | - Fernando Kawai
- 1 Division of Geriatrics and Palliative Care, NewYork-Presbyterian Queens, Flushing, New York
| | - Clara Oromendia
- 2 Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York
| | - Archana Bushan
- 3 Department of Medicine, Sinai Hospital, Baltimore, Maryland
| | - Yera Patel
- 4 Department of Medicine, Jamaica Hospital Medical Center, Jamaica, New York
| | - Jane Morris
- 5 Department of Nursing, NewYork-Presbyterian Queens, Flushing, New York
| | - Cynthia X Pan
- 1 Division of Geriatrics and Palliative Care, NewYork-Presbyterian Queens, Flushing, New York
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von Gunten CF, Twaddle M, Preodor M, Neely KJ, Martinez J, Lyons J. Evidence of improved knowledge and skills after an elective rotation in a hospice and palliative care program for internal medicine residents. Am J Hosp Palliat Care 2016; 22:195-203. [PMID: 15909782 DOI: 10.1177/104990910502200309] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There is compelling evidence that residents training in primary care need education in palliative care. Evidence for effective curricula is needed. The objective of this study was to test whether a clinical elective improves measures of knowledge and skill. Residents from three categorical training programs in internal medicine were recruited to an elective including clinical experiences in an acute hospital palliative care consultation service, on an acute hospice and palliative care unit, and in-home hospice care. A 25-question pre- and post-test and a videotaped interview with a standardized patient were used to assess communication skills and measure outcomes. Residents demonstrated a 10 percent improvement in knowledge after the four-week elective (p < 0.05). All residents demonstrated basic competency in communication skills at the end of the rotation. These results indicate that clinical rotation shows promise as an educational intervention to improve palliative care knowledge and skills in primary care residents. An important limitation of the study is that it is an elective; further studies with a required rotation and/or a control group are needed to confirm the findings.
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Affiliation(s)
- Charles F von Gunten
- Center for Palliative Studies, San Diego Hospice & Palliative Care, San Diego, California, USA
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Long AC, Downey L, Engelberg RA, Ford DW, Back AL, Curtis JR. Physicians' and Nurse Practitioners' Level of Pessimism About End-of-Life Care During Training: Does It Change Over Time? J Pain Symptom Manage 2016; 51:890-897.e1. [PMID: 26826677 PMCID: PMC4875853 DOI: 10.1016/j.jpainsymman.2015.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 11/27/2015] [Accepted: 12/01/2015] [Indexed: 10/22/2022]
Abstract
CONTEXT An enhanced understanding of trainee attitudes about end-of-life care is needed to inform interventions to improve clinician communication about dying and death. OBJECTIVES To examine changes in trainee pessimism about end-of-life care over the course of one academic year and to explore predictors of pessimism among residents, fellows, and nurse practitioners. METHODS We used baseline and follow-up surveys completed by trainees during a randomized controlled trial of an intervention to improve clinician communication skills. Surveys addressed trainee feelings about end-of-life care. Latent variable modeling was used to identify indicators of trainee pessimism, and this pessimism construct was used to assess temporal changes in trainee attitudes about end-of-life care. We also examined predictors of trainee pessimism at baseline and follow-up. Data were available for 383 trainees from two training programs. RESULTS There was a significant decrease in pessimism between baseline and follow-up assessments. Age had a significant inverse effect on baseline pessimism, with older trainees being less pessimistic. There was a direct association of race/ethnicity on pessimism at follow-up, with greater pessimism among minority trainees (P = 0.028). The model suggests that between baseline and follow-up, pessimism among younger white non-Hispanic trainees decreased, whereas pessimism among younger trainees in racial/ethnic minorities increased over the same period. CONCLUSION Overall, trainee pessimism about end-of-life care decreases over time. Pessimism about end-of-life care among minority trainees may reflect the influence of culture on clinician attitudes about communication with seriously ill patients. Further research is needed to understand the evolution of trainee attitudes about end-of-life care during clinical training.
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Affiliation(s)
- Ann C Long
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.
| | - Lois Downey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Dee W Ford
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Anthony L Back
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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Chen E, McCann JJ, Lateef OB. Attitudes Toward and Experiences in End-of-life Care Education in the Intensive Care Unit: A Survey of Resident Physicians. Am J Hosp Palliat Care 2014; 32:738-44. [PMID: 24939207 DOI: 10.1177/1049909114539038] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Resident physicians provide the most physician care to intensive care unit (ICU) patients. The body of literature about residents' palliative and end-of-life care (PC/EOLC) experiences in the ICU is limited. To our knowledge, this is the first study to assess resident physicians in multiple specialties regarding PC/EOLC in the ICU. METHODS A Web-based survey was developed and administered to all resident physicians in a single academic institution who had completed at least 1 dedicated ICU rotation. RESULTS Residents reported moderate comfort in dealing with end-of-life (EOL) issues and felt somewhat prepared to care for critically ill patients at the EOL. Feedback should be provided to residents regarding their PC/EOLC skills, and education should be tailored to residents rotating in the ICU.
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Affiliation(s)
- Elaine Chen
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA Department of Medicine, Division of Geriatrics, Section of Pain and Palliative Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Judith J McCann
- Rush University College of Nursing, Rush University Medical Center, Chicago, IL, USA Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, IL, USA
| | - Omar B Lateef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA
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Wastila LJ, Farber NJ. Residents' Perceptions about Surrogate Decision Makers' Financial Conflicts of Interest in Ventilator Withdrawal. J Palliat Med 2014; 17:533-9. [DOI: 10.1089/jpm.2013.0361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lisa J. Wastila
- San Diego School of Medicine, University of California, San Diego, La Jolla, California
| | - Neil J. Farber
- San Diego School of Medicine, University of California, San Diego, La Jolla, California
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Kramer BJ, Cleary J, Mahoney JE. Enhancing palliative care for low-income elders with chronic disease: feasibility of a hospice consultation model. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2014; 10:356-377. [PMID: 25494931 PMCID: PMC4321750 DOI: 10.1080/15524256.2014.975088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Challenges exist in assimilating palliative care within community-based services for nursing home eligible low-income elders with complex chronic illness as they approach the end of life (EOL). This study assessed the feasibility of a consultation model, with hospice clinicians working with three Care Wisconsin Partnership Program teams. Consults occurred primarily during team meetings and also informally and on joint patient visits and were primarily with the palliative care nurse addressing physical issues. Fifty-seven percent of consultant recommendations were implemented. Benefits of consultation were identified with focus groups of clinical staff as were opportunities and barriers to the implementation. Models of integration are proposed.
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Affiliation(s)
- Betty J. Kramer
- University of Wisconsin-Madison, School of Social Work, 1350 University Ave., Madison, WI 53706, 608-263-3830
| | - Jim Cleary
- University of Wisconsin-Madison, School of Medicine and Public Health, Division of Hematology/Oncology and Palliative Care
| | - Jane E. Mahoney
- University of Wisconsin-Madison, School of Medicine and Public Health, Division of Geriatrics
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Szmuilowicz E, Neely KJ, Sharma RK, Cohen ER, McGaghie WC, Wayne DB. Improving residents' code status discussion skills: a randomized trial. J Palliat Med 2012; 15:768-74. [PMID: 22690890 DOI: 10.1089/jpm.2011.0446] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Inpatient Code Status Discussions (CSDs) are commonly facilitated by resident physicians, despite inadequate training. We studied the efficacy of a CSD communication skills training intervention for internal medicine residents. METHODS This was a prospective, randomized controlled trial of a multimodality communication skills educational intervention for postgraduate year (PGY) 1 residents. Intervention group residents completed a 2 hour teaching session with deliberate practice of communication skills, online modules, self-reflection, and a booster training session in addition to assigned clinical rotations. Control group residents completed clinical rotations alone. CSD skills of residents in both groups were assessed 2 months after the intervention using an 18 item behavioral checklist during a standardized patient encounter. Average scores for intervention and control group residents were calculated and between-group differences on the CSD skills assessment were evaluated using two-tailed independent sample t tests. RESULTS Intervention group residents displayed higher overall scores on the simulated CSD (75.1% versus 53.2%, p<0.0001) than control group residents. The intervention group also displayed a greater number of key CSD communication behaviors and facilitated significantly longer conversations. The training, evaluation, and feedback sessions were rated highly. CONCLUSION A focused, multimodality curriculum can improve resident performance of simulated CSDs. Skill improvement lasted for at least 2 months after the intervention. Further studies are needed to assess skill retention and to set minimum performance standards.
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Affiliation(s)
- Eytan Szmuilowicz
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Jacobsen J, Robinson E, Jackson VA, Meigs JB, Billings JA. Development of a cognitive model for advance care planning discussions: results from a quality improvement initiative. J Palliat Med 2011; 14:331-6. [PMID: 21247300 DOI: 10.1089/jpm.2010.0383] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Residents struggle with advance care planning (ACP) discussions in the inpatient setting, and may not be aware of newer models for ACP that stress the importance of giving prognostic information and making a recommendation about cardiopulmonary resuscitation to patients and families. METHODS A controlled study of a cognitive model for ACP embedded in a quality improvement (QI) project. RESULTS In the setting of a QI project for medical residents and interdisciplinary staff, we developed and implemented a cognitive model of ACP discussions that involved two types of meetings for patients: (1) information-sharing meetings for seriously ill but clinically stable patients and (2) decision-making meetings for clinically unstable patients. Patients on the intervention floor were significantly more likely to have a discussion about goals of care (33.8%) than patients on the control floor (21.2%, p = < 0.001) and significantly more likely to have a limitation of life-sustaining treatment upon discharge (19.1% vs. 13.9%, p = 0.04). CONCLUSIONS For both residents and interdisciplinary staff, application of a cognitive model that clearly defines goals and expectations for ACP discussions prior to meeting with patients and families improves rates of ACP discussions.
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Affiliation(s)
- Juliet Jacobsen
- Palliative Care Service, Massachusetts General Hospital , Boston, MA 02114, USA.
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Lester PE, Daroowalla F, Harisingani R, Sykora A, Lolis J, Patrick PA, Feuerman M, Berger JT. Evaluation of housestaff knowledge and perception of competence in palliative symptom management. J Palliat Med 2011; 14:139-45. [PMID: 21214379 DOI: 10.1089/jpm.2010.0305] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE The Accreditation Council for Graduate Medical Education requires that internal medicine (IM) core curricula include end-of-life care and pain management concepts and that fellows in hematology/oncology, pulmonary/critical care, and geriatrics should receive formal instruction and clinical experience in palliative and end-of-life care. We aimed to assess the effectiveness of current teaching methods for housestaff in these fields. METHOD All of the IM residents, geriatric medicine fellows, hematology/oncology fellows, and pulmonary/critical care fellows from four regional graduate medical education sites were asked to participate in an online survey at the beginning and end of the 2008-2009 academic year. We evaluated seven domains of knowledge of palliative care and pain management with a self-assessment of competence in these areas. We also asked participants to describe their current curriculum and training in palliative medicine. RESULTS There were 326 e-mailed survey invitations. There were 180 responses for the start-year survey and 102 responses for the end-year survey. All sites were represented in the responses. The only learners to significantly improve their palliative knowledge during a year of training were PGY-1s and PGY-4s. The majority of housestaff surveyed report that their current palliative medicine training is inadequate. The vast majority (84.6%) said a dedicated palliative medicine rotation would be "useful" or "very useful." CONCLUSIONS Housestaff recognize their lack of experience and training in palliative medicine and are interested in many teaching venues to improve their skills. A more focused curriculum in palliative and end-of-life care is required at both resident and subspecialty fellowship levels.
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Affiliation(s)
- Paula E Lester
- Division of Geriatric Medicine, Winthrop-University Hospital, Mineola, New York, USA.
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Billings ME, Engelberg R, Curtis JR, Block S, Sullivan AM. Determinants of medical students' perceived preparation to perform end-of-life care, quality of end-of-life care education, and attitudes toward end-of-life care. J Palliat Med 2010; 13:319-26. [PMID: 20178433 DOI: 10.1089/jpm.2009.0293] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Medical students' learning about end-of-life care can be categorized into three learning modalities: formal curriculum, taught in lectures; informal curriculum, conveyed through clinical experiences; and "hidden curriculum," inferred from behaviors and implicit in medical culture. In this study, we evaluated associations between survey items assessing these learning modalities and students' perceptions of their preparation, quality of education, and attitudes toward end-of-life care. METHODS Data were collected from a national survey of fourth-year medical students (n = 1455) at 62 medical schools in 2001. Linear regression analyses were performed to assess associations between formal, informal and hidden end-of-life care curricula and students' perceived preparedness to provide end-of-life care, quality of end-of-life care education and attitudes toward end-of-life, controlling for students' demographics and clustered by school. RESULTS Students reporting more exposure to formal and informal curricula felt more prepared and rated their end-of-life care education higher. Students with more exposure to a hidden curriculum that devalued end-of-life care perceived their preparation as poorer and had poorer attitudes toward end-of-life care. Minority students had slightly more negative attitudes but no differences in perceived end-of-life care preparation. CONCLUSIONS Medical students' sense of preparedness for end-of-life care and perceptions of educational quality are greater with more coursework and bedside teaching. By contrast, the hidden curriculum conveying negative messages may impair learning. Our findings suggest that implicit messages as well as intentional teaching have a significant impact on students' professional development. This has implications for designing interventions to train physicians to provide outstanding end-of-life care.
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Affiliation(s)
- Martha E Billings
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington 98104, USA.
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Billings ME, Curtis JR, Engelberg RA. Medicine residents' self-perceived competence in end-of-life care. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2009; 84:1533-9. [PMID: 19858811 PMCID: PMC5847268 DOI: 10.1097/acm.0b013e3181bbb490] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
PURPOSE Internal medicine residents frequently provide end-of-life care, yet feel inadequately trained and uncomfortable providing this care, despite efforts to improve end-of-life care curricula. Understanding how residents' experiences and attitudes affect their perceived competence in providing end-of-life care is important for targeting educational interventions. METHOD Medicine residents (74) at the University of Washington and Medical University of South Carolina enrolled in a trial investigating the efficacy of a communication skills intervention to improve end-of-life care. On entry to the study in the fall of 2007, residents completed a questionnaire assessing their prior experiences, attitudes, and perceived competence with end-of-life care. Multivariate regression analysis was performed to assess whether attitudes and experiences with end-of-life care were associated with perceived competence, controlling for gender, race/ethnicity, training year, training site, and personal experience with death of a loved one. RESULTS Residents had substantial experience providing end-of-life care. In an adjusted multivariate model including attitudes and clinical experience in end-of-life care as predictors, only clinical experience providing end-of-life care was associated with self-perceived competence (P=.015). CONCLUSIONS Residents with more clinical experience during training had greater self-perceived competence providing end-of-life care. Increasing the quantity and quality of the end-of-life care experiences during residency with appropriate supervision and role modeling may lead to enhanced skill development and improve the quality of end-of-life care. The results suggest that cultivating bedside learning opportunities during residency is an appropriate focus for educational interventions in end-of-life care education.
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Affiliation(s)
- Martha E Billings
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington 98104, USA.
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Weissman DE, Ambuel B, von Gunten CF, Block S, Warm E, Hallenbeck J, Milch R, Brasel K, Mullan PB. Outcomes from a national multispecialty palliative care curriculum development project. J Palliat Med 2007; 10:408-19. [PMID: 17472513 DOI: 10.1089/jpm.2006.0183] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In 1998 we completed a successful regional pilot project in palliative care curriculum development among 32 internal medicine residency programs recruited from the mid-western United States. Between 1999 and 2004 this project was expanded to include 358 U.S. programs, from four specialties, based on new training requirements in internal medicine, family medicine, neurology, and general surgery. OBJECTIVE To assess the 1-year outcomes from residency programs participating in a national multispecialty palliative care curriculum development project. MEASUREMENT Outcome data obtained from residency programs' responses to a structured progress report 12 months after enrolling in the project and from published residency project reports. RESULTS Three hundred fifty-eight residency programs, representing 27% of all eligible training programs in the four specialties, participated in the project. Outcome data was available from 224 residencies (63%). Most programs started new teaching in pain, non-pain symptom management, and communication skills. More than 50% of programs integrated palliative care topics within established institutional grand rounds, morbidity/mortality conferences or morning report. More than 70% of internal medicine and family practice programs began new direct patient care training opportunities utilizing hospital-based palliative care or hospice programs. New faculty development initiatives and use of quality improvement projects to drive curriculum change were reported in less than 50% of programs. CONCLUSIONS Focused short-term instruction in palliative care curriculum development, in a diverse group of residency programs, is feasible and associated with significant curriculum change.
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Ellman MS, Rosenbaum JR, Bia M. Development and implementation of an innovative ward-based program to help medical students acquire end-of-life care experience. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2007; 82:723-7. [PMID: 17595576 DOI: 10.1097/acm.0b013e3180674b3a] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The authors developed and implemented a new ward-based end-of-life care experience for third-year medical students at Yale University School of Medicine, which began on a pilot basis in 2005. The primary objectives of the program, which still continues, are to improve students' comfort and skills in communicating with and assessing patients facing the end of life and to reflect on their experiences. Students interview a hospitalized patient, family, and caregivers; assess specified end-of-life domains and management plans; reflect on the experience; and then prepare a report for presentation at a case conference facilitated by dedicated multidisciplinary faculty. Many students interview patients while rotating on psychiatry consults, and the case conference occurs during the psychiatry clerkship. A total of 45 students in the pilot year (2005), 76 students in the following year, and 48 thus far in the current year have completed the program. An assessment of the personal impact of the exercise on the students who completed the program in 2005 and 2006 revealed six themes, including students' recognition of the complexity of patients' reactions to dying, students' appreciation of the value of the clinicians' presence, and students' personal reflections. This experience suggests that a hands-on end-of-life exercise is feasible and will be well received in the acute inpatient setting. Key features for success include separate, dedicated faculty for the case conference (which is integrated into a single clerkship), emphasis on student self-reflection, and a requirement that the written component become part of the student's portfolio.
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Affiliation(s)
- Matthew S Ellman
- Yale University School of Medicine, New Haven, Connecticut 06510, USA.
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Meert KL, Eggly S, Pollack M, Anand KJS, Zimmerman J, Carcillo J, Newth CJL, Dean JM, Willson DF, Nicholson C. Parents' perspectives regarding a physician-parent conference after their child's death in the pediatric intensive care unit. J Pediatr 2007; 151:50-5, 55.e1-2. [PMID: 17586190 PMCID: PMC1993355 DOI: 10.1016/j.jpeds.2007.01.050] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2006] [Revised: 12/01/2006] [Accepted: 01/31/2007] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate parents' perspectives on the desirability, content, and conditions of a physician-parent conference after their child's death in the pediatric intensive care unit (PICU). STUDY DESIGN Audio-recorded telephone interviews were conducted with 56 parents of 48 children. All children died in the PICU of one of six children's hospitals in the National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN) 3 to 12 months before the study. RESULTS Only seven (13%) parents had a scheduled meeting with any physician to discuss their child's death; 33 (59%) wanted to meet with their child's intensive care physician. Of these, 27 (82%) were willing to return to the hospital to meet. Topics that parents wanted to discuss included the chronology of events leading to PICU admission and death, cause of death, treatment, autopsy, genetic risk, medical documents, withdrawal of life support, ways to help others, bereavement support, and what to tell family. Parents sought reassurance and the opportunity to voice complaints and express gratitude. CONCLUSIONS Many bereaved parents want to meet with the intensive care physician after their child's death. Parents seek to gain information and emotional support, and to give feedback about their PICU experience.
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Zapka JG, Hennessy W, Lin Y, Johnson L, Kennedy D, Goodlin SJ. An interdisciplinary workshop to improve palliative care: Advanced
heart failure— Clinical guidelines and healing words. Palliat Support Care 2006; 4:37-46. [PMID: 16889322 DOI: 10.1017/s1478951506060056] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Objective: Effective communication is recognized as an
essential process to providing quality care, including palliative and
end-of-life care. Discussion of prognosis and support needs of patients
with heart failure is particularly challenging given the nature of the
condition and care across several settings. The objective was to design,
implement, and evaluate an interdisciplinary workshop aimed at improving
attitudes and skills related to communication with patients and family,
health team communication and documentation, and assessment of physical
and emotional symptoms.Methods: A pretest, delayed posttest evaluation design was
used to evaluate two 4-h workshops offered to nurses, social workers, and
other nonphysician clinicians.Results: Although baseline reports of skills were high for
the participants, significant improvement was noted for objectives
emphasized in the workshop.Significance of results: This project demonstrated the
feasibility of designing, marketing a brief workshop, and positively
impacting communication and documentation skills.
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Affiliation(s)
- Jane G Zapka
- Department of Biostatistics, Bioinformatics and Epidemiology, Medical University of South Carolina, Charleston, SC 29425, USA.
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Sears SF, Sowell LV, Kuhl EA, Handberg EM, Kron J, Aranda JM, Conti JB. Quality of Death: Implantable Cardioverter Defibrillators and Proactive Care. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 29:637-42. [PMID: 16784431 DOI: 10.1111/j.1540-8159.2006.00412.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The purpose of this paper is to discuss quality of death (QOD) among patients with congestive heart failure (CHF) and implantable cardioverter defibrillators. We outline recommendations that enhance QOD from the device patient and specialty cardiology perspectives. BACKGROUND Contemporary treatment of CHF patients routinely includes both pharmacologic therapy and the use of cardiac devices. The implantable cardioverter defibrillator prevents premature death in heart failure patients, though not death itself. CONCLUSIONS Active discussion and consideration of patient's QOD is indicated in implantable cardioverter defibrillator patients to prevent unnecessary treatment and to increase control over perceived quality of life by patients and family.
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Affiliation(s)
- Samuel F Sears
- Department of Clinical and Health Psychology, University of Florida Health Science Center, Gainesville, Florida 32610, USA.
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Ogle KS, Mavis B, Thomason C. Learning to provide end-of-life care: postgraduate medical training programs in Michigan. J Palliat Med 2006; 8:987-97. [PMID: 16238511 DOI: 10.1089/jpm.2005.8.987] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE A statewide survey of postgraduate medical training programs was conducted to determine the current status of training related to end-of-life (EOL) care and hospice care training. METHODS A mail survey of 275 program directors was conducted with a response rate of 70%. The questionnaire focused on information about training in EOL care and hospice care: specific content, required and elective experiences, teaching formats, and program directors' ratings of the perceived adequacy of training. This study received Institutional Review Board (IRB) approval. RESULTS Less than half (46%) of the residency programs reported any formal training in EOL care, and less than one third (31%) reported training in hospice care. A majority of programs with EOL and/or hospice training required it for all residents. Of the programs with required hospice training, only half included a clinical component; fewer programs with EOL training reported a clinical component. Most program directors rated their programs as adequate or excellent in terms of EOL and hospice care, whether they had formal training or not. CONCLUSIONS The results of the survey demonstrate considerable variability in training with respect to hospice and EOL care. Training through direct clinical experience was infrequently reported. There has been little formal adoption of published curricula in this area. The high level of adequacy in the rating of training by program directors contrasts with relative lack of reported curriculum content and implementation, suggesting that improvements in EOL care training will be slow to come if left in the hands of program directors.
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Affiliation(s)
- Karen S Ogle
- Department of Family Practice, Michigan State University, East Lansing, Michigan 48824, USA.
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Abstract
ICUs are a vital component of modern health care. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance to a different paradigm that emphasizes the need to assess and improve ICU systems and processes. This is the first part of a two-part treatise. It discusses existing problems in ICU care, and the methods for defining and measuring ICU performance.
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Affiliation(s)
- Allan Garland
- Division of Pulmonary and Critical Care Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, 2500 MetroHealth Dr, Cleveland, OH 44109, USA.
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Montagnini M, Varkey B, Duthie E. Palliative Care Education Integrated into a Geriatrics Rotation for Resident Physicians. J Palliat Med 2004; 7:652-9. [PMID: 15588356 DOI: 10.1089/jpm.2004.7.652] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The authors present the curricular elements of a palliative care experience for internal medicine residents at the Medical College of Wisconsin (MCW) and the Zablocki Veterans Affairs Medical Center (ZVAMC), Milwaukee, Wisconsin. To improve resident physicians' knowledge and skills in palliative care, a structured clinical/educational experience was integrated into an existing required geriatrics rotation for senior medicine residents. Each month, two residents rotate simultaneously in the palliative care and the geriatrics evaluation and management units at the ZVAMC. The curricular elements of palliative care include prognostication, assessment and management of pain and nonpain symptoms in end-of-life care. The geriatrics component emphasizes mechanisms of aging, pathophysiology of common geriatric diseases, clinical pharmacology and psychosocial aspects of geriatric care. Teaching methods include direct patient care, bedside teaching rounds, lectures, and multidisciplinary and family meetings. Rotation design avoided conflicting time demands on the residents. In a prerotation/postrotation knowledge self-assessment questionnaire, residents (n = 28) indicated significant knowledge improvement in all palliative care domains taught during the experience. The rotation was well integrated into the existing curricular elements in geriatrics and palliative medicine at MCW. This combined rotation can serve as a reference for educators interested in developing new or enhancing existing palliative care training programs.
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Affiliation(s)
- Marcos Montagnini
- Medical College of Wisconsin, and Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA.
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Okon TR, Evans JM, Gomez CF, Blackhall LJ. Palliative Educational Outcome with Implementation of PEACE Tool Integrated Clinical Pathway. J Palliat Med 2004; 7:279-95. [PMID: 15130206 DOI: 10.1089/109662104773709404] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND House officers frequently lack basic competency in end-of-life care. Few studies have evaluated educational interventions deliberately utilizing physicians' learning strategies, particularly in the context of a concomitant effort at modification of practice patterns. STUDY DESIGN Prospective controlled trial utilizing pre-intervention and post-intervention cross-sectional surveys. PARTICIPANTS Internal medicine residents at a university hospital in their first, second, and third years of training. SURVEY A 25-item survey modified from previously published instruments. INTERVENTION Residents in the intervention group utilized an experiential learning intervention (integrated, end-of-life clinical pathway: PEACE Tool). The control group delivered care in a standard fashion. DATA ANALYSIS SURVEY item and test responses were tabulated and pair-wise comparisons between group means evaluated statistically using two-sample t tests. RESULTS Fifty-four internal medicine residents (n = 24, first-year; n = 17, second-year; and n = 13, third-year) completed the survey. Pre-intervention mean scores on a 16-item knowledge scale were 7.4 (46% correct) for first-year, 8.1 (51%) for second-year, and 9.2 (58%) for third-year residents. Eighteen first-year residents participated in the intervention phase (8 in the intervention, 10 in the control). Mean overall knowledge scores were 46% higher in the intervention group compared to the control group (11.8 versus 8.1 p < 0.001). CONCLUSIONS A time-effective, practice-based strategy led to a significant improvement in knowledge of end-of-life care. Prior to implementation of this strategy competency in end-of-life care was suboptimal among internal medicine residents, in spite of desirable attitudes. Factual knowledge improved slightly with standard, pre-intervention training and experience.
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Affiliation(s)
- Tomasz R Okon
- Division of General Internal Medicine, Section of Palliative Care, University of Virginia, Charlottesville, VA, USA.
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Abstract
OBJECTIVE To examine interns' perceptions of the emotional support they were able to provide to dying patients and their families, as well as their evaluation of attending physicians as role models caring for dying patients and their families. METHODS A semistructured, face-to-face interview of a convenience sample of 38 internal medicine interns in two New York City teaching hospitals who were the primary house officers of patients dying between January 2000 and April 2000. RESULTS Fifty-eight percent of interns rated their comfort level in talking to their patient and family about end-of-life issues as good to excellent. Sixty percent of interns estimated that their impact on their patient's emotional experiences as they approached death as none to minimal. Seventy-four percent of interns rated their patient's physical comfort level good to excellent. Interns rated attending physicians as effective role models in 66% of cases; 34% percent were rated as poor to mediocre. Observation of attending physicians with patients and families was rated as the most effective method to learn how to care for dying patients. CONCLUSIONS While most interns felt comfortable speaking to their patients and their families about end-of-life issues, they also believed that they provided only minimal emotional support. Interns believe that direct observation of attending physicians is the most effective way to improve their skills caring for dying patients and their families; however, they report wide variability in attending physician performance as role models.
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Affiliation(s)
- Jennifer Rhodes-Kropf
- Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine, Division of Geriatrics, Bronx, New York 10467-2490, USA.
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Ogle K, Mavis B, Wang T. Hospice and primary care physicians: attitudes, knowledge, and barriers. Am J Hosp Palliat Care 2003; 20:41-51. [PMID: 12568436 DOI: 10.1177/104990910302000111] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Underuse of hospice services is a significant problem in the United States. Primary care physicians constitute an increasing referral base and have been hypothesized to be important barriers to increased use. We conducted a mail survey of 131 primary care physicians (overall response rate of 72 percent), examining their attitudes toward, knowledge about, and perceived benefits and barriers to hospice care. Physicians demonstrated very favorable attitudes towards hospice. They had correct knowledge about most aspects of hospice, and, where they did not, they were far more likely to be uncertain than erroneous. Primary care physicians perceived many benefits to hospice care and identified patient and family readiness as the major barrier to earlier hospice referrals. A significant subgroup had concerns about problems in interacting with hospices. There were very few differences between family practitioners and general internists. These findings have many implications for directing collaborative efforts between primary care physicians and hospices to improve end-of-life care.
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Affiliation(s)
- Karen Ogle
- Program in Palliative Care Education and Research, and Department of Family Practice, Michigan State University, East Lansing, Michigan, USA
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Von Gunten CF, Mullan PB, Harrity S, Diamant J, Heffernan E, Ikeda T, Roberts WL. Residents from five training programs report improvements in knowledge, attitudes and skills after a rotation with a hospice program. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2003; 18:68-72. [PMID: 12888378 DOI: 10.1207/s15430154jce1802_06] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND The faculty of the Center for Palliative Studies teach residents from 5 different primary care residency training programs who rotate at San Diego Hospice: 3 in Internal Medicine, 2 in Family Medicine. Residents participate in the care of patients in the inpatient care setting and make joint home visits with physicians and other team members. A series of 4 lectures on end-of-life care is given on Tuesday mornings: management of pain, other symptoms, interdisciplinary roles of chaplains, social workers, nurses, and grief/bereavement are discussed. In addition, there is a Tuesday noon conference that follows a journal club format. Because of scheduling, residents from some programs are not able to attend all lectures and conferences. METHODS A 27-item self-assessment evaluation tool was developed for administration to residents before and after their experience. A total of 65 evaluations for residents rotating in academic year 1997-98 and 1998-1999 were collated and analyzed. RESULTS When evaluated as a whole, residents noted significant improvements in their ability to assess and treat symptoms, to tell patient/family about the dying process and to care for dying patients at home (range in improvement from 26% to 67%, p < 0.05 using paired t-test). About half of the residents perceived that the content was not available elsewhere in their training. CONCLUSION We conclude that a single hospice rotation can effectively contribute to resident education in multiple programs.
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Affiliation(s)
- Charles F Von Gunten
- Center for Palliative Studies, San Diego Hospice and Palliative Care, San Diego, CA 92103, USA.
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Mullan PB, Weissman DE, Ambuel B, von Gunten C. End-of-life care education in internal medicine residency programs: an interinstitutional study. J Palliat Med 2002; 5:487-96. [PMID: 12353495 DOI: 10.1089/109662102760269724] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Integrating end-of-life care (EOL) education into medical residency programs requires knowledge of what programs currently teach and what residents learn. OBJECTIVE Evaluate EOL teaching content and practices in internal medicine residency programs and the EOL knowledge of their faculty and residents. DESIGN An interinstitutional pilot study. We examined patterns of EOL education, discerned from program directors' responses to structured surveys of institutional teaching and evaluation practices, and EOL knowledge, derived from the performance of faculty and residents on a 36-item knowledge examination. SUBJECTS Program directors, faculty, and residents at 32 accredited U.S. internal medicine residency programs. RESULTS Although all programs cited inclusion of some EOL education, expected EOL domains were not systematically taught or assessed. Pain assessment and treatment training was required in only 60% of programs. Even fewer programs required instruction on nonpain symptoms (<30%) or hospice and nonhospital care settings (22%). EOL assessment depends primarily on faculty's general ratings of residents' global competency; few programs use knowledge examinations or structured skill assessments. Directors identified barriers and support for improving education. On the knowledge examination, the mean score of residents increased across training levels (F = 21.7, p < .001), and the mean score of faculty was higher than residents' (57.6%: 48.9%, t = 51.6, p < .001). CONCLUSIONS Existing internal medicine residency education lacks training in critical EOL care domains. Residency programs need additional training for residents and teaching faculty in EOL content and skills, with assessment practices that demonstrate competencies have been acquired. Program directors perceive institutional support for making these changes.
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Weissman DE, Mullan PB, Ambuel B, von Gunten C. End-of-life curriculum reform: outcomes and impact in a follow-up study of internal medicine residency programs. J Palliat Med 2002; 5:497-506. [PMID: 12353496 DOI: 10.1089/109662102760269733] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In 1998 we initiated a pilot project to evaluate the feasibility of recruiting and training internal medicine residency programs in methods designed to enhance and integrate end-of-life (EOL) instruction and assessment into their curriculum. OBJECTIVE To evaluate participants' assessment of the training program and the 12-month impact of the training on the 32 residency programs' EOL teaching. DESIGN Prospective multi-institutional study. MEASUREMENT AND RESULTS After participating in training, all participants agreed/strongly agreed that the skills-related objectives of the training were met. Mean ratings of intention to continue with the program were consistent across trainees representing different academic ranks (F = 2.8, p = 0.07), levels of experience in EOL education (F = 1.3, p = 0.28), and involvement in other national EOL training programs (F = 1.5, p = 0.23). Twelve months after training, most programs (78%) continued with the project and had initiated EOL curriculum reform in seven key EOL domains.). CONCLUSIONS The study suggests that focused training in EOL teaching methods and institutional change strategies can facilitate EOL curriculum reform.
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Abstract
Deficiencies in education about end-of-life care are widely recognized, both in the "formal" or structured curriculum, and in the "informal" curriculum (the culture in which students are immersed as they learn medicine). Numerous approaches to addressing these deficiencies have been identified. These approaches include developing palliative care leaders; improving curricula; creating standards and a process for certification of competence; creating and enhancing educational resources for end-of-life education; faculty development; growing palliative care clinical programs as venues for education; textbook revision; and creating palliative care fellowship training opportunities. Current efforts in these areas are reviewed, and barriers to their implementation are highlighted.
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Affiliation(s)
- Susan D Block
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, 44 Binney Street, Boston, MA 02115, USA.
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Weissman DE, Block SD. ACGME requirements for end-of-life training in selected residency and fellowship programs: a status report. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2002; 77:299-304. [PMID: 11953294 DOI: 10.1097/00001888-200204000-00008] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
INTRODUCTION National recommendations have been developed for physicians' end-of-life (EOL) education. No comprehensive assessment has been done to examine postgraduate (residency and fellowship) EOL training. METHOD The authors reviewed the EOL content for 46 specialties in postgraduate training programs that affect the care of seriously ill and dying patients, using data from the 2000/2001 AMA Graduate Medical Education Directory. RESULTS Internal medicine, geriatrics, and neurology contained the most comprehensive EOL requirements. Most surgical specialties contained no EOL requirement except ethics. Ethics (n = 25) and psychosocial care (n = 22) were the most common EOL domains mandated, although specific EOL content was not specified. Training in EOL communication (n = 1), personal awareness (n = 3), and EOL clinical experiences (n = 5) were the least often required instructional domains. Instruction in pain assessment and management was required in only one surgical specialty. CONCLUSIONS The lack of comprehensive EOL training requirements may help explain the known problems in physicians' EOL care. Major reform in EOL requirements is needed at the level of residency review committees.
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Affiliation(s)
- David E Weissman
- Palliative Care Program, Medical College of Wisconsin, c/o Froedtert Hospital, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Blevins D, Deason-Howell LM. End-of-life care in nursing homes: the interface of policy, research, and practice. BEHAVIORAL SCIENCES & THE LAW 2002; 20:271-286. [PMID: 12111988 DOI: 10.1002/bsl.486] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Much attention has begun to focus on the quality of care for persons near the end of life. Palliative care, especially through hospice, has generated much discussion as possibly the most holistic care available. Consideration of how chronically ill older adults receive such care as a result of public policy can benefit from adopting a multidimensional perspective. This paper adopts Bronfenbrenner's ecological model to understand current end-of-life care for nursing home residents, followed by consideration of how each of these dimensions or levels of influence can be used to foster both research agendas and policy reforms to improve end-of-life care of nursing home residents. Specifically, the benefits of considering the influence of such policy initiatives as the Medicare hospice benefit and the Patient Self-Determination Act (PSDA) on end-of-life care in nursing homes and the means through which policy can be informed by clinical research is emphasized.
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Affiliation(s)
- Dean Blevins
- Department of Psychology, The University of Akron, OH 44325-4301, USA.
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Abstract
The importance of an interdisciplinary end-of-life curricula for the intensive care unit is now recognized. Educational agendas for interdisciplinary end-of-life curricula are being developed across the United States. However, the limited database on palliative care education precludes evidence-based recommendations. Through a case-based approach, the need for an interdisciplinary team is explored, including the definition of an interdisciplinary team and the step-wise incorporation of specific members, such as physicians, nurses, social workers, and the chaplain, as patient care evolves. Core competencies for end-of-life care are enumerated including the approaches to end-of-life care, ethical and legal constraints, symptom management, specific end-of-life syndromes/palliative crises, and development of communication skills for trusting relationships. Finally, four phases of ICU management of curative and comfort care are proposed: phase I, focus on checklist for transfer; phase II, focus on life-saving treatments; phase III, focus on the "whole" patient; and phase IV, focus on palliative care.
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Affiliation(s)
- R A Mularski
- Department of Medicine, Oregon Health Sciences University and Veterans Affairs Medical Center, Portland, Oregon 97201-3098, USA
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Nelson W, Angoff N, Binder E, Cooke M, Fleetwood J, Goodlin S, Goodman K, Kaplan KO, McCormick T, Meyer ML, Sheehan M, Townsend T, Williams P, Winslade W. Goals and Strategies for Teaching Death and Dying in Medical Schools. J Palliat Med 2000; 3:7-16. [PMID: 15859716 DOI: 10.1089/jpm.2000.3.7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Teaching medical students to respond to needs of the dying represents an important challenge for medical educators. This article describes the goals and objectives that should be identified before medical schools can meet this challenge, as well as strategies that, when implemented, will provide students with the necessary knowledge, skills, and attitudes to meet the needs of the dying patients. The goals and objectives were identified through a modified group consensus process developed during Choice In Dying's 5-year project "Integrating Education on Care of the Dying into Medical Schools." The authors have diverse experiences and backgrounds and are actively involved in death and dying teaching at 11 medical schools. They conclude that after accepting the goals and objectives, key medical school faculty can work cooperatively to develop strategies to integrate them into the school's curriculum. Without first establishing a set of goals and objectives and developing evaluation methods, medical schools could miss their mark in fostering the student's ability to care for the dying.
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Affiliation(s)
- W Nelson
- VHA National Center for Ethics, and Choice In Dying, New York, New York, USA
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Affiliation(s)
- N MacDonald
- Center for Bioethics, Clinical Research Institute of Montreal, Canada
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