From Theory to Practice: Measuring end-of-life communication quality using multiple goals theory

OBJECTIVES

To describe how multiple goals theory can be used as a reliable and valid measure (i.e., coding scheme) of the quality of conversations about end-of-life issues.

METHODS

We analyzed conversations from 17 conversations in which 68 participants (mean age=51years) played a game that prompted discussion in response to open-ended questions about end-of-life issues. Conversations (mean duration=91min) were audio-recorded and transcribed. Communication quality was assessed by three coders who assigned numeric scores rating how well individuals accomplished task, relational, and identity goals in the conversation.

RESULTS

The coding measure, which results in a quantifiable outcome, yielded strong reliability (intra-class correlation range=0.73-0.89 and Cronbach's alpha range=0.69-0.89 for each of the coded domains) and validity (using multilevel nonlinear modeling, we detected significant variability in scores between games for each of the coded domains, all p-values <0.02).

CONCLUSIONS

Our coding scheme provides a theory-based measure of end-of-life conversation quality that is superior to other methods of measuring communication quality.

PRACTICE IMPLICATIONS

Our description of the coding method enables researches to adapt and apply this measure to communication interventions in other clinical contexts.

Do faculty and resident physicians discuss their medical errors?

BACKGROUND

Discussions about medical errors facilitate professional learning for physicians and may provide emotional support after an error, but little is known about physicians' attitudes and practices regarding error discussions with colleagues.

METHODS

Survey of faculty and resident physicians in generalist specialties in Midwest, Mid-Atlantic and Northeast regions of the US to investigate attitudes and practices regarding error discussions, likelihood of discussing hypothetical errors, experience role-modelling error discussions and demographic variables.

RESULTS

Responses were received from 338 participants (response rate = 74%). In all, 73% of respondents indicated they usually discuss their mistakes with colleagues, 70% believed discussing mistakes strengthens professional relationships and 89% knew at least one colleague who would be a supportive listener. Motivations for error discussions included wanting to learn whether a colleague would have made the same decision (91%), wanting colleagues to learn from the mistake (80%) and wanting to receive support (79%). Given hypothetical scenarios, most respondents indicated they would likely discuss an error resulting in no harm (77%), minor harm (87%) or major harm (94%). Fifty-seven percent of physicians had tried to serve as a role model by discussing an error and role-modelling was more likely among those who had previously observed an error discussion (OR 4.17, CI 2.34 to 7.42).

CONCLUSIONS

Most generalist physicians in teaching hospitals report that they usually discuss their errors with colleagues, and more than half have tried to role-model discussions. However, a significant number of these physicians report that they do not usually discuss their errors and some do not know colleagues who would be supportive listeners.

Four approaches to doing ethics

Within the field of medical ethics there is a startling amount of diversity regarding which issues and relationships are deemed relevant for ethical inquiry and analysis, what strategies are appropriate for examining and resolving ethical conflict, what should be the goals for medical ethics, even who should participate in that project. What I will try to make clear in this paper is that how we go about this process of doing medical ethics, of examining, reflecting, decisionmaking, and behaving, makes a practical difference, and not just a philosophical one, in terms of the understandings we will reach about ethical matters. Without attempting to resolve any of the conflicts within or between different conceptions of doing ethics, I will try to articulate the differences in orientation, and particularly the tone and educational emphasis, that attend four major contemporary approaches to ethical inquiry and analysis: deductivism, principlism, modern casuistry, and feminist/relationist ethics.