Effective Goals-of-Care Conversations: From Skills Training to Bedside.

Introduction: Goals-of-care (GOC) conversations are essential to ensure high-quality care for people with serious illness. We developed a simulation experience to train internal medicine residents in GOC conversations near end of life, followed by a real-life GOC conversation as a Mini-Clinical Evaluation Exercise (Mini-CEX) including direct feedback from participating patients. Methods: The 3-hour simulation session trained teams of two learners each to interact with standardized patients portraying a patient with end-stage heart failure and an accompanying family member. Residents completed pre- and postsurveys regarding their self-assessed abilities and confidence in conducting these conversations. Piloted in 2016, the Mini-CEX was completed in 2017 with 28 residents 3-9 months after simulation. Patients and participating family members were invited to complete an optional, deidentified survey of their experience. Results: From 2015 to 2017, 84 residents completed simulation training. Ninety percent of postsurvey responders felt more prepared to conduct GOC conversations after simulation compared to 42% before training. Eighty percent or more reported confidence in discussing GOC (previously 67%), prognosis (previously 62%), and hospice (previously 49%). Analysis of Mini-CEX scores revealed that the majority of residents' skills were the same or improved compared with their performance in simulation; more than 70% demonstrated improvement in ensuring patients' comfort, displaying empathy, and recognizing/responding to emotion. Almost all patients and families reported feeling heard and satisfied with their conversation with the resident. Discussion: This curriculum was well received, and initial data support its effectiveness in enhancing residents' self-perceived confidence and interpersonal skills in real-world patient encounters.

Hemoglobinuria misidentified as hematuria: review of discolored urine and paroxysmal nocturnal hemoglobinuria.

Discolored urine is a common reason for office visits to a primary care physician and urology referral. Early differentiation of the type or cause of discolored urine is necessary for accurate diagnosis and prompt management. Paroxysmal nocturnal hemoglobinuria is a clonal disorder caused by acquired somatic mutations in the PIG-A gene on the X- chromosome of hemopoietic stem cells and leads to deficiency of surface membrane anchor proteins. The deficiency of these proteins leads to an increased risk of hemolysis of erythrocytes and structural damage of platelets, resulting in a clinical syndrome characterized by complement-mediated intravascular hemolytic anemia, bone marrow failure, and venous thrombosis. Patients with this clinical syndrome present with paroxysms of hemolysis, causing hemoglobinuria manifesting as discolored urine. This can be easily confused with other common causes of discolored urine and result in extensive urologic work-up. Three commonly confused entities of discolored urine include hematuria, hemoglobinuria, and myoglobinuria. Specific characteristics in a dipstick test or urinalysis can guide differentiation of these three causes of discolored urine. This article begins with a case summary of a woman presenting with cranberry-colored urine and a final delayed diagnosis of paryxysmal nocturnal hemoglobinuria. Her hemoglobinuria was misdiagnosed as hematuria, leading to extensive urologic work-up. The article also gives an overview of the approach to diagnosing and treating discolored urine.