Launching the Next Steps to Improve Hospice and Palliative Medicine Fellow Performance Assessment: A Look Back to the Initial Toolkit of Assessment Methods.

Education leaders in hospice and palliative medicine (HPM) have long acknowledged the challenge of fellow performance assessment and the need for HPM-specific fellow assessment tools. In 2010, and in alignment with the Accreditation Council for Graduate Medical Education's (ACGME's) directive toward competency-based medical education, the national HPM Competencies Workgroup curated a set of assessment tools, the HPM Toolkit of Assessment Methods. The Toolkit has been a resource for HPM fellowship directors in evolving practical, multifaceted fellow assessment strategies. Now, as American Academy of Hospice and Palliative Medicine plans for a national workgroup in 2020 to define current HPM fellow assessment methods and to propose strategies to strengthen and standardize future assessment, the Toolkit provides a strong base from which to launch. However, the field learned important lessons from the 2010 Workgroup about the consensus process, gaps in areas of assessment, opportunities to address gaps with new or adapted tools, and limitations in implementing the Toolkit over time in terms of tracking, accessibility, and dissemination. This article describes the development of the Toolkit, including recommended tools and methods for assessment within each ACGME competency domain, and links the lessons learned to recommendations for the 2020 workgroup to consider in creating the next HPM assessment strategy and toolkit. Effective implementation will be crucial in supporting fellows to reach independent practice, which will further strengthen the field and workforce to provide the highest quality patient and family-centered care in serious illness. This will require an inspired, committed effort from the HPM community, which we enthusiastically anticipate.

Effects of Early Integrated Palliative Care on Caregivers of Patients with Lung and Gastrointestinal Cancer: A Randomized Clinical Trial.

BACKGROUND: The family and friends (caregivers) of patients with advanced cancer often experience tremendous distress. Although early integrated palliative care (PC) has been shown to improve patient-reported quality of life (QOL) and mood, its effects on caregivers' outcomes is currently unknown. MATERIALS AND METHODS: We conducted a randomized trial of early PC integrated with oncology care versus oncology care alone for patients who were newly diagnosed with incurable lung and noncolorectal gastrointestinal cancers and their caregivers. The early PC intervention focused on addressing the needs of both patients and their caregivers. Eligible caregivers were family or friends who would likely accompany patients to clinic visits. The intervention entailed at least monthly patient visits with PC from the time of diagnosis. Caregivers were encouraged, but not required, to attend the palliative care visits. We used the Hospital Anxiety and Depression Scale (HADS) and Medical Health Outcomes Survey Short-Form to assess caregiver mood and QOL. RESULTS: Two hundred seventy-five caregivers (intervention n = 137; control n = 138) of the 350 patients participated. The intervention led to improvement in caregivers' total distress (HADS-total adjusted mean difference = -1.45, 95% confidence interval [CI] -2.76 to -0.15, p = .029), depression subscale (HADS-depression adjusted mean difference = -0.71, 95% CI -1.38 to -0.05, p = .036), but not anxiety subscale or QOL at week 12. There were no differences in caregivers' outcomes at week 24. A terminal decline analysis showed significant intervention effects on caregivers' total distress (HADS-total), with effects on both the anxiety and depression subscales at 3 and 6 months before patient death. CONCLUSION: Early involvement of PC for patients with newly diagnosed lung and gastrointestinal cancers leads to improvement in caregivers' psychological symptoms. This work demonstrates that the benefits of early, integrated PC models in oncology care extend beyond patient outcomes and positively impact the experience of caregivers. IMPLICATIONS FOR PRACTICE: Early involvement of palliative care for patients with newly diagnosed lung and gastrointestinal cancers leads to improvement in caregivers' psychological symptoms. The findings of this trial demonstrate that the benefits of the early, integrated palliative care model in oncology care extend beyond patient outcomes and positively impact the experience of caregivers. These findings contribute novel data to the growing evidence base supporting the benefits of integrating palliative care earlier in the course of disease for patients with advanced cancer and their caregivers.

Radiation oncology resident palliative education.

PURPOSE: Although palliative care is recognized as integral to oncology care, limited data exist regarding the extent to which palliative care training is incorporated into radiation oncology residency training in the United States. We aim to characterize US radiation oncology residents' perceived palliative care educational needs and experience to guide future palliative oncology educational interventions. METHODS AND MATERIALS: An 8-person expert panel developed a survey to assess resident perceptions of generalist palliative care education within radiation oncology residency. Domains of palliative oncology education, derived from national guidelines, included symptom management (pain and non-pain), communication about goals of care, advance care planning, psychosocial issues, cultural considerations, spiritual needs, care coordination, and ethical/legal issues. Residents rated adequacy of their training and their perceived competency in each domain. A total of 433 US radiation oncology residents were identified for participation; 404 completed the survey (response rate, 93%). RESULTS: Residents characterized themselves as "not at all/minimally/somewhat confident" in their ability to take care of patients with palliative care issues in the following domains: symptom management (36% pain, 44% non-pain), communication about goals of care (31%), advance care planning (48%), psychosocial (55%), cultural (22%), spiritual (44%), care coordination (50%), and ethical/legal (50%). On average, 79% of residents rated their training as "not/minimally/somewhat" adequate across all domains. Most (96%) view palliative care as an important competency within radiation oncology and 81% desire more palliative care education. CONCLUSIONS: Although the majority of residents view palliative care as an important competency for radiation oncologists, a majority perceived their educational training as inadequate across multiple domains. Most residents desire further palliative oncology care training. These findings suggest efforts should be made to improve palliative care education during radiation oncology training.

Prognosis, Communication, and Advance Care Planning in Heart Failure: A Module for Students, Residents, Fellows, and Practicing Clinicians.

INTRODUCTION: The increasing prevalence, high symptom burden, and medical advances that often prolong the advanced phase of heart failure mandate an organized and thoughtful approach to medical decision making. However, many clinicians have difficulty discussing prognosis and goals of care with patients. Barriers include disease- and therapy-specific prognostication challenges in heart failure and a lack of evidence-based primary palliative care education initiatives. METHODS: In response, we developed this 45-minute training module, which consists of a case-based small-group session and a communication guide. The curriculum highlights prognostication challenges in heart failure and introduces an illness trajectory-based framework to cue iterative goals of care conversations. RESULTS: We piloted this learning module with 46 internal medicine residents and interdisciplinary palliative care fellows in groups of three to 15 and obtained anonymous quantitative and qualitative postsession learner survey data to examine feasibility and acceptability. Trainees rated the session highly. One hundred percent of learners either strongly agreed or agreed the session was clinically useful. Learners unanimously found the teaching methods effective, and most felt they could easily apply these skills to their clinical work. In open-ended feedback, learners said the session gave them a better understanding of the heart failure illness trajectory, an improved framework for discussing goals of care with heart failure patients, and specific language to use when having these discussions. DISCUSSION: This module represents a new paradigm for teaching both prognostication and advance care planning in heart failure in which illness trajectory guides timing and content of goals of care conversations.

Patient-reported Limitations to Surgical Buy-in: A Qualitative Study of Patients Facing High-risk Surgery.

OBJECTIVE: To characterize how patients buy-in to treatments beyond the operating room and what limits they would place on additional life-supporting treatments. BACKGROUND: During a high-risk operation, surgeons generally assume that patients buy-in to life-supporting interventions that might be necessary postoperatively. How patients understand this agreement and their willingness to participate in additional treatment is unknown. METHODS: We purposively sampled surgeons in Toronto, Ontario, Boston, Massachusetts, and Madison, Wisconsin, who are good communicators and routinely perform high-risk operations. We audio-recorded their conversations with patients considering high-risk surgery. For patients who were then scheduled for surgery, we performed open-ended preoperative and postoperative interviews. We used directed qualitative content analysis to analyze the interviews and surgeon visits, specifically evaluating the content about the use of postoperative life support. RESULTS: We recorded 43 patients' conversations with surgeons, 34 preoperative, and 27 postoperative interviews. Patients expressed trust in their surgeon to make decisions about additional treatments if a serious complication occurred, yet expressed a preference for significant treatment limitations that were not discussed with their surgeon preoperatively. Patients valued the existence or creation of an advance directive preoperatively, but they did not discuss this directive with their surgeon. Instead they assumed it would be effective if needed and that family members knew their wishes. CONCLUSIONS: Patients implicitly trust their surgeons to treat postoperative complications as they arise. Although patients may buy-in to some additional postoperative interventions, they hold a broad range of preferences for treatment limitations that were not discussed with the surgeon preoperatively.

Effects of Early Integrated Palliative Care in Patients With Lung and GI Cancer: A Randomized Clinical Trial.

Purpose We evaluated the impact of early integrated palliative care (PC) in patients with newly diagnosed lung and GI cancer. Patients and Methods We randomly assigned patients with newly diagnosed incurable lung or noncolorectal GI cancer to receive either early integrated PC and oncology care (n = 175) or usual care (n = 175) between May 2011 and July 2015. Patients who were assigned to the intervention met with a PC clinician at least once per month until death, whereas those who received usual care consulted a PC clinician upon request. The primary end point was change in quality of life (QOL) from baseline to week 12, per scoring by the Functional Assessment of Cancer Therapy-General scale. Secondary end points included change in QOL from baseline to week 24, change in depression per the Patient Health Questionnaire-9, and differences in end-of-life communication. Results Intervention patients ( v usual care) reported greater improvement in QOL from baseline to week 24 (1.59 v -3.40; P = .010) but not week 12 (0.39 v -1.13; P = .339). Intervention patients also reported lower depression at week 24, controlling for baseline scores (adjusted mean difference, -1.17; 95% CI, -2.33 to -0.01; P = .048). Intervention effects varied by cancer type, such that intervention patients with lung cancer reported improvements in QOL and depression at 12 and 24 weeks, whereas usual care patients with lung cancer reported deterioration. Patients with GI cancers in both study groups reported improvements in QOL and mood by week 12. Intervention patients versus usual care patients were more likely to discuss their wishes with their oncologist if they were dying (30.2% v 14.5%; P = .004). Conclusion For patients with newly diagnosed incurable cancers, early integrated PC improved QOL and other salient outcomes, with differential effects by cancer type. Early integrated PC may be most effective if targeted to the specific needs of each patient population.

Survey on Clinician Perceptions and Practices Regarding Goals of Care Conversations.

BACKGROUND: Early conversations between clinicians and patients about goals of care may improve patients' quality of life and prevent nonbeneficial care near the end of life, but these conversations are limited in frequency and scope. To address this issue, clinicians are increasingly asked to use standardized medical order forms, like the Medical Orders for Life-Sustaining Treatment (MOLST), to document end-of-life conversations and to help ensure that patients' wishes are realized. In kind, the Centers for Medicare and Medicaid Services recently decided to reimburse physicians as well as nurse practitioners and physician assistants for these conversations. OBJECTIVE: To explore physicians' and advanced practitioners' (APs') attitudes and behaviors around initiating and documenting goals of care conversations and to identify targets for improvement. DESIGN: Online survey administered between October 1, 2014 and February 20, 2015. SETTING/SUBJECTS: Physicians (n = 2492) and APs (n = 336) at an urban academic medical center. MEASUREMENTS: Clinicians' perceptions and self-reported behaviors regarding goals of care conversations and the Massachusetts MOLST form. RESULTS: We found that 44.0% of physicians and 33.0% of APs reported that they discussed goals of care with all patients with serious, life-limiting illness (p < 0.001). APs were more likely than physicians to report awareness of MOLST forms (55.1% vs. 45.1%, p < 0.001) but less likely to feel comfortable making recommendations on end-of-life care (25.3% vs. 41.0% recommending against resuscitation, p < 0.001; 35.1% vs. 55.7% recommending for resuscitation, p < 0.001). CONCLUSIONS: These findings suggest the need to educate physicians and empower APs to facilitate goals of care conversations and use standardized forms, as well as an opportunity for interdisciplinary collaboration.

Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council.

UNLABELLED: Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence. PERSPECTIVE: This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.

Building Resiliency in a Palliative Care Team: A Pilot Study.

CONTEXT: Palliative care clinicians (PCCs) are vulnerable to burnout as a result of chronic stress related to working with seriously ill patients. Burnout can lead to absenteeism, ineffective communication, medical errors, and job turnover. Interventions that promote better coping with stress are needed in this population. OBJECTIVES: This pilot study tested the feasibility of the Relaxation Response Resiliency Program for Palliative Care Clinicians, a program targeted to decrease stress and increase resiliency, in a multidisciplinary cohort of PCCs (N = 16) at a major academic medical center. METHODS: A physician delivered the intervention over two months in five sessions (12 hours total). Data were collected the week before the program start and two months after completion. The main outcome was feasibility of the program. Changes in perceived stress, positive and negative affect, perspective taking, optimism, satisfaction with life, and self-efficacy were examined using nonparametric statistical tests. Effect size was quantified using Cohen's d. RESULTS: The intervention was feasible; all participants attended at least four of the five sessions, and there was no attrition. After the intervention, participants showed reductions in perceived stress and improvements in perspective taking. CONCLUSION: Our findings suggest that a novel team-based resiliency intervention based on elicitation of the relaxation response was feasible and may help promote resiliency and protect against the negative consequences of stress for PCCs.

Promoting resiliency among palliative care clinicians: stressors, coping strategies, and training needs.

BACKGROUND: Palliative care clinicians (PCCs) are susceptible to burnout, as they regularly witness immense patient and family suffering; however, little is known about their specific challenges and training needs to enhance their long-term sustainability. OBJECTIVE: The purpose of this qualitative study was to explore common stressors, coping strategies, and training needs among PCCs in efforts to inform the development of a targeted Resiliency Program. METHODS: Utilizing a semistructured interview guide, we conducted a series of in-depth interviews with 15 PCCs at the Massachusetts General Hospital. RESULTS: Content analysis highlighted three main areas of stressors: (1) systematic challenges related to managing large, emotionally demanding caseloads within time constraints; (2) patient factors, such as addressing patients' mutable needs, managing family dynamics, and meeting patient and family demands and expectations; and (3) personal challenges of delineating emotional and professional boundaries. Engaging in healthy behaviors and hobbies and seeking emotional support from colleagues and friends were among the most common methods of coping with stressors. In terms of programmatic topics, PCCs desired training in mind-body skills (e.g., breathing, yoga, meditation), health education about the effects of stress, and cognitive strategies to help reduce ruminative thoughts and negative self-talk. A majority of clinicians stressed the need for brief strategies that could be readily integrated in the workplace. CONCLUSIONS: These results suggest that an intervention aimed to enhance PCC sustainability should focus on utilizing a skill-building approach to stress reduction that imparts strategies that can be readily utilized during work hours.

Racial variation in the use of life-sustaining treatments among patients who die after major elective surgery.

BACKGROUND: Although various studies have documented increased life-sustaining treatments among racial minorities in medical patients, whether similar disparities exist in surgical patients is unknown. METHODS: A retrospective cohort study using the Nationwide Inpatient Sample (2006 to 2011) examining patients older than 39 years who died after elective colectomy was performed. Primary predictor variable was race, and main outcome was the use of life-sustaining treatment. RESULTS: In univariate analysis, significant differences existed in use of cardiopulmonary resuscitation (CPR; black, 35.9%; Hispanic, 29.0%; other, 24.5%; white, 11.7%; P = .002) and reintubation (Hispanic, 75.0%; other, 69.0%; black, 52.3%; white, 45.2%; P = .01). In multivariate analysis, black (odds ratio [OR], 3.67; P = .01) and Hispanic (OR, 4.21; P = .03) patients were more likely to have undergone CPR, and Hispanic patients (OR, 4.24; P = .01) were more likely to have been reintubated (reference: white). CONCLUSIONS: Blacks and Hispanics had increased odds of experiencing CPR, and Hispanics were more likely to have been reintubated before death after a major elective operation. These variations may imply worse quality of death and increased associated costs.

Integration of palliative care in end-stage liver disease and liver transplantation.

BACKGROUND: Patients with end-stage liver disease (ESLD) have a life-limiting illness that causes multiple distressing symptoms and negatively affects quality of life (QOL). This population traditionally has not had much attention within the palliative care community. DISCUSSION: This article provides an evidence-based review of palliative care issues that patients with ESLD and those awaiting liver transplant face, including approaches to prognosis, symptom management, advance care planning, and end-of-life care. CONCLUSION: Tremendous opportunity exists to integrate palliative medicine into the care of these patients.

Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents.

PURPOSE: Given the shortage of palliative care specialists in the United States, to ensure quality of care for patients with serious, life-threatening illness, generalist-level palliative care competencies need to be defined and taught. The purpose of this study was to define essential competencies for medical students and internal medicine and family medicine (IM/FM) residents through a national survey of palliative care experts. METHOD: Proposed competencies were derived from existing hospice and palliative medicine fellowship competencies and revised to be developmentally appropriate for students and residents. In spring 2012, the authors administered a Web-based, national cross-sectional survey of palliative care educational experts to assess ratings and rankings of proposed competencies and competency domains. RESULTS: The authors identified 18 comprehensive palliative care competencies for medical students and IM/FM residents, respectively. Over 95% of survey respondents judged the competencies as comprehensive and developmentally appropriate (survey response rate = 72%, 71/98). Using predefined cutoff criteria, experts identified 7 medical student and 13 IM/FM resident competencies as essential. Communication and pain/symptom management were rated as the most critical domains. CONCLUSIONS: This national survey of palliative care experts defines comprehensive and essential palliative care competencies for medical students and IM/FM residents that are specific, measurable, and can be used to report educational outcomes; provide a sequence for palliative care curricula in undergraduate and graduate medical education; and highlight the importance of educating medical trainees in communication and pain management. Next steps include seeking input and endorsement from stakeholders in the broader medical education community.

An evaluation of interactive web-based curricula for teaching code status discussions.

BACKGROUND: Teaching resuscitation discussions to medical students and residents is time intensive and should be taught by teachers with competence in this area of clinical practice. There are plenty of data that these discussions are often inadequate, and that communication skills training, while time and faculty intensive, improves these conversations. The role of online instruction in teaching communication skills, such as resuscitation discussions, is not established. OBJECTIVE: The study objective was to evaluate the effectiveness of an interactive online curriculum in teaching code status discussions to third-year medical students at one medical school. DESIGN: In this study we block randomized third-year medical students to one of two web-based curricula versus a similar written curriculum and used standardized patient scores on a communication exercise to measure differences in performance. We used student surveys to measure student satisfaction with the curricula. SETTING/SUBJECTS: Of 121 students participating in the study between April 2007 and March 2008, 88 were randomized to one of two website formats and 33 to the written curriculum. MEASUREMENTS: We compared average scores on content and communication checklists between groups. RESULTS: There were no differences between the three groups in the primary outcome of student performance. We could not analyze data on satisfaction with or completion rates for the three curricula due to poor response rates to the student surveys. CONCLUSIONS: This block randomized study of web-based curricula versus a written curriculum did not show differences in student performance in code status discussions. The optimal use of online communication training remains unclear and requires further investigation.

Patient-physician communication about code status preferences: a randomized controlled trial.

BACKGROUND: Code status discussions are important in cancer care, but the best modality for such discussions has not been established. The objective of this study was to determine the impact of a physician ending a code status discussion with a question (autonomy approach) versus a recommendation (beneficence approach) on patients' do-not-resuscitate (DNR) preference. METHODS: Patients in a supportive care clinic watched 2 videos showing a physician-patient discussion regarding code status. Both videos were identical except for the ending: one ended with the physician asking for the patient's code status preference and the other with the physician recommending DNR. Patients were randomly assigned to watch the videos in different sequences. The main outcome was the proportion of patients choosing DNR for the video patient. RESULTS: A total of 78 patients completed the study, and 74% chose DNR after the question video, whereas 73% chose DNR after the recommendation video. Median physician compassion score was very high and not different for both videos. All 30 of 30 patients who had chosen DNR for themselves and 30 of 48 patients who had not chosen DNR for themselves chose DNR for the video patient (100% versus 62%). Age (odds ratio = 1.1/year) and white ethnicity (odds ratio = 9.43) predicted DNR choice for the video patient. CONCLUSIONS: Ending DNR discussions with a question or a recommendation did not impact DNR choice or perception of physician compassion. Therefore, both approaches are clinically appropriate. All patients who chose DNR for themselves and most patients who did not choose DNR for themselves chose DNR for the video patient. Age and race predicted DNR choice.

Work-life balancing: challenges and strategies.

BACKGROUND: Balancing the personal and the professional is an ongoing struggle for most professionals, and palliative care clinicians are no exception. A sustained lack of balance can lead to feelings of frustration, inadequacy, and guilt. Palliative care physicians may find this balance particularly difficult due to the nature of their work: caring for patients and families who are often suffering and in crisis. DISCUSSION: In this article, we describe challenges to work-life balancing and strategies that may promote balance, including "timeshifting," goal setting, cognitive reframing, and self-care. We argue that the search for balance is a lifelong endeavor that entails self-reflection and continuing examination of one's values and goals.

Transitional clerkship: an experiential course based on workplace learning theory.

Starting clerkships is anxiety provoking for medical students. To ease the transition from preclerkship to clerkship curricula, schools offer classroom-based courses which may not be the best model for preparing learners. Drawing from workplace learning theory, the authors developed a seven-day transitional clerkship (TC) in 2007 at the University of California, San Francisco School of Medicine in which students spent half of the course in the hospital, learning routines and logistics of the wards along with their roles and responsibilities as members of ward teams. Twice, they admitted and followed a patient into the next day as part of a shadow team that had no patient-care responsibilities. Dedicated preceptors gave feedback on oral presentations and patient write-ups. Satisfaction with the TC was higher than with the previous year's classroom-based course. TC students felt clearer about their roles and more confident in their abilities as third-year students compared with previous students. TC students continued to rate the transitional course highly after their first clinical rotation. Preceptors were enthusiastic about the course and expressed willingness to commit to future TC preceptorships. The transitional course models an approach to translating workplace learning theory into practice and demonstrates improved satisfaction, better understanding of roles, and increased confidence among new third-year students.

Skin findings in palliative care patients.

The prevalence of dermatologic disease and its effect on quality of life has not been well studied in patients with advanced illness. We sought to describe skin findings in inpatient palliative care patients and determine how often they are addressed by the primary or palliative care teams. We collected patient demographic and clinical data from the medical record, performed total body skin examinations, and determined how often significant cutaneous findings were documented in the chart. We also characterized skin findings as uncomfortable and treatable. Twenty palliative care patients participated in the study over a 2-month period. Common findings included skin breakdown (20/54; 37%), skin infections (14/54; 26%), inflammatory dermatoses (9/54; 17%), and skin conditions related to systemic disease (7/54; 13%) or treatment of systemic disease (4/54; 7%). Most of these conditions were not documented by primary or palliative care clinicians. Eighty percent of the patients had uncomfortable, but treatable skin conditions of which 62% (13/21) were undocumented or incorrectly documented. These limited data suggest the need for palliative care clinicians to conduct more complete skin examinations, and to improve their knowledge of common skin abnormalities in patients with serious illness. A larger scale investigation of skin disease and its effect on quality of life in the palliative care population is warranted.

Discussing resuscitation preferences with patients: challenges and rewards.

Discussing preferences regarding resuscitation is a challenging and important task for any physician. Understanding patients' wishes at the end of life allows physicians to provide the type of care patients want, to avoid unwanted interventions, and to promote patient autonomy and dignity. Hospitalists face an even greater challenge because they are often meeting a patient for the first time in a crisis situation. Despite the frequency with which clinicians have these conversations, they typically fall short when discussing code status with patients. In this evidence-based review, we discuss physician barriers to conducting effective discussions, offer a variety of approaches to enhancing these conversations, and review important communication techniques.