Ethical and Legal Considerations in End-of-Life Care.

In caring for dying patients, family medicine practitioners intentionally adopt care plans that affect the manner and timing of death. These decisions are morally weighty. This article provides guidance regarding the ethical and legal appropriateness of practitioner decisions near the end of life. Topics include surrogate decision making, advance care planning, medical nutrition and hydration, double effect, futile care, physician-assisted death, voluntarily stopping eating and drinking, palliative sedation to unconsciousness, and cultural humility.

Advance Care Planning in Community: An Evaluation of a Pilot 2-Session, Nurse-Led Workshop.

BACKGROUND:: Engaging patients in advance care planning (ACP) is challenging but crucial to improving the quality of end-of-life care. Group visits and multiple patient-clinician interactions may promote advance directive (AD) completion. OBJECTIVE:: Facilitate ACP discussions with patients and caregivers and the creation of notarized AD's at a comprehensive cancer center. DESIGN:: Two-session, nurse-led ACP workshops for patients and their family caregivers. SETTING/PARTICIPANTS:: The workshop was offered to patients with cancer at a comprehensive cancer center and their family caregivers. MEASUREMENTS:: Validated 4-question ACP engagement survey, creation of a notarized AD by end of the workshop, and semistructured interviews. RESULTS:: Thirty-five patients participated in 10 workshops held March 2017 to February 2018. Median age was 52. Of 35, 24 (68.5%) patients completed pre- and postworkshop evaluation surveys. Mean preworkshop ACP readiness was 3.64 of 5; postworkshop readiness increased to 4.26 of 5 ( P = .001). Of 26, 17 (65.4%) of the patients who attended both workshop sessions had a new notarized AD scanned into the electronic medical record at the completion of the workshop series. Three family caregivers completed and had their own ADs notarized. Patient and family member response was overwhelmingly positive, with participants citing opportunities for group discussion and inclusion of family caregivers as important. CONCLUSIONS:: The ACP workshop was well received by participants and increased ACP readiness, discussion, and completion. Attendance at the workshop was low and barriers to attending workshops must be explored.

Advance Care Planning and Shared Decision-Making: An Interprofessional Role-Playing Workshop for Medical and Nursing Students.

Introduction: Advance care planning (ACP) is an essential discussion between a health care provider and a patient about their future care during serious illness. In clinical practice, high-quality ACP may be addressed with an interprofessional approach. Role-playing is an ideal method to practice both ACP and shared decision-making before having these conversations with patients. Methods: This asynchronous role-playing workshop is prefaced with two prerecorded 25-minute videos for faculty and student preparation with one introducing ACP concepts, and one depicting a patient-physician ACP discussion. During the 2-hour workshop, students complete four role-play ACP scenarios with the following roles: patient, family member, nurse, nurse practitioner, and physician. Students rotate through different roles guided by scripts, and have a fact sheet for each scenario detailing prognostic information for disease processes. The role-play works optimally with three nursing students, three medical students, and one faculty facilitator per group. Facilitators are provided with a timeline, a guide for debriefing, and an evaluation rubric. Results: The survey data from 85 students spread over four course offerings were summarized. When asked both if learning objectives were met, and to reflect on the clinical relevance, teaching effectiveness, and the overall workshop experience, most participants reported a good to excellent rating. Discussion: This role-play activity allows students to practice ACP and shared decision-making, both with patient and family presence, and in premeeting rounds with the health care team. ACP exposure during student training helps trainees recognize the impact of high-quality interprofessional conversations on the care patients want and ultimately receive.