Outcomes of a Multi-Site Mentored Implementation Approach to Promoting Goals of Care Conversations.

CONTEXT: The Preference-Aligned Communication and Treatment (PACT) Project is a multi-site quality improvement effort that has been shown to increase the frequency of goals of care (GOC) conversations in hospitalized patients with serious illness. OBJECTIVES: To evaluate the effect of PACT on goal-discordant care and resource utilization. METHODS: Hospitals enrolled in a multi-year mentored implementation quality improvement initiative to facilitate GOC conversations for seriously ill hospitalized patients. The primary outcome was the percentage of patients with care discordant with stated preferences, assessed by comparing documented wishes to Medicare claims data for patients who were admitted to intervention units and died over the study period. Secondary outcomes evaluated end-of-life resource utilization by comparing Medicare claims data for intervention patients with propensity score-matched controls. RESULTS: In the 9 hospitals included in the study, 1347 intervention group patients were compared to 4019 in the control group. Rates of discordance between wishes and care were generally low in the intervention group. Compared to the control group, patients in the intervention group had lower costs (-976.05 dollars, p=0.010), were less likely to be admitted to the ICU (OR 0.9, p=0.005), less likely to be on a ventilator or undergo CPR or cardioversion, more likely to enroll in hospice (OR 1.81, p<0.001) and had a longer hospice stay (3.35 more days, p=0.041). CONCLUSION: A multi-site mentored implementation quality improvement intervention for seriously ill hospitalized patients resulted in care aligned with goals and decreased resource utilization at the end of life.

Development of a Simulation-Based Mastery Learning Curriculum for Late Goals of Care Discussions.

INTRODUCTION: Fellows in critical care medicine (CCM) routinely help patients and families navigate complex decisions near the end of life. These "late goals of care" (LGOC) discussions require rigorous skills training and impact patient care. Innovation is needed to ensure that fellow training in leading these discussions is centered on reproducible competency-based standards. The aims of this study were to (1) describe the development of a simulation-based mastery learning (SBML) curriculum for LGOC discussions and (2) set a defensible minimum passing standard (MPS) to ensure uniform skill acquisition among learners. INNOVATION: We developed an SBML curriculum for CCM fellows structured around REMAP, a mnemonic outlining foundational components of effective communication around serious illness. A multidisciplinary expert panel iteratively created an LGOC discussion assessment tool. Pilot testing was completed to refine the checklist, set the MPS, and assess skill acquisition. OUTCOMES: The LGOC discussion assessment tool included an 18-item checklist and 6 scaled items. The tool produced reliable data (k ≥ 0.7 and ICC of ≥ 0.7). Using the Mastery Angoff method, the panel set the MPS at 87%. Ten CCM fellows participated in the pilot study. Performance on the checklist significantly improved from a median score of 52% (IQR 44%-72%) at pretest to 96% (IQR 82%-97%) at post-test (P = 0.005). The number of learners who met the MPS similarly improved from 10% during pre-testing to 70% during post-testing (P = 0.02). COMMENT: We describe the development of a LGOC SBML curriculum for CCM fellows which includes a robust communication skills assessment and the delineation of a defensible MPS.

The PACT Project: Feasibility of a Multidisciplinary, Multi-Faceted Intervention to Promote Goals of Care Conversations.

BACKGROUND: Patients living with serious illness generally want their physicians to facilitate Goals of Care conversations (GoCc), yet physicians may lack time and skills to engage in these conversations in the outpatient setting. The problem may be addressed by supporting multiple members of the clinical team to facilitate GoCc with the patient while admitted to the hospital. METHODS: A multi-modal training and mentored implementation program was developed. A group of 10 hospitals were recruited to participate. Each hospital selected a primary inpatient unit on which to start the intervention, then expanded to a secondary unit later in the project. The number of trained facilitators (champions) and the number of documented GoCc were tracked over time. RESULTS: Nine of 10 hospitals completed the 3-year project. Most of the units were general medical-surgical units. Forty-eight champions were trained at the kick-off conference, attended primarily by nurses, physicians, and social workers. By the end of the project, 153 champions had been trained. A total of 51 087 patients were admitted to PACT units with 85.4% being screened for eligibility. Of the patients who were eligible, over 68% had documented GoCc. CONCLUSION: A multifaceted quality improvement intervention focused on serious illness communication skills can support a diverse clinical workforce to facilitate inpatient GoCc over time.

Clinical Experience Is Not a Proxy for Competence: Comparing Fellow and Medical Student Performance in a Breaking Bad News Simulation-Based Mastery Learning Curriculum.

BACKGROUND: It is unknown whether traditional medical education ensures competence among fellows in the key skill of breaking bad news (BBN). While simulation-based mastery learning (SBML) has been used to train fourth-year medical students (M4s) in BBN, it is unclear if it adds similar value for fellows. OBJECTIVE: We examined the effect of traditional medical training on BBN skills by comparing baseline fellow and M4 skills and confidence and assessed the impact of a BBN SBML curriculum for fellows. METHODS: Fellows training in six programs at Northwestern University from November 2018 to May 2019 were eligible for inclusion. Fellows completed a BBN SBML curriculum including a pretest, individualized feedback using a previously published assessment tool, and ongoing deliberate practice until all achieved a minimum passing standard (MPS). The primary outcomes were checklist and scaled item scores on the assessment tool. Fellow performance was compared to a historical M4 cohort. RESULTS: Twenty-eight of 38 eligible fellows completed the curriculum and were included for analysis. Fellows reported significantly more experience and confidence in BBN compared to M4s, yet their pre-training performance was significantly worse on checklist (57.1% vs 65.0%, P = .02) and scaled items; only 4% reached the MPS. After training, fellow performance significantly improved on checklist (57.1% to 92.6%, SD = 5.2%, P < .001) and scaled items; all reached the MPS. CONCLUSIONS: Despite higher confidence and BBN clinical experience, fellows performed worse than untrained M4s, confirming that experience is not a proxy for skill. Programs must develop competency-based assessments to ensure entrustment of communication skills.

Identifying Patients in Need of Goals of Care Conversations: Reliability, Acceptability, and Prognostic Significance of the Preference-Aligned Communication and Treatment Conversation Trigger Tool for Patients with Cancer.

Background: Simple methods to help teams identify patients with goals of care (GOC) conversation needs are lacking. Objectives: To develop a tool to identify hospitalized patients who may benefit from GOC conversations. Methods: The Preference-Aligned Communication and Treatment (PACT) Conversation Trigger Tool was implemented as part of a quality improvement initiative in 10 Illinois hospitals and validated in a cohort of patients admitted to the coordinating site's oncology unit (n = 135). Results: The tool was reliable and acceptable to clinicians using it across sites. Thirty percent (n = 40) of patients screened at the coordinating site's oncology unit triggered positive. These patients were more likely to have a do-not-resuscitate order (43% vs. 11%) and palliative care consult (53% vs. 20%) and had lower mean survival time (125 vs. 248 days) than those who did not trigger (p < 0.001). Conclusions: The tool is reliable, acceptable, and can identify hospitalized oncology patients who may benefit from GOC conversations.

Promoting Readiness for Residency: Embedding Simulation-Based Mastery Learning for Breaking Bad News Into the Medicine Subinternship.

PURPOSE: It is challenging to add rigorous, competency-based communication skills training to existing clerkship structures. The authors embedded a simulation-based mastery learning (SBML) curriculum into a medicine subinternship to demonstrate feasibility and determine the impact on the foundational skill of breaking bad news (BBN). METHOD: All fourth-year students enrolled in a medicine subinternship at Northwestern University Feinberg School of Medicine from September 2017 through August 2018 were expected to complete a BBN SBML curriculum. First, students completed a pretest with a standardized patient using a previously developed BBN assessment tool. Learners then participated in a 4-hour BBN skills workshop with didactic instruction, focused feedback, and deliberate practice with simulated patients. Students were required to meet or exceed a predetermined minimum passing standard (MPS) at posttest. The authors compared pretest and posttest scores to evaluate the effect of the intervention. Participant demographic characteristics and course evaluations were also collected. RESULTS: Eighty-five students were eligible for the study, and 79 (93%) completed all components. Although 55/79 (70%) reported having personally delivered serious news to actual patients, baseline performance was poor. Students' overall checklist performance significantly improved from a mean of 65.0% (SD = 16.2%) items correct to 94.2% (SD = 5.9%; P < .001) correct. There was also statistically significant improvement in scaled items assessing quality of communication, and all students achieved the MPS at mastery posttest. All students stated they would recommend the workshop to colleagues. CONCLUSIONS: It is feasible to embed SBML into a required clerkship. In the context of this study, rigorous SBML resulted in uniformly high levels of skill acquisition, documented competency, and was positively received by learners.

Preventing Readmissions Through Effective Partnerships-Communication and Palliative Care (PREP-CPC): A Multisite Intervention for Encouraging Goals of Care Conversations for Hospitalized Patients Facing Serious Illness.

BACKGROUND: Despite evidence showing that goals of care (GOC) conversations increase the likelihood that patients facing a serious illness receive care that is concordant with their wishes, only a minority of at-risk patients receive the opportunity to engage in such conversations. OBJECTIVE: The Preventing Readmissions through Effective Partnerships-Communication and Palliative Care (PREP-CPC) intervention was designed to increase the frequency of GOC conversations for hospitalized patients facing serious illness. METHODS: The PREP-CPC employed a sequential, multicohort design using a yearlong mentored implementation approach to support nonpalliative care health-care professionals at participating hospitals to implement quality improvement projects focused on GOC conversations. RESULTS: Over the 3-year study period, 134 clinicians from 29 hospital teams were trained to facilitate GOC conversations. After the kickoff conference, participants reported improvements in their confidence in facilitating GOC conversations. The hospital teams then instituted site-specific pilot interventions to promote GOC conversations, identifying essential elements required for ongoing improvement. Since projects varied by hospital, results did as well, but reported positive outcomes included increased GOC conversations, increased Practitioner Orders for Life-Sustaining Treatment form completion rates, new screening and documentation methods, and increased support from leadership. CONCLUSIONS: The PREP-CPC pilot successfully engaged a diverse set of hospitals to participate in quality improvement collaborative promoting primary palliative care and more frequent GOC conversations. This initiative revealed several lessons that should guide future interventions.

Use and Meaning of "Goals of Care" in the Healthcare Literature: a Systematic Review and Qualitative Discourse Analysis.

BACKGROUND: The specific phrase "goals of care" (GOC) is pervasive in the discourse about serious illness care. Yet, the meaning of this phrase is ambiguous. We sought to characterize the use and meaning of the phrase GOC within the healthcare literature to improve communication among patients, families, clinicians, and researchers. METHODS: A systematic review of the English language healthcare literature indexed in MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus was performed in October of 2018. We searched for all publications with the exact phrase "goals of care" within the title or abstract; no limitations on publication date or format were applied; conference abstracts were excluded. We used qualitative, discourse analysis to identify key themes and generate an operational definition and conceptual model of GOC. RESULTS: A total of 214 texts were included in the final analysis. Use of GOC increased over time with 87% of included texts published in the last decade (2009-2018). An operational definition emerged from consensus within the published literature: the overarching aims of medical care for a patient that are informed by patients' underlying values and priorities, established within the existing clinical context, and used to guide decisions about the use of or limitation(s) on specific medical interventions. Application of the GOC concept was described as important to the care of patients with serious illness, in order to (1) promote patient autonomy and patient-centered care, (2) avoid unwanted care and identify valued care, and (3) provide psychological and emotional support for patients and their families. DISCUSSION: The use of the phrase "goals of care" within the healthcare literature is increasingly common. We identified a consensus, operational definition that can facilitate communication about serious illness among patients, families, and clinicians and provide a framework for researchers developing interventions to improve goal-concordant care.

Development of a Simulation-Based Mastery Learning Curriculum for Breaking Bad News.

INTRODUCTION: Physician communication impacts patient outcomes. However, communication skills, especially around difficult conversations, remain suboptimal, and there is no clear way to determine the validity of entrustment decisions. The aims of this study were to 1) describe the development of a simulation-based mastery learning (SBML) curriculum for breaking bad news (BBN) conversation skills and 2) set a defensible minimum passing standard (MPS) to ensure uniform skill acquisition among learners. INNOVATION: An SBML BBN curriculum was developed for fourth-year medical students. An assessment tool was created to evaluate the acquisition of skills involved in a BBN conversation. Pilot testing was completed to confirm improvement in skill acquisition and set the MPS. OUTCOMES: A BBN assessment tool containing a 15-item checklist and six scaled items was developed. Students' checklist performance improved significantly at post-test compared to baseline (mean 65.33%, SD = 12.09% vs mean 88.67%, SD = 9.45%, P < 0.001). Students were also significantly more likely to have at least a score of 4 (on a five-point scale) for the six scaled questions at post-test. The MPS was set at 80%, requiring a score of 12 items on the checklist and at least 4 of 5 for each scaled item. Using the MPS, 30% of students would require additional training after post-testing. COMMENTS: We developed a SBML curriculum with a comprehensive assessment of BBN skills and a defensible competency standard. Future efforts will expand the mastery model to larger cohorts and assess the impact of rigorous education on patient care outcomes.

Faculty Communication Knowledge, Attitudes, and Skills Around Chronic Non-Malignant Pain Improve with Online Training.

OBJECTIVE: Many physicians struggle to communicate with patients with chronic, non-malignant pain (CNMP). Through the use of a Web module, the authors aimed to improve faculty participants' communication skills knowledge and confidence, use of skills in clinical practice, and actual communication skills. SUBJECTS: The module was implemented for faculty development among clinician-educators with university faculty appointments, outpatient clinical practices, and teaching roles. METHODS: Participants completed the Collaborative Opioid Prescribing Education Risk Evaluation and Mitigation Strategy (COPE-REMS®) module, a free Web module designed to improve provider communication around opioid prescribing. Main study outcomes were improvements in CNMP communication knowledge, attitudes, and skills. Skills were assessed by comparing a subset of participants' Observed Structured Clinical Exam (OSCE) performance before and after the curriculum. RESULTS: Sixty-two percent of eligible participants completed the curriculum in 2013. Knowledge-based test scores improved with curriculum completion (75% vs. 90%; P < 0.001). Using a 5-point Likert-type scale, participants reported improved comfort in managing patients with CNMP both immediately post-curriculum and at 6 months (3.6 pre vs. 4.0 post vs. 4.1 at 6 months; P = 0.02), as well as improvements in prescribing opioids (3.3 vs. 3.8 vs. 3.9, P = 0.01) and conducting conversations about discontinuing opioids (2.8 vs. 3.5 vs. 3.9, P < 0.001). Additionally, CNMP-specific communication skills on the OSCE improved after the curriculum (mean 67% vs. 79%, P = 0.03). CONCLUSIONS: Experienced clinician-educators improved their communication knowledge, attitudes, and skills in managing patients with CNMP after implementation of this curriculum. The improvements in attitudes were sustained at six months. A Web-based curriculum such as COPE-REMS® may be useful for other programs seeking improvement in faculty communication with patients who have CNMP.

Pediatric Palliative Care Pilot Curriculum: Impact of "Pain Cards" on Resident Education.

BACKGROUND: Prior research has shown that less than 40% of pediatric program directors believe their graduating residents competent in palliative care. While many curricula have been developed to address this need, few have demonstrated improved comfort and/or knowledge with palliative care principles. The purpose of this study was to test a pocket card educational intervention regarding resident knowledge and comfort with palliative care principles. METHODS: Pocket reference cards were created to deliver fundamentals of pediatric palliative care to resident learners; didactics and case studies emphasized principles on the cards. Self-reported comfort and objective knowledge were measured before and after the curriculum among residents. RESULTS: Of 32 post-graduate year 2 (PGY2) residents, 23 (72%) completed the pre-test survey. The post-test was completed by 14 PGY2 residents (44%) and 16 of 39 PGY3/4 residents (41%). There was improvement in comfort with communication, as well as pain and symptom management among the residents. Knowledge of palliative care principles improved in part, with only a few survey questions reaching statistical significance. 100% of respondents recommended the cards be provided to their colleagues. CONCLUSION: This longitudinal curriculum, designed specifically for pediatric residents, was built into an existing training program and proved to be popular, feasible, and effective at improving comfort with basic palliative care principles.

Writing abstracts and developing posters for national meetings.

Presenting posters at national meetings can help fellows and junior faculty members develop a national reputation. They often lead to interesting and fruitful networking and collaboration opportunities. They also help with promotion in academic medicine and can reveal new job opportunities. Practically, presenting posters can help justify funding to attend a meeting. Finally, this process can be invaluable in assisting with manuscript preparation. This article provides suggestions and words of wisdom for palliative care fellows and junior faculty members wanting to present a poster at a national meeting describing a case study or original research. It outlines how to pick a topic, decide on collaborators, and choose a meeting for the submission. It also describes how to write the abstract using examples that present a general format as well as writing tips for each section. It then describes how to prepare the poster and do the presentation. Sample poster formats are provided as are talking points to help the reader productively interact with those that visit the poster. Finally, tips are given regarding what to do after the meeting. The article seeks to not only describe the basic steps of this entire process, but also to highlight the hidden curriculum behind the successful abstracts and posters. These tricks of the trade can help the submission stand out and will make sure the reader gets the most out of the hard work that goes into a poster presentation at a national meeting.

Management of intractable nausea and vomiting in patients at the end of life: "I was feeling nauseous all of the time . . . nothing was working".

Nausea and vomiting, symptoms that occur commonly near the end of life, represent a substantial source of physical and psychological distress for patients and families. In the context of the case of Mr Q, a 50-year-old man with metastatic esophageal cancer admitted to the hospital with intractable nausea and vomiting, we review the evaluation and treatment of this symptom complex. A thorough history and physical examination are essential first steps in the management of these patients because they define the severity of the symptoms and clues to their underlying etiology. Once the most likely cause is determined, the clinician discerns the mechanism, specific transmitters, and receptors by which this etiology is triggering nausea and vomiting. Subsequent pharmacological management focuses on prescribing the appropriate antagonist to the implicated receptors. If symptoms are refractory despite adequate dosage and around-the-clock prophylactic administration, an empirical trial combining several therapies to block multiple emetic pathways should be attempted. Less traditional agents are also discussed, although evidence for their use is limited. Often, oral administration of medication is not feasible and alternate routes such as rectal suppositories, subcutaneous infusions, and orally dissolvable tablets should be considered. Using this step-wise approach, nausea and vomiting can be successfully managed in most patients at the end of life.