Goals, Values, and Priorities of Hospitalized Patients: Using a Structured Communication Tool to Engage Medical Students in Serious Illness Communication.

Background: To build third-year medical students' serious illness communication skills, we implemented a structured communication tool-the VALUES tool-focused on patients' goals, values, and priorities and described students' experiences using this tool. Methods: Medical students participated in a social worker-led VALUES didactic and discussion with a patient on the palliative care consult service and, subsequently, completed an anonymous survey about their comfort with the VALUES tool and its usefulness for learning (5-point Likert scales). Results: Of the 142 medical students who participated in the VALUES didactic, 37 completed the survey (26%). The VALUES tool was rated highly in terms of usefulness (mean 4.5; standard deviation [SD] 0.7) and rated lower in terms of overall comfort (mean 3.7; SD 0.7). Conclusion: Our project explored the integration of a VALUES tool into medical student education, and we show that the tool is well rated by learners in terms of comfort and usefulness.

PedsTalk: A Pilot Communication Skills Education Course for Pediatric Residents.

OBJECTIVE: Communication skills are critical to pediatric practice, but few pediatric residency programs provide formal communication skills education. Pediatric residents often lack confidence in these skills. We hypothesized that a simulation-based communication skills course would improve resident confidence in the skills required for serious illness conversations with patients/families. METHODS: In collaboration with multidiscipline VitalTalk-trained faculty, we developed PedsTalk, a communication skills course for pediatric residents based on the VitalTalk framework. In PedsTalk, faculty/peers offered real-time coaching during simulation sessions with actors. Resident participants self-rated confidence in 9 communication skills using a 5-point Likert scale before, immediately after, and 4 months after course participation, with course nonparticipants serving as controls. Responses were analyzed by using Friedman tests and Wilcoxon rank tests. Thematic analysis was conducted to identify themes among free-text responses. RESULTS: Twenty-seven pediatric residents participated in PedsTalk, 11 of whom completed survey assessments at all timepoints. Eleven course nonparticipants served as controls. Over time, participants' confidence in the following communication skills was retained or significantly improved: "difficult conversations" (P < .001), "recognizing emotion" (P < .01), "using silence" (P < .008), "headline statements" (P < .001), eliciting "VALUES" (P < .001), and asking "permission to continue" (P < .001). Over time, controls had significant improvements in confidence in 2 skills: headline statements (P < .014) and eliciting "VALUES" (P < .031). CONCLUSIONS: PedsTalk is a novel approach to communication skills education in pediatric residency. Participation improved residents' confidence in 6 communication skills, including overall confidence in having difficult conversations. Although confidence in some skills may naturally develop through clinical experiences, PedsTalk further enhances communication skills education among trainees.

Developing Palliative Medicine as an Accredited Medical Specialty in Kenya.

PURPOSE: Most people living with life-limiting illnesses in Kenya lack access to palliative care. Globally, palliative medicine is a growing specialty that equips clinicians with the training required to improve the quality of life for people living with a wide variety of serious illnesses. Optimal delivery relies on a skilled workforce with specialty-level training, and we identified the absence of board-accredited training programs for clinical officers (COs) and physicians as a barrier to providing high-quality palliative care in Kenya. METHODS: We held a series of stakeholder meetings with expert palliative care clinicians, leaders, and educators from Kenya and other countries to develop and implement a comprehensive, evidence-based palliative medicine curriculum for COs. RESULTS: We developed a higher diploma program that is being administered by the Moi Teaching and Referral Hospital College in Eldoret, Kenya, with faculty from Moi University School of Medicine and affiliated institutions. We have collaborated to create the first diploma awarding program in palliative medicine in Kenya. Our efforts have led the Kenyan CO Council adding palliative medicine to their list of recognized and licensed specialties. COs are now enrolled in an 18-month program that will lead to a higher diploma and national recognition as palliative care specialists. CONCLUSION: Early building of consensus and educating policymakers, regulatory bodies, and government personnel was an important step to overcome the challenge of palliative care misconceptions. The unique capacity of global partnerships and early and frequent stakeholder involvement is critical in novel program development. Local ownership of such in-country programs is key, and the stakeholders should be included in strategies for sustainability.

Virtual Geritalk: Improving Serious Illness Communication of Clinicians Who Care for Older Adults.

CONTEXT: High quality communication is essential to older adults' medical decision-making, quality of life, and adjustment to serious illness. Studies have demonstrated that Geritalk, a two day (16 hours total) in-person communication skills training improves self-assessed preparedness, skill acquisition, and sustained practice of communication skills. Due to the COVID-19 pandemic, Geritalk was adapted to a virtual format (four days, 10 hours total). OBJECTIVES: Our study evaluated the change in participants' self-assessed preparedness for serious illness communication before and after the virtual course and satisfaction with the course, and compared these findings to responses from a prior in-person Geritalk course. METHODS: Geriatrics and Palliative Medicine fellows at three urban academic medical centers completed surveys, which employed five-point Likert scales, before and after the virtual course to assess satisfaction with the course and preparedness for serious illness communication. RESULTS: Of the 20 virtual Geritalk participants, 17 (85%) completed the pre-course assessment, and 14 (70%) completed the post-course assessment. Overall, satisfaction with the course was high (mean 4.9 on a 5-point scale). Compared to in-person Geritalk participants, virtual course participants reported comparable and significant (P < 0.01) improvements in mean self-reported preparedness across all surveyed communication skills. CONCLUSION: We show that a virtual communication skills training is feasible and effective. Our findings suggest that the innovative virtual Geritalk course has the potential to increase access to communication skills training, improve serious illness communication skills, and in improve the quality of care received by older adults with serious illness.

A pilot trial of decision aids to give truthful prognostic and treatment information to chemotherapy patients with advanced cancer.

Most cancer patients do not have an explicit discussion about prognosis and treatment despite documented adverse outcomes. Few decision aids have been developed to assist the difficult discussions of palliative management. We developed decision aids for people with advanced in curable breast, colorectal, lung, and hormone-refractory prostate cancers facing first-, second-, third-, and fourth-line chemotherapy. We recruited patients from our urban oncology clinic after gaining the permission of their treating oncologist. We measured knowledge of curability and treatment benefit before and after the intervention. Twenty-six of 27 (96%) patients completed the aids, with ameanage of 63, 56% female, 56% married, 56% African American, and 67% with a high school education or more. Most patients (14/27, 52%) thought a person with their advanced cancer could be cured, which was reduced (to 8/26, 31%, P = 0.15) after the decision aid. Nearly all overestimated the effect of palliative chemotherapy. No distress was noted, and hope did not change. The majority (20/27, 74%) found the information helpful to them, and almost all (25/27, 93%) wanted to share the information with their family and physicians. It is possible to give incurable patients their prognosis, treatment options, and options for improving end-of-life care without causing distress or lack of hope. Almost all find the information helpful and want to share it with doctors and family. Research is needed to test the findings in a larger sample and measure the outcomes of truthful information on quality of life, quality of care, and costs.

Giving honest information to patients with advanced cancer maintains hope.

BACKGROUND: Oncologists often do not give honest prognostic and treatment-effect information to patients with advanced disease. One of the primary reasons stated for witholding this information is to "not take away hope." We could find no study that tested if hope was influenced by honest clinical information. METHODS: We tested decision-aids in 27 patients with advanced cancer who were facing first-, second-, third-, and fourth-line chemotherapy. These aids had printed estimates of treatment effect and the patient's chance of survival and being cured (always zero). We measured hope using the Herth Hope Index, which ranks patients' responses to 12 questions and yields a maximum score of 48. RESULTS: The scores on the Herth Hope Index did not change and the patients remained uniformly hopeful about their future. The pretest score was 44.2 (SD 3.9), and it increased to 44.8 (SD 3.86; P = .55 by paired Student's t-test). CONCLUSION: Hope is maintained when patients with advanced cancer are given truthful prognostic and treatment information, even when the news is bad.

Paradoxes in advance care planning: the complex relationship of oncology patients, their physicians, and advance medical directives.

PURPOSE: Many seriously ill patients with cancer do not discuss prognosis or advance directives (ADs), which may lead to inappropriate and/or unwanted aggressive care at the end of life. Ten years ago, patients with cancer said they would not like to discuss ADs with their oncologist but would be willing to discuss them with an admitting physician. We assessed whether this point of view still held. PATIENTS AND METHODS: Semi-structured interviews were conducted with 75 consecutively admitted patients with cancer in the cancer inpatient service. RESULTS: Of those enrolled, 41% (31 of 75) had an AD. Nearly all (87%, 65 of 75) thought it acceptable to discuss ADs with the admitting physician with whom they had no prior relationship, and 95% (62 of 65) thought that discussing AD issues was very or somewhat important. Only 7% (5 of 75) had discussed ADs with their oncologist, and only 23% (16 of 70) would like to discuss ADs with their oncologist. When specifically asked which physician they would choose, 48% (36 of 75) of patients would prefer their oncologist, and 35% (26 of 75) would prefer their primary care physician. CONCLUSION: Fewer than half of seriously ill patients with cancer admitted to an oncology service have an AD. Only 23% (16 of 70) would like to discuss their ADs with their oncologist but nearly all supported a policy of discussing ADs with their admitting physician. However, fully 48% (36 of 75) actually preferred to discuss advance directives with their oncologist if AD discussion was necessary. We must educate patients on why communicating their ADs is beneficial and train primary care physicians, house staff, hospitalists, and oncologists to initiate these difficult discussions.