Goals-of-Care Decisions by Hospitalized Patients With Advanced Cancer: Missed Clinician Opportunities for Facilitating Shared Decision-Making.

CONTEXT: Hospitalized patients with advanced cancer often face complex, preference-sensitive decisions. How clinicians and patients engage in shared decision-making during goals-of-care discussions is not well understood. OBJECTIVE: The objective of this study was to explore decision-making by patients and clinicians during inpatient goals-of-care discussions. METHODS: This is a qualitative study of audio-recorded goals-of-care discussions between hospitalized patients with advanced cancer and their clinicians. Grounded theory was used to analyze transcripts. RESULTS: Sixty-two patients participated in goals-of-care discussions with 51 unique clinicians. Nearly half of patients (n = 30) were female and their mean age was 60.1 years (SD = 12.7). A palliative care attending or fellow was present in 58 of the 62 discussions. Decisions centered on three topics: 1) disease-modifying treatments; 2) hospice; and 3) code status. Clinicians' approach to decision-making included the following stages: "information exchange," "deliberation," "making a patient-centered recommendation," and "wrap-up: decisional status." Successful completion of each stage varied by the type of decision. When discussing code status, clinicians missed opportunities to engage patients in information exchange and to wrap up decisional status. By contrast, clinicians discussing disease-modifying treatments and hospice failed to integrate patient preferences. Clinicians also missed opportunities to make patient-centered recommendations when discussing treatment decisions. CONCLUSION: Clinicians missed opportunities to facilitate shared decision-making regarding goals of care, and these missed opportunities differed by type of decision being discussed. Opportunities for clinician communication training include engagement in collaborative deliberation with patients and making patient-centered recommendations in situations of high medical uncertainty.

Simulation-Based Mastery Learning for Thoracentesis Skills Improves Patient Outcomes: A Randomized Trial.

PURPOSE: Physicians-in-training often perform bedside thoracenteses in academic medical centers, and complications are more common among less experienced clinicians. Simulation-based mastery learning (SBML) is one potential solution to this problem. This study evaluated the effects of a randomized trial of thoracentesis SBML on patient complications: iatrogenic pneumothorax (IP), hemothorax, and reexpansion pulmonary edema (REPE). METHOD: The authors randomized internal medicine residents to undergo thoracentesis SBML at a tertiary care academic center from December 2012 to May 2016. They subsequently compared thoracentesis complications from procedures performed by SBML-trained residents, traditionally trained residents (no simulation training), and those referred to pulmonary medicine or interventional radiology (IR). RESULTS: During the study period, 917 thoracenteses were performed on 709 patients. IP occurred in 60 (6.5%) procedures, of which 7 (11.6%) were clinically meaningful. SBML-trained residents performed procedures with a trend toward lower combined clinically meaningful complications (IP, hemothorax, REPE) compared with traditionally trained residents (7.9% vs. 0%; P = .06). SBML-trained residents caused fewer clinically meaningful IPs compared with traditionally trained residents, pulmonary, and IR referrals (P = .02). Hemothorax occurred after 4 (0.4%) thoracenteses, and SBML-trained residents had a trend toward lower hemothorax (0) compared with other groups (P = .07). REPE occurred after 3 (0.3%) procedures, with no differences between groups. SBML-trained residents performed procedures with lower combined clinically meaningful complications compared with other groups (P = .008). CONCLUSIONS: Residents randomized to an SBML intervention performed thoracenteses with low rates of clinically meaningful complications. Rigorous education represents a successful quality improvement strategy.

Evaluation of a Mastery Learning Intervention on Hospitalists' Code Status Discussion Skills.

CONTEXT: Although code status discussions (CSD) occur frequently in the hospital setting, discussions often lack content necessary for informed decision making. Simulation-based mastery learning (SBML) has been used to improve clinical skills among resident physicians and may provide a novel way to improve hospitalists' CSD skills. OBJECTIVES: The objective of this pilot randomized controlled trial was to develop and evaluate a CSD SBML intervention for hospitalists. METHODS: Twenty hospitalists were randomized to control vs. a CSD SBML intervention. Hospitalists conducted a baseline standardized patient encounter (pretest) that was scored using a 19-item CSD checklist and controls completed a repeat standardized patient encounter six months later (post-test). Intervention group hospitalists received at least one two-hour training session featuring deliberate practice and feedback and were expected to meet a minimum passing score (MPS) on the post-test of 84% set by an expert panel. RESULTS: Only two of the 20 hospitalists met the MPS at pretest. Seventy percentage of intervention hospitalists achieved the MPS after a single training session. Post-test median checklist scores were higher for intervention hospitalists compared with controls (16.5 vs. 12.0, P = 0.0001). Intervention hospitalists were significantly more likely to ask about previous experiences with end-of-life decision making (70% vs. 20%, P = 0.03), explore values/goals (100% vs. 50%, P = 0.01), ask permission to make a recommendation regarding code status (60% vs. 0%, P = 0.003), and align recommendations with patient values/goals (90% vs. 40%, P = 0.02) than controls. CONCLUSION: Few hospitalists demonstrated mastery of CSD skills at baseline; SBML was an effective way to improve these skills.