Teaching palliative care in the intensive care unit: how to break the news.

BACKGROUND: Palliative care education is often lacking in graduate medical education curricula. Studies show that many physicians are uncomfortable discussing end-of-life issues with patients and providing palliative care to dying patients and their families. We used a case-based approach to improve resident confidence in delivering bad news, discussing poor prognoses, explaining the dying process, and providing palliative care in the intensive care unit. METHODS: The medical intensive care unit (MICU) curriculum involved a 3-pronged approach, including role modeling by the attending physician and palliative care team, tutorials, and a case-based debriefing at the end of each month-long rotation. Case-based debriefing consisted of discussions by the house officers of cases they encountered during the MICU rotation. Sessions were moderated by a staff physician trained in palliative care and a palliative care advanced practice nurse. Open-ended questions stimulated the residents' reflection on their decisions and guided the discussion pertinent to palliative care. Using a survey instrument with a 4-point Likert scale, house officers assessed themselves before and after the rotation, rating their confidence in 9 areas of palliative care. Paired t tests were used to compare the cohort's scores before and after the rotation. RESULTS: A total of 214 house officers completed prerotation and postrotation surveys from April 2007 to September 2011. After completing the course, house officers demonstrated statistically significant improvement in confidence with conducting family conferences (mean 2.6 before vs 3.1 after [P<0.001]), delivering bad news (mean 3.1 before vs 3.5 after [P<0.001]), discussing do not resuscitate orders (3.1 before vs 3.6 after [P<0.001]), discussing comfort care (mean 2.8 before vs 3.4 after [P<0.001]), discussing withdrawal of life-sustaining treatment (mean 2.6 before vs 3.2 after [P<0.001]), managing pain (mean 3.0 before vs 3.5 after [P<0.001]), managing terminal symptoms (mean 2.8 before vs 3.4 after [P<0.001]), assessing decision-making capacity (mean 2.8 before vs 3.4 after [P<0.001]), and discussing advance directives (mean 2.8 before vs 3.4 after [P<0.001]). CONCLUSION: Using a multidisciplinary team to teach a structured curriculum that includes a case-based debriefing improves house officer confidence in discussing end-of-life care and providing palliative care to patients in the intensive care setting.

The role of palliative care at the end of life.

The goal of palliative care is to relieve the suffering of patients and their families by the comprehensive assessment and treatment of physical, psychosocial, and spiritual symptoms experienced by patients. As death approaches, a patient's symptoms may require more aggressive palliation. As comfort measures intensify, so should the support provided to the dying patient's family. After the patient's death, palliative care focuses primarily on bereavement and support of the family.