Online Module Builds Skills for Internal Medicine Interns in Responding to Emotions During Complex Serious Illness Conversations.

CONTEXT: Responding to emotion cues is an essential skill for communicating with patients and families, but many health care trainees have difficulty applying this skill within the context of a complex conversation. OBJECTIVES: We created an original online module to facilitate deliberate practice of a three-skill framework for responding to emotion cues during complex or nonlinear serious illness conversations. METHODS: Our original online module uses a gamebook format, which prompts trainees to engage in focused and repetitive practice of three well-defined skills for responding to emotion cues in a simulated family conference. We implemented the module as a part of a communication skills curriculum for interns rotating in the intensive care unit. After completing the module, all interns answered an open-ended survey question about their perceived skill acquisition. Results were analyzed by a qualitative method and coded into themes. RESULTS: About 71% of interns (n = 65 of 92) completed the online module and open-ended survey question. About 89% of participants responded that they would use a naming, understanding, respecting, supporting, or exploring statement in response to an emotion cue. Nearly two-thirds of participants articulated their rationale for using naming, understanding, respecting, supporting, or exploring statements (e.g., preparing patients to process complex medical information, eliciting information about patient perspective.) CONCLUSION: Our online emotion cue module is a novel tool for deliberate practice of advanced skills for responding to emotion cues in serious illness conversations. In future studies, we will investigate whether our module's efficacy is enhanced by using it as a part of a flipped classroom curriculum with an in-person simulation session.

Excellence in Postlicensure Interprofessional Palliative Care Education: Consensus Through a Delphi Survey.

An increasing number of palliative care educational programs strive to meet the workforce need for palliative care clinicians. This growth necessitates development of robust quality standards. The purpose of this Delphi consensus process was to describe high-quality postlicensure interprofessional palliative care education programs. The steering committee, composed of 6 faculty with experience implementing interprofessional palliative care educational programs, developed initial characteristics, definitions, and subcategories, which were refined through a series of 3 iterative Delphi surveys and a public presentation at a national palliative care meeting. More than 50 palliative care clinicians and educators representing multiple professions were invited to participate in the Delphi surveys; 20 completed round 1, 23 completed round 2, and 15 participants completed round 3. The final consensus included 6 characteristics with definitions, and both required and recommended subcategories for each characteristic. Identified characteristics include competencies, content, educational strategies, interprofessional focus, evaluation, and systems integration. This initial description of quality for postlicensure interprofessional palliative care education programs may be used by learners to guide program selection, new or existing program faculty for course development or quality improvement, or professional organizations to evaluate program quality in a program certification or quality award initiative.

Moral Distress and Attitudes About Timing Related to Comfort Care for Hospitalized Patients: A Survey of Inpatient Providers and Nurses.

CONTEXT: Providing nonbeneficial care at the end of life and delays in initiating comfort care have been associated with provider and nurse moral distress. OBJECTIVE: Evaluate provider and nurse moral distress when using a comfort care order set and attitudes about timing of initiating comfort care for hospitalized patients. METHODS: Cross-sectional survey of providers (physicians, nurse practitioners, and physician assistants) and nurses at 2 large academic hospitals in 2015. Providers and nurses were surveyed about their experiences providing comfort care in an inpatient setting. RESULTS: Two hundred five nurse and 124 provider surveys were analyzed. A greater proportion of nurses compared to providers reported experiencing moral distress "some, most, or all of the time" when using the comfort care order set (40.5% and 19.4%, respectively, P = .002). Over 60% of nurses and providers reported comfort care was generally started too late in a patient's course, with physician trainees (81.4%), as well as providers (80.9%) and nurses (84.0%) < 5 years from graduating professional school most likely to report that comfort care is generally started too late. CONCLUSIONS: The majority of providers and nurses reported that comfort care was started too late in a patient's course. Nurses experienced higher levels of moral distress than providers when caring for patients using a comfort care order set. Further research is needed to determine what is driving this moral distress in order to tailor interventions for nurses and providers.

Pilot Study of an Interprofessional Palliative Care Curriculum: Course Content and Participant-Reported Learning Gains.

CONTEXT: The National Consensus Project for Quality Palliative Care Clinical Practice Guidelines recommend that palliative care clinicians work together as interprofessional teams. We created and piloted a 9-month curriculum that focused on 3 related domains: (1) patient-centered, narrative communication skills; (2) interprofessional team practice; and (3) metrics and systems integration. The multifaceted curriculum was delivered through 16 webinars, 8 online modules, 4 in-person workshops, reflective skill practice, written reflections, and small group online discussions. OBJECTIVES: Report evaluations of the course content and skill self-assessments from 24 interprofessional palliative care clinicians. METHODS: Participants rated each learning activity and completed a retrospective pre-post test skill assessment. Learning gains were measured as the difference in the percentage of participants reporting "strong" or "highly competent" skill levels at baseline and the end of the course. Participants also provided examples of how they used the skills in practice. RESULTS: Participants achieved an average learning gain of 50% across all domains, and in each domain communication (54%), interprofessional team practice (52%), and metrics and systems integration (34%). They also gave high ratings for the curriculum content (overall mean [standard deviation] rating of 5.5 (0.7) out of 6). Examples of practice impacts included improved skills in responding to emotions, understanding the equal importance of all professions on their team and incorporating different perspectives into their practice, and learning about outcome measurement in palliative care. CONCLUSION: This curriculum demonstrated success in increasing perceived skills for interprofessional palliative care clinicians in advanced communication, team practice, and metrics and system integration.

A New Generation of Comfort Care Order Sets: Aligning Protocols with Current Principles.

BACKGROUND: There are few published comfort care order sets for end-of-life symptom management, contributing to variability in treatment of common symptoms. At our academic medical centers, we have observed that rapid titration of opioid infusions using our original comfort care order set's titration algorithm causes increased discomfort from opioid toxicity. OBJECTIVE: The aim of this study was to describe the process and outcomes of a multiyear revision of a standardized comfort care order set for clinicians to treat end-of-life symptoms in hospitalized patients. DESIGN: Our revision process included interdisciplinary group meetings, literature review and expert consultation, beta testing protocols with end users, and soliciting feedback from key committees at our institutions. We focused on opioid dosing and embedding treatment algorithms and guidelines within the order set for clinicians. SETTING: The study was conducted at two large academic medical centers. RESULTS: We developed and implemented a comfort care order set with opioid dosing that reflects current pharmacologic principles and expert recommendations. Educational tools and reference materials are embedded within the order set in the electronic medical record. There are prompts for improved collaboration between ordering clinicians, nurses, and palliative care. CONCLUSIONS: We successfully developed a new comfort care order set at our institutions that can serve as a resource for others. Further evaluation of this order set is needed.

A Procedural Approach to Teaching Residents To Conduct Intensive Care Unit Family Conferences.

RATIONALE: Family conferences are an essential component of high-quality ICU care and an important skill for physicians. For residents, intensive care unit (ICU) rotations represent an opportunity to learn to conduct family conferences, and residents are already familiar with an approach for learning ICU procedures with steps of increasing responsibility organized as a module. OBJECTIVES: To determine the acceptability and feasibility of a procedure-training module for teaching family conferences. METHODS: We conducted a feasibility pilot study of a family conference training module with residents during a one-month ICU rotation over a three-month period. The module had five components: (1) two-minute instructional video; (2) faculty observation of two family conferences; (3) standardized observation and formative evaluation; (4) online resident procedure log; and (5) family conference note template to document the conference in the medical record. We evaluated acceptability with an anonymous survey. RESULTS: Twenty-seven residents rotated through the ICU during the pilot with 11 completing only one observed conference (41%) and 4 completing two or three observed conferences (15%). The most common reasons for not having conducted observed and evaluated conferences included competing work demands and conferences occurring at night. The survey response rate was 44% (12/27). Of respondents, 92% gave the module a rating of good, very good, or excellent and 92% stated they would recommend the module to others. CONCLUSIONS: This five-component module for teaching family conferences was rated as acceptable by most respondents, but significant barriers to successful implementation must be addressed before this is likely to be an effective teaching method.

The Cambia Sojourns Scholars Leadership Program: Project Summaries from the Inaugural Scholar Cohort.

BACKGROUND: As palliative care grows and evolves, robust programs to train and develop the next generation of leaders are needed. Continued integration of palliative care into the fabric of usual health care requires leaders who are prepared to develop novel programs, think creatively about integration into the current health care environment, and focus on sustainability of efforts. Such leadership development initiatives must prepare leaders in clinical, research, and education realms to ensure that palliative care matures and evolves in diverse ways. METHODS: The Cambia Health Foundation designed the Sojourns Scholar Leadership Program to facilitate leadership development among budding palliative care leaders. RESULTS: The background, aims, and results to date of each of the projects from the scholars of the inaugural cohort are presented.

Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis.

BACKGROUND: A rapid response system (RRS) consists of providers who immediately assess and treat unstable hospitalized patients. Examples include medical emergency teams and rapid response teams. Early reports of major improvements in patient outcomes led to widespread utilization of RRSs, despite the negative results of a subsequent cluster-randomized trial. PURPOSE: To evaluate the effects of RRSs on clinical outcomes through a systematic literature review. DATA SOURCES: MEDLINE, BIOSIS, and CINAHL searches through August 2006, review of conference proceedings and article bibliographies. STUDY SELECTION: Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies reporting effects of an RRS on inpatient mortality, cardiopulmonary arrests, or unscheduled ICU admissions. DATA EXTRACTION: Two authors independently determined study eligibility, abstracted data, and classified study quality. DATA SYNTHESIS: Thirteen studies met inclusion criteria: 1 cluster-randomized controlled trial (RCT), 1 interrupted time series, and 11 before-after studies. The RCT showed no effects on any clinical outcome. Before-after studies showed reductions in inpatient mortality (RR = 0.82, 95% CI: 0.74-0.91) and cardiac arrest (RR = 0.73, 95% CI: 0.65-0.83). However, these studies were of poor methodological quality, and control hospitals in the RCT reported reductions in mortality and cardiac arrest rates comparable to those in the before-after studies. CONCLUSIONS: Published studies of RRSs have not found consistent improvement in clinical outcomes and have been of poor methodological quality. The positive results of before-after trials likely reflects secular trends and biased outcome ascertainment, as the improved outcomes they reported were of similar magnitude to those of the control group in the RCT. The effectiveness of the RRS concept remains unproven.

Dications of fluorenylidenes. The relationship between redox potentials and antiaromaticity for meta- and para-substituted diphenylmethylidenefluorenes.

[reaction: see text] Electrochemical oxidation of meta-substituted diphenylmethylidenefluorenes (3a-g) results in the formation of fluorenylidene dications that are shown to be antiaromatic through calculation of the nucleus independent chemical shift (NICS) for the 5- and 6-membered rings of the fluorenyl system. There is a strong linear correlation between the redox potential for the dication and both the calculated NICS and sigma(m). Redox potentials for formation of dications of analogously substituted tetraphenylethylenes shows that, with the exception of the p-methyl derivative, the redox potentials for these dications are less positive than for formation of the dications of 3a-g and for dications of p-substituted diphenylmethylidenefluorenes, 2a-g. The greater instability of dications of 2a-g and 3a-g compared to the reference system implies their antiaromaticity, which is supported by the positive NICS values. The redox potentials for formation of the dications of meta-substituted diphenylmethylidenes (3a-g) are more positive than for the formation of dications of para-substituted diphenylmethylidenes (2a-g), indicating their greater thermodynamic instability. The NICS values for dications of 3a-g are more antiaromatic than for dications of 2a-g, which is consistent with their greater instability of the dications of 3a-g. Although the substituted diphenylmethyl systems are not able to interact with the fluorenyl system through resonance because of their geometry, they are able to moderate the antiaromaticity of the fluorenyl cationic system. Two models have been suggested for this interaction, sigma to p donation and the ability of the charge on the substituted ring system to affect delocalization. Examination of bond lengths shows very limited variation, which argues against sigma to p donation in these systems. A strong correlation between NICS and sigma constants suggests that factors that affect the magnitude of the charge on the benzylic (alpha) carbon of the diphenylmethyl cation affect the antiaromaticity of the fluorenyl cation. Calculated atomic charges on carbons 1-8 and 10-13 show an increase in positive charge, and therefore greater delocalization of charge in the fluorenyl system, with increasing electronegativity of the substituent. The change in the amount of positive charge correlated strongly with NICS, supporting the model in which the amount of delocalization of charge is related to the antiaromaticity of the species. Thus, both aromatic and antiaromatic species are characterized by extensive delocalization of electron density.