Physicians' confidence in discussing do not resuscitate orders with patients and surrogates.

PURPOSE: Physicians are often reluctant to discuss "Do Not Resuscitate" (DNR) orders with patients. Although perceived self-efficacy (confidence) is a known prerequisite for behavioural change, little is understood about the confidence of physicians regarding DNR discussions. SUBJECTS AND METHODS: A survey of 217 internal medicine attendings and 132 housestaff at two teaching hospitals about their attitudes and confidence regarding DNR discussions. RESULTS: Participants were significantly less confident about their ability to discuss DNR orders than to discuss consent for medical procedures (p<0.001), and this was true for both attendings (p = 0.002) and housestaff (p<0.001). In a multivariate logistic model of confidence regarding DNR discussions, women were less confident than men (OR = 0.52, CI = 0.29 to 0.92); house officers were less confident than attendings (OR = 0.35, CI = 0.20 to 0.61), those who were less confident of their ability to discuss medical procedures were less confident discussing DNR (OR = 0.12, CI = 0.06 to 0.25), and those who found talking to patients about DNR orders very difficult reported less confidence than those who did not (OR = 0.06, CI = 0.02 to 0.16). CONCLUSION: We conclude that physicians' confidence regarding DNR discussions is low compared with their confidence regarding other medical discussions and that confidence varies by sex and perceived difficulty of the task. Efforts to improve DNR discussions should explore the need to tailor educational interventions to fit these characteristics.

A needs assessment for a palliative care curriculum.

To ensure the success of a new curriculum at an institution, information about the educational needs of learners, available resources, and potential obstacles needs to be systematically collected and analyzed prior to the development and implementation of the actual curriculum. This process, known as needs assessment, is important in the development of palliative care training for internal medicine residents, because internal medicine has only recently begun to address these issues in a formalized way and palliative care is a relatively new topic in medical education and clinical medicine. Therefore, institutional issues and resistance, lack of knowledge and appropriate attitudes among trainees and faculty, and a paucity of educational models for individual internal medicine training programs present potential obstacles. Although curricula that have been developed by national organizations can serve as "guideposts, " these documents are unable to address the specific needs and culture of an individual institution. This paper outlines a systematic methodology of needs assessment for palliative care curricula at individual institutions that could be applied to the development and implementation of palliative care training for different groups of learners. An institution-specific needs assessment was developed based upon the findings of a systematic literature review and interviews with experts in palliative medicine and medical education. The following methods were utilized: 1) an anonymous survey; 2) focus groups; 3) topic rankings; and 4) individual interviews. The needs assessment revealed the following educational, clinical, and institutional information: 1) interns had very little exposure to palliative care in medical school; 2) there was no formalized system formal education and clinical exposure; 3) tremendous interest in palliative care education existed; 4) patients, families, physicians, and nurses perceived a need to improve the quality of palliative care; and 5) there are several political, logistical, and resource (time and financial) obstacles that needed to be addressed. An institution-specific needs assessment is an important part of the successful development and implementation of any new curriculum for medical residents and was specifically necessary for our palliative care program. As a result of the needs assessment process, a curriculum consisting of ten units of case-based and problem-based teaching was successfully implemented.