The Palliative Care Clinical Evaluation Exercise (CEX): An Experience-Based Intervention for Teaching End-of-Life Communication Skills

ArticleinAcademic Medicine 80(7):669-76 · July 2005with23 Reads
DOI: 10.1097/00001888-200507000-00009 · Source: PubMed
To pilot test the "Palliative Care Clinical Evaluation Exercise (CEX)," a new experience-based intervention to teach communication skills in giving bad news and discussing code status. The intervention allows faculty to observe, evaluate, and give feedback to housestaff in their discussions with patients and families. In 2002-03, the intervention was piloted among 60 first-year residents in the categorical Internal Medicine Residency Programs at the University of Pittsburgh. The authors collected feasibility measurements at the time of intervention, and interns' attitudes were measured before and one week after intervention and at the end of the intern year. Forty-four residents (73%) completed the intervention. Discussions averaged a total of 49.5 minutes (SD 24.1), divided among 12.7 minutes (SD 7.5) for prediscussion counseling between the resident and faculty observer, 25.6 minutes (SD 16.1) for the resident-patient discussion, and 12.1 minutes (SD 5.7) for postdiscussion feedback. Residents rated the Palliative Care CEX favorably (>3 on a five-point scale) on ease of arranging the exercise, educational value, quality of the experience, effect on their comfort with discussions, importance to their education, and value of preceptor feedback. Self-ratings of communication competence showed improvement one week after the intervention. The Palliative Care CEX is feasible and positively valued by residents. The findings from this initial pilot study support the value of further efforts to refine the intervention, to confirm its feasibility in other settings, and to validate its use as an educational and assessment tool.
    • "Lorin et al. reported improvement in objective evaluations of EOL discussion skills among medical students on their ICU clerkship following a brief intervention consisting of a lecture, discussions, and interaction with a simulated patient [23]. Han et al. reported improvement in residents' self-rated communication skills after a supervised clinical interaction with a real patient [21]. In reporting results of a retreat for internal medicine residents, Yuen et al. showed that self-assessed comfort significantly improved immediately following a slide presentation and 4-hour interactive session [24]. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction. Although residents frequently lead end-of-life (EOL) discussions in the intensive care unit (ICU), training in EOL care during residency has been required only recently, and few educational interventions target EOL communication in the ICU. This study evaluated a simulation-based intervention designed to improve resident EOL communication skills with families in the ICU. Methods. Thirty-four second-year internal medicine residents at a large urban teaching hospital participated in small group sessions with faculty trained in the "VitalTalk" method. A Likert-type scale questionnaire measured self-assessed preparedness before, immediately following, and approximately 9 months after intervention. Data were analyzed using Wilcoxon rank-sum analysis. Results. Self-assessed preparedness significantly improved for all categories surveyed (preintervention mean; postintervention mean; p value), including discussing bad news (3.3; 4.2; p < 0.01), conducting a family conference (3.1; 4.1; p < 0.01), discussing treatment options (3.2; 3.9; p < 0.01), discussing discontinuing ICU treatments (2.9; 3.5; p < 0.01), and expressing empathy (3.9; 4.5; p < 0.01). Improvement persisted at follow-up for all items except "expressing empathy." Residents rated the educational quality highly. Conclusion. This study provides evidence that brief simulation-based interventions can produce lasting improvements in residents' confidence to discuss EOL care with family members of patients in the ICU.
    Full-text · Article · Jul 2015
    • "Based on the authors' review of published PC/EOL training studies, our challenge with scheduling training dates for our trainers and trainees has not been previously reported in the literature. One explanation for this gap in the literature is that the majority of published research reports on PC/EOL training programs have been focused on physicians who were in training roles (e.g., medical students, fellows, residents ) that provided protected time for the lead investigator to schedule dates for the trainees to participate in planned PC/EOL educational programs (Back et al., 2007; Back et al., 2003; Fischer & Arnold, 2007; FryerEdwards et al., 2006; Furman, Head, Lazor, Casper, & Ritchie, 2006; Han, Keranen, Lescisin, & Arnold, 2005). Hence, we recommend that investigators consider adding extra time to their study timeline to allow for scheduling training dates for practicing health care providers. "
    [Show abstract] [Hide abstract] ABSTRACT: When a child's prognosis is poor, physicians and nurses (MDs/RNs) often struggle with initiating discussions about palliative and end-of-life care (PC/EOL) early in the course of illness trajectory. We describe evaluation of training procedures used to prepare MD/RN dyads to deliver an intervention entitled: Communication Plan: Early Through End of Life (COMPLETE) intervention. Our training was delivered to 5 pediatric neuro-oncologists and 8 pediatric nurses by a team of expert consultants (i.e., in medical ethics, communication, and PC/EOL) and parent advisors. Although half of the group received training in a 1-day program and half in a 2-day program, content for all participants included 4 modules: family assessment, goal-directed treatment planning, anticipatory guidance, and staff communication and follow-up. Evaluations included dichotomous ratings and qualitative comments on content, reflection, and skills practice for each module. Positive aspects of our training included parent advisers' insights, emphasis on hope and non-abandonment messages, written materials to facilitate PC/EOL communication, and an MD/RN dyad approach. Lessons learned and challenges related to our training procedures will be described. Overall, the MDs and RNs reported that our PC/EOL communication-training procedures were helpful and useful. Future investigators should carefully plan training procedures for PC/EOL communication interventions. © 2015 by Association of Pediatric Hematology/Oncology Nurses.
    Article · Jan 2015
    • "These programs could be strengthened by more robust evaluation strategies to assess skill retention, such as observing students demonstrate learned skills during encounters with standardized patients in an Observed Structured Clinical Examination (OSCE †). Structured observation of residents' encounters with actual patients has been used to assess similar curricula in graduate medical education [13], but this methodology may not be appropriate to assess medical students. Competency in end-of-life care communication requires ability in additional content areas such advance directives and goals of care, but whether it is best to present these as part of undergraduate or graduate medical education needs to be determined. "
    [Show abstract] [Hide abstract] ABSTRACT: Innovative approaches are needed to teach medical students effective and compassionate communication with seriously ill patients. We describe two such educational experiences in the Yale Medical School curriculum for third-year medical students: 1) Communicating Difficult News Workshop and 2) Ward-Based End-of-Life Care Assignment. These two programs address educational needs to teach important clinical communication and assessment skills to medical students that previously were not consistently or explicitly addressed in the curriculum. The two learning programs share a number of educational approaches driven by the learning objectives, the students’ development, and clinical realities. Common educational features include: experiential learning, the Biopsychosocial Model, patient-centered communication, integration into clinical clerkships, structured skill-based learning, self-reflection, and self-care. These shared features ― as well as some differences ― are explored in this paper in order to illustrate key issues in designing and implementing medical student education in these areas.
    Article · Jun 2012
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