Increasing Residency Training of Goal-oriented Treatment Options in Patients with Life-limiting IllnessesTae Joon Lee, Qing Cao, Stella Hayes, Phillip Austin, Muhammad Zafar, Shiv Patil, Robert Newman

East Carolina University, Greenville, North Carolina

Results Abstract

Conclusion

References

Poster A80

Qing Cao, MD, HRSA 1-K01 HP20471 Geriatric Academic Career Award . The investigators retain full independence in the conduct of this research

Objectives: For many patients with life-limiting illnesses, defining and discussing goals of future medical care (advance care planning) are very important. This study measures the effects of education to the in-training residents of family medicine (FM) and internal medicine (IM) residency programs at East Carolina University (ECU).

Design: Based on the results of the informal assessment of need from the residents and faculty, educational materials were developed. These included discussion of advance care planning, MOST (POLST) form, FIVE WISHES, healthcare power of attorney, and living will. A 2-hour education and discussion session was given to all in-training FM and IM residents at ECU. Pre- and post-tests were administered to measure their medical knowledge as well as attitudes toward advance care planning.

Results: A total of 70 pre-test and 53 post-test scores were analyzed. Overall knowledge improved with the educational sessions (74.9% vs 90.5% correctly answered pre- and post-test, respectively). Also, the residents’ own attitude toward advance care planning changed favoring less aggressive care at the end-of-life (EOL).

Conclusions: Educational sessions significantly impacted residents’ knowledge and attitude about advance care planning and EOL care.

BackgroundMost seriously ill patients are not able to make decisions at the end of lifeSurrogate decision maker to patient concordance about treatment preferences is often poorImprovement of surrogate understanding of patient preferences has the potential to improve both patient and surrogate outcomesStructured, facilitated patient-surrogate conversations are associated with improved surrogate understanding of patient wishes.Resident physician training in discussion of goal-oriented treatment options is not standardized.

Methods

Based on the results of the informal assessment of need from the residents and faculty, 2-hour educational materials were developed. These included discussion of advance care planning, MOST (POLST) form, FIVE WISHES, healthcare power of attorney, and living will. Pre- and post-tests were administered to measure their medical knowledge as well as attitudes toward advance care planning.

Sample Educational Material

Age (yr)Patients with In-Hospital CPR

number (percent)Survival to Hospital Discharge

percent (95%CI)

65-69 63,299 (14.6) 22.2 (21.9-22.6)

70-74 84,353 (19.4) 20.9 (20.6-21.1)

75-79 98,263 (22.6) 19.1 (18.9-19.3)

80-84 91,471 (21.1) 17.0 (16.8-17.3)

85-89 62,530 (14.4) 15.1 (14.8-15.4)

>=90 34,069 (6.9) 12.2 (11.9-12.6)

Admitted from a SNF

Yes 10,924 (2.5) 11.5 (10.9-12.1)

No 423,061 (97.5) 18.5 (18.4-18.6)

Educational sessions significantly impacted residents’ knowledge and attitude about advance care planning and EOL care. Some residents felt more comfortable with discussion regarding goals of care, MOST (POLST) form use, advance directives, HCPOA, and living will. Time and training are significant factors in residents’ ability to discuss these issues with patients. More targeted educational opportunities and longer follow up are needed and need to be standardized in medical training.

CPR & Sudden Cardiac Arrest (SCA), Fact Sheet, as of April 26, 2010.Epidemiologic Study of In-Hospital Cardiopulmonary Resuscitation in the Elderly, The New England Journal of Medicine Jul 2, 2009. Vol. 361, Iss. 1; pg. 22One-year trajectories of care and resource utilization for recipients of prolonged mechanicalventilation: A cohort study, Unroe M, Tulsky JA, Cox CE, Ann Intern Med 2010 153:167-75Survival of people with clinical diagnosis of dementia in primary care: cohort study, BMJ 2010; 341:c3584 doi: 10.1136/bmj.c3584 (Published 5 August 2010), Cite this as: BMJ 2010; 341:c3584 Survival and comfort after treatment of pneumonia in advanced dementia, Arch Intern Med. 2010 Jul 12;170(13):1102-7Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia, The American Journal of Gastroenterology (2000) 95, 1472–1475

Goals of Care:

Knowledge ScoresPre-Test

Post- test

p value

Overall Knowledge 75% 91%<0.00

1

Which EOL planning tools do you know about? 77% 92%<0.00

1

In which order can the following individuals make medical decisions if a patient is incapable?

56% 89%<0.00

1

How many patients with a witnessed cardiac arrest survive CPR?

84% 91%<0.00

1

If pneumonia is not treated with antibiotics, does this increase discomfort level for patients with advanced dementia?

64% 85% 0.017

How many patients with advanced illnesses who get CPR in the hospital survive?

79% 93% 0.057

Does tube feeding eliminate the risk of aspiration pneumonia for patients with advanced dementia?

90% 94% 0.643

Attitude Test ScorePre Test

Post Test

p value

Overall Attitude 33% 41% 0.037

Whether to treat infections at EOL

24% 40% 0.095

Location of care at EOL 52% 69% 0.090

Interest in advanced directives 62% 75% 0.197

Whether to use tube feeding at EOL

63% 58% 0.245

Whether use IV fluids at EOL 19% 27% 0.543

Desire CPR 10% 15% 0.578

Resident comments:

1. Not enough time2. Family or patient did not want to talk about end of life issues or code status 3. Resident is not familiar with resources available (still not sure how to use MOST, living will, 5 wishes, etc)