Increasing Residency Training of Goal-oriented Treatment Options in Patients with Life-limiting Illnesses Poster
Tae Joon Lee, Qing Cao, Stella Hayes, Phillip Austin, Muhammad Zafar, Shiv Patil, Robert Newman
Qing Cao, MD, HRSA 1-K01 HP20471 Geriatric
Academic Career Award . The investigators retain full
independence in the conduct of this research
A80
East Carolina University, Greenville, North Carolina
Abstract
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).
Sample Educational Material
Conclusions: Educational sessions significantly impacted
residents’ knowledge and attitude about advance care
planning and EOL care.
Background
Most seriously ill patients are not able to make
decisions at the end of life
Surrogate decision maker to patient concordance
about treatment preferences is often poor
Improvement of surrogate understanding of patient
preferences has the potential to improve both patient
and surrogate outcomes
Structured, facilitated patient-surrogate
conversations are associated with improved
surrogate understanding of patient wishes.
Resident physician training in discussion of goaloriented treatment options is not standardized.
Alive
8%
Attitude Test Score
Goals of Care:
Alive
Dead
Dead
92%
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).
Results
Survival After Un-witnessed CPR
Alzheimer’s Dementia Diagnosed
Overall Attitude
Knowledge Scores
Pre
Test
33%
Overall Knowledge
75%
91%
<0.00
1
41%
0.037
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
Whether to treat infections at
EOL
24%
40%
0.095
Location of care at EOL
52%
69%
0.090
Interest in advanced
6
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
How many patients with advanced illnesses
who get CPR in the hospital survive?
79%
93%
0.057
Desire CPR
10%
15%
0.578
Does tube feeding eliminate the risk of
aspiration pneumonia for patients with
advanced dementia?
90%
94%
0.643
5
4
Average
Years
Until
Death
3
2
1
0
At age 60- At age 70- At age 80- At age 90 or
69
79
89
older
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)
Yes
10,924 (2.5)
11.5 (10.9-12.1)
No
423,061 (97.5)
18.5 (18.4-18.6)
Admitted from a SNF
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.
Postp
test value
Post
p
Test value
8
7
PreTest
Resident comments:
1. Not enough time
2. 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)
Conclusion
 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.
References
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. 22
One-year trajectories of care and resource utilization for recipients of prolonged mechanical
ventilation: A cohort study, Unroe M, Tulsky JA, Cox CE, Ann Intern Med 2010 153:167-75
Survival 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):1102-7
Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia, The American Journal of Gastroenterology (2000) 95, 1472–
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