Code Status Discussions Research Articles

Goals-of-Care Decisions by Hospitalized Patients With Advanced Cancer: Missed Clinician Opportunities for Facilitating Shared Decision-Making

ContextHospitalized patients with advanced cancer often face complex, preference-sensitive decisions. How clinicians and patients engage in shared decision-making during goals-of-care discussions is not well understood. ObjectiveThe objective of this study was to explore decision-making by patients and clinicians during inpatient goals-of-care discussions. MethodsThis is a qualitative study of audio-recorded goals-of-care discussions between hospitalized patients with advanced cancer and their clinicians. Grounded theory was used to analyze transcripts. ResultsSixty-two patients participated in goals-of-care discussions with 51 unique clinicians. Nearly half of patients (n = 30) were female and their mean age was 60.1 years (SD = 12.7). A palliative care attending or fellow was present in 58 of the 62 discussions. Decisions centered on three topics: 1) disease-modifying treatments; 2) hospice; and 3) code status. Clinicians' approach to decision-making included the following stages: “information exchange,” “deliberation,” “making a patient-centered recommendation,” and “wrap-up: decisional status.” Successful completion of each stage varied by the type of decision. When discussing code status, clinicians missed opportunities to engage patients in information exchange and to wrap up decisional status. By contrast, clinicians discussing disease-modifying treatments and hospice failed to integrate patient preferences. Clinicians also missed opportunities to make patient-centered recommendations when discussing treatment decisions. ConclusionClinicians missed opportunities to facilitate shared decision-making regarding goals of care, and these missed opportunities differed by type of decision being discussed. Opportunities for clinician communication training include engagement in collaborative deliberation with patients and making patient-centered recommendations in situations of high medical uncertainty.

Checklist-guided Shared Decision-making for Code Status Discussions in Medical Inpatients.

Checklist-guided Shared Decision-making for Code Status Discussions in Medical Inpatients.

Annals for Educators - 5 March 2019.

Annals for Educators - 5 March 2019.

The Effects of Adding Reassurance Statements: Cancer Patients' Preferences for Phrases in End-of-Life Discussions

ContextWhen discussing end-of-life issues with cancer patients, the addition of reassurance statements is considered helpful. However, patients' preferences for such statements have not been systematically demonstrated. ObjectivesThe objectives of this study were to clarify if phrases with additional reassurance statements would be more preferable to phrases without them and explore variables associated with patients' preferences. MethodsIn a cross-sectional survey, 412 cancer patients assessed their own preferences for phrases with/without additional statements using a six-point scale (1 = not at all preferable; 6 = very preferable). These included the statements of “hope for the best and prepare for the worst” (“hope/prepare”) when discussing prognosis; symptom palliation when discussing code status; and specific goals, continuity of care, and nonabandonment when discussing hospice referral. We evaluated demographic data and the coping style and conducted multivariate regression analysis. ResultsCompared with the phrase of life expectancy (i.e., median + typical range) alone [mean (SD), 3.5 (1.2); 95% CI, 3.4–3.6], the phrase with the additional “hope/prepare” statement was more preferable [3.8 (1.4); 3.7–3.9]. Compared with the phrase of do-not-resuscitate alone (3.1(1.3); 3.0–3.3), the phrase with the additional statement of symptom palliation was more preferable [3.9 (1.3); 3.7–4.0]. Compared with the phrase of hospice referral alone [3.4 (1.2); 3.3–3.5], phrases with the addition of a specific goal [3.9 (1.0); 3.8–4.0], specific goal and continuity (4.4(1.0); 4.3–4.5), and specific goal, continuity, and nonabandonment [4.8 (1.2); 4.7–4.9] were more preferable. In multivariate analyses, task-oriented coping was significantly correlated with preferences for phrases including additional reassurance statements. ConclusionCancer patients systematically preferred reassurance statements. In end-of-life discussions, especially with patients with task-oriented coping, clinicians may provide additional reassurance statements.

The Geriatric Patient

An aging population combined with the increasing availability of invasive medical procedures has created a growing number of elderly patients that anesthesiologists care for every day. Geriatric patients present unique challenges that must be taken into consideration when crafting an anesthetic plan. To start with, one must first decide what it means to be elderly. Is it an age cutoff? If so, at what age does a patient become elderly? Is it a physiologic definition? If so, what amount of physiologic derangement must be present and in how many organ systems for someone to be classified as elderly? Although there is no clear consensus, a reasonable definition would combine age with the patient’s physical tolerance towards the stresses of surgery. This chapter attempts to address the myriad challenges faced by the perioperative physician who is planning to anesthetize an elderly patient. There are unique points to be noted in the preoperative physical examination, cognitive evaluation, creation of the anesthetic plan, and risk stratification. There are additional concerns related to a patient’s wishes regarding code status and potential end-of-life care. By addressing all these issues, anesthesiologists can provide safe, successful, and compassionate care to a complex and diverse elderly population. This review contains 5 figures, 3 tables, and 52 references. Key Words: anesthetizing the elderly, code status discussion, delirium, pharmacokinetic changes of aging, postoperative cognitive decline, physiologic changes of aging, regional anesthesia for orthopedic surgery, risk stratification

Decoding the Code Status: Can a Palliative Care-Led Curriculum Improve Communications Skills in Critical Care and Emergency Department Clinicians? (FR461A)

•Recognize the need for Code Status Discussion training for ICU and ER physicians.•Consider the role of the HPM-practitioner in leading Code Status Discussion training. Communicating effectively with patients/families is an important skill. Palliative care (PC) specialists are often consulted to help with complex communication. In acute settings like the intensive care unit (ICU) and the emergency department (ED) a PC-specialist may not be immediately available, and Code Status Discussions (CSDs) are often required urgently. To evaluate the implementation and efficacy of a newly designed CSD curriculum for ED/ICU clinicians. ED and ICU medical trainees at a single tertiary care center were asked to participate in the CSD curriculum. CSD curriculum featured the NURSE-SPIKES model of delivering bad news and the PULSES model for CSDs. The 2-hour curriculum included lecture, roleplay/feedback, and handouts. Participants were surveyed before, at 30 and 60 days about their CSD comprehension and communication self-efficacy using Bieber’s Questionnaire on the Quality of Physician-Patient Interaction (Cronbach Alpha=0.95). Likert scores were analyzed using Pratt’s modified Wilcoxon signed-rank test. Of 38 medical trainees, N=17 completed the pre-survey. Female=35%; Caucasian=53%, Hispanic=24%, Other=24%; ED=65%, ICU=35%. Of respondents, 82% reported prior contact with PC, and only 47% reported prior PC training. 94% rated CSD-training fairly or extremely important, 35% rated their current training inadequate. N=10 completed 30-/60-day surveys. At 30 days, there was significant improvement in 5/14 self-efficacy metrics (one-tailed, alpha=0.05); at 60 days in 10/14 metrics. Improved areas included: interest in patient’s problems, giving detailed information on illness and options, physician-patient trust, joint decision-making, risks/side effects discussion, understanding patient needs, understanding impact of illness, putting patients at ease, and respecting opinion differences regarding treatment. 83% found the course helpful. A CSD curriculum is a useful tool for developing complex communication skills for ED and ICU physicians.

Periprocedural Code Status Discussions for Inpatients Undergoing Percutaneous Gastrostomy Tube Placement (S836)

1.Describe recommendations for “Do-Not-Resuscitate” orders in the periprocedural period.2.Discuss current low rate of documented periprocedural code status conversations for patients undergoing inpatient G-tube placement. Gastrostomy tube (G-tube) placement is a common procedure performed for patients with life-limiting diseases. Patients may present for G-tube with a “Do-Not-Resuscitate” (DNR) order. Despite multiple national societies recommending periprocedural conversations for patients with a DNR status, it is not clear how often these conversations occur. We sought to evaluate the frequency of documented code status conversations for inpatients who are DNR at the time of G-tube placement at an academic medical center. We also explored factors associated with the presence of a documented conversation. We performed a retrospective chart review for adult in patients undergoing G-tube placement between May 2016 and May 2017. We abstracted demographic information, type of G-tube inserted, code status, indication for G-tube and mortality data. For patients with a code status other than “Full” at time of G-tube, notes five days pre- and post-procedure were reviewed for documentation of a code status discussion. We identified 254 adult inpatients who underwent G-tube placement during the one-year study period. 101/254 patients (44%) were 66 or older, 62% were male and more than half had the highest severity of illness. The most common indication for G-tube was dysphagia/aspiration (23% of patients). Thirty-three (13%) had code status other than “Full” at the time of procedure. Of those, 9 (27%) had documented code status discussion. Patients for whom anesthesia was involved were significantly more likely to have a documented code status discussion (89% of patients with an anesthesia consult vs. 33% of patients without; p=.0057). The majority of patients with code status other than “Full” at the time of procedure did not have documented discussions in the chart despite clear recommendations from major medical societies.

Improving Goals of Care Discussion: Innovative Curriculum Development for Internal Medicine Residents (S829)

1.Describe the development of a communication workshop for internal medicine trainees focused on goals of care and code status discussions.2.Recognize that brief educational interventions can improve palliative care communication skills. Palliative care communication skills are applicable to all physicians regardless of specialty. All internists need to understand and develop skills to facilitate conversations that ascertain patient preferences regarding life-sustaining therapies and goals of care (GOC), particularly in the context of serious illness. Internal medicine and palliative care educators both recognize the need to further develop curriculum structures that address these communication skills. This project will assess an initiative focused on enhancing these skills. Assess the impact of a communication workshop for internal medicine trainees focused on goals of care and code status discussions. The learners consisted of internal medicine residents (n=67) at the University of Iowa during the 2017-2018 academic year. We developed and implemented a 100-minute interactive GOC communication workshop to introduce learners to the knowledge and skills of negotiating GOC and code status (CD). Multiple teaching strategies were used including pre-assigned reading material, video clips demonstrating effective GOC discussion, didactics, and facilitated role-playing led by interdisciplinary faculty. The evaluation included: 1) a standard session evaluation survey to examine learner reaction to the training; and 2) a retrospective pre/post self-assessment survey on confidence in discussing GOC. 31 residents completed the survey. Analysis of paired evaluations showed significant improvements in residents’ confidence in conducting 1) GOC discussions (p=0.0012); 2) CD discussion (p=0.03) and 3) end-of-life discussions (p=0.01). 87% found the curriculum to be useful; 97% reported that palliative care training is essential. The GOC communication workshop was successfully implemented and increased internal medicine residents’ confidence in having difficult discussions. We need to further implement such curriculum in other residency-training programs.

To Code or Not To Code: Teaching Multidisciplinary Clinicians to Conduct Code Status Discussions.

Background: Code status discussions (CSDs) can be challenging for many clinicians. Barriers associated with them include lack of education, comfort level, and experience. Objective: To conduct an educational intervention to improve knowledge and communication approaches related to CSDs. Design: A cross-sectional multidisciplinary educational intervention was conducted over one year consisting of an interactive presentation, live role-play, and pre- and post-intervention tests to measure impact of the formal training. Evaluations and comments were also collected. Setting/Subjects: Attending physicians, nurses, residents, fellows, and physician assistants (PAs) at an urban community teaching hospital of 500 beds serving an ethnically diverse population. Measurements: Data from pre- and post-intervention tests evaluating knowledge and communication approach regarding CSDs were collected. Participants completed a qualitative evaluation of the program. Results: There were 165 participants: 29 attending physicians, 26 residents, 17 fellows, 18 PAs, and 75 nurses. All (100%) completed the pre-intervention test and 154 (93.3%) completed the post-intervention test. There was an overall improvement in scores, 43.8% pre-intervention to 75.6% post-intervention (p-values <0.005). Attending physicians and fellows had the highest pre-intervention scores, while nurses and PAs had the lowest. Most participants (97%) reported they learned new information and 91% stated they would change patient management. Conclusions: Our study found that a brief educational intervention with multipronged teaching tools improved knowledge concerning CSDs. Participants felt it provided new insights and would change their practice. This study contributes to the literature by examining CSD training across different disciplines, allowing for cross-group comparisons. Future studies should try to correlate educational interventions and clinician knowledge with clinical practice outcomes.

Application of Kern’s 6-Step Approach in the Development of a Novel Anesthesiology Curriculum for Perioperative Code Status and Goals of Care Discussions

Code status discussions, goals of care discussions, and shared decision-making in the perioperative setting are of great importance. As perioperative physicians, anesthesiologists are uniquely poised to handle these discussions. Yet formal training for anesthesiology residents in how to approach these scenarios is currently lacking. Using Kern's 6-step approach to curriculum development, we describe an innovative curriculum for anesthesiology residents designed to teach the necessary skills to successfully conduct code status and goals of care discussions and to assess its efficacy. Our curriculum is composed of the following educational components: (1) formal, online learning modules, (2) selected journal articles describing code status and goals of care discussions skills and communication strategies, and (3) 2 objective-structured clinical examination experiences, with 1 occurring prior to and the other occurring after completion of the educational content. The educational content focuses on evidence-based best practices content covering professional guidelines, current literature, shared decision-making, and effective communication strategies. We also describe the potential methodology to evaluate the effectiveness of our proposed educational interventions. Using Kern's framework, we developed a curriculum focusing on code status discussions, goals of care discussions, and shared decision-making in the perioperative setting which provides trainees with the opportunity to practice communication skills and receive feedback from a standardized patient through participation in an objective structured clinical examination.

The pyramid of treatment levels: A tool to convey goal-based treatment options.

147 Background: 60% of Americans die in acute care hospitals and under 40% of advanced cancer patients have end-of-life care discussions with their health care providers. Didactic methods and tools to teach about symptom management, navigation of treatment decisions, code status, and end-of-life care decisions within an inpatient setting are a necessity to meet this high demand. Methods: A model of medical care systematically dividing clinical management decisions into escalating levels of medical care relative to illness severity, treatment goals, and code status was created. The model is illustrated as a pyramid with a base of symptom management as the initial level of medical care. The second level represents disease-focused medical care including antibiotics, disease-modifying drugs, and chemotherapy administration. Hospitalization with increasingly complex and invasive interventions represents the third level followed by critical illness care including ICU admission and vasopressors as the fourth level. Intubation comprises the fifth level and CPR forms the top of the pyramid. Results: This model has been used extensively at our institution in educating medical students, residents, fellows, and faculty. All groups reported it was helpful in understanding POLST forms, code status, and collaboratively developing appropriate goal-based care plans with their patients. Symptom management remaining as a non-negotiable foundation of care emphasizes its importance. This depiction of medical care may facilitate goals of care and code status discussions and is particularly helpful for determining appropriate care goals or options when considering de-escalation of medical therapies. Used implicitly or explicitly in patient and family discussions, it has facilitated decision-making and discerning the appropriateness of the overall treatment plan relative to patient goals of care. Conclusions: This model of care with its companion pyramid accommodate a wide range of clinical scenarios, is an effective, high yield didactic device for patients, families, and healthcare providers alike, and has applications as supportive tool to optimize goal-based clinical decision making in the context of serious illness.

Case-Based PowerPoint to Improve Knowledge and Comfort of Having Code Status Discussions by Physician Assistant and Nurse Practitioner Students.

Little is known about how certain educational interventions may improve informed code status discussions by physician assistant (PA) and nurse practitioner students. This is a prospective, prospective, single academic center pilot study utilizing a short case-based PowerPoint that reviewed the differences between code status choices and the likelihood of survival to hospital discharge of attempted resuscitation after a cardiac arrest. Training occurred between September 1, 2017, and May 31, 2018. The study population included PA and adult gerontology acute care nurse practitioner (AGACNP) students during their inpatient internal medicine rotation (n = 9) and preclinical PA students (n = 5). After training, there was a significant increase in knowledge in the likelihood of survival to hospital discharge (P = .01) and comfort level in having an informed code status discussion (3.36 ± 0.81 vs 4.10 ± 0.80, P = .02). For questions related to identification of the correct code status, there were no significant differences before and after the intervention. A short case-based PowerPoint viewed by PA and AGACNP students increased the knowledge about the likelihood of survival to hospital discharge of attempted resuscitation after a cardiac arrest and increased the comfort level of having code status discussions with patients by PA and AGACNP students.

Admission to intensive care: A qualitative study of triage and its determinants

To examine physicians' decision making and its determinants about admission to intensive care. ICU physicians (n=12) and internists (n=12) working in a Swiss tertiary care hospital. We conducted in-depth interviews. Interviews were analyzed using an inductive thematic approach. Admission decisions regarding seriously ill or elderly patients with comorbidities are complex. Nonmedical factors such as ICU beds availability, health care resources on the ward, information about patient preferences, and family behavior determine the decision. Code status and the quality of interaction between physicians are key determinants. The absence of code status or poor documentation of code status discussions makes decisions more difficult and laden emotionally, as physicians feel they are making a life-death decision. Mutual respect and collaborative decision making facilitate the decision. Tensions arise due to ICU physicians' postponing the decision because of lack of beds, ICU physicians' dismissive attitudes, perceived shortcomings in the other physician's completion of expected tasks, and preconceptions about the other physician. Systematic documentation of code status, and fostering collaboration between ICU physicians and internists would facilitate ICU admission decisions in complex clinical situations.

Protocol driven palliative care consultation: Outcomes of the ENABLE CHF-PC pilot study

BackgroundLittle has been reported about protocol-driven outpatient palliative care consultation (OPCC) for advanced heart failure (HF). ObjectivesTo describe evaluation practices and treatment recommendations made during protocol-driven OPCCs for advanced HF. MethodsWe performed content analysis of OPCCs completed as part of ENABLE CHF-PC, an early palliative care HF intervention, conducted at sites in the Northeast and Southeast. T-tests, Fisher's exact, and Chi-square tests were used to evaluate sociodemographic, outcome measures, and site content differences. ResultsOf 61 ENABLE CHF-PC participants, 39 (64%) had an OPCC (Northeast, n=27; Southeast, n=12). Social and medical history assessed most were close relationships (n=35, 90%), family support (n=33, 85%), advance directive status (n=33, 85%), functional status (n=30, 77%); and symptoms were mood (n= 35, 90%), breathlessness (n=28, 72%), and chest pain (n=24, 62%). Treatment recommendations focused on care coordination (n=13, 33%) and specialty referrals (n=12, 31%). Between-site OPCC differences included assessment of family support (Northeast vs. Southeast: 100% vs. 50%), code status (96% vs. 58%), goals of care discussions (89% vs. 41.7%), and prognosis understanding (85% vs. 33%). ConclusionOPCCs for HF focused on evaluating medical and social history, along with goals of care and code status discussions. Symptom evaluation commonly included mood disorders, pain, dyspnea, and fatigue. Notable regional differences were found in topics evaluated and OPCC completion rates.

Factors associated with combined do-not-resuscitate and do-not-intubate orders: A retrospective chart review at an urban tertiary care center

BackgroundIn clinical practice, do-not-intubate (DNI) orders are generally accompanied by do-not-resuscitate (DNR) orders. Use of do-not-resuscitate (DNR) orders is associated with older patient age, more comorbid conditions, and the withholding of treatments outside of the cardiac arrest setting. Previous studies have not unpacked the factors independently associated with DNI orders. ObjectiveTo compare factors associated with combined DNR/DNI orders versus isolated DNR orders, as a means of elucidating factors associated with the addition of DNI orders. DesignRetrospective chart review. Setting/subjectsPatients who died on a General Medicine or MICU service (n = 197) at an urban public hospital over a 2-year period. MeasurementsLogistic regression was used to identify demographic and medical data associated with code status. ResultsCompared with DNR orders alone, DNR/DNI orders were associated with a higher median Charlson Comorbidity Index (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13–1.43); older age (OR 1.02, 95% CI 1.01–1.04); malignancy (OR 2.27, 95% CI 1.18–4.37); and female sex (OR 1.98, 95% CI 1.02–3.87). In the last 3 days of life, they were associated with morphine administration (OR 2.76, 95% CI 1.43–5.33); and negatively associated with use of vasopressors/inotropes (OR 10.99, 95% CI 4.83–25.00). ConclusionsCompared with DNR orders alone, combined DNR/DNI orders are more strongly associated with many of the same factors that have been linked to DNR orders. Awareness of the extent to which the two directives may be conflated during code status discussions is needed to promote patient-centered application of these interventions.

A Pilot Study to Evaluate Compliance with Guidelines for Preprocedural Reconsideration of Code Status Limitations.

Periprocedural providers are encountering more patients with code status limitations (CSLs) regarding their preferences for resuscitation and life-sustaining treatment who choose to undergo palliative procedures. Surgical and anesthesia guidelines for preprocedural reconsideration of CSLs have been available for several years, but it is not known whether they are being followed in practice. We assessed compliance with existing guidelines for patients undergoing venting gastrostomy tube (VGT) for malignant bowel obstruction (MBO), serving as an example of a palliative procedure received by patients near the end of life. Code status was determined at admission and throughout the hospitalization by chart review. Documentation of code status discussions (CSDs) was identified from provider notes and compared with existing guidelines. An institutional database retrospectively identified patients who underwent VGT placement for MBO at two academic hospitals (2014-2015). We identified 53 patients who underwent VGT placement for MBO. Interventional radiologists performed 88% of these procedures. Other periprocedural providers involved in these cases included surgeons, gastroenterologists, anesthesiologists, and sedation nurses. CSLs were documented before the procedure in only 43% of cases, and a documented CSD with a periprocedural provider was identified in only 22% of CSL cases. Of all VGT placements performed in patients with CSLs before the procedure, only 13% were compliant with the guidelines of preprocedural reconsideration of CSLs. Increased compliance with guidelines published by the American Society of Anesthesiologists, the American College of Surgeons, and the Association of Perioperative Registered Nurses is necessary to ensure goal-concordant care of patients with CSLs who undergo a procedure. Efforts should be made to incorporate these guidelines into the training of all periprocedural providers.

Challenges to code status discussions for pediatric patients.

ObjectivesIn the context of serious or life-limiting illness, pediatric patients and their families are faced with difficult decisions surrounding appropriate resuscitation efforts in the event of a cardiopulmonary arrest. Code status orders are one way to inform end-of-life medical decision making. The objectives of this study are to evaluate the extent to which pediatric providers have knowledge of code status options and explore the association of provider role with (1) knowledge of code status options, (2) perception of timing of code status discussions, (3) perception of family receptivity to code status discussions, and (4) comfort carrying out code status discussions.DesignNurses, trainees (residents and fellows), and attending physicians from pediatric units where code status discussions typically occur completed a short survey questionnaire regarding their knowledge of code status options and perceptions surrounding code status discussions.SettingSingle center, quaternary care children’s hospital.Measurements and main results203 nurses, 31 trainees, and 29 attending physicians in 4 high-acuity pediatric units responded to the survey (N = 263, 90% response rate). Based on an objective knowledge measure, providers demonstrate poor understanding of available code status options, with only 22% of providers able to enumerate more than two of four available code status options. In contrast, provider groups self-report high levels of familiarity with available code status options, with attending physicians reporting significantly higher levels than nurses and trainees (p = 0.0125). Nurses and attending physicians show significantly different perception of code status discussion timing, with majority of nurses (63.4%) perceiving discussions as occurring “too late” or “much too late” and majority of attending physicians (55.6%) perceiving the timing as “about right” (p<0.0001). Attending physicians report significantly higher comfort having code status discussions with families than do nurses or trainees (p≤0.0001). Attending physicians and trainees perceive families as more receptive to code status discussions than nurses (p<0.0001 and p = 0.0018, respectively).ConclusionsProviders have poor understanding of code status options and differ significantly in their comfort having code status discussions and their perceptions of these discussions. These findings may reflect inherent differences among providers, but may also reflect discordant visions of appropriate care and function as a potential source of moral distress. Lack of knowledge of code status options and differences in provider perceptions are likely barriers to quality communication surrounding end-of-life options.

The PULSES project: Teaching the vital elements of code status discussions to oncology residents.

46 Background: Discussions with cancer patients around cardiopulmonary resuscitation, or ‘code status,’ are often led by trainees in oncology, but formal education for this competency is lacking. In this study, we developed and tested a novel communication tool, the PULSES framework, for informed code status decision-making (a six-step approach summarized by the PULSES acronym [see Table]), through an educational workshop. Methods: A multicentre randomized controlled trial was carried out at 3 academic cancer centres in Ontario, Canada. Residents in medical oncology (MO) and radiation oncology (RO) programs completed a workshop and an observed structured clinical exam (OSCE). Participants were randomized to complete the training before the OSCE (experimental arm) or after the OSCE (control arm). Randomization was stratified for centre and oncology discipline. Expert raters evaluated communication with two rating tools: the novel PULSES scale and the communication skills assessment form (CSAF), a validated benchmark tool that is not specific to oncology content. The primary outcome was improvement in PULSES scores. Results: Forty-six residents consented to participate (28 RO and 18 MO). Groups were well balanced for program and year of training. Participants in the experimental group had higher mean PULSES score than those in the control group (80.4±13.5 vs 63.4±9.7; p&lt;.001; maximum score = 108). There was no significant effect for oncology program and no significant interaction between program and training condition. Scores from the PULSES and CSAF scales were highly correlated (R = 0.864). Conclusions: The PULSES training improved performance among oncology residents for code status discussions. Improved communication scores were not scale-specific. The PULSES framework offers a standardized approach and can be incorporated into competency-based curricula for postgraduate oncology programs. Future work will explore whether communication training in this area impacts patient-level outcomes. [Table: see text]

Code status communication training in Canadian postgraduate oncology programs: A needs assessment survey.

13 Background: Discussions with cancer patients on cardiopulmonary resuscitation directives, or ‘code status,’ are often led by trainees in oncology. This study was carried out across Canada to identify current educational practices and gaps in training for this communication skill. Methods: Medical and radiation oncology residents and program directors (PDs) from across Canada were invited to complete a survey. Questions addressed current teaching practices, perceived importance of this competency, satisfaction with current education and barriers to teaching code status discussion skills. Relative frequencies of categorical and ordinal responses were calculated. Results: Between November 2016 and February 2017, 95 residents (58.6% response rate [RR]) and 17 PDs (63% RR) completed surveys. Both oncology disciplines and trainees at all levels were represented. Only 54.1% and 48.3% of medical and radiation oncology residents, respectively, had experienced any form of code status communication training before entering an oncology program. During oncology training, 41.1% of residents expect to receive formal teaching on this topic and 47.1% of PDs endorsed inclusion of this topic in curricula. Only 20% of residents reported receiving any formal evaluation for this competency while 41.2% of program directors indicated that formal evaluations are provided. All PDs and 98% of residents positively endorsed the importance of this competency in residency and clinical practice. Among residents, 88% felt that more training would be beneficial, and 82.3% of PDs identified a need for new educational resources in this area. Lack of time, educational resources and evaluation tools were among the most commonly identified barriers to teaching (by PDs and trainees). Conclusions: Canadian medical and radiation oncology residency PDs and trainees feel that code status communication is an important competency, yet teaching and evaluation are limited in this area. Barriers to teaching and skill-building have been identified. Further work is underway to develop novel educational resources for code status communication training to include in postgraduate curricula.

End-of-life (EOL) care in medical oncology fellows' clinics.

75 Background: Medical oncology fellowship training presents a critical time for developing skills necessary for discussing end of life (EOL) care preferences with patients and delivering EOL care. There is little data exploring the delivery of EOL care by fellows in practice. We describe our fellows’ experience and identify areas to improve delivery of EOL care and communication. Methods: We retrospectively reviewed electronic medical records (EMR) of patients at our center with advanced (metastatic or recurrent) solid tumors who received care in fellows’ clinics and died between 7/1/2016 and 6/7/2017. We used Fisher’s exact test to determine associations between variables. Results: We included 103 patients from 46 distinct fellow clinics covered by 16 fellows. 54 (52%) were male; median age was 70 (37-94) years. 42 (40%) had a gastrointestinal malignancy, 31 (30%) had lung cancer. Median duration of advanced cancer was 12 (0.5-120) months. Patients received a median of 2 (1-10) lines of chemotherapy. 10 (10%) received chemotherapy within 14 days of death. 10 (10%) used outpatient palliative care (PC). 48 (47%) had EOL/hospice discussions in the outpatient clinic, while 10 (10%) had code status documented in a clinic encounter, and 20 (19%) had a copy of an advanced directive in the EMR. Median time from EOL discussion to death was 30 days (4-171). 69 (67%) enrolled in hospice and median length of stay on hospice was 18 days (1-142). 58 (56%) were hospitalized and 13 (13%) admitted to the ICU within 30 days of death. Of patients not enrolled in hospice, 8 (8%) died at home without hospice, 23 (22%) died in a hospital or ICU, 3 (3%) died in other or unknown places. Patients who had EOL discussions in clinic were more likely to enter hospice (p = .006) and less likely to be hospitalized (p = 0.016) within 30 days of death. Conclusions: Fellows at our center have significant exposure to outpatient EOL discussions and delivery of EOL care. EOL discussions in clinic were associated with decreased rates of health care utilization within 30 days of death. There were low rates of outpatient code status discussions and documentation of advanced directives, and few patients received outpatient PC, which represent potential areas to enhance fellow training and improve patient EOL care.