Primary Palliative Care Skills Research Articles

Nephrologists' perspectives and experiences with hospice among older adults with end-stage kidney disease.

Hospice care leads to improved patient and family outcomes. Hospice use among older adults with end-stage kidney disease (ESKD) is markedly lower than among older adults with other serious illnesses, and the majority of those with ESKD who use hospice enroll in the last days of life. Here, our aim was to explore barriers to timely receipt of high-quality hospice care for older adults with ESKD. Utilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi-structured interviews with 20 nephrologists in the United States focused on treatment decision-making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high-quality hospice. With a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists' interviews revealed two interrelated contributors to the lack of timely access to high-quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD. Our findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients.

Primary Palliative Care for Pediatric Residents: A Curricular Framework and Pilot.

Palliative care (PC) is high-value, holistic care for a child and their family across the entire arc of an illness. All physicians should be competent in symptom management and providing goal-concordant care that acknowledges the quality of life; however, there is insufficient education in pediatric residency to develop competence in basic or ..úPrimary..Ñ PC. We completed a needs assessment and developed a longitudinal, comprehensive, and integrated primary PC curriculum for pediatric residents with the goal of developing foundational primary PC skills regardless of eventual career trajectory. After 1 year of implementation, we assessed resident comfort with primary PC skills via a retrospective pre-post survey. We found a statistically significant (P.ß<.ß.05) increase in residents... comfort with pain management, delivering serious news, and discussing goals of care. An increase in comfort with the management of other symptoms was not statistically significant. After 1 year of implementation, residents describe an increase in comfort with primary PC skills. The next steps include more rigorous evaluation and expansion to include more education in medical ethics. While the educational need is universal, resident needs are constantly evolving and each institution should tailor this curriculum to fit their specific trainee needs and institutional expertise.

Teaching Primary Palliative Care Skills to EM Residents

Teaching Primary Palliative Care Skills to EM Residents

Factors Associated with Antimicrobial Use at the End-Of-Life Among Hospitalized Cancer Patients.

Background: Antimicrobials are frequently administered at end-of-life (EOL) and their non-beneficial use may subject patients to unnecessary harms. Studies analyzing factors for antimicrobial prescribing in solid tumor cancer patients at the EOL are lacking. Thus, we aimed to identify factors and patterns associated with antimicrobial use in hospitalized adults with cancer at EOL. Methods: We used a retrospective cohort design to review electronic medical records of terminal hospitalized patients ≥18 years with solid tumors admitted to non-intensive care units in a metropolitan comprehensive cancer center during 2019 and assessed antimicrobial use in the last 7 days of life. Results: Among 633 cancer patients, 59% (n = 376) received antimicrobials (AM+) within the last 7 days of life. AM + patients were older (P = .012), mostly of male gender (55%), and non-Hispanic ethnicity (87%). AM + patients were significantly more likely to have a foreign device, suspected signs of infection, neutropenia, positive blood culture result, documented advance directive; receive laboratory or radiologic testing, and a palliative care or infectious disease consultation (all P < .05). No statistically significant differences were observed in the presence of documented goals of care discussions, or EOL discussions/EOL care orders. Conclusion: Antimicrobial use at the EOL is common in solid tumor cancer patients at the EOL and is associated with increased utilization of invasive interventions. There is an opportunity for infectious disease specialists to build primary palliative care skills and partner with antimicrobial stewardship programs to better advise patients, decision makers, and primary teams on the use of antimicrobials at the EOL.

New ways to impact primary palliative care practices using online continuing education.

Healthcare professionals trained in palliative care (PC) improve satisfaction and decrease healthcare overutilization for patients with serious illness and their families. A continuing education (CE) series on primary PC aligned to the National Clinical Practice Guidelines for Quality PC was developed by local, interdisciplinary experts for a target audience of rural, primary care healthcare professionals. The modules were accessed on an online learning management system platform. The study objectives were to assess differences in participants' knowledge, competence, performance, and ability to improve patient care as well as commitment to change practice after taking each of the CE modules. To achieve these objectives, a descriptive design was used with a convenience sample of healthcare professionals who registered for the CE series and completed at least one module. Participants completed demographic questions and an evaluation survey after completing each module. So far, 158 healthcare professionals have registered for the series with the majority being nurses and social workers. Although the professionals reported having extensive healthcare experience, they did not report having the same level of PC experience. The professionals represent nine different states. All the CE modules increased teamwork skills for most participants. The CE modules on cultural aspects and self-care had the biggest influence on participants' ability to improve patient outcomes. Cultural aspects, care of the actively dying, and advance care planning had the greatest impact on participants' knowledge, competence, and performance. The primary PC education series improved self-reported skills in teamwork, practice habits, and meeting goals of healthcare professionals from a variety of disciplines and settings. These enhanced primary PC skills will improve the incorporation of PC into a variety of practice settings, by multiple disciplines to enhance access to PC outside of, and potentially referrals to, specialty PC programs.Palliative care (PC) is an emerging field of healthcare aimed at positively affecting patients living with serious illness and their families. An important factor that influences a health professional's successful delivery of PC may be their knowledge, experiences, and confidence. PC training provided to healthcare professionals improves patients' and healthcare professionals' satisfaction and reduces healthcare expenditures through cost savings and cost avoidance.1,2.

Primary palliative care skills in caring for surgical patients in the neonatal intensive care unit

Primary palliative care skills in caring for surgical patients in the neonatal intensive care unit

Beyond 9 to 5: Expansion of an Inpatient Specialist Palliative Care Service to 24/7 Onsite Presence.

For seriously ill hospitalized patients with a diagnosis of cancer, there exists a need for specialist palliative care, 24 hours a day, 7 days a week. This article describes the expansion of a palliative care consult service in a metropolitan, dedicated cancer hospital to provide 24/7 specialist palliative care including onsite overnight presence by advanced practice registered nurses and to evaluate the impact of this change on nighttime utilization of the consult service. Inpatient management encounters and outpatient calls were compared before and after the expansion. The onsite availability of a palliative care specialist between midnight and 8 am increased from less than 10% of the time in 2019 to 100% of the time in 2021. The number of inpatient overnight calls and pages increased from a median of 4 to 16, and the number of follow-up visits evaluated increased from a median of 0 to 6. However, the number of overnight palliative care consults and outpatient calls evaluated did not change significantly. Expansion of a hospital-based palliative care service to include 24/7 onsite overnight presence increased patient, family, and night staff access to high-quality palliative care, prompt symptom management, and staff coaching on primary palliative care skills.

Identifying barriers and facilitators to palliative care integration in the management of hospitalized patients with COVID-19: A qualitative study

Background: Palliative care is well suited to support patients hospitalized with COVID-19, but integration into care has been variable and generally poor. Aim: To understand barriers and facilitators of palliative care integration for hospitalized patients with COVID-19. Methods: Internists, Intensivists and palliative care physicians completed semi-structured interviews about their experiences providing care to patients with COVID-19. Results were analysed using thematic analysis. Results: Twenty-three physicians (13 specialist palliative care, five intensivists, five general internists) were interviewed; mean ± SD age was 42 ± 11 years and 61% were female. Six thematic categories were described including: patient and family factors, palliative care knowledge, primary provider factors, COVID-19 specific factors, palliative care service factors, and leadership and culture factors. Patient and family factors included patient prognosis, characteristics that implied prognosis (i.e., age, etc.), and goals of care. Palliative care knowledge included confidence in primary palliative care skills, misperception that COVID-19 is not a ‘palliative diagnosis’, and the need to choose quantity or quality of life in COVID-19 management. Primary provider factors included available time, attitude, and reimbursement. COVID-19 specific factors were COVID-19 as an impetus to act, uncertain illness trajectory, treatments and outcomes, and infection control measures. Palliative care service factors were accessibility, adaptability, and previous successful relationships. Leadership and culture factors included government-mandated support, presence at COVID planning tables, and institutional and unit culture. Conclusion: The study findings highlight the need for leadership support for formal integrated models of palliative care for patients with COVID-19, a palliative care role in pandemic planning, and educational initiatives with primary palliative care providers.

Palliative Care Always: Hepatology-Virtual Primary Palliative Care Training for Hepatologists.

Palliative care (PC) benefits patients with serious illness including end‐stage liver disease (ESLD). As part of a cluster randomized trial, hepatologists were trained to deliver primary palliative care to patients with ESLD using an online course, Palliative Care Always: Hepatology (PCA:Hep). Here we present a multimethod formative evaluation (feasibility, knowledge acquisition, self‐efficacy, and practice patterns) of PCA:Hep. Feasibility was measured by completion of coursework and achieving a course grade of >80%. Knowledge acquisition was measured through assessments before and throughout the course. Pre/post‐course surveys were conducted to determine self‐efficacy and practice patterns. The hepatologists (n = 39) enrolled in a 12‐week online course and spent 1‐3 hours on the course weekly. The course was determined to be feasible as 97% successfully completed the course and 100% passed. The course was acceptable to participants; 91.7 % reported a positive course experience and satisfaction with knowledge gained (91.6%). The pre/post knowledge assessment showed an improvement of 6.0% (pre 85.9% to post 91.9%, 95% CI [2.8, 9.2], P = 0.001). Self‐efficacy increased significantly (P < 0.001) in psychological symptom management, hospice, and psychosocial support. A year after training, over 80% of the hepatologists reported integrating a variety of PC skills into routine patient care. Conclusion: PCA:Hep is feasible, acceptable, and improves learner knowledge and confidence in palliative care skills. This is a viable method to teach primary PC skills to specialists caring for patients with ESLD.

Health Professionals Palliative Care Education for Older Adults: Overcoming Ageism, Racism, and Gender Bias.

Purpose of reviewMost aging Americans lack access to specialist palliative care aimed at those experiencing serious illness and/or high symptom burden at end of life. The curricula used by training programs for all healthcare professions should focus on helping learners develop the primary palliative care skills and competencies necessary to provide compassionate bias-free care for adults with serious illness. We believe there is much opportunity to improve this landscape via the incorporation of palliative care competencies throughout generalist healthcare professional programs.Recent findingsSeveral recent publications highlight multiple issues with recruitment and retention of diverse students and faculty into healthcare professional training programs. There are also concerns that the curricula are reinforcing age, race, and gender biases. Due to these biases, healthcare professionals graduate from their training programs with socialized stereotypes unquestioned when caring for older adult minority patients and caregivers.SummaryImportant lessons must be incorporated to assure that bias against age, race, and gender are discovered and openly addressed in healthcare professional’s education programs. This review highlights these three types of bias and their interrelationships with the aim of revealing hidden truths in the education of healthcare professionals. Ultimately, we offer targeted recommendations of focus for programs to address implicit bias within their curricula.

Too Many Appointments: Assessing Provider and Nursing Perception of Barriers to Referral for Outpatient Palliative Care.

Background: Integration of early outpatient palliative care for patients with advanced cancer requires overcoming logistical constraints as well as attitudinal barriers of referring providers. This pilot study assessed provider perception of logistical and attitudinal barriers to outpatient palliative care referral as well as provider acceptability of an embedded onco-palliative clinic model.Methods: This was a cross-sectional survey-based study of medical oncologists, palliative care physicians, advanced practice providers (APP), and oncology nurses at a large U.S. academic center. Participants were invited to participate through anonymous online survey. Participants rank ordered logistical barriers influencing referral to an outpatient palliative clinic. Respondents indicated level of agreement with attitudinal perception of palliative care and acceptability of an embedded palliative clinic model through five-item Likert-like scales.Results: There were a total of 54 study participants (28 oncology physicians/APPs, 15 palliative physicians/APPs, and 11 oncology nurses). Across the three cohorts, most survey respondents ranked “time burden to patients” as the primary logistical barrier to outpatient palliative care referral. Both oncology and palliative providers indicated comfort with primary palliative care skills although palliative providers were more comfortable with symptom management compared with oncology providers (93.3% vs. 32.2%). A majority of participants (94.9%) were willing to refer to a palliative care provider embedded within an oncology clinic.Conclusion: Additional health care time cost to patients is a major barrier to outpatient palliative care referral. Embedding a palliative care provider in an oncology clinic may be an acceptable model to increase patient access to outpatient palliative care while supporting the oncology team.

Outcomes of palliative care consultation inpatients with ESRD who received cardiopulmonary resuscitation.

The majority of dialysis patients receive aggressive burdensome treatment near the end of life. Currently, we lack interventions to improve end-of-life care (EoLC) for these patients. We examined the association of palliative care consultation with improving EoLC for critically ill patients with end-stage renal disease (ESRD) who received cardiopulmonary resuscitation (CPR). In this retrospective study, we included patients with ESRD admitted to a large academic center who received CPR either prior to or during their hospital stay. Over 8 years, 17 out of 403 patients received palliative care consultation during their hospital stay; consultations were not standardized in their content. Main outcomes of interest to operationalize better EoLC were: (1) change in code status from full code to do not resuscitate (DNR) and (2) withdrawal from intensive care. Of the patients studied, 60.5% were African-American and 43.2% were female. Demographic differences between those with palliative care consultation and those with usual care were not statistically significant. Palliative care consultation was associated with higher odds of change in code status to DNR (odds ratio 8.10, 95% confidence interval 2.19 - 29.94) and withdrawal from intensive care (odds ratio 8.82, 95% confidence interval 2.69 - 28.91) in patients with ESRD who had received CPR. Palliative care consultation was not associated with any change in in-hospital mortality. Palliative care consultation needs to be considered for hospitalized ESRD patients with limited expected prognoses as it may reduce aggressive and burdensome therapies at the end of life. Furthermore, primary palliative care skills such as communication and decision-making should be taught to nephrologists to improve EoLC for dialysis patients.

Reducing Stress and Anger Among Family Members.

Reducing Stress and Anger Among Family Members.

Emerging Palliative Care Innovations in the ED: A Qualitative Analysis of Programmatic Elements During the COVID-19 Pandemic

ContextHealth systems have aspired to integrate palliative care (PC) into the emergency department (ED) to improve care quality for over a decade, yet there are very few examples of implemented models in the literature. The coronavirus disease 2019 (COVID-19) pandemic led to an increase in the volume of seriously ill patients in EDs and a consequent rapid increase in PC integration in many EDs. ObjectivesTo describe the new PC-ED delivery innovations that emerged during the COVID-19 pandemic. MethodsFor this qualitative study of PC programs in EDs, semistructured interviews were conducted with ED and PC clinicians between June 30, 2020 and August 18, 2020. Participants were asked about PC-ED integration before, during, and after COVID. We conducted a two-phased rapid analysis using a rapid analysis template and consolidated matrix to identify innovations. ResultsUsing purposive and snowball sampling, we interviewed 31 participants, representing 52 hospitals. Several new innovations in care delivery were identified. These included elements of fully embedded PC, the use of PC extenders, technology both within the electronic medical record and outside it, and innovations in training emergency clinicians in primary PC skills to support care delivery. Most PC efforts focused on increasing goals-of-care conversations. Institutions that implemented these programs reported that they increased PC utilization in the ED, were well received by clinicians, and changed patient's care trajectories. ConclusionSeveral new innovations in PC-ED care delivery emerged during COVID. Many innovations leveraged different types of clinicians to deliver care, an increased physical presence of PC in the ED, and used technology to enhance care delivery. These innovations may serve as a framework for institutions as they plan for evolving needs in the ED during and after COVID. Additional research is needed to evaluate the impact of these programs and understand their applicability beyond the pandemic.

Pediatric Palliative Care and the PICU: Where We Have Been and Where We Are Going

This review provides pediatric intensivists and other pediatric clinicians a review of pediatric palliative care, focusing on its integration into the pediatric intensive care unit (PICU) and outlining vital skills for the intensivist. Pediatric palliative care is a relatively young but growing field and is becoming increasingly available at many children’s hospitals. However, there has been a shortage of palliative care physicians historically (Lupu, J Pain Symptom Manag. 40(6):899–911, 2010). Palliative care teams are multidisciplinary and focus on assisting the PICU with pain and symptom management, communication with families, goals of care discussions, complicated grief, and bereavement. Palliative care team involvement may prolong life, improve quality of life by addressing physical and psychological suffering, decrease lengths of hospital and intensive care stay, and improve hospital wide resource utilization. Many PICU patients may benefit from palliative care services. All providers, including pediatric intensivists, should be able to perform primary, or basic, palliative care, including evaluating symptoms and communicating about goals of care and end of life (Hughes and Smith, Annu Rev Public Health. 35:459–475, 2014). More advanced secondary and tertiary palliative care relies on specialists to help navigate more nuanced communications and symptom management (Hughes and Smith, Annu Rev Public Health. 35:459–475, 2014). Palliative care has been shown to have great benefits for patients across the spectrum of diagnoses and prognoses. All providers, including intensivists, should have formalized training in primary palliative care. Mastering and incorporating primary palliative care skills into the clinical practice of non-palliative care providers will facilitate its delivery to patients.

We Will All Be Changed: Palliative Care Transformation in the Time of COVID-19.

Journal of Palliative MedicineVol. 23, No. 9 Notes from the EditorFree AccessWe Will All Be Changed: Palliative Care Transformation in the Time of COVID-19Laura C. HansonLaura C. HansonAddress correspondence to: Laura C. Hanson, MD, MPH, Division of Geriatric Medicine, UNC Palliative Care Program, Chapel Hill, NC 27599, USA E-mail Address: laura_hanson@med.unc.eduSearch for more papers by this authorPublished Online:18 Aug 2020https://doi.org/10.1089/jpm.2020.0446AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Transformation began in early 2020. In December of 2019, a novel respiratory illness was described in China, and the era of the global pandemic caused by severe acute respiratory syndrome coronavirus 2 began. Coronavirus disease 2019 (COVID-19) has expanded globally to infect millions of people and to cause over half a million deaths—and these numbers are underestimates due to lack of widespread testing. By the time this article is published, this epidemiology will be far out of date, since the number of cases and deaths per day continues to rise globally and in the United States. People who are presymptomatic and minimally symptomatic will shed and share this virus that is so adapted to our human desire to touch, to interact, and to live in proximity to one another. Although most people who are infected will recover, a significant percentage will die or live on with major chronic effects on lung, renal, or neurologic function. Every facet of ordinary life is affected, from celebrations to funerals, from grocery shopping to employment, from household cleaning to visiting older relatives. And frankly, although research is progressing on treatment and vaccines, we all know this new normal will be sustained for an indefinite amount of time.Palliative care clinicians are called upon to provide rapid and adaptive education for ourselves and our colleagues. Skills in symptom management, prognostic awareness, and goals of care communication are seen as central to the response to this pandemic. Many local palliative care programs—including my own—were asked to provide training in primary palliative care skills to equip clinicians in emergency medicine and critical care medicine. Within weeks, leading educators from the Center to Advance Palliative Care, Vital Talk, and Ariadne Labs created and disseminated COVID-19–specific communication guides and training tools.1–3 Our professional organizations have also responded—websites for the American Academy of Hospice and Palliative Medicine and for the National Coalition for Hospice and Palliative Care provide links to resources for clinical care, policy, and payment changes.4,5 Our self-education and clinical skills will continue to adapt as new information emerges on infection risk, an expanding list of acute and chronic symptoms, and changing data on prognosis and outcomes.Our clinical practice is being transformed, as we develop and deploy new skills and novel collaborative care models with frontline teams. We have been called “into the room” virtually with patients struggling to breathe and with families facing agonizing decisions. Plunging into visits by phone and video connections, each of us has wondered whether we could convey compassionate human presence, replace the insights from physical examination, and fill the gaps when missing nonverbal cues. Yet together, we share emerging best practices in “webside manner,” as coined by members of the Massachusetts General Hospital palliative care team.6 Virtual visits have allowed us to console and support families shut out by visitation policy, and to bring them to the bedside through video visits with patients. These new skills remind us that before COVID-19, many families were unable to visit due to lack of transportation or ill health—and we will continue virtual visits even when COVID-19 runs its course.Palliative care clinicians seek to bring comfort in the face of suffering magnified by COVID-19 health disparities. As many teams—including ours—now know from their daily census, hospitalization rates with COVID-19 are four to five times higher for African American/black, Latinx, and native people than for people who identify as white.7 Unlike so many causes of illness and death, this one is contagious and sweeps through populations in crowded housing, nursing homes, prisons, and meat packing plants. Hospital intensive care units are filled with people of color across the United States, including the wrenching sadness of illness affecting multiple members of the same family. In an eerie echo from the Black Lives Matter movement, the cry “I can't breathe” fills crowded emergency departments serving these diverse communities. The public health emergency created by COVID-19 is surfacing social determinants of health, and clinicians and families will not forget its implications for just health care.

"Tell Me More": Students Can Practice and Self-Evaluate Primary Palliative Care Skills in a Large, Multistate Internal Medicine Clerkship.

Background: Experts recommend integrating palliative care throughout the four-year medical school curriculum, including in required clerkships such as internal medicine (IM). Objective: The aim of this study was to determine whether third-year medical students could gain meaningful experience in primary palliative care during their IM clerkship with observation and feedback from internists and/or IM residents or fellows. Design: We implemented two clinical exercises: (1) perform advance care planning with a patient and (2) participate in the delivery of important news. Students self-reported aspects of their experience in a confidential online survey. Setting/Subjects: Third-year medical students enrolled in a required IM clerkship. Measurements: Students reported the setting in which they completed the exercises, their level of independence, and their level of comfort with advance care planning after completing the exercise. We performed a qualitative analysis of open-ended comments to determine domains, themes, and subthemes and a separate analysis to determine the extent to which the comments suggested learning relevant to the stated learning objectives for each exercise. Results: The majority of students completed both exercises without palliative care specialists present, 76% (196/258) for the advance care planning exercise and 75% (195/259) for important news. Fifty-one percent (132/258) of students completed advance care planning with a significant level of independence, and 70% (182/258) reported being comfortable or very comfortable with advance care planning after completing the exercise. Qualitative analyses of student comments found that the majority of students described learning something related to the stated learning objectives for each exercise and suggested that they gained an appreciation of the complexity of patient-provider interactions around serious illness and palliative care. Conclusion: We found it feasible to integrate clinical exercises in advance care planning and delivering important news into an IM clerkship.

Primary care service use by end-of-life cancer patients: a nationwide population-based cohort study in the United Kingdom

BackgroundEnd of life (EoL) care becomes more complex and increasingly takes place in the community, but there is little data on the use of general practice (GP) services to guide care improvement. This study aims to determine the trends and factors associated with GP consultation, prescribing and referral to other care services amongst cancer patients in the last year of life.MethodsA retrospective cohort study of cancer patients who died in 2000–2014, based on routinely collected primary care data (the Clinical Practice Research DataLink, CPRD) covering a representative sample of the population in the United Kingdom. Outcome variables were number of GP consultations (primary), number of prescriptions and referral to other care services (yes vs no) in the last year of life. Explanatory variables included socio-demographics, clinical characteristics and the status of palliative care needs recognised or not. The association between outcome and explanatory variables were evaluated using multiple-adjusted risk ratio (aRR).ResultsOf 68,523 terminal cancer patients, 70% were aged 70+, 75% had comorbidities and 45.5% had palliative care needs recognised. In the last year of life, a typical cancer patient had 43 GP consultations (Standard deviation (SD): 31.7; total = 3,031,734), 71.5 prescriptions (SD: 68.0; total = 5,074,178), and 21(SD: 13.0) different drugs; 58.0% of patients had at least one referral covering all main clinical specialities. More comorbid conditions, prostate cancer and having palliative care needs recognised were associated with more primary care consultations, more prescriptions and a higher chance of referral (aRRs 1.07–2.03). Increasing age was related to fewer consultations (aRRs 0.77–0.96), less prescriptions (aRR 1.09–1.44), and a higher chance of referral (aRRs 1.08–1.16) but less likely to have palliative care needs recognised (aRRs 0.53–0.89).ConclusionsGPs are very involved in end of life care of cancer patients, most of whom having complex care needs, i.e. older age, comorbidity and polypharmacy. This highlights the importance of enhancing primary palliative care skills among GPs and the imperative of greater integration of primary care with other healthcare professionals including oncologists, palliative care specialists, geriatricians and pharmacists. Research into the potential of deprescribing is warranted. Older patients have poorer access to both primary care and palliative care need to be addressed in future practices.

From Simulation to Bedside: A Pilot Study to Measure Impact of Communication Skills Training Program (QI630)

•Describe an approach to evaluating residents' performance in serious illness communication and reinforcing their skills over time.•Describe ways to engage patients and families to provide constructive feedback to residents on their communication skills. There is a growing national mandate to train all clinicians in primary palliative care skills including serious illness communication. As a result, there has been extraordinary growth of programs to teach complex communication, but few studies to evaluate retention of skills acquired in training. At University of Massachusetts, internal medicine (IM) residents have a mandatory training in serious illness communication using simulation and patient actors. We designed a pilot to compare residents' performance in simulation versus real-life bedside encounters with hospitalized patients. To evaluate the impact of simulation training on residents' performance in real-life conversations about serious illness with hospitalized patients and families. IM residents identified a hospitalized patient in need of a serious illness conversation during their inpatient medicine rotations and arranged for a family meeting. Faculty from simulation training observed and evaluated the resident using a mini-clinical evaluation exercise (mini-CEX) tool which mirrored the evaluation tool used in simulation. Patients and families were offered a brief survey to provide feedback for the resident at the end of encounter. All the bedside evaluations occurred 3–12 months after the simulation training. Between 2017–2019, 53 residents completed simulation training and mini-CEX evaluation. Analysis of mini-CEX scores revealed the majority of residents' communication skills were the “same or improved” at the bedside, with significant improvement in ensuring patients' comfort, using silence, displaying empathy, and recognizing and responding to emotion. However, residents were more likely to discuss prognosis during simulation versus real-life encounters. Many patients and families completed a postsurvey and reported feeling heard and satisfied with their conversation with the resident. Our pilot program demonstrated a trend towards retention and improvement of residents' communication skills in real-life patient encounters after simulation training. Our findings contribute to the gap in understanding the downstream impact of training programs on the communication skills and patient satisfaction.

Defining the Boundaries of Palliative Care in Pediatric Oncology

ContextAlthough palliative care (PC) continues to be integrated into pediatric oncological care, only a minority of patients with cancer receive a formal PC consult. ObjectivesWe sought to describe oncologists' current understanding of PC and how primary PC is provided for children with cancer. MethodsThis mixed-methods study explored pediatric oncology providers' definitions of PC and self-reported PC practices through semistructured audiotaped interviews. Conventional content analysis was applied to interview transcripts. ResultsSeventy-seven participants with diverse training backgrounds (30 attending physicians, 21 nurses, 18 fellows, five nurse practitioners, and two child life specialists) completed an interview. Approximately 75% provided a modern definition of PC (e.g., not limited to end-of-life care); all participants acknowledged primary PC skills as part of their daily clinical activities. However, participants expressed wide variation in the comfort and time spent performing primary PC tasks (i.e., symptom management, addressing mental health and psychosocial needs) and over half reported that patients' PC needs are not adequately met. In addition, some reported confusion about the benefits of PC consultation, despite acknowledging that PC needs to be better integrated into the care of pediatric oncology patients. ConclusionOur findings demonstrate that although most pediatric oncologists accept a modern definition of PC in theory, how to integrate PC into pediatric oncology practice is less understood. Formalized training and standardization of practice surrounding identification of PC needs in patients who may require secondary or tertiary PC services may help to overcome current barriers for PC integration in pediatric oncology.