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Improving Residents’ End-of-Life Communication Skills with a Short Retreat: A Randomized Controlled Trial (313-A)
462
Schedule with Abstracts
(60%) did not want their PCP to “have a spiritual discussion with them.” Only 12% of patients reported having been asked about the importance of spirituality to them and 14% had been offered a chaplaincy referral. Men were more likely than women to have been offered a chaplaincy referral (P = .01). Most PCPs (68%) reported that it was at least “moderately” important to address patients’ spiritual concerns but 64% had never offered a chaplaincy referral. Female PCPs believed it more important than male PCPs to attend to patients’ spiritual concerns (P = .03) and more frequently asked whether patients were part of a spiritual community (P = .05). Faculty/fellows were more likely than residents to ask if patients were part of a spiritual community (P = .0001), to ask about the importance of spirituality (P = .001), and to offer a chaplaincy referral (P = .01). V. Conclusions. The majority of both seriously ill outpatients and PCPs consider spiritual care important. However, few patients have experienced, and few PCPs practice, such care. There were several differences in spiritual care based on gender and clinical experience. VI. Implications for research, policy, or practice. Further research into gender and training differences in spiritual care is indicated. Domain Spiritual, Religious, and Existential Aspects of Care
Teaching Family Carers About How to Support a Dying Relative at Home: Final Results from a Group Education Program (312-B) Peter L Hudson, PhD RN, St. Vincent’s & The University of Melbourne, Victoria, Australia (Hudson has disclosed no relevant financial relationships.) Objectives 1. Understand the importance of evidence-based family-centered palliative care. 2. Gain insight regarding the typical needs of family carers. 3. Learn about an effective strategy designed to prepare family carers for the role of supporting a dying relative. I. Background. Despite the considerable body of evidence, which identifies that family carers of palliative care patients want much more support and guidance to prepare them for their role, there has been a shortage of evaluated interven-
Vol. 37 No.3 March 2009
tions. II. Research Objectives. A group education program (GEP) was developed to provide family carers with information, support, and strategies to assist them to care for a dying relative at home. III. Methods. The GEP was conducted via three sessions at six palliative care services in regional and metropolitan Australia. Participants were required to complete self-report questionnaires: Time 1 was immediately before the program; Time 2 was immediately after the program; and Time 3 was 2 weeks after the program. The questionnaires included measures of Carer: Preparedness, Competence, Rewards, and Unmet Needs. Participants also completed a program evaluation form and the managers of the participating services were asked to report on their perceptions of the utility of the program. IV. Results. Thirty-two education programs were conducted with a total of 156 family carers attending. The intervention had a statistically significant effect on preparedness, competence, rewards, and having needs met, from Time 1 to Time 2, which was maintained at Time 3. The overwhelming majority of family carers reported that the program was applicable, useful, and accessible. The utility of the program was also reinforced via positive feedback from the program facilitators and managers of the clinical sites. V. Conclusions. The evaluation of the GEP for home-based carers demonstrated its effectiveness in meeting the needs of carers and also enhanced their competence and preparedness for caregiving. Carers also reported increased positive feelings related to their role. VI. Implications for research, policy, or practice. Although further evaluation is recommended, from the feedback obtained, the program could be implemented into practice with a moderate level of additional resources. Domains Structure and Processes of Care; Social Aspects of Care; Psychological and Psychiatric Aspects of Care; Care of the Imminently Dying Patient
Landscapes of Loss: Social Ecology of Illness, Death, and Dying (312-C) Beverly Rosa Williams, PhD MA, Birmingham VA Medical Center and the University of Alabama at Birmingham, Birmingham, AL; Lesa L. Woodby, PhD, Birmingham VA Medical Center and the University of Alabama at Birmingham,
Vol. 37 No.3 March 2009
Schedule with Abstracts
Birmingham, AL (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. Articulate the social ecological approach to health and illness. 2. Describe the impact of social ecology on the health and illness experience of low-SES advanced cancer patients. I. Background. Death of a loved one is a primary stressor. Low-SES communities have some of the highest morbidity and mortality rates. Poor persons have increased risk of multiple exposures to the ravages of illness and death. Stress of loss can contribute to socioeconomic and social-psychological distress of advanced cancer. II. Research Objectives. Explore the experience of loss among low-SES advanced cancer patients; describe the frequency of loss across the life span; Examine the social ecological context and cultural salience of loss. III. Methods. We conducted open-ended, in-depth interviews with 33 low-SES, community-dwelling, terminally ill cancer patients in the Southeast United States. Participants were 70% female and 70% African American. We used a grounded theory approach to data analysis and interpretation, identifying exemplary quotes that highlighted the salience of loss across the life course. IV. Results. Sickness and loss are pervasive among poor and minority persons. Impact of a cancer diagnosis is intensified by personal acquaintance with cancer trajectories of others or knowledge of the illness course. The word “cancer” can carry such powerful cultural connotations that it can function as a synonym for all serious illness. V. Conclusions. For low-SES persons in this study, bereavement events are part of a stressful social ecology that shapes the experience of health and illness. As losses accumulate over the life course, the occurrence of sickness and death takes on a cultural salience, highlighting how inequality in life cannot be separated from inequality in death. VI. Implications for research, policy, or practice. Researchers, policy makers, and clinicians should give systematic attention to the social-ecologic context of health and illness, particularly as it pertains to low-SES persons living with advanced, life-limiting conditions. This is the first step in the development of interventions which target the social ecological context of human suffering. Domains
463
Structure and Processes of Care; Social Aspects of Care; Psychological and Psychiatric Aspects of Care; Cultural Aspects of Care
Improving Residents’ End-of-Life Communication Skills with a Short Retreat: A Randomized Controlled Trial (313-A) Eytan Szmuilowicz, MD, Northwestern University, Chicago, IL; Areej El-Jawahri, Harvard Medical School, Boston, MA; Laurel Chiappetta, MS, Data D.I.V.A. Consulting, Pittsburgh, PA; Mihir Kamdar, MD, Massachusetts General Hospital, Boston, MA; Susan D. Block, MD FAAHPM, Dana-Farber Cancer Institute, Boston, MA (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. Learn about a successful program in communication skills education for medical residents. 2. Appreciate that communication skills, including empathic responses, can be learned with a brief intervention. I. Background. Residents are unprepared and inadequately taught to carry out end-of-life (EOL) conversations. There is evidence that these skills can be taught, but data from randomized controlled trials are lacking. II. Research Objectives. We studied whether a daylong communication skills training retreat would lead to enhanced confidence with, and performance in, EOL conversations. We also studied the effect of the retreat on residents’ ability to respond to patient emotions. III. Methods. PGY-2 Internal Medicine residents at Brigham and Women’s Hospital were randomly assigned to a retreat group or a control group. The retreat focused on “breaking bad news” (BBN) and “direction of care” (DOC) discussions. Retreat sessions involved a combination of teaching styles and skills practice with standardized patients. All participants were evaluated carrying out a BBN and a DOC conversation with a standardized patient before (T1) and after (T2) the intervention phase. Conversations were audio-taped and rated by a researcher blinded to group assignment and time of assessment. IV. Results. Twenty-three residents participated in the retreat and 26 served as controls. Compared to controls, retreat participants demonstrated significant improvement in overall skills at T2. Improvement was driven by enhanced “breaking bad news” skills and ability to respond to emotion.
Schedule with Abstracts
(60%) did not want their PCP to “have a spiritual discussion with them.” Only 12% of patients reported having been asked about the importance of spirituality to them and 14% had been offered a chaplaincy referral. Men were more likely than women to have been offered a chaplaincy referral (P = .01). Most PCPs (68%) reported that it was at least “moderately” important to address patients’ spiritual concerns but 64% had never offered a chaplaincy referral. Female PCPs believed it more important than male PCPs to attend to patients’ spiritual concerns (P = .03) and more frequently asked whether patients were part of a spiritual community (P = .05). Faculty/fellows were more likely than residents to ask if patients were part of a spiritual community (P = .0001), to ask about the importance of spirituality (P = .001), and to offer a chaplaincy referral (P = .01). V. Conclusions. The majority of both seriously ill outpatients and PCPs consider spiritual care important. However, few patients have experienced, and few PCPs practice, such care. There were several differences in spiritual care based on gender and clinical experience. VI. Implications for research, policy, or practice. Further research into gender and training differences in spiritual care is indicated. Domain Spiritual, Religious, and Existential Aspects of Care
Teaching Family Carers About How to Support a Dying Relative at Home: Final Results from a Group Education Program (312-B) Peter L Hudson, PhD RN, St. Vincent’s & The University of Melbourne, Victoria, Australia (Hudson has disclosed no relevant financial relationships.) Objectives 1. Understand the importance of evidence-based family-centered palliative care. 2. Gain insight regarding the typical needs of family carers. 3. Learn about an effective strategy designed to prepare family carers for the role of supporting a dying relative. I. Background. Despite the considerable body of evidence, which identifies that family carers of palliative care patients want much more support and guidance to prepare them for their role, there has been a shortage of evaluated interven-
Vol. 37 No.3 March 2009
tions. II. Research Objectives. A group education program (GEP) was developed to provide family carers with information, support, and strategies to assist them to care for a dying relative at home. III. Methods. The GEP was conducted via three sessions at six palliative care services in regional and metropolitan Australia. Participants were required to complete self-report questionnaires: Time 1 was immediately before the program; Time 2 was immediately after the program; and Time 3 was 2 weeks after the program. The questionnaires included measures of Carer: Preparedness, Competence, Rewards, and Unmet Needs. Participants also completed a program evaluation form and the managers of the participating services were asked to report on their perceptions of the utility of the program. IV. Results. Thirty-two education programs were conducted with a total of 156 family carers attending. The intervention had a statistically significant effect on preparedness, competence, rewards, and having needs met, from Time 1 to Time 2, which was maintained at Time 3. The overwhelming majority of family carers reported that the program was applicable, useful, and accessible. The utility of the program was also reinforced via positive feedback from the program facilitators and managers of the clinical sites. V. Conclusions. The evaluation of the GEP for home-based carers demonstrated its effectiveness in meeting the needs of carers and also enhanced their competence and preparedness for caregiving. Carers also reported increased positive feelings related to their role. VI. Implications for research, policy, or practice. Although further evaluation is recommended, from the feedback obtained, the program could be implemented into practice with a moderate level of additional resources. Domains Structure and Processes of Care; Social Aspects of Care; Psychological and Psychiatric Aspects of Care; Care of the Imminently Dying Patient
Landscapes of Loss: Social Ecology of Illness, Death, and Dying (312-C) Beverly Rosa Williams, PhD MA, Birmingham VA Medical Center and the University of Alabama at Birmingham, Birmingham, AL; Lesa L. Woodby, PhD, Birmingham VA Medical Center and the University of Alabama at Birmingham,
Vol. 37 No.3 March 2009
Schedule with Abstracts
Birmingham, AL (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. Articulate the social ecological approach to health and illness. 2. Describe the impact of social ecology on the health and illness experience of low-SES advanced cancer patients. I. Background. Death of a loved one is a primary stressor. Low-SES communities have some of the highest morbidity and mortality rates. Poor persons have increased risk of multiple exposures to the ravages of illness and death. Stress of loss can contribute to socioeconomic and social-psychological distress of advanced cancer. II. Research Objectives. Explore the experience of loss among low-SES advanced cancer patients; describe the frequency of loss across the life span; Examine the social ecological context and cultural salience of loss. III. Methods. We conducted open-ended, in-depth interviews with 33 low-SES, community-dwelling, terminally ill cancer patients in the Southeast United States. Participants were 70% female and 70% African American. We used a grounded theory approach to data analysis and interpretation, identifying exemplary quotes that highlighted the salience of loss across the life course. IV. Results. Sickness and loss are pervasive among poor and minority persons. Impact of a cancer diagnosis is intensified by personal acquaintance with cancer trajectories of others or knowledge of the illness course. The word “cancer” can carry such powerful cultural connotations that it can function as a synonym for all serious illness. V. Conclusions. For low-SES persons in this study, bereavement events are part of a stressful social ecology that shapes the experience of health and illness. As losses accumulate over the life course, the occurrence of sickness and death takes on a cultural salience, highlighting how inequality in life cannot be separated from inequality in death. VI. Implications for research, policy, or practice. Researchers, policy makers, and clinicians should give systematic attention to the social-ecologic context of health and illness, particularly as it pertains to low-SES persons living with advanced, life-limiting conditions. This is the first step in the development of interventions which target the social ecological context of human suffering. Domains
463
Structure and Processes of Care; Social Aspects of Care; Psychological and Psychiatric Aspects of Care; Cultural Aspects of Care
Improving Residents’ End-of-Life Communication Skills with a Short Retreat: A Randomized Controlled Trial (313-A) Eytan Szmuilowicz, MD, Northwestern University, Chicago, IL; Areej El-Jawahri, Harvard Medical School, Boston, MA; Laurel Chiappetta, MS, Data D.I.V.A. Consulting, Pittsburgh, PA; Mihir Kamdar, MD, Massachusetts General Hospital, Boston, MA; Susan D. Block, MD FAAHPM, Dana-Farber Cancer Institute, Boston, MA (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. Learn about a successful program in communication skills education for medical residents. 2. Appreciate that communication skills, including empathic responses, can be learned with a brief intervention. I. Background. Residents are unprepared and inadequately taught to carry out end-of-life (EOL) conversations. There is evidence that these skills can be taught, but data from randomized controlled trials are lacking. II. Research Objectives. We studied whether a daylong communication skills training retreat would lead to enhanced confidence with, and performance in, EOL conversations. We also studied the effect of the retreat on residents’ ability to respond to patient emotions. III. Methods. PGY-2 Internal Medicine residents at Brigham and Women’s Hospital were randomly assigned to a retreat group or a control group. The retreat focused on “breaking bad news” (BBN) and “direction of care” (DOC) discussions. Retreat sessions involved a combination of teaching styles and skills practice with standardized patients. All participants were evaluated carrying out a BBN and a DOC conversation with a standardized patient before (T1) and after (T2) the intervention phase. Conversations were audio-taped and rated by a researcher blinded to group assignment and time of assessment. IV. Results. Twenty-three residents participated in the retreat and 26 served as controls. Compared to controls, retreat participants demonstrated significant improvement in overall skills at T2. Improvement was driven by enhanced “breaking bad news” skills and ability to respond to emotion.