Amanda Roze des Ordons

Goals of care conversation teaching in residency – a cross-sectional survey of postgraduate program directors

BackgroundResidents are commonly involved in establishing goals of care for hospitalized patients. While education can improve the quality of these conversations, whether and how postgraduate training programs integrate such teaching into their curricula is not well established. The objective of this study was to characterize perceptions of current teaching and assessment of goals of care conversations, and program director interest in associated curricular integration.MethodsAn electronic survey was sent to all postgraduate program directors at the University of Calgary. Quantitative data was analyzed using descriptive statistics and qualitative comments were analyzed using thematic analysis.ResultsThe survey response rate was 34% (22/64). Formal goals of care conversation teaching is incorporated into 63% of responding programs, and most commonly involves lectures. Informal teaching occurs in 86% of programs, involving discussion, direct observation and role modeling in the clinical setting. Seventy-three percent of programs assess goals of care conversation skills, mostly in the clinical setting through feedback. Program directors believe that over two-thirds of clinical faculty are prepared to teach goals of care conversations, and are interested in resources to teach and assess goals of care conversations. Themes that emerged include 1) general perceptions, 2) need for teaching, 3) ideas for teaching, and 4) assessment of goals of care conversations.ConclusionsThe majority of residency training programs at the University of Calgary incorporate some goals of care conversation teaching and assessment into their curricula. Program directors are interested in resources to improve teaching and assessment of goals of care conversations.

Family participation in intensive care unit rounds: Comparing family and provider perspectives.

Purpose: To describe and compare intensive care unit (ICU) patient family member and provider experiences, preferences, and perceptions of family participation in ICU rounds. Methods: Cross‐sectional survey of ICU family members and providers of patients admitted to 4 medical‐surgical ICUs from September 2014 to March 2015. Measurements and main results: Surveys were completed by 63 (62%) family members and 258 (43%) providers. Provider respondents included physicians (9%), nurses (56%), respiratory therapists (24%), and other ICU team members (11%). Although 38% of providers estimated only moderate family member interest in participating in rounds, 97% of family members expressed high interest. Family members and providers reported listening (95% vs 96%; P = .594) and sharing information about the patient (82% vs 82%; P = .995) as appropriate roles for family members during rounds, but differed in their perceptions on asking questions (75% vs 86%; P = .043) and participating in decision making (36% vs 59%; P = .003). Compared with family members, providers were more likely to perceive family participation in rounds to cause family stress (7% vs 22%; P = .020) and confusion (0% vs 28%; P < .001). Conclusion: Family members and providers share some perspectives on family participation in ICU rounds although other perspectives are discordant, with implications for communication strategies and collaborative decision making.

An exploration of contextual dimensions impacting goals of care conversations in postgraduate medical education

BackgroundPostgraduate medical trainees are not well prepared difficult conversations about goals of care with patients and families in the acute care clinical setting. While contextual nuances within the workplace can impact communication, research to date has largely focused on individual communication skills. Our objective was to explore contextual factors that influence conversations between trainees and patients/families about goals of care in the acute care setting.MethodsWe conducted an exploratory qualitative study involving five focus groups with Internal Medicine trainees (n = 20) and a series of interviews with clinical faculty (n = 11) within a single Canadian centre. Thematic framework analysis was applied to categorize the data and identify themes and subthemes.ResultsChallenges and factors enabling goals of care conversations emerged within individual, interpersonal and system dimensions. Challenges included inadequate preparation for these conversations, disconnection between trainees, faculty and patients, policies around documentation, the structure of postgraduate medical education, and resource limitations; these challenges led to missed opportunities, uncertainty and emotional distress. Enabling factors were awareness of the importance of goals of care conversations, support in these discussions, collaboration with colleagues, and educational initiatives enabling skill development; these factors have resulted in learning, appreciation, and an established foundation for future educational initiatives.ConclusionsContextual factors impact how postgraduate medical trainees communicate with patients/families about goals of care. Attention to individual, interpersonal and system-related factors will be important in designing educational programs that help trainees develop the capacities needed for challenging conversations.

Adapting Feedback to Individual Residents: An Examination of Preceptor Challenges and Approaches

Background Feedback conversations between preceptors and residents usually occur in closed settings. Little is known about how preceptors address the challenges posed by residents with different skill sets, performance levels, and personal contexts. Objective This study explored the challenges that preceptors experienced and approaches taken in adapting feedback conversations to individual residents. Methods In 2015, 18 preceptors participated in feedback simulations portraying residents with variations in skill, insight, confidence, and distress, followed by debriefing of the feedback conversation with a facilitator. These interactions were recorded, transcribed, and analyzed using thematic and framework analysis. Results The preceptors encountered common challenges with feedback conversations, including uncertainty in how to individualize feedback to residents and how to navigate tensions between resident- and preceptor-identified goals. Preceptors questioned their ability to enhance skills for highly performing residents, whether they could be directive when residents had insight gaps, how they could reframe the perceptions of the overly confident resident, and whether they should offer support to emotionally distressed residents or provide feedback about performance. Preceptors adapted their approach to feedback, drawing on techniques of coaching for highly performing residents, directing for residents with insight gaps, mediation with overly confident residents, and mentoring with emotionally distressed residents. Conclusions Examining the feedback challenges preceptors encounter and the approaches taken to adapt feedback to individual residents can provide insight into how preceptors meet the challenges of competency-based medical education, in which frequent, focused feedback is essential for residents to achieve educational milestones and entrustable professional activity expectations.

Improving partnerships with family members of ICU patients: study protocol for a randomized controlled trial

BackgroundOver the last decade, health care delivery has shifted to partnering with patients and their families to improve health and quality of care, and to lower costs. Partnering with family members (FMs) of critically ill patients who lack capacity is particularly important for improving experiences and outcomes for both patients and FMs. How best to apply such partnering strategies, however, is yet unknown. The IMPACT trial will evaluate two interventions that enable partnerships with families of critically ill patients, each in a distinct content area, but similar in that they empower and support FMs.MethodsThis multi-center, open-label, randomized, phase II clinical trial aims to randomize 150 older, long-stay ICU patients and their families into one of three groups (50 in each group): (1) The OPTimal nutrition by Informing and Capacitating FMs of best practices (OPTICs) group, a multi-faceted intervention to engage and empower FMs to advocate for, and audit, best nutritional practices for their critically ill FMs, (2) A web-based decision-support intervention called the ICU Workbook (The Canadian Researchers at the End of Life Network (CARENET) ICU Workbook; https://www.myicuguide.ca/. Accessed 3 Feb 2017.) to support families in shared decision-making process regarding goals of medical treatments, and (3) Usual care. The main outcomes for this trial include nutritional adequacy in hospital and hand-grip strength prior to hospital discharge; satisfaction with decision-making; decision conflict; and degree of shared decision-making.DiscussionWith the goal of improving the functional recovery of nutritionally high-risk older patients and the quality of care at the end of life for these patients and their FMs in the ICU, we have proposed two novel family capacitation strategies. We hope that the nutrition and decision-support interventions implemented and evaluated in our study will contribute to the evidentiary basis for best family partnered care pathways focused on optimizing the quality of ICU care for patients with life-threatening illness and their families.Trial registrationClinical trials.gov, ID: NCT02920086. Registered on 30 September 2016. Protocol version dated 11 October 2016.

Withholding and withdrawing life support: difficult decisions around care at the end of life

In this issue of the Journal, the Canadian Critical Care Society (CCCS) released a position paper by Bandrauk et al. on withholding and withdrawing life-sustaining treatment (WWLST). The authors’ objective was to create a framework for healthcare professionals to help them understand and develop an approach to end-of-life care decision-making in the intensive care unit (ICU). End-oflife care and WWLST are common issues in the ICU, and as the authors have identified in their article, these practices require careful attention to a number of ethical factors and legal precedents as well as to the context of the patient/family and healthcare professionals. This editorial provides additional comments on WWLST and end-of-life care. When a critically ill patient is unlikely to survive or the medical therapies and prognosis are no longer aligned with the patient’s previously expressed goals, it is appropriate for healthcare professionals to consider withdrawing LST and, if appropriate, to transition their focus to palliative care. These should always be difficult decisions. For most patients, the transition to end-of-life care occurs without conflict, and understanding and agreement between the patient, family, and healthcare team facilitate a caring and dignified death. Although rare, when consensual agreement is not achieved, it may result in significant distress for all involved. Poor experiences with the healthcare system, both current and past, including complications of treatment or lack of respect for beliefs or concerns, may predictably lead to conflict. The patient and family may feel alienated and resentful towards the medical team as they advocate for treatments that have been determined to be medically unhelpful and inappropriate. Even less frequently, but often with significant media attention, some disputes over discontinuing LST are brought before the judicial system for resolution, adding to the stress and suffering of all involved. While there are times when conflict may be unavoidable, an emphasis on prevention is critical. As Bandrauk et al. have stressed, sensitive communication with patients and their families about WWLST facilitates consensual decision-making. The words on the Canadian Medical Association’s Coat of Arms, i.e., integrity and compassion ‘‘integritate et misericordia’’ are foundational in these situations. Integrity and a healthy dose of humility can remind healthcare professionals of their position of authority and the vulnerability of their patients and their families. The nuances of language and how information is presented can easily sway decisions. Compassion is essential in recognizing and acknowledging the distress a family experiences as they participate in decisions about whether the life of a loved one may either continue in an uncertain state or end in loss. Before entering into conversations about prognosis and recommendations for treatment, it is important to take the K. J. Solverson, MD, MSc, FRCPC A. L. Roze des Ordons, MD, MMEd, FRCPC C. J. Doig, MD, MSc, FRCPC (&) Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, AB T2N 5A1, Canada e-mail: cdoig@ucalgary.ca

A modified Delphi process to identify clinical and research priorities in patient and family centred critical care

Purpose: To identify elements which enable patient and family centred care (PFCC) in the intensive care unit (ICU) and priorities for PFCC research. Materials and methods: We engaged a panel of multidisciplinary stakeholders in a modified Delphi process. Items generated from a literature review and panelist suggestions were rated in 3 successive rounds on a scale from 1 to 7. Median score was used to rate each items priority, with 5 or more indicating “essential priority,” 4 or 5 “moderate priority” and 3 or less “low priority.” Interquartile range (IQR) was used to measure consensus, with IQR of 1 indicating “high” consensus, 2 “moderate” consensus, and 3 or greater “low” consensus. Results: Six items were rated essential elements for facilitating PFCC with high consensus (flexible visiting hours, family participation in bedside care, trained family support person, interventions to facilitate continuity of care, staff education to support families, continuity of staff assignments). Three items were rated essential research topics: interventions to facilitate continuity of care following ICU discharge (moderate consensus), family participation in bedside care (low consensus), and decision aids for end of life decision‐making (low consensus). Conclusions: Stakeholders identified clear and distinct priorities for PFCC in clinical care and research, though there was greater consensus for clinical care. HighlightsWe used modified Delphi to develop consensus for patient‐ and family centred ICU care.Clinical and research priorities for patient‐ and family centred care are distinct.Consensus was higher for clinical than research priorities in patient and family centred care.Local priorities for patient‐ and family centred care can vary from guidelines.

55: DETERMINING BEST PRACTICES FOR FAMILY PARTICIPATION IN ICU ROUNDS

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) 24 hr. Results: Twenty six matched pairs met the inclusion criteria. Of these, 17 pairs had preserved renal function and nine pairs required continuous venovenous hemofiltration. The weight-based daily maintenance dose in obese patients was 25.57 mg/kg versus 43.84 mg/kg in non-obese patients (p<0.01). Therapeutic 24 hour levels were achieved in 24/26 versus 23/26 in obese and non-obese, respectively (p=0.63). Mean 24 hour vancomycin level was 20.33 ± 3.81 mcg/ ml for obese compared to 20.03 ± 3.79 mcg/ml for non-obese (p=0.77). Mean BMI was 40.9 kg/m2 in obese versus 24.8 kg/m2 in the non-obese. Conclusions: The results of our study suggest that critically ill obese patients treated with CI required a significantly lower maintenance dose per body weight than non-obese patients to achieve the same target level.