Jillian Gustin

Acute lung injury and acute respiratory distress syndrome requiring tracheal intubation and mechanical ventilation in the intensive care unit: impact on managing uncertainty for patient-centered communication.

A case of acute lung injury (ALI) progressing to acute respiratory distress syndrome (ARDS) requiring tracheal intubation and mechanical ventilation (ETMV) is presented. The palliative medicine service was asked to address concerns expressed by the patients spouse reflecting uncertainty regarding outcome expectations. Acknowledging and confronting the uncertainties of a critical illness is an essential component of patient-centered communication. Addressing and managing uncertainty for the case scenario requires consideration of both short- and long-term outcomes including mortality, ventilator independence, and adverse effects on quality of life for survivors. In this paper, ALI/ARDS requiring ETMV in the ICU was used as a focal point for preparing a prognostic assessment incorporating these issues. This assessment was based on a review of recently published literature regarding mortality and ventilator independence of survivors for adult patients receiving ETMV for ALI/ARDS in the ICU. In the studies reviewed, long-term survival reported at 60 days to 1 year was 50-73% with greater than 84% of the survivors in each study breathing independently. Selected articles discussing outcomes other than mortality or recovery of respiratory function, particularly quality of life implications for ALI/ARDS survivors, were also reviewed. A case of of ALI/ARDS requiring ETMV in the ICU is used to illustrate the situation of an incapacitated critically ill patient where the outcome is uncertain. Patient-centered communication should acknowledge and address this uncertainty. Managing uncertainty consists of effectively expressing a carefully formulated prognostic assessment and using sound communication principles to alleviate the distress associated with the uncertain outcome probabilities.

Acute Renal Failure Requiring Renal Replacement Therapy in the Intensive Care Unit: Impact on Prognostic Assessment for Shared Decision Making

A 69-year-old female was receiving renal replacement therapy (RRT) for acute renal failure (ARF) in an intensive care unit (ICU). Consultation was requested from the palliative medicine service to facilitate a shared decision-making process regarding goals of care. Clinician responsibility in shared decision making includes the formulation and expression of a prognostic assessment providing the necessary perspective for a spokesperson to match patient values with treatment options. For this patient, ARF requiring RRT in the ICU was used as a focal point for preparing a prognostic assessment. A prognostic assessment should include the outcomes of most importance to a discussion of goals of care: mortality risk and survivor functional status, in this case including renal recovery. A systematic review of the literature was conducted to document published data regarding these outcomes for adult patients receiving RRT for ARF in the ICU. Forty-one studies met the inclusion criteria. The combined mean values for short-term mortality, long-term mortality, renal-function recovery of short-term survivors, and renal-function recovery of long-term survivors were 51.7%, 68.6%, 82.0%, and 88.4%, respectively. This case example illustrates a process for formulating and expressing a prognostic assessment for an ICU patient requiring RRT for ARF. Data from the literature review provide baseline information that requires adjustment to reflect specific patient circumstances. The nature of the acute primary process, comorbidities, and severity of illness are key modifiers. Finally, the prognostic assessment is expressed during a family meeting using recommended principles of communication.

Add Your Voice: Vetting the Entrustable Professional Activities for HPM Physicians (TH335)

1994 to 2003, the PDIA created funding initiatives in professional and public education, the arts, research, clinical care, and public policy that transformed care for patients living with serious illnesses in the United States. Four PDIA Awards will be presented: the AAHPM PDIA Palliative Medicine National Leadership Award, the AAHPM PDIA Palliative Medicine Community Leadership Award, the HPNF PDIA Nursing Leadership Award in Palliative Care, and the SWPHN PDIA Career Achievement Award. Award recipients will participate in panel presentations on topics such as career trajectory, lessons learned, and take-away ‘‘pearls’’ for the attendees.

Family Meeting Behavioral Skills (FMBS) Instrument

Objectives 1. Develop an observed structured clinical examination (OSCE) to assess and give feedback to residents on their ability to provide prognostic information and recommend hospice as part of an existing required palliative care curriculum in our institution’s internal medicine residency program. Background. Over the past decade, late referral to hospice has become an increasing problem in the United States. Barriers to hospice referral are not well understood, but the lack of residency training in essential generalist palliative care competencies, such as giving prognostic information and recommending hospice, is a potential barrier to improving hospice utilization. Using observed structured clinical examinations (OSCEs) to improve trainees’ interpersonal and communication skills may address this barrier. Methods. The OSCE case was developed by an expert palliative care educator and modified though an iterative process consisting of 22 pilot OSCEs. An extensive literature review informed the development of the OSCE assessment tool, and items were reviewed and revised by six palliative and geriatric medicine experts. The assessment tool was revised in an iterative process over the course of 16 OSCEs with internal medicine residents. One standardizedpatient was used for all OSCEs. Results. The final OSCE assessment tool consists of a 20-item behavior checklist. Preliminary results suggest high interrater reliability (K1⁄40.97). Pilot assessment of 13 internal medicine residents found that the most frequently missed behaviors were assessing a patient’s desire for prognostic information, identifying social workers or chaplains as part of the hospice team, and describing the hospice team’s role after the patient dies (pronouncement, post-mortem care, and bereavement care). Of participants who evaluated the OSCE, all reported that the exercise was useful and ‘‘better than average’’ compared with other residency educational activities. Common ‘‘take home’’ points for residents included identifying members of the hospice team and asking patientswhat they understand and want to know about their prognosis. Results from an additional 20 OSCEs will be reported using the final assessment tool. Discussion. This OSCE offers an opportunity for standardized assessment and individualized feedback to improve internal medicine residents’ medical knowledge and skills related to the essential generalist palliative care competencies discussing prognosis and recommending hospice. Although originally developed for internal medicine residents, this tool could be readily applied to other specialties. Conclusion. The Discussing Prognosis and Recommending Hospice OSCE is a useful and effective tool for identifying and addressing residents’ gaps in knowledge and communication skills around discussing prognosis and recommending hospice.