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Serious Illness Conversation-Evaluation Exercise: A Novel Assessment Tool for Residents Leading Serious Illness Conversations.

ABSTRACT: Background/Objectives: The serious illness conversation (SIC) is an evidence-based framework for conversations with patients about a serious illness diagnosis. The objective of our study was to develop and validate a novel tool, the SIC-evaluation exercise (SIC-Ex), to facilitate assessment of resident-led conversations with oncology patients. Design: We developed the SIC-Ex based on SIC and on the Royal College of Canada Medical Oncology milestones. Seven resident trainees and 10 evaluators were recruited. Each trainee conducted an SIC with a patient, which was videotaped. The evaluators watched the videos and evaluated each trainee by using the novel SIC-Ex and the reference Calgary-Cambridge guide (CCG) at months zero and three. We used Kane's validity framework to assess validity. Results: Intra-class correlation using average SIC-Ex scores showed a moderate level of inter-evaluator agreement (range 0.523-0.822). Most evaluators rated a particular resident similar to the group average, except for one to two evaluator outliers in each domain. Test-retest reliability showed a moderate level of consistency among SIC-Ex scores at months zero and three. Global rating at zero and three months showed fair to good/very good inter-evaluator correlation. Pearson correlation coefficients comparing total SIC-Ex and CCG scores were high for most evaluators. Self-scores by trainees did not correlate well with scores by evaluators. Conclusions: SIC-Ex is the first assessment tool that provides evidence for incorporating the SIG guide framework for evaluation of resident competence. SIC-Ex is conceptually related to, but more specific than, CCG in evaluating serious illness conversation skills.

SUBMITTER: Ko JJ

PROVIDER: S-EPMC8241377 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ObjectivesThe Serious Illness Conversation Guide (SICG) has emerged as a framework for conversations with patients with a serious illness diagnosis. This study reports on narratives generated from open-ended questions of a novel assessment tool, the Serious Illness Conversation-Evaluation Exercise (SIC-Ex), to assess resident-led conversations with patients in oncology outpatient clinics.DesignQualitative study using template analysis.SettingThree academic cancer centres in Canada.Participants7 resident physicians (trainees), 7 patients from outpatient cancer clinics, 10 preceptors (raters) consisting of medical oncologists, palliative care physicians and radiation oncologists.InterventionsEach trainee conducted an SIC with a patient, which was videotaped. The raters watched the videos and evaluated each trainee using the novel SIC-Ex and the reference Calgary-Cambridge Guide (CCG) initially and again 3 months later. Two independent coders used template analysis to code the raters' narrative comments and identify themes/subthemes.Outcome measuresHow narrative comments aligned with elements of the CCG and SICG.ResultsTemplate analysis yielded four themes: adhering to SICG, engaging patients and family members, conversation management and being mindful of demeanour. Narrative comments identified numerous verbal and non-verbal elements essential to SICG. Some comments addressing general skills in engaging patients/families and managing the conversation (eg, setting agenda, introduction, planning, exploring, non-verbal communication) related to both the CCG and SICG, whereas other comments such as identifying substitute decision maker(s), affirming commitment and introducing Advance Care Planning were specific to the SICG.ConclusionsNarrative comments generated by SIC-Ex provided detailed and nuanced insights into trainees' competence in SIC, beyond the numerical ratings of SIC-Ex and the general communication skills outlined in the CCG, and may contribute to a more fulsome assessment of SIC skills.

Project description:BackgroundThe Serious Illness Care Program (SICP) increases quality of documentation about patients' values and priorities, but it is not known whether patient characteristics and goals of care are associated with the elements documented. The purpose of this study was to explore for associations between the quantity and type of elements documented after SICP conversations with patient characteristics and goals of care order.MethodsDocumentation of SICP conversations by internal medicine physicians with hospitalized patients was evaluated in a retrospective chart review between March 2018 to December 2019. The conversations occurred after SICP implementation in a Tertiary Hospital, Medical teaching unit which uses "Goals of Care Designation" (GCD) medical orders to communicate a patient's general intent, specific interventions, and preferred locations of care. A validated SICP codebook was used to determine the frequency of conversation elements documented for (1) Goals and Values; (2) Prognosis/illness understanding; (3) End-of-life care planning and (4) GCD/Life-sustaining treatment preferences. Univariate and multivariate generalized linear models were used to analyze associations between quantity of elements documented and patient characteristics (age, gender, frailty, language spoken and GCD).ResultsOf 175 SICP conversations documented, in the univariate analysis more goals and values were documented for patients who understand/speak English (0.89; 95% CI: 0.14 - 1.63) and more content was recorded for patients with a non-resuscitative GCD focus ("Medical": 2.42; 95% CI: 1.51 - 3.33; "Comfort": 1.06; 95% CI: 0.24 - 1.88) although not in all domains. In the multivariate analysis, controlling for age, gender, language and frailty, the association between content scores and GCD remained highly significant. Patients with a non-resuscitative GCD had higher total domain scores than those with a resuscitative GCD ("Medical": 1.27 95% CI: 0.42-2.13; "Comfort": 2.67, 95% CI:1.71-3.62).ConclusionThe type of content documented by physicians after a SICP conversation is associated with the patient's goals of care.

Project description:BackgroundAdvance care planning (ACP) conversations are associated with improved end-of-life healthcare outcomes and patients want to engage in ACP with their healthcare providers. Despite this, ACP conversations rarely occur in primary care settings. The objective of this study was to implement ACP through adapted Serious Illness Care Program (SICP) training sessions, and to understand primary care provider (PCP) perceptions of implementing ACP into practice.MethodsWe conducted a quality improvement project guided by the Normalization Process Theory (NPT), in an interprofessional academic family medicine group in Hamilton, Ontario, Canada. NPT is an explanatory model that delineates the processes by which organizations implement and integrate new work. PCPs (physicians, family medicine residents, and allied health care providers), completed pre- and post-SICP self-assessments evaluating training effectiveness, a survey evaluating program implementability and sustainability, and semi-structured qualitative interviews to elaborate on barriers, facilitators, and suggestions for successful implementation. Descriptive statistics and pre-post differences (Wilcoxon Sign-Rank test) were used to analyze surveys and thematic analysis was used to analyze qualitative interviews.Results30 PCPs participated in SICP training and completed self-assessments, 14 completed NoMAD surveys, and 7 were interviewed. There were reported improvements in ACP confidence and skills. NoMAD surveys reported mixed opinions towards ACP implementation, specifically concerning colleagues' abilities to conduct ACP and patients' abilities to participate in ACP. Physicians discussed busy clinical schedules, lack of patient preparedness, and continued discomfort or lack of confidence in having ACP conversations. Allied health professionals discussed difficulty sharing patient prognosis and identification of appropriate patients as barriers.ConclusionsTraining in ACP conversations improved PCPs' individual perceived abilities, but discomfort and other barriers were identified. Future iterations will require a more systematic process to support the implementation of ACP into regular practice, in addition to addressing knowledge and skill gaps.

Project description:Background: International family-centered critical care guidelines recommend formal, structured communication to ensure that clinical decision making is informed by a shared understanding of diagnosis and prognosis and patient goals and preferences. Tools to facilitate these recommendations are limited. Objective: To examine the feasibility, acceptability, and utility of a standardized serious illness conversation (SIC) to guide communication between nonpalliative care trained providers and surrogates of critically ill, mechanically ventilated patients. Methods: After providers received training, including simulation, we implemented SIC in October 2018. A total of 11 hospitalist providers were eligible to perform SICs over the study interval. Providers met in person with surrogates of adult, mechanically ventilated patients in the medical intensive care unit within 48 hours of intubation. To determine acceptability, surrogates were surveyed 2 months after SIC completion, and providers were surveyed between June and July 2018. To determine feasibility and utility, two independent investigators reviewed SIC documentation and coded responses into categories. Results: Of 72 eligible patients, advanced care planning documentation was completed in 50 patients, including 36 SICs, for an advance care planning completion rate of 69% and an SIC completion rate of 50%. The average SIC was completed in 30 minutes, 3 days after intubation. Of the 19 surrogates surveyed, 95% found the SIC to be mostly or extremely worthwhile. Nine of 11 hospitalist providers completed the follow-up survey. Each of the nine providers who completed the survey found the guide valuable to patient care and easy to administer. The conversation yielded valuable information in terms of goals, fears, and worries; sources of strength; abilities critical to the patient; and understanding how much the patient would be willing to go through for the possibility of gaining more time. Conclusion: We found that implementation of a structured communication tool in the intensive care unit was feasible and acceptable to surrogates and providers; yet, fidelity to the timing and completion was modest. The tool appeared to yield valuable information for understanding the goals, fears, and care preferences of mechanically ventilated patients. Steps to increase fidelity, in accordance with family-centered care guidelines, are warranted.

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Serious Illness Conversation-Evaluation Exercise: A Novel Assessment Tool for Residents Leading Serious Illness Conversations.

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