Pediatric fellows receive little palliative care (PC) education and have few opportunities to practice communication skills.
Objective:
In this pilot study, we assessed (1) the relative effectiveness of simulation-based versus didactic education, (2) communication skill retention, and (3) effect on PC consultation rates.
Design:
Thirty-five pediatric fellows in cardiology, critical care, hematology/oncology, and neonatology at two institutions enrolled: 17 in the intervention (simulation-based) group (single institution) and 18 in the control (didactic education) group (second institution). Intervention group participants participated in a two-day program over three months (three simulations and videotaped PC panel). Control group participants received written education designed to be similar in content and time.
Measurements:
(1) Self-assessment questionnaires were completed at baseline, post-intervention and three months; mean between-group differences for each outcome measure were assessed. (2) External reviewers rated simulation-group encounters on nine communication domains. Within-group changes over time were assessed. (3) The simulation-based site's PC consultations were compared in the six months pre- and post-intervention.
Results:
Compared to the control group, participants in the intervention group improved in self-efficacy (p = 0.003) and perceived adequacy of medical education (p < 0.001), but not knowledge (p = 0.20). Reviewers noted nonsustained improvement in four domains: relationship building (p = 0.01), opening discussion (p = 0.03), gathering information (p = 0.01), and communicating accurate information (p = 0.04). PC consultation rate increased 64%, an improvement when normalized to average daily census (p = 0.04).
Conclusions:
This simulation-based curriculum is an effective method for improving PC comfort, education, and consults. More frequent practice is likely needed to lead to sustained improvements in communication competence.
Get full access to this article
View all access options for this article.
References
1.
FeudtnerC, ChristakisDA, ConnellFA: Pediatric deaths attributable to complex chronic conditions: A population-based study of Washington State, 1980–1997. Pediatrics, 2000; 106(1 Pt 2):205–209.
2.
Institute of Medicine:. When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families—Summary. Washington, DC: The National Academies Press,. 2003.
3.
KuhlthauK, KahnR, HillKS, et al.: The well-being of parental caregivers of children with activity limitations. Matern Child Health J, 2010; 14:155–163.
4.
MeyerEC, RitholzMD, BurnsJP, et al.: Improving the quality of end-of-life care in the pediatric intensive care unit: Parents' priorities and recommendations. Pediatrics, 2006; 117:649–657.
5.
MeertKL, EgglyS, PollackM, et al.: Parents' perspectives on physician-parent communication near the time of a child's death in the pediatric intensive care unit. Pediatr Crit Care Med, 2008; 9:2–7.
6.
American Academy of Pediatrics Section on Hospice and Palliative Medicine and Committee on Hospital Care: Pediatric Palliative Care and Hospice Care Commitments, Guidelines, and Recommendations. Pediatrics, 2013; 132:966–972.
7.
Institute of Medicine:. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: The National Academies Press,. 2014.
8.
ControN, LarsonJ, ScofieldS, et al.: Family perspectives on the quality of pediatric palliative care. Arch Pediatr Adolesc Med, 2002; 156:14–19.
9.
KolarikRC, WalkerG, ArnoldRM: Pediatric resident education in palliative care: A needs assessment. Pediatrics, 2006; 117:1949–1954.
SerwintJR, RutherfordLE, HuttonN: Personal and professional experiences of pediatric residents concerning death. J Palliat Med, 2006; 9:70–81.
12.
MichelsonKN, RyanAD, JovanovicB, et al.: Pediatric residents' and fellows' perspectives on palliative care education. J Palliat Med, 2009; 12:451–457.
13.
SheetzMJ, BowmanMA: Pediatric palliative care: An assessment of physicians' confidence in skills, desire for training, and willingness to refer for end-of-life care. Am J Hosp Palliat Care, 2008; 25:100–105.
14.
ControNA, LarsonJ, ScofieldS, et al.: Hospital staff and family perspectives regarding quality of pediatric palliative care. Pediatrics, 2004; 114:1248–1252.
15.
BakerJN, TorkildsonC, BaillargeonJG, et al.: National survey of pediatric residency program directors and residents regarding education in palliative medicine and end-of-life care. J Palliat Med, 2007; 10:420–429.
16.
RiderEA, VolkanK, HaflerJP: Pediatric residents' perceptions of communication competencies: Implications for teaching. Med Teach, 2008; 30:e208–e217.
17.
McCabeME, HuntEA, SerwintJR: Pediatric residents' clinical and educational experiences with end-of-life care. Pediatrics, 2008; 121:e731–e737.
18.
OrgelE, McCarterR, JacobsS: A failing medical educational model: A self-assessment by physicians at all levels of training of ability and comfort to deliver bad news. J Palliat Med, 2010; 13:677–683.
19.
LevetownM, American Academy of Pediatrics Committee onB: Communicating with children and families: From everyday interactions to skill in conveying distressing information. Pediatrics, 2008; 121:e1441–e1460.
20.
RothM, WangD, KimM, et al.: An assessment of the current state of palliative care education in pediatric hematology/oncology fellowship training. Pediatr Blood Cancer, 2009; 53:647–651.
21.
FileW, BylundCL, KesselheimJ, et al.: Do pediatric hematology/oncology (PHO) fellows receive communication training?. Pediatr Blood Cancer, 2014; 61:502–506.
22.
FeracoAM, BrandSR, MackJW, et al.: Communication skills training in pediatric oncology: Moving beyond role modeling. Pediatr Blood Cancer, 2016; 63:966–972.
23.
KersunL, GyiL, MorrisonWE: Training in difficult conversations: A national survey of pediatric hematology-oncology and pediatric critical care physicians. J Palliat Med, 2009; 12:525–530.
24.
LitrivisE, SinghAL, MoonianA, et al.: An assessment of end-of-life-care training: Should we consider a cross-fellowship, competency-based simulated program?. J Pediatr Hematol Oncol, 2012; 34:488–489.
25.
BossRD, HuttonN, DonohuePK, et al.: Neonatologist training to guide family decision making for critically ill infants. Arch Pediatr Adolesc Med, 2009; 163:783–788.
26.
SchiffmanJD, ChamberlainLJ, PalmerL, et al.: Introduction of a pediatric palliative care curriculum for pediatric residents. J Palliat Med, 2008; 11:164–170.
27.
YamadaNK, FuerchJH, HalamekLP: Impact of standardized communication techniques on errors during simulated neonatal resuscitation. Am J Perinatol, 2016; 33:385–392.
28.
BennettSC, FinerN, HalamekLP, et al.: Implementing delivery room checklists and communication standards in a multi-neonatal ICU quality improvement collaborative. Jt Comm J Qual Patient Saf, 2016; 42:369–376.
29.
ChengA, DuffJ, GrantE, et al.: Simulation in paediatrics: An educational revolution. Paediatr Child Health, 2007; 12:465–468.
30.
BouletJR, Ben-DavidMF, ZivA, et al.: Using standardized patients to assess the interpersonal skills of physicians. Acad Med, 1998; 73(10Suppl):S94–S96.
31.
BackAL, ArnoldRM, BaileWF, et al.: Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med, 2007; 167:453–460.
32.
SzmuilowiczE, el-JawahriA, ChiappettaL, et al.: Improving residents' end-of-life communication skills with a short retreat: A randomized controlled trial. J Palliat Med, 2010; 13:439–452.
33.
FreerJP, ZinnerstromKL: The palliative medicine extended standardized patient scenario: A preliminary report. J Palliat Med, 2001; 4:49–56.
34.
WeissmanDE, AmbuelB, von GuntenCF, et al.: Outcomes from a national multispecialty palliative care curriculum development project. J Palliat Med, 2007; 10:408–419.
35.
FujimoriM, ShiraiY, AsaiM, et al.: Effect of communication skills training program for oncologists based on patient preferences for communication when receiving bad news: A randomized controlled trial. J Clin Oncol, 2014; 32:2166–2172.
36.
WarmEJ, RomerAL: Introducing end-of-life care into the University of Cincinnati Internal Medicine Residency Program. J Palliat Med, 2003; 6:809–820.
37.
TulskyJA, ArnoldRM, AlexanderSC, et al.: Enhancing communication between oncologists and patients with a computer-based training program: A randomized trial. Ann Intern Med, 2011; 155:593–601.
38.
BrownCM, LloydEC, SwearingenCJ, et al.: Improving resident self-efficacy in pediatric palliative care through clinical simulation. J Palliat Care, 2012; 28:157–163.
39.
ToblerK, GrantE, MarczinskiC: Evaluation of the impact of a simulation-enhanced breaking bad news workshop in pediatrics. Simul Healthc, 2014; 9:213–219.
40.
CarterBS, SwanR: Pediatric palliative care instruction for residents: An introduction to IPPC. Am J Hosp Palliat Care, 2012; 29:375–378.
41.
HautC, MichaelM, Moloney-HarmonP: Implementing a program to improve pediatric and pediatric ICU nurses' knowledge of and attitudes toward palliative care. J Hosp Palliat Nurs, 2012; 14:71–79.
42.
LindsayJ: Introducing nursing students to pediatric end-of-life issues using simulation. Dimens Crit Care Nurs, 2010; 29:175–178.
43.
BaughcumAE, GerhardtCA, Young-SalemeT, et al.: Evaluation of a pediatric palliative care educational workshop for oncology fellows. Pediatr Blood Cancer, 2007; 49:154–159.
44.
HarrisLL, PlacenciaFX, ArnoldJL, et al.: A structured end-of-life curriculum for neonatal-perinatal postdoctoral fellows. Am J Hosp Palliat Care, 2015; 32:253–261.
45.
YoungbloodAQ, ZinkanJL, TofilNM, et al.: Multidisciplinary simulation in pediatric critical care: The death of a child. Crit Care Nurse, 2012; 32:55–61.
46.
BatemanLB, TofilNM, WhiteML, et al.: Physician communication in pediatric end-of-life care: A simulation study. Am J Hosp Palliat Care, 2016; 33:935–941.
47.
GerhardtCA, GrollmanJA, BaughcumAE, et al.: Longitudinal evaluation of a pediatric palliative care educational workshop for oncology fellows. J Palliat Med, 2009; 12:323–328.
48.
BrockK, CohenH, SourkesB, et al.: Teaching Pediatric Fellows Palliative Care Through Simulation and Video Intervention: A Practical Guide to Implementation. MedEdPORTAL Publications, Washington, DC,. 2015. www.mededportal.org/publication/10284 (last accessed
September2016
).
49.
MeierD: Center to Advance Palliative Care. The Human Connection of Palliative Care: Ten Steps for What To Say and Do [video]. 2013. www.youtube.com/watch?v=7kQ3PUyhmPQ (Last accessed
June2015
).
National Institute for Nursing Research: Starting a Conversation about Pediatric Palliative Care.. 2014. www.youtube.com/watch?v=hKK24Bp1elQ (Last accessed
June2015
).
52.
National Institute for Nursing Research: Pediatric Palliative Care: A Personal Story.. 2014. www.youtube.com/watch?v=-hOBYFS_Z68 (Last accessed
June2015
).
53.
National Hospice and Palliative Care Organization: Pediatric Hospice Palliative Care—NHF.. 2013. www.youtube.com/watch?v=xEbYbM_HY0s (Last accessed
June2015
).
54.
FriedrichsdorfSJ, KangTI: The management of pain in children with life-limiting illnesses. Pediatr Clin North Am, 2007; 54:645–672, x.
55.
BrockKE, CohenHJ, PopatRA, et al.: Reliability and validity of the pediatric palliative care questionnaire for measuring self-efficacy, knowledge, and adequacy of prior medical education among pediatric fellows. J Palliat Med, 2015; 18:842–848.
56.
DavisDA, MazmanianPE, FordisM, et al.: Accuracy of physician self-assessment compared with observed measures of competence: A systematic review. JAMA, 2006; 296:1094–1102.
57.
DicksonRP, EngelbergRA, BackAL, et al.: Internal medicine trainee self-assessments of end-of-life communication skills do not predict assessments of patients, families, or clinician-evaluators. J Palliat Med, 2012; 15:418–426.
58.
CalhounAW, RiderEA, MeyerEC, et al.: Assessment of communication skills and self-appraisal in the simulated environment: Feasibility of multirater feedback with gap analysis. Simul Healthc, 2009; 4:22–29.
59.
PetersonEB, CalhounAW, RiderEA: The reliability of a modified Kalamazoo Consensus Statement Checklist for assessing the communication skills of multidisciplinary clinicians in the simulated environment. Patient Educ Couns, 2014; 96:411–418.
HallgrenKA: Computing inter-rater reliability for observational data: An overview and tutorial. Tutor Quant Methods Psychol, 2012; 8:23–34.
62.
CicchettiD: Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychol Assessment, 1994; 6:284–290.
63.
DupontWD, PlummerWDJr.: Power and sample size calculations for studies involving linear regression. Control Clin Trials, 1998; 19:589–601.
64.
GreenbergLW, OchsenschlagerD, O'DonnellR, et al.: Communicating bad news: A pediatric department's evaluation of a simulated intervention. Pediatrics, 1999; 103:1210–1217.
65.
HowardG, DaileyP: Response-shift bias: A source of contamination of self-report measures. J Appl Psychol, 1979; 64:144–150.
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
