Physician Health Belief Attitude Survey 15 items assessed in a 6-point Likert scale Principle Components (4): Opinion: Assess pt perspective/opinion about disease Belief: Determine pt’s health beliefs Context: Assess pt social/cultural context Quality: Determine pt perspective for “good health”
The ability to communicate with families affected how much information was conveyed during family meetings When communication was easy, often more headway was made in reaching treatment decisions that satisfied all How did this affect the outcome of the case (review in medical student #1) 76 yo M Chinese admitted multiple times with respir failure in the setting of advanced/non-curable NSCLC. Intubated x 3. And now discussion terminal extubation. Language and interpreter issues the biggest barrier.
Family Meetings are a give and take, soliciting what the patient understands and what the medical team knows Feelings have to be addressed, both from the family but also from the care team. Sometimes information cannot be communicated until family members can set aside feelings Get background information on the case (student #6) Patient admitted s/p PEA arrest in the field. After >72 hours of care the patient had not neurologic function. Team wanted to get neurology involved to determine brain death. The family was distraught and uncomfortable having this family meeting. In part b/c of the unexpected suddenness of this tragic event. Members of the family felt uncomfortable with conversation and there lacked an alliance between family and physicians.
Although there is often one healthcare proxy, the family meetings often elicited the perspective of each individual Family and group dynamics were apparent and needed to be balanced with individual concerns Conflict – When conflict was present it either led to consensus or led to the healthcare proxy making a solo decision Consensus – Some family members were synchronized in their perspectives from the start, and some reached consensus after being able to share their perspectives in the family meetings Find out background information in the case #18: Patient with multiple comorbidities and multiple hospitalizations, intubated >14 days and family meeting to discuss DNR/DNI upon extubation with goals to go home. Conflict between family members….But also med student feeling conflicted by lack of ability of the patient to participate in this decision as the student values autonomy.
Find out background of student #4: 78 yo female with 2 sons admitted with large multifocal stroke causing left sided weakness, inability to walk and dysarthria. She received TPA without improvement persistent dysarthria and weakness. Family had a difficult time understanding that she would not be able to swallow and needed a feeding tube vs CMO. When the MD acknowledged the difficulty of the decision, the family became open to further discussion and trust/relationship was established.
CULTURALCOMPETENCY IN END OFLIFE CARE IN THE ICU:WHAT STUDENTSLEARNED IN A PILOTCURRICULUMAmy Chi, MDElisabeth E. Bennett, PhDRebecca D. Blanchard, PhD
Background Decisions about end of life (EOL) care arecomplex and influenced by factors such as: Understanding prognosis, preferences in life-prolonging treatment, family beliefs, patient-physician communication and culture Navigating EOL care discussions can bechallenging with families/patients of differentcultures Limited literature describing implementationand impact of a cultural competencycurriculuminEOLcare
Cultural Competency PilotCurriculum in End of Life Care• Funding from Innovation in Diversity EducationAward (Tufts Medical School)• Implemented cultural competency in end of lifecare curriculum from 2011-2012• Target: Medical Students during 4thyear ICUclerkship• Duration of curriculum: 4 weeks during ICUclerkship/block• Total 69 students participated over ten blocks– 32 completed the curriculum (including pre-/post-testsand observation form)
Outcome Measures:QuantitativeSurvey(n=32)Pre-Post TestingPhysician Health BeliefAttitude(15 items. 6 point Likertscale)No ChangeKnowledge Assessment(25 items)No ChangeLevel of Comfort withCultural Competency(5 point scale)Improvement(pre 3.31 vs post 4.01,p<0.01)Dobbie, 2002, Family Physicians Health Conference
Results: Qualitative AnalysisObservation Forms• Observations from reflection tools:– All observations forms analyzed using generalinductive methods, resulting in 3 categories• Students learnedthat in navigating culturalcompetency:(1) Level of understanding influenced caredecisions(2) Conversations must balance information andfeelings(3) Balance between individual and familydynamics is important (specifically conflicts andconsensus)
(1) Level of understandinginfluenced care decisions “With the non-English speaking, wife at thebedside day-in and day-out she was witness tomuchshedidnot understand. Inability to reachthe HCP (patient’s daughter) on a regularbasis meant that her main source ofinformation on the patient’s status was via hermother’s interpretationof herhusband’s care.This situation led to miscommunicationandfrustrationon both sides with the patient stuckin the middle…I felt very frustrated that ourability to explain the patient’s condition to him
(2) Conversations must balanceinformation and feelings “The care providers did listento the family’ssufferingandunderstandingof what thepatient’s illness was. The family didnot seemto fullyunderstandhow ill he was, and howhigh the chances of brain death were.”
(3) Balance between individual &family dynamics Conflict: “There was conflict between the twodaughters involved in the care. One wanted allpossiblemeasures taken to ‘cure’ their fatherand help him live longer and the other wantedto let naturetakeits coursewhen he wasextubated…[The care team] realized thecomplicated family dynamics and were carefulnot to take sides but instead deal with theHCP.”
(3) Balance between individual& family dynamics Consensus: “The two sons were able to bothexpress their concerns and have theirquestions answered about their mother’scurrent situation. It was vital to hear whereeach of them were coming from in order toprovide them with helpful information andguide the discussion. While oneof thebrothers[the HCP] seemed at peace with the decisionto pursue hospice, the other was having amoredifficult timeaccepting her prognosis…Finally, the HCP made the decision to pursuehospice, and hewas ableto convincehis
Conclusion: Communication surrounding EOL care can bechallenging Witnessing family meetings allowed students adeeper understanding of the complexities ofculturally competent care in the ICU Family meetings are not simply conveyinginformation, they must allow for an exchangefor ideas and emotion, and manage complexindividual and group dynamics
Curriculum Outline: Objectives: Integrate how culture influences end of lifedecision making Improve knowledge and attitudes about howculture influences end of life decision making Teaching Framework: LEARN framework Components: Lecture, On-line modules,Observation of family meeting, ReflectionTool, Small group debriefing
The LEARN ModelBe rlin and Fo wke sListen to the patient’s perception of the problemExplain your perception of the problemAcknowledge and discussdifferences/similaritiesRecommend treatmentNegotiate treatmentBerlin EA et al. West J Med 1983: 139: 934 – 938. Helen Fernandez, MD, MPH