The emergency department visit for a patient with serious illness represents a sentinel event, signalling a change in the illness trajectory. By better understanding patient and family wishes, emergency physicians can reinforce advance care plans and ensure the hospital care provided matches the patient's values. Despite their importance in care at the end of life, emergency physicians have received little training on how to talk to seriously ill patients and their families about goals of care. To expand communication skills training to emergency medicine, we developed a programme to give emergency medicine physicians the ability to empathically deliver serious news and to talk about goals of care. We have built on lessons from prior studies to design an intervention employing the most effective pedagogical techniques, including the use of simulated patients/families, role-playing and small group learning with constructive feedback from master clinicians. Here, we describe our evidence-based communication skills training course EM Talk using simulation, reflective feedback and deliberate practice.
- Education and training
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The emergency department (ED) visit for a patient with serious illness represents a sentinel event, signalling a change in the illness trajectory. By better understanding patient and family wishes, emergency physicians (EPs) can reinforce advance care plans and ensure the hospital care provided matches the patient's values. Despite their importance in care at the end of life, EPs have received little training on how to talk to seriously ill patients and their families about goals of care. Here, we describe a novel protocol for an emergency medicine communication skills training programme for patients and families with serious illness.
Relevance of communication skills training to emergency medicine
EPs frequently perform invasive procedures, such as intubation and central line placement that initiate ‘care cascades’ within the hospital environment. This form of aggressive care may initiate an intensive care unit stay without regard to patient's goals of care and goals of invasive therapies. While such interventions can be lifesaving, for seriously ill patients with life-limiting illness they may have questionable impact on quality of life, be inconsistent with their wishes1 and even prolong suffering.2–5 Given that EPs often set the trajectory when patients with serious illness come to the ED, it is important they are able to discuss goals of care with seriously ill patients.
State of the science around communication in patients with serious illness
Communication training programmes significantly improve communication skills for clinicians caring for patients with serious illness.6–8 OncoTalk, an NCI-funded project developed by Vital Talk resulted in oncology fellows improved communication skills in both delivering bad news and determining goals of care in non-emergent settings.9 ,10 EDs are inherently noisy, chaotic, fast-paced environments focused on diagnosis, clinical stabilisation, timely disposition and ensuring proper access to subspecialty care. Emergency providers often feel uncomfortable initiating conversations due to lack of prior doctor–patient relationship, lack of comfort in communication skills and uncertain knowledge about prognosis.11
To expand communication skills training to emergency medicine, we developed a programme to give emergency medicine physicians the ability to empathically deliver serious news and to talk about goals of care.9 ,12 We have built on lessons from prior studies13 ,14 to design an intervention employing the most effective pedagogical techniques, including the use of simulated patients/families, role-playing and small group learning with constructive feedback from master clinicians. Here, we describe the creation and content of our evidence-based communication skills training course EM Talk using simulation, reflective feedback and deliberate practice. We do this by first reviewing the methodological foundation for the work, describing the genesis and content of the emergency medicine-specific curriculum, and by linking workshop activities to specific behaviours and skills to be acquired.
The Vital Talk communication skills workshop utilises evidence-based pedagogical techniques, and includes simulated patients/families, role-playing, teaching-to-teach exercises and small group learning with constructive feedback from master clinicians. A rich literature supports the use of learner-centered techniques, specifically attention to affect, and skills-based exercises for teaching communication skills to physicians.15 In all of these techniques, the focus is on teaching behaviours and skills rather than the simple provision of knowledge.16 We know, for example, that traditional lecture-style presentations minimally change physician performance.17 While we incorporate short lectures into our 1-day workshop, these sessions set the foundation for the true learning that occurs during skills practice. Social learning theory states that adopting new skills and behaviours requires that one step into a new role.18 Doing so engrains a behaviour more effectively than reading or hearing about it.19 For these reasons, our intervention emphasises role modelling and skills practice. The basic premise of adult learning is that the learner must be motivated to learn for skill development and behaviour change to occur.20 By focusing on topics that previous research has shown EPs want to learn (eg, palliative care skills and communication),11 ,21–23 our intervention builds on and meets our learners’ needs. In addition to these principles, we also utilise lessons from positive psychology, which is based on the premise that if one asks a person to do more of something they are already doing well, you are more likely to see behaviour change and success than if you only point out what they are doing poorly.24 The intervention's feedback process is structured to emphasise what the physician did well in addition to discussing areas for improvement.
The communication skills workshop is built on self-efficacy theory,25–27 which has guided interventions for changing clinician behaviours.28–31 In self-efficacy theory, the impetus for change resides in the individual's efficacy expectations, that is, one's ‘confidence in one's ability to take action and persist in action’.32 These expectations reflect the learner's beliefs about how capable s/he is to perform the task. Efficacy expectations are acquired from four sources: performance accomplishments, vicarious experience, verbal persuasion and emotional state. Performance accomplishments refer to the learner's actual experience. This suggests that for behaviour change to occur, the learner must have the opportunity to succeed in performing the new skills. For this reason, our curriculum focuses on practice with simulated families. Vicarious experiences include observing other people undertaking and succeeding at the tasks. This component supports our teaching in small groups where learners receive feedback from others about their skills and watch to see how other learners interact with families. Verbal persuasion is the degree to which the learner feels supported or encouraged to change. Our intervention incorporates structured, learner-centered feedback to enhance verbal persuasion. Finally, the influence of emotional state on efficacy expectations suggests that addressing clinicians’ anxiety about confronting death or a grief-stricken family may be an important prerequisite for improving clinical skills.33 ,34 Reflective exercises are integrated to discuss learners’ emotional reactions to talking about death and dying.
Genesis of EM Talk
EPs demonstrate interest in education and training in primary palliative care skills including communication, but report a lack of knowledge and few programmes to obtain such training.11 Subsequent qualitative research delineated the barriers to ED-based palliative care among hospital administrators, including a palliative care workforce shortage.35 While engaging palliative care specialists is an option, few are available evenings and weekends when most ED patients arrive. Thus, many patients are not seen by palliative care until the following day. Based on this work, we concluded that developing primary palliative care skills, such as teaching EPs how to engage in discussions around goals of care, is both vital to improving care in the ED for patients with serious illness and the only feasible way to ensure patients receive the goal-directed care they deserve, given the palliative care workforce deficiency.
In 2011, a national group of nine EPs with expertise in palliative medicine created a working group to develop a communication skills curriculum for emergency providers to address the most commonly encountered challenges in communicating with ED patients with serious illness. The group met quarterly via conference call and in person up to two times a year beginning in 2012 at national meetings of emergency medicine and palliative care. They represented a group of large institutions, including nine academic medical centres and a large integrated health system. There was representation from all four geographic regions of the USA, including six different states (California, Connecticut, Florida, Michigan, New York and Pennsylvania). The group conducted an environmental scan of the available communications skills training programmes available to physicians in the USA. While short, intensive palliative care training programmes exist, such as the Palliative Care Education Program at Harvard, the group concluded that a short, but intensive skills workshop focused specifically on communication in serious illness was our highest priority. We identified Vital Talk, a non-profit devoted to communications skills training for clinicians, as the ideal partner to adapt a course to emergency medicine.
The partnership with Vital Talk began with members of our group participating as learners in a Vital Talk course. In 2012, a number of our working group members then participated in a GeriTalk or PalliTalk workshop in New York City. Over the subsequent 2 years, the group worked with Vital Talk to develop a communication skills training programme with case-specific scenarios relevant to emergency medicine. While the overall course structure was initially developed for oncology (http://depts.washington.edu/oncotalk/), we adapted this novel, evidence-based framework to emergency medicine practice to focus on skills relevant to EM: delivering serious news, assessing goals of care in patients and their families with serious, life-limiting illness, and negotiating conflict. Dr Robert Arnold, one of the nation's leading experts on communication in serious illness and a co-founder of Vital Talk, advised this group in the development of case-based learning modules and teaching methodologies. Simultaneously, we applied for funding to train a group of faculty in the Vital Talk teaching methodology to develop a cadre of emergency medicine faculty who could then teach the course at their own institutions.
In 2014, we designed an intensive 1-day communication skills educational intervention focusing on communication skills specific to emergency medicine. Components of the 1-day course for learners are detailed below, and include (1) large group presentations by faculty trainers; (2) small group communication skills practice using patient actors; and (3) debriefing and reflection. Table 1 details the core communication skills to be taught and the primary teaching method associated with each skill. Table 2 is an abbreviated schedule and box 1 is a sample case.
Example case description
Diagnosis: Dementia with recurrent aspiration pneumonia
Age/ethnicity/gender: 82-year-old African-American man
Frequent admissions for aspiration pneumonia (3 times in 6 months)
Brought in for shortness of breath, hypoxia and respiratory distress with likely aspiration.
Recent feeding tube placement following failed swallowing studies. Feedings frequently interrupted due to agitation
Initial blood pressure: 100/60, heart rate: 138, oxygen saturation: 92% on non-rebreather, respiratory rate: 28, temperature: 97
Sodium 149, blood urea nitrogen/creatinine increased from baseline 18/1.0 to 32/2.2, white cell count: 18 000
Patient has been stabilised on 6 L nasal cannula and 1500 mL hydration
The patient currently requires soft restraints to prevent pulling at intravenous tubing and monitor wires.
Family (interaction issues):
Wife is sad about her husband's rapid decline over last months. She does not think he would have wanted to live this way and thinks he would want to come home to die.
Son is angry that dad is sick again. Feels tube feedings should be resumed so dad can get his strength back and come home like mom wants.
Where: Emergency department family consultation room
When: 1.5 h after presentation
Patient's background: You have stabilised the patient, an 82-year-old man with dementia and recurrent aspiration pneumonia. His dementia and functional decline have worsened significantly over the past 6 months. He is frequently agitated in the skilled nursing facility. You want to explore whether transition to hospice care is appropriate for this patient and his family.
Healthcare team members present: Nurse, social worker
Family present: Wife, Millie and son, Charles
Communication Challenge/ Task(s): What the learner is supposed to accomplish.
Conflict resolution and transition to hospice
Give medical facts without jargon
Recognise son's emotions (NURSE statements)
Recognise wife's emotions (NURSE statements)
Explore patient's personal values and personality
Assess what the members of the family are ‘hoping for’
Learner facilitates discussion of goals for the patient.
Make a recommendation for hospice enrolment
Interactive didactic presentations
First, essential communication skills for EPs are taught in demonstration seminars co-led by master clinicians. Didactic presentations include demonstrations of role-play, videotaped examples of good physician–family communication, and interviews with simulated family members. Essential tasks covered include (1) effectively providing information and assessing family members’ understanding, (2) discussing goals of therapy, (3) discussing withholding and withdrawal of life support, including Do Not Attempt Resuscitation orders. For each of these topics, participants receive written material describing a ‘how to do it’ protocol for the communication skill, pearls and pitfalls, sample cases, and references to the literature. This material, along with training videotapes and faculty PowerPoint slides, are kept on a protected website, allowing the faculty to review the material and to ensure consistency.
Communication skills practice
The largest portion of the course time is devoted to intensive small group learning. Each small group consists of 6–8 participants and 2facilitators (Vital Talk faculty). The high ratio of facilitators to learners, coupled with the small group size, ensure that all participants have several opportunities to participate directly in role-plays, receive individual feedback from faculty and other learners, and observe other participants and provide them with feedback. Each 1 h skills practice session focuses on an essential task, such as delivering bad news, determining goals of care and transitioning to palliative care. The faculty facilitator and participants use role-play with simulated patients to practice the core skills discussed in the preceding didactic session. The simulations employ trained actors who receive intensive training to develop the characters of the persons they portray, consistent with the learning goals of each session. Actors are not rigidly scripted as usually found in standardised patients from assessment examinations, but instead develop a particular character who responds consistently to the interaction as it unfolds. Actors are also trained to give specific information about how certain phrases or words make the patient feel, providing the learner with immediate and powerful feedback.
Feedback integrating knowledge, attitudes and skills
Participants receive direct feedback on their performance by the actors, the faculty facilitator and the other participants. In debriefing these sessions, we emphasise communication skills applicable to interaction with critically ill patients and their families. Knowledge provided to the participants includes a structure for conversations and a method to navigate conversations that support decision-making in the face of prognostic uncertainty. We also address skills regarding more general empathic techniques such as reflection, naming emotion and providing supportive statements. Feedback helps identify specific non-verbal behaviours and verbal statements which can promote relationship building, information gathering and negotiation.
Reflective exercises: promoting constructive attitudes and effective coping
One challenge in caring for terminally ill patients is the fear that emotions generated by the interaction will overwhelm the clinician. Consequently, clinicians may respond by withdrawing from terminally ill patients, using false reassurance or changing the topic. Unfortunately for patients and families, these behaviours occur precisely when patients most need emotional support, along with information to make realistic decisions about medical care. Educational interventions that include attention to clinicians’ emotional responses to their patients can increase self-awareness and lead to effective coping strategies that do not involve withdrawal or avoidance.
Conclusions and next steps
Despite their importance in care at the end of life, EPs have been a largely untapped physician group for engaging patients with serious illness in conversations around goals of care. In 2 years of working together, a group of emergency medicine champions in palliative care developed an emergency medicine-specific communications skills workshop adapted from the Vital Talk experience. In 2015, we pilot tested the course at a single institution (New York University School of Medicine) and trained 24 faculty as teachers in this methodology. Current work includes continually refining the course content via semistructured interviews with participants to best fit the curriculum to the time pressures of the ED. Next steps include continuing to pilot the work in other institutions that may have different organisational structure or culture, as well as rigorously evaluating the impact of this training on patients and families with serious illness in the ED.
Twitter Follow Lillian Emlet at @lilcatemccm
Contributors All authors made substantial contributions to the conception or design of the work, drafted the work or revising it critically for important intellectual content, and provided final approval of the version published.
Funding Support for the project was provided by the Fridolin Charitable Trust.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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