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INTRODUCTION
Many physicians are uncomfortable discussing end-of-life issues and care goals with patients and families and providing palliative care to dying patients. Temel et al demonstrated a result of this discomfort, showing that only 20% of patients with metastatic cancer had a documented code status on their outpatient charts. In teaching hospitals, these conversations are commonly led by house officers. However, end-of-life discussions can be challenging even for an experienced physician, especially because medical decisionmaking has evolved from a paternalistic approach to one that is patient and family centered. Patient-centered care presumes active involvement of patients and their families in decisionmaking about individual options for treatment and requires skillful communication and coordination. These discussions are becoming more challenging as the population ages and medical technology advances. However, house officers are not being taught how to conduct these conversations. One recent study revealed that only one-third of residents felt comfortable leading these conversations and very few had received formal training in delivering bad news or leading end-of-life discussions. 2 Furthermore, miscommunication can occur with inadequately trained residents as manifested by the absence of do not resuscitate (DNR) orders for patients who did not want resuscitation. 3
With the ongoing growth of hospitalist and intensivist models of care delivery, end-of-life conversations may occur more often upon admission to the hospital or intensive care unit (ICU). These conversations do not take place in the primary care clinic. Therefore, we implemented our house officer curriculum in the medical intensive care unit (MICU).
Multidisciplinary palliative care teams have increased in the United States. These teams can be a resource for teaching end-of-life care, supporting house officers who may experience personal difficulties with end-of-life cases, and demonstrating the importance of interdisciplinary teamwork. We used just such a team for our course. These interdisciplinary educators used a case-based approach within a structured curriculum to improve resident confidence in delivering bad news, discussing poor prognoses, explaining the dying process, and providing palliative care within the MICU.
METHODS
A structured curriculum was implemented as part of the MICU rotation for house officers. The curriculum involved a 3-part approach that included tutorials, role modeling by the attending physician and the palliative care team, and a case-based debriefing at the end of each rotation. We used...