Zehm April, Lindvall Charlotta, Parks Kimberly, Schaefer Kristen, Chittenden Eva
Palliative Care Physician, Division of Palliative Care and Geriatrics, Massachusetts General Hospital.
Instructor, Harvard Medical School.
MedEdPORTAL. 2017 Jun 16;13:10596. doi: 10.15766/mep_2374-8265.10596.
The increasing prevalence, high symptom burden, and medical advances that often prolong the advanced phase of heart failure mandate an organized and thoughtful approach to medical decision making. However, many clinicians have difficulty discussing prognosis and goals of care with patients. Barriers include disease- and therapy-specific prognostication challenges in heart failure and a lack of evidence-based primary palliative care education initiatives.
In response, we developed this 45-minute training module, which consists of a case-based small-group session and a communication guide. The curriculum highlights prognostication challenges in heart failure and introduces an illness trajectory-based framework to cue iterative goals of care conversations.
We piloted this learning module with 46 internal medicine residents and interdisciplinary palliative care fellows in groups of three to 15 and obtained anonymous quantitative and qualitative postsession learner survey data to examine feasibility and acceptability. Trainees rated the session highly. One hundred percent of learners either strongly agreed or agreed the session was clinically useful. Learners unanimously found the teaching methods effective, and most felt they could easily apply these skills to their clinical work. In open-ended feedback, learners said the session gave them a better understanding of the heart failure illness trajectory, an improved framework for discussing goals of care with heart failure patients, and specific language to use when having these discussions.
This module represents a new paradigm for teaching both prognostication and advance care planning in heart failure in which illness trajectory guides timing and content of goals of care conversations.
心力衰竭的患病率不断上升，症状负担沉重，而且医学进步常常使心力衰竭的晚期阶段延长，这就要求采取有条理且深思熟虑的方法来进行医疗决策。然而，许多临床医生在与患者讨论预后和护理目标时存在困难。障碍包括心力衰竭中特定疾病和治疗的预后预测挑战，以及缺乏循证的初级姑息治疗教育举措。
作为回应，我们开发了这个45分钟的培训模块，它由一个基于案例的小组会议和一份沟通指南组成。该课程突出了心力衰竭中的预后预测挑战，并引入了一个基于疾病轨迹的框架，以提示护理目标对话的迭代目标。
我们以三到十五人的小组形式，对46名内科住院医师和跨学科姑息治疗研究员试用了这个学习模块，并获得了匿名的定量和定性的课后学习者调查数据，以检验其可行性和可接受性。学员对该课程评价很高。100%的学习者要么强烈同意要么同意该课程在临床上有用。学习者一致认为教学方法有效，并且大多数人觉得他们可以轻松地将这些技能应用到临床工作中。在开放式反馈中，学习者表示该课程让他们对心力衰竭疾病轨迹有了更好的理解，为与心力衰竭患者讨论护理目标提供了一个改进的框架，以及在进行这些讨论时可以使用的具体措辞。
这个模块代表了一种在心力衰竭中教授预后预测和预先护理计划的新范式，其中疾病轨迹指导护理目标对话的时间和内容。
