Bansal Aarti, Monk Alice, Norman Megan, Fingas Samuel
Academic Unit of Medical Education, Sam Fox House, Northern General Hospital, Sheffield, UK.
The Medical School, University of Sheffield, Sheffield, UK.
Clin Teach. 2020 Dec;17(6):705-710. doi: 10.1111/tct.13214. Epub 2020 Jul 30.
End-of-life discussions are associated with improved quality of care for patients. In the UK, the General Medical Council outlines a requirement for medical graduates to involve patients and their families in discussions on their care at the end-of-life. However medical students feel ill-equipped to conduct these discussions.
In 2018, Sheffield Medical School introduced a small group role-play session on end-of-life discussions for all final year medical students. Scenarios were devised to improve confidence in the following learning domains: communicating prognosis with patients and family; ascertaining patient's goals, values and preferred place of death; discussing escalation of treatment, discussing do not attempt resuscitation orders, care in the dying phase of illness and pre-emptive prescribing. Evaluation was conducted over 16 weeks with a before and after questionnaire. Students rated their confidence in the above learning domains on a Likert-style scale and explained their ratings in free-text boxes.
There was a 76% response rate to the questionnaire and analysis showed statistically significant improvements in confidence across all learning domains following the session. Qualitative analysis of free-text responses showed that prior to the sessions, students expressed low confidence due to lack of experience and fear of upsetting patients. After the session students felt they had gained skills but expressed persistent anxiety and a desire for further practice.
Our innovation suggests that the opportunity to experience End-of-life discussions through role-play can significantly improve students' confidence in conducting these conversations. However, repeated sessions are likely necessary for students to feel prepared upon graduation.
临终讨论与改善患者护理质量相关。在英国，医学总会概述了一项要求，即医学毕业生要让患者及其家属参与临终护理的讨论。然而，医学生觉得自己没有能力进行这些讨论。
2018年，谢菲尔德医学院为所有医学专业最后一年的学生引入了一个关于临终讨论的小组角色扮演环节。设计了一些场景，以提高在以下学习领域的信心：与患者及其家属沟通预后；确定患者的目标、价值观和 preferred place of death（此处疑有误，可能是“首选死亡地点”）；讨论治疗升级、讨论不要尝试心肺复苏医嘱、疾病临终阶段的护理和预先开药。通过一份前后问卷进行了为期16周的评估。学生们用李克特量表对他们在上述学习领域的信心进行评分，并在自由文本框中解释他们的评分。
问卷的回复率为76%，分析表明，该环节后所有学习领域的信心都有统计学上的显著提高。对自由文本回复的定性分析表明，在该环节之前，学生们由于缺乏经验和担心让患者不安而表现出信心不足。该环节之后，学生们觉得自己获得了技能，但仍表示持续焦虑，并希望进一步练习。
我们的创新表明，通过角色扮演体验临终讨论的机会可以显著提高学生进行这些对话的信心。然而，可能需要多次进行该环节，学生才能在毕业时感到有所准备。
