ADVANCE CARE PLANNING CURRICULUM FOR MEDICAL STUDENTS

INSTRUCTOR’S GUIDE

Curriculum Description:

Advance care planning (ACP) is a critical component of quality end-of-life care, yet there is little formal training in medical school education. This novel curriculum enables third-year medical students to develop the communication skills and build confidence interviewing a patient about advance care planning, personal values and quality of life. The curriculum consists of a: lecture, online module, readings, demonstration video, and an in-home, mock interview with a senior “trained patient.” Senior volunteers were recruited from an independent senior building that is part of a retirement community. These "trained patients" participate in a 1.5-hour training session preparing them for the interview and to evaluate students' clinical interviewing skills. Students receive verbal feedback from trained patients and a written skills assessment. They complete a self-assessment of skills survey, attend a debriefing discussion session, and write a 250 word reflective essay about the encounter.

Materials:

1. For Faculty:a. Guide for Trained Patient Training Sessionb. Slide presentation with speaker’s notes

2. For Students:a. Reading: “A Personal Decision” by the Illinois State Medical Medical Society (ISMS).

Available at https://www.isms.org/uploadedFiles/Main_Site/Content/Resources/For_Physicians/Advance_Directives/PersonalDecision.pdf

b. Online module: Advance Care Planning, by the University of North Carolina Chapel Hill, POGOe product #19059 http://www.pogoe.org/productid/19059

c. Video demonstration of interviewd. Advance Care Planning Interview Questions

3. Evaluation Instruments:a. Skills assessment and curriculum evaluation b. Evaluation of advance care planning interview – completed by trained patientsc. Reflective essay assignment for students

Methods/Logistics:

I. Recruiting and training seniors to participate as “trained patients” What is a senior “trained patient”?

o An older adult who volunteers to participate in a medical student training program involving practice interviews with medical students in his/her home

Qualifications of a “trained patient”?o Cognitively intact and able to communicate and be understoodo Able to attend a 1.5-hour training session

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o Willing and able to comply with the program expectations Determining how many older adult “trained patients” to recruit?

o Know how many students are completing the curriculum.o Consider having seniors participate in more than one student interview, if they are

willing to do so.o Consider assigning student pairs for interviews.o Recruit more seniors than needed in case a few become unable to participate.

Where to recruit senior volunteers?o For this curriculum, senior volunteers were recruited from an independent, senior

retirement community. It was helpful to have one of the senior residents serve as a liaison between the independent living community members and the course director. A liaison should be acquainted with many of the residents, understand the qualifications of a trained patient, and be able to communicate regularly with the program director.

o Alternatives to consider: Integrating this curriculum into an existing senior mentor program Recruiting trained patients from a local church, synagogue or senior community

center Recruiting older adults who have experience participating in standardized or

simulated patient encounter

II. Conducting a trained patient training session: logistics, materials and methods Logistics

o Length of training session: approximately 1.5 hourso Recommended group size: 15-20 seniors: Two training sessions may be offered if

more seniors will be trained.o Site of training: convenient location for trainees, such as a senior

community center, or retirement, independent living community building, etc.

Materialso Sample training session Manual which explains the purpose and format of the

interview about advance care planning, and how to evaluate student’s interviewing skills, a release for participation and evaluation of training session.

o The Manual should be senior-friendly, printed in larger font and health literacy appropriate.

Methodso It is recommended that the training session begins with introductions by all in

attendance, seniors and facilitators.o The sample training session manual provides a step-by-step introduction and

explanation of the program for the facilitator(s) to follow. o The manual addresses the goals of the training session and how to accomplish each:

To explain the purpose of the curriculum (e.g, why it is important for medical students to learn how to conduct a conversation on end of life care and advance care planning)

To explain the logistics such as scheduling interviews and returning evaluation forms

To familiarize seniors with the questions the students may ask in the interview To train the seniors on how to give feedback to students and what to evaluate

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o It is convenient to wrap-up with seniors signing up for designated interview dates.

III. Curriculum components and process Students attend a 1-hour lecture on Advance Care Planning presented by faculty in family

medicine, geriatrics, or palliative medicine. Slides with speaker’s notes included. Students view the online module, “Advance Care Planning” by the University of North Carolina

Chapel Hill, POGOe product ID #19059. http://www.pogoe.org/productid/19059 Assigned readings

o Mandatory: “A Personal Decision” by the Illinois State Medical Medical Society (ISMS). Available at https://www.isms.org/uploadedFiles/Main_Site/Content/Resources/For_Physicians/Advance_Directives/PersonalDecision.pdf

o Optional: Emanuel LL, Danis M, Pearlman RA, Singer PA. Advance care planning as a process: structuring the discussions in practice. JAGS 1995;43(4):440-6.

Interview with trained patient on advance care planning.o Time: approximately 1 houro Logistics: Interviews are scheduled and assigned to students in advance. They are

conducted by pairs or individual students, and held in the trained patient’s home or in a private, non-medical setting

o Students are encouraged to build rapport and get to know with the trained patient, allow the conversation to flow naturally, and listen to the trained patient to understand his/her values and views on end of life care and the life experiences that shaped them. The “ACP Interview Questions” form should not be used as a script, rather as a guide to the discussion.

o Students should expect to receive verbal feedback from the trained patient at the end of the interview.

o Trained patients evaluate students’ interviewing and communication skills by completing the “Evaluation of Advance Care Planning Interview” and returning it to the course director. Course director may determine whether to share this evaluation with students or do so on a case-by-case basis.

Debriefing session with facultyo Time: 1 houro Recommended group size: 6 studentso Students are encouraged to share their experiences interviewing a trained patient and

express any lingering questions or concerns. o Take-home messages are that end of life (EOL) planning is a topic a physician should

discuss with every patient but particularly when patients are most vulnerable (aging, new illness, uncontrolled illness, before surgery or hospitalization) , and EOL decisions are fluid/dynamic depending on the acuity of illness and what’s important for patients.

Skills post-test may be conducted electronically or on paper. Reflective essay assignment: Students are asked to write a 250-word essay about their

experience interviewing the trained patient and submit to the course director or administrator.

Total Time Required: 4.5 hours

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Training session for senior trained patients approximately 1.5 hrs. Lecture 1 hour Advance care planning interview with trained patient 1 hour Debriefing session with students 1 hour

Learning Objectives:

After completing this curriculum, learners should be able to:1. Define and differentiate among types of code status, health care proxies, and advance directives

in Illinois.2. Utilize effective communication techniques in completing an advance directive discussion with a

patient.3. Identify own biases and attitudes toward advance care planning.

Course Director:

Faculty in Family Medicine, Geriatrics, Internal Medicine, or Palliative Medicine

Additional Staff:

Administrative support is needed for recruiting senior volunteers, coordinating “Trained Patient Training Session(s),” and scheduling student interviews with trained patients.

Learners:

Third-year medical student at the University of Chicago Pritzker School of Medicine complete this curriculum as part of the Family Medicine Clerkship. The curriculum is also suitable for nursing, chaplaincy and social work students.

Results:

One hundred fifty-six third year medical students at the University of Chicago Pritzker School of Medicine completed the Advance Care Planning Curriculum from 2012 – 2014. Learner assessment included: reflective essays, trained patient evaluation of students’ skills, a post-course self-assessment of skills survey. Students also evaluated each of the learning modalities in the curriculum.

Reflective Essays

All students completed a 250-word essay reflecting on their interviewing experience. Grounded qualitative analysis of students’ reflective essays from 2012-2013 revealed five themes: (1) students’ initial apprehension or discomfort with the task, (2) the importance of understanding and respecting patients’ end-of-life preferences, (3) recognizing patients’ values and definitions of quality of life, (4), the importance of timing ACP: when patients are healthy and then re-visiting the topic regularly, and (5) the value of practicing ACP discussions with actual patients.

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Trained Patient Evaluation

Trained patients’ evaluation of students’ interviewing and communication skills was uniformly strong, with students receiving the highest ratings on the checklist across all ten measures. Trained patients provide a subjective, and nonprofessional view simulating a patient perspective of the encounter.

Skills Assessment

A post-course survey on confidence communicating with patients about end of life care and advance care planning was administered to 131 students. There was significant change in students’ self-assessments of confidence in all skill areas upon completion of the curriculum. Data reported in the table below.

Confidence in communication skills about advance care planning1=Not at all confident, 5=Completely confident

Skill:Mean Rating

Pre

Mean Rating Post

N

Introducing the subject of end-of-life decision-making 2.97 4.11 131Answering the question "What is an advance directive?" 3.09 4.34 130Assessing a person's values, goals, and priorities in life 3.18 4.14 130Discussing with a person his or her feelings about an earlier experience with death

3.02 4.08 130

Assessing a person's expectations about treatment and hospitalization 3.04 4.13 130Effectively explaining what happens when a person has CPR, including typical outcomes

3.18 4.05 130

Dealing with my own feelings regarding end-of-life choices and recognizing my limitations in helping others

3.34 4.14 127

Curriculum Evaluation

Students rated the helpfulness of each learning component toward preparing them for the practice interview and gaining comfort discussing advance care planning with an older adult. The lecture and debriefing session were added mid-year; data has not been gathered yet. The trained patient interview was rated the highest in relation to the other learning venues for helping students become comfortable discussing advance care planning with an older adult. The mean rating=4.42 on a 5-point Likert scale with 5=strongly agree and 1= strongly disagree. Additionally, they reported “feeling prepared for the interview” (mean rating=4.24). Please see the table below.

5=strongly agree, 1=strongly disagreeCriteria: Mean

RatingResponse Rate (%)

N

The sample interview video was helpful in preparing for the trained patient interview.

3.88 92 121

The online module was helpful in preparing for the "trained patient" 3.43 99 129

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interview.The assigned reading was helpful in preparing for the trained patient interview.

3.79 73 95

The trained patient interview helped me to feel more comfortable discussing end-of-life care with patients.

4.42 92 130

I felt prepared for the interview. 4.24 99 129I found the trained patient feedback constructive. 4.03 86 113

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