Canadian national survey of oncology residency program directors and trainees; randomized trial of medical education intervention / Purpose: This work addresses teaching communication skills for eliciting cardiopulmonary resuscitation (CPR) wishes, or code status discussions, with cancer patients. The objectives of this thesis include: 1) define current teaching practices for code status communication training in Canadian oncology residency programs, and 2) examine the effect of teaching a novel communication framework for code status discussions to oncology residents. Methods: All current residents and program directors in Canadian medical and radiation oncology residency programs were surveyed regarding education, perceived gaps in training, attitudes towards and patterns of clinical practice for code status discussions with cancer patients. We carried out a multicentre randomized trial to determine the effect of teaching a code status communication framework to oncology learners. Residents completed a training workshop and were evaluated in simulated patient encounters (observed structured clinical exam [OSCE]). Participants were randomized to complete the training before the OSCE (experimental arm), or after the OSCE (control arm). The primary outcome was objective rating of code status communication skills. Results: Current postgraduate oncology curricula lack formal teaching and evaluation of code status communication skills. Educators support the need for innovative teaching tools in this field. Accordingly, a novel six-step communication framework was created in which core themes were summarized by the mnemonic acronym PULSES (Prognosis, Underlying values, Long-term outcome and Short-term outcome of CPR, provision of an Educated recommendation, Summary, style and documentation). A total of 46 oncology residents from 3 training centres participated in the randomized trial. Overall, learners in the experimental group had higher mean content-specific, general communication, and global rating communication scores than those in the control group. The training program conferred the greatest benefit among junior residents. Scores across rating tools were highly correlated. Conclusions: Communication training for code status discussions in Canadian oncology residency programs is lacking. With use of a novel communication framework, we have shown that structured teaching on code status discussions can improve competence in this challenging communication task. Moreover, we have developed educational resources that can be implemented in current curricula. Building capacity for clear and effective code status communication with cancer patients will contribute to high quality end of life care in Canada. / Thesis / Master of Science (MSc) / Medical learners in oncology (cancer care) training programs often lead discussions with cancer patients about code status, that is, patients’ wishes for use or non-use of life-sustaining resuscitation interventions including CPR. Learners receive little training for these complex encounters; yet, decisions regarding resuscitation wishes can influence the quality of care received by cancer patients at end of life. In this study we conducted a survey of trainees and program directors in Canada to better understand current educational practices and attitudes towards education on this topic. Most trainees are not receiving formal teaching or evaluation, and new educational resources are needed. We then developed a 6-step communication guide for code status discussions. We studied the effect of a training workshop in which the communication guide was taught to learners in oncology. We found that the training program improved communication ability among learners with the greatest impact seen among junior learners.

Chronic obstructive pulmonary disease (COPD) requiring long-term oxygen therapy (LTOT) is an incurable lung disease often complicated by other comorbidities. Research is limited for hospitalized COPD exacerbations with LTOT and palliative care services. The purpose of this quantitative research study was to determine the correlation between palliative care interventions and COPD patient outcomes specific to an intensive care unit (ICU) stay, invasive mechanical ventilator support, physician orders for cardiopulmonary resuscitation (CPR) code status, and hospital discharge to hospice care. The theoretical base for this study was Donabedian's quality improvement theory. The quasi-experimental, nonequivalent groups design divided COPD hospitalized patient sample into 2 groups, those with and those without palliative care, for comparison. An independent-samples t test, one-way MANOVA, and follow-up univariate ANOVAS was done to compare the means of ICU days and ventilator days; a cross tabulation, chi-square test of independence, and Fisher exact test was done to compare code status and place of hospital discharge. The mean number of the ICU days and ventilator days for palliative care patients was significantly higher than patients who did not receive palliative care. A significant interaction was found for palliative care and code status change from CPR to no CPR; however, data relating to palliative care and hospital discharge to hospice was insignificant. In conclusion, palliative care does not reduce costs by limiting the number of days spent in an ICU or the number of days on invasive mechanical ventilation; although, it may have an important role in the code status order change from CPR to no CPR to align with the patient's end of life care preference.