Simulation and Skills Training: A New Way to Teach and Practice High-Stakes End of Life Skills

Transcription

1 Simulation and Skills Training: A New Way to Teach and Practice High-Stakes End of Life Skills Naomi Goloff, MD FAAP, Anne Woll, MS, Erik Norbie University of Minnesota Disclosures All planners, presenters, and authors have disclosed relevant relationships with commercial interests and have no conflicts of interest to report but wish that they did. Objectives 1) Understand how simulation and skills-based training can be applied to teaching end of life (EOL) care 2) Identify 1-2 opportunities to use simulation and skills-based training for your learners 1

2 Questions... Who has experience with simulations (aside from BLS, ACLS, etc)? Who has participated in a simulation focused on EOL care? Training for End of Life Care The Need Despite a need for practice and competency in pediatric EOL care, there is a lack of: Recognition of technical complexity of EOL care skills Formal Training Opportunities to practice and receive feedback Training with colleagues and other care providers Criteria to assess level of competency 2

3 Participant Characteristics Number (n=17) of participants that have: Participated in an end-of-life discussion with a pediatric patient and/or family of a pediatric patient. Led an end-of-life discussion with a pediatric patient and/or family of a pediatric patient. Participated in an extubation at end of life with a pediatric patient. 17 (100%) 12 (70.6%) 14 (82.4%) Led an extubation at end of life with a pediatric patient. 10 (58.8%) Participant Characteristics N=17 Don t know I have had good modeling from attendings on how to provide end of life care. I have had specific training (i.e., formal teaching or observation) in providing end of life care. I have had training (i.e., formal teaching or observation) in responding to patients' and families' psychosocial needs. None A little Some A great deal 3 (17.7%) 14 (82.4%) 1 (5.9%) 5 (29.4%) 9 (52.9%) 2 (11.8%) 6 (35.3%) 8 (47.1%) 3 (17.7%) The Need Examples of EOL care skills 3

4 The Need Examples of EOL care skills Medication dosing and escalation Anticipatory guidance Withdrawal of life sustaining treatment Communication techniques Navigating care decisions and disagreements EOL ethics And... Self-Reported Confidence (Pre Workshop) Don't Know I feel confident about my ability to lead a conversation about a terminal prognosis. I feel confident about my ability to prepare a patient's family for end of life decisions. Strongly Disagree Disagree I feel confident about my ability to make collaborative decisions about withdrawal of lifesustaining treatment. I feel confident about my ability to address difficult questions (e.g., pain, process of dying, etc.) honestly and compassionately. I feel confident about my ability to give anticipatory guidance about end of life. Agree I feel confident about my ability to order medications for an extubation at end of life. Strongly Agree I feel confident about my ability to manage symptoms during an extubation at end of life Overall, I feel confident about my ability to provide end of life care to patients. Current Guidelines EOL care not always specified in guidelines for physician training (ACGME, AAP) e.g. Neonatology EPA Neonatology EPA (AAP) Yet EOL skills are necessary in Neonatal Intensive Care Unit (NICU) In , our hospital had 259 total deaths, 114 of which were infants (44%). 4

5 Traditional Training Of the EOL skill training that does happen, it typically occurs in lectures and at the bedside Lectures have limitations (similar to resuscitation training) Bedside experiences may be infrequent and limited to observation Is this really skill training? I was never taught how to perform a compassionate extubation. My attending just sent me in and told me that I would be fine. I spent weeks afterward dreaming of this, and wondering if I had done a good job. - pediatric ICU fellow My husband and I wondered why they gave us so much time memory making with our daughter before she went to surgery. We did not understand that we were preparing for the end of her life. - parent 5

6 Zoya Palliative Care Memorial Fund As a physician, I know how much time we spent practicing resuscitation. But we do not practice care at EOL. How much better care would be if we did. We want to help make that happen with this fund. -parent/physician A New Approach to End of Life Training The Genesis Could a simulation-based workshop provide effective training and practice for high-stakes EOL skills? What would this workshop involve? How will we know if it is effective? 6

7 Project Goals Provide instruction to fellows using a skills-based workshop to practice EOL care Provide an immersive experience for fellows to practice integrating EOL skills Bring together a diverse learning community around EOL care Pilot an educational experience to inform future EOL care training Collaboration A University of Minnesota partnership to co-create an educational experience between: Clinical Experts in Pediatrics and Palliative Care Physicians (NICU, PICU, Heme Onc, Palliative Care) Nurse Practitioners (Palliative Care) Registered Nurses (PICU, Palliative Care) Social Work Parent Advisors IERC and AHC Simulation Center IERC and AHC Simulation Center at the U of M Our team of simulation professionals: Provides resources for clinical skills education, simulations, and interprofessional education Serves learners in programs across the Academic Health Center and the surrounding professional healthcare workforce Supports the spectrum of simulation modalities: standardized patients (SPs), full-body mannequins, task trainers, and hybrid simulation 7

8 EOL Skills Training Using Simulation Communication skills training at the University of Minnesota: Delivery of terminal diagnosis in adults Internal Medicine Residents Heme Onc Fellows (Regions) EOL (adult) planning discussions Surgery Residents Palliative Care Faculty/Preceptors Global Health Program Rural Physician Associate Program (MS3) Why Simulation Makes Sense What is simulation? A strategy in which a particular set of conditions are created or replicated to resemble authentic situations that are possible in real life to promote, improve, or validate a participant s performance. 8

9 Skill Development through Simulation Creating Simulation is an active learning process Experience real emotions and learner engagement Practice higher-order skills beyond just doing EOL care requires nuanced skills uniquely applied to each situation (i.e. creating) Evaluating Analyzing Applying Understanding Remembering Bloom s Taxonomy, Revised Anderson, L. (2001) Simulation: A Safe Place for Mistakes An expert is a person who has made all the mistakes that can be made in a very narrow field. Neils Bohr When to use Simulation Types of skills Frequency/risk: Commonly occurring challenges High-risk / low-incidence situations Level: Basic skills Advanced, highly-nuanced skills Objectives Teaching: Introduce skills Practice and develop skills Assessment: Assess skill proficiency Demonstrate competency Scholarship: Share work Develop protocols or best practices 9

10 Deliberate Design Simulation allows you to create the educational opportunity needed: Isolating skills (e.g. dosing for symptom management, extubation at EOL) New skills gain comfort, experience success Familiar skills repeated practice helps develop expertise (Ericsson, 2004) Integrating skills (e.g. EOL family conference) Reflects the demands of professional practice The challenge is greater than the sum of its parts Changing Future Performance Debriefing is key: Allows trainees to reflect on their performance Reveals thought processes (or frames ) Reinforce effective frames Develop alternative mental models Change future actions and results Debriefing is the reason for the simulation Debriefing leads to new frames Debriefing changes later actions Frames Actions Results Rudolph, JW, et al. (2007) Workshop Design 10

11 Workshop At-A-Glance 40 minutes 35 minutes 35 minutes 35 minutes 35 minutes 40 minutes Group 1 Group 2 Group 3 Group 4 Pre-briefing Bedside Family Conference Consult Skills Station Bedside Family Conference Consult Bedside Family Conference Consult Skills Station Bedside Family Conference Consult Debriefing Skills Station Case Series Facilitated by faculty Standardized RN Immersive Scenarios Bedside Consult 11

12 Examples of Question Prompts What will happen if we keep Russell like this, asleep and on the breathing machine? Are we giving up on him? How long will he live for after the ventilator is off? Will he be in pain? Immersive Scenarios Family Conference Examples of Question Prompts How do people make this decision? If we stop dialysis or chemo aren t we causing her death? I m worried I ll regret making this decision. There are so many tubes how can we possibly do this at home? If we stop dialysis, how long will she have? 12

13 What We Learned Confidence Survey Pre Workshop Post Workshop Don t Know Strongly Disagree Disagree Agree Strongly Agree

14 Workshop Impact: Themes Fellows recognized the need for and were appreciative of this workshop and continued practice Differing perceptions of patient-centered care between fellows and SPs / Observers (e.g. menu of care options) Challenges of finding language Gaps in knowledge (e.g. Hospice) Impact of workshop order (skills station vs. immersive simulations) Next Steps Refresher workshops for repeated practice and to prevent skill decay Sessions to address knowledge gaps Hospice Information Everything you ever wanted to ask a parent Adding interprofessional partners for subsequent iterations Study the impact EOL Simulation-Based Training at Your Organization 14

15 Strategies for Broader Implementation Identify resources Collaboration partners Local simulation resources ASPE, SSH Variations on a theme Fidelity Reflection What are ways you can adapt / modify this kind of workshop for your organization? It dawned on me... It is an honor to give someone the right death the same way it is a privilege to give someone a right birth. - Bedside RN speaking about first experience with longtime patient who had died 15

16 Questions? References Anderson, L. W., Krathwohl, D. R., Airasian, P., Cruikshank, K., Mayer, R., Pintrich, P.,... & Wittrock, M. (2001). A taxonomy for learning, teaching and assessing: A revision of Bloom s taxonomy. New York. Longman Publishing. Artz, AF, & Armour-Thomas, E.(1992). Development of a cognitive-metacognitive framework for protocol analysis of mathematical problem solving in small groups. Cognition and Instruction, 9(2), Brock, K. E., H. J. Cohen, B. M. Sourkes, J. J. Good and L. P. Halamek (2017). "Training Pediatric Fellows in Palliative Care: A Pilot Comparison of Simulation Training and Didactic Education." J Palliat Med 20(10): El Sayed, M. F., M. Chan, M. McAllister and J. Hellmann (2013). "End-of-life care in Toronto neonatal intensive care units: challenges for physician trainees." Arch Dis Child Fetal Neonatal Ed 98(6): F Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine, 79(10), S70-S81. Gillan, P. C., S. Jeong and P. J. van der Riet (2014). "End of life care simulation: a review of the literature." Nurse Educ Today 34(5): References Henner, N. and R. D. Boss (2017). "Neonatologist training in communication and palliative care." Semin Perinatol 41(2): Hope, A. A., S. J. Hsieh, J. M. Howes, A. B. Keene, J. A. Fausto, P. A. Pinto and M. N. Gong (2015). "Let's Talk Critical. Development and Evaluation of a Communication Skills Training Program for Critical Care Fellows." Ann Am Thorac Soc 12(4): Lamba, S., L. S. Tyrie, S. Bryczkowski and R. Nagurka (2016). "Teaching Surgery Residents the Skills to Communicate Difficult News to Patient and Family Members: A Literature Review." J Palliat Med 19(1): Lu, A., D. Mohan, S. C. Alexander, C. Mescher and A. E. Barnato (2015). "The Language of End-of-Life Decision Making: A Simulation Study." J Palliat Med 18(9): Meyer, E. C., M. D. Ritholz, J. P. Burns and R. D. Truog (2006). "Improving the quality of end-of-life care in the pediatric intensive care unit: parents' priorities and recommendations." Pediatrics 117(3): Rudolph, J. W., Simon, R., Rivard, P., Dufresne, R. L., & Raemer, D. B. (2007). Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiology clinics, 25(2),

17 Naomi Goloff Anne Woll Erik Norbie 17