Discussing Death and Dying: An End of Life Curriculum to Empower Residents

One of the most challenging roles a physician can serve is delivering life altering and/or bad news to patients and their families, and yet this skill is not widely taught to physicians. A survey from 2003 of pediatric residents found that not only was there minimal education and training in this area, but that they felt there was no natural improvement in their skills from the first to third year of training. It has also been shown that the art of eliciting a patient or family's concerns about death and responding to them is felt to be poorly taught. Worse, residents have indicated that a hidden curriculum in medicine seems to indicate that there is no value to these conversations at all. Residents are not the only stakeholders involved who have expressed concern with this reality. Parents of pediatric patients have repeatedly reported wanting increased sensitivity and clarity during sharing of life-altering information. Up to 75% of parents have reported a negative experience involving end of life (EOL) discussions, and cited inexperience, lack of comfort in communication, and a lack of knowledge as contributing factors to their negative experiences. Less than 18% of students and residents report receiving formal education in EOL discussions, despite the fact that 90% or more of residents have identified caring for those dying as part of a physician's responsibilities. Of residents who do get experience with EOL discussions, less than 2/3 receive feedback. Some residencies, such as internal medicine, have recognized the need for formal instruction on how to have EOL discussions is needed and have implemented formal programs to answer it, and it has even become a standard expectation for many fellowships. Formal education regarding EOL has also become a standard expectation for many fellowships, including pediatric neonatology, intensive care, and hematology/oncology. Despite the evidence that there is need for formal intervention and education regarding EOL care, there has been little advancement towards implementing a formal curriculum in pediatric residency programs. Review of the literature demonstrates that only one study has developed a formal curriculum involving a method called SPIKES (Setting, Perception, Involvement, Knowledge, Empathy, and Summary) that targets pediatric residents. The initial data from this study is promising and indicates increased comfort level in residents. However, to date no study has evaluated if the method of instruction affects the resident education, an important consideration as some interventions (ex. standardized patients) are more costly and time consuming than others (ex. facilitator guided small group sessions).