Original Article
Attitudes Toward and Experiences in End-of-life Care Education in the Intensive Care Unit: A Survey of Resident Physicians
American Journal of Hospice & Palliative Medicine® 2015, Vol. 32(7) 738-744 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114539038 ajhpm.sagepub.com
Elaine Chen, MD1,2, Judith J. McCann, PhD, RN3,4, and Omar B. Lateef, DO1
Abstract Introduction: Resident physicians provide the most physician care to intensive care unit (ICU) patients. The body of literature about residents’ palliative and end-of-life care (PC/EOLC) experiences in the ICU is limited. To our knowledge, this is the first study to assess resident physicians in multiple specialties regarding PC/EOLC in the ICU. Methods: A Web-based survey was developed and administered to all resident physicians in a single academic institution who had completed at least 1 dedicated ICU rotation. Results: Residents reported moderate comfort in dealing with end-of-life (EOL) issues and felt somewhat prepared to care for critically ill patients at the EOL. Feedback should be provided to residents regarding their PC/EOLC skills, and education should be tailored to residents rotating in the ICU. Keywords palliative care, end-of-life care, graduate medical education, life-sustaining treatment, intensive care units, death
Introduction With rapid advances in medical technology, intensive care unit (ICU) use has increased in the recent years. Mortality rates in the ICUs range from 5% to 40%,1 and more than 20% of deaths—or approximately 540 000 annually—in the United States occur in the ICUs.2 Do-not-resuscitate orders are increasing,3 and ICU deaths increasingly involve withholding or withdrawing of life-sustaining therapies.4-6 The ICU physicians must provide compassionate care to dying patients and their families to aid in the transition of goals from cure to comfort. Palliative and end-of-life care (PC/EOLC) in the ICU is thus a growing need. Palliative care is important for symptom management when death is not imminent and becomes indispensable at the end-of-life (EOL). Early and frequent discussions about prognosis and uncertainty are important factors in communication with families about critically ill patients.7,8 Thus, the initial ICU encounter is an optimal time to initiate discussion about prognosis and possible EOL issues. In teaching hospitals, the initial physician encounter in the ICU is often with house staff such as residents or interns. House staff should be skilled and comfortable in the delivery of PC/EOLC. Although some studies have been undertaken on PC/EOLC education in trainees, it is a field in need of further study. The PC/EOLC education has been studied in residents in single specialties,9-14 all showing improvement in residents’ skills following educational interventions. Surveys indicate that
American medical school graduates have low self-perceived comfort with EOL communication and that experience with dying patients contributed more strongly to perceived comfort and skill than classroom teaching.15 In critical care education, a single-center PC curriculum was designed and implemented for critical care fellows. The program included small group sessions, didactic sessions, and a PC rotation; it led to improvement in both knowledge and attitude.1 However, PC/EOLC education has not been compared among multiple specialties in the ICU, where educational opportunities may abound. Overall, PC/EOLC education is an important component of medical training for residents in many disciplines and should not be neglected in the ICU. In teaching hospitals with a wide range of residency programs and specialty ICUs, the PC/EOLC
1
Department of Medicine, Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA 2 Department of Medicine, Division of Geriatrics, Section of Pain and Palliative Medicine, Rush University Medical Center, Chicago, IL, USA 3 Rush University College of Nursing, Rush University Medical Center, Chicago, IL, USA 4 Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, IL, USA Corresponding Author: Elaine Chen, MD, 1750W Harrison Street, Jelke 204, Rush University Medical Center, Chicago, IL 60612, USA. Email: [email protected]
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experiences are likely to vary greatly.16 The purpose of this study was to assess the opinions, attitudes, and experiences of residents regarding PC/EOLC education during their ICU training. To our knowledge, this is the first study to simultaneously assess resident physicians in multiple specialties related to PC/EOLC in the ICU. We hoped to better understand (1) how residents perceive the importance of and need for PC/EOLC education in the ICU, (2) how they rate current PC/EOLC education in the ICU, and (3) how receptive they are to curricular reform.
Table 1. Response Rates. Program Neurology Anesthesia Surgery Internal Medicine Total
Invited
Responded
Response rate
16 65 65 158 304
7 37 23 90 157
43.8% 56.9% 35.4% 57.0% 51.6%
Table 2. Demographic Data for Respondents.a
Methods Literature review for surveys on PC/EOLC, medical education, and ICU experiences revealed no validated instruments. Survey questions were developed with the assistance of experienced survey designers using previous studies as a guide.17,18 The study population included all current residents in a single academic medical center who had completed at least 1 month-long dedicated adult ICU rotation in the past 2 years, which included all residents in internal medicine, anesthesia, neurology, and general surgery. The survey was approved by the institutional review board and administered in the last month of the academic year to maximize available patients. A Web-based survey tool (Survey Monkey) was used, and invitations to participate were distributed via e-mail. Although the survey was open, weekly e-mail reminders were sent through the survey tool to participants who had not yet responded. Responses were collected anonymously. Data analysis was performed using the SAS software program. The Likert-type questions were grouped to create 4 composite measures of opinions and attitudes related to (1) family meetings, (2) technical skill in PC/EOLC, (3) prior training in PC/EOLC, and (4) education on PC/EOLC. Initial analysis examined reliability, central tendency, and variability for the 4 composite measures and for the total measure. Stepwise multivariate regression analysis was conducted to examine whether physician demographic data or physician EOL experience was associated with the 4 composite measures. The criterion for variables to enter the stepwise regression model was significance at the 0.05 level; all variables retained in the model were significant at the 0.10 level.
Gender Ethnicity
Year of training
ICU months completed
Eventual career plans
Religious beliefs
Importance of religion
Male Female Caucasian Indian Asian Hispanic African American Middle Eastern Other PGY1 PGY2 PGY3 PGY 4 or greater 1 month 2 months 3 months 4 or more months General Critical Care Other subspecialty Unsure Christian Hindi/Sikh/Jain Agnostic Jewish Muslim Atheist Buddhist Extremely important Very important Somewhat important A little important Not at all important
Number
Percent
81 76 78 29 25 10 6 3 6 38 40 43 36 19 39 36 63 31 15 86 24 82 21 21 11 10 6 4 16 35 51 25 29
51.6 48.4 49.7 18.5 15.9 6.4 3.8 1.9 3.8 24.2 25.5 27.4 22.9 12.1 24.9 22.9 40.1 19.9 9.6 55.1 15.4 52.9 13.5 13.5 7.1 6.5 3.9 2.6 10.3 22.4 32.7 16.0 18.6
Abbreviations: ICU, intensive care unit; PGY, postgraduate year. a n ¼ 157.
Results End-of-Life-Care Experiences of Residents Of the 304 surveys distributed, 162 were returned for a response rate of 53.3%; 5 surveys had missing data resulting in an analytic sample of 157. Response rates were highest for residents in anesthesia and internal medicine (Table 1). Backgrounds and experiences of the respondents varied broadly (Table 2; Figure 1). Most (80%) residents agreed or strongly agreed that the most deaths they have been involved in during residency occurred in the ICU. Subgroup analyses using chi-square tests were performed by type of residency program on EOL experiences of the residents.
Neurology residents were excluded in subgroup analyses due to small sample size. More residents in internal medicine and surgery had encountered greater than 20 EOL cases than their counterparts in anesthesia (Figure 2). Chi-square analyses showed that compared with their counterparts in anesthesia and surgery programs, residents in internal medicine had more experience in all tested facets of death and dying. When comparing Internal Medicine residents to all other residents, chisquare analyses showed that internal medicine residents had significantly more encounters in family meetings, pronouncing death, and requesting autopsy. Chi-square analyses comparing
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American Journal of Hospice & Palliative Medicine® 32(7)
740
Figure 1. End-of-life care experience of residents.
Figure 2. For how many dying patients have you been involved with provision of care?
year of training and number of dedicated ICU rotations showed a trend toward both being associated with greater number of encounters with death and dying.
Residents’ Opinions and Attitudes Toward PC/EOLC Questions in the opinions/attitudes section are shown in Table 3 with the mean Likert-type response and standard deviation along with the grouping for composite measure analysis. Overall, residents felt somewhat prepared to care for critically ill patients at the EOL (Table 3, Question 19). Average responses
for the composite measures were slightly above the mid-point indicating residents were only moderately comfortable dealing with EOL issues and with the training they received. Cronbach a values ranged from .42 to .71 (Table 4) indicating moderate internal consistency reliability for the questions in the composite measures and for the total measure. In step 1 of regression analysis, we examined the effect of gender and ethnicity on the 4 composite measures and on the total measure. Female residents had more positive views than male residents toward PC/EOLC education in an ICU setting (estimate ¼ 0.23; P value ¼ .004). Otherwise, gender and
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Table 3. Likert Scale Responses to Questions.a
Family meeting
Technical skill
Training
Education
1 2 3Rb 4 5 6 7 8 9 10 11 12 13 14 15Rb 16 17Rb 18Rb 19
Question
Mean (SD)
I am comfortable leading a family meeting to discuss goals of care regarding a patient with imminent death I am comfortable representing prognosis to a critically ill patient and/or family members of a critically ill patient If given a choice, I prefer to avoid discussions about end-of-life care with patients and families I am comfortable with the process of withdrawal of life support from a physician standpoint I know how to medically manage symptoms of distress, anxiety, and pain in a dying patient I am comfortable discussing organ donation with family members When approaching family to request an autopsy after a patient has died, I can accurately describe the procedure I am comfortable notifying family after a patient’s death I have had excellent previous training in end of life care during my medical training outside the ICU I have had excellent previous training in end of life care during my medical training in the ICU setting I have had adequate feedback on my end of life care skills during my training The most deaths I have been involved in during residency were in the ICU The fellows and attendings serve as good role models in the provision of end of life care in the ICU There is adequate time during a one month ICU rotation to incorporate more education on palliative and end of life care There is already too much education on palliative and end of life care in the ICU Learning to provide palliative and end of life care in an ICU has a significant impact on my future practice of medicine During an ICU rotation, it is more important to learn procedures and aggressive care than palliative care Providing aggressive care is more challenging than providing palliative care In general, I am well prepared to care for a critically ill patient at the end of life
3.3 (1.09) 3.5 (0.91) 2.4 (0.86) 4.0 (0.79) 3.7 (0.81) 3.6 (0.89) 3.0 (1.05) 3.6 (0.92) 2.8 (1.01) 2.9 (0.94) 2.4 (0.86) 3.9 (0.94) 3.8 (0.76) 3.3 (0.95) 2.0 (0.64) 3.7 (0.98) 2.7 (0.98) 2.9 (0.98) 3.5 (0.80)
Abbreviations: EOLC, end-of-life care; ICU, intensive care unit; PC, palliative care; SD, standard deviation. a Likert-type scale from 1 (Strongly disagree) to 5 (Strongly agree); higher values indicate greater comfort dealing with PC and EOLC issues, more positive training experiences, and more positive attitudes toward the need for PC and EOLC education. b Questions coded with ‘‘R’’ were reverse coded for composite variable calculations.
Table 4. Opinions/Attitudes of Residents Toward PC and EOLC Issues.a Standard deviation
Cronbach a reliability
3.48
0.77
.72
3.59
0.60
.70
3.15 3.48 3.43
0.53 0.50 0.37
.53 .42 .71
Composite Measuresb Mean Family meetings (3 items) Technical skill (5 items) Training (5 items) Education (5 items) Total measure
Abbreviations: EOLC, end-of-life care; ICU, intensive care unit; PC, palliative care. a N ¼ 157. b Likert-type scale from 1 (Strongly disagree) to 5 (Strongly agree); higher values indicate greater comfort dealing with PC and EOLC issues, more positive training experiences, and more positive attitudes toward the need for PC and EOLC education.
ethnicity were not significant predictors of any of the measures. In step 2, we retained gender and ethnicity and added the physician demographic variables (type of residency training, religion, importance of religion, and number of ICU months completed) using forward stepwise selection. In step 3, we examined the effect of physician EOL encounters (Figure 1) on the 4 composite measures and on the total measure. Results of steps 2 and 3 are reported for each outcome separately.
Comfort With Family Meetings In step 2, residency program and ICU months completed were significant predictors of comfort with family meetings. Anesthesia residents were significantly less comfortable with family meetings than internal medicine residents, and residents with only 1 month of ICU experience were significantly less comfortable than residents with 4 or more months of ICU experience. In step 3, all 5 variables reflecting physician EOL experiences were significantly positively associated with comfort in family meetings. However, only 1 variable (number of family meetings conducted) was retained in the final stepwise model (Table 5). Residency program and ICU months completed were also retained, and the amount of variance explained increased from 14% in step 2 to 31% in step 3.
Technical Skill In step 2, residency program and importance of religion were significant predictors of technical skill. Surgery residents had a significantly higher perception of their technical skill than internal medicine residents. Residents who described their religion as ‘‘somewhat important’’ had significantly lower scores in technical skill than residents who described their religion as ‘‘not important.’’ In step 3, all 5 variables reflecting physician EOL experiences were significantly positively associated with technical skill. However, only 1 variable (number of times
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Table 5. Results of Stepwise Multivariate Regression Analysis for Composite and Total Measures of Opinions and Attitudes Toward PC/EOLC.a
Predictors Residency program Internal Med (reference) Anesthesia Surgery ICU months completed 4þ months (reference) 3 months 2 months 1 month Importance of religion Not important (reference) Somewhat important Very important Physician PC/EOLC encounters No. of family meetings attended No. of family meetings conducted No. of dying patients cared for No. of dying patients pronounced No. of autopsy/organ donations R2 (P value)
Family meetings
Technical skill
Training
Education
Total measure
Estimate (P value)
Estimate (P value)
Estimate (P value)
Estimate (P value)
Estimate (P value)
0.42 (.001) NS
NS 0.42 (.002)
NS NS
NS NS
NS NS
NS NS 0.30 (.09)
NS NS NS
NS NS NS
NS NS NS
NS NS NS
NS NS
0.18 (.06) NS
NS 0.20 (.03)
NS NS
0.14 (.02) NS
NS 0.32 (
Attitudes Toward and Experiences in End-of-life Care Education in the Intensive Care Unit: A Survey of Resident Physicians
American Journal of Hospice & Palliative Medicine® 2015, Vol. 32(7) 738-744 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114539038 ajhpm.sagepub.com
Elaine Chen, MD1,2, Judith J. McCann, PhD, RN3,4, and Omar B. Lateef, DO1
Abstract Introduction: Resident physicians provide the most physician care to intensive care unit (ICU) patients. The body of literature about residents’ palliative and end-of-life care (PC/EOLC) experiences in the ICU is limited. To our knowledge, this is the first study to assess resident physicians in multiple specialties regarding PC/EOLC in the ICU. Methods: A Web-based survey was developed and administered to all resident physicians in a single academic institution who had completed at least 1 dedicated ICU rotation. Results: Residents reported moderate comfort in dealing with end-of-life (EOL) issues and felt somewhat prepared to care for critically ill patients at the EOL. Feedback should be provided to residents regarding their PC/EOLC skills, and education should be tailored to residents rotating in the ICU. Keywords palliative care, end-of-life care, graduate medical education, life-sustaining treatment, intensive care units, death
Introduction With rapid advances in medical technology, intensive care unit (ICU) use has increased in the recent years. Mortality rates in the ICUs range from 5% to 40%,1 and more than 20% of deaths—or approximately 540 000 annually—in the United States occur in the ICUs.2 Do-not-resuscitate orders are increasing,3 and ICU deaths increasingly involve withholding or withdrawing of life-sustaining therapies.4-6 The ICU physicians must provide compassionate care to dying patients and their families to aid in the transition of goals from cure to comfort. Palliative and end-of-life care (PC/EOLC) in the ICU is thus a growing need. Palliative care is important for symptom management when death is not imminent and becomes indispensable at the end-of-life (EOL). Early and frequent discussions about prognosis and uncertainty are important factors in communication with families about critically ill patients.7,8 Thus, the initial ICU encounter is an optimal time to initiate discussion about prognosis and possible EOL issues. In teaching hospitals, the initial physician encounter in the ICU is often with house staff such as residents or interns. House staff should be skilled and comfortable in the delivery of PC/EOLC. Although some studies have been undertaken on PC/EOLC education in trainees, it is a field in need of further study. The PC/EOLC education has been studied in residents in single specialties,9-14 all showing improvement in residents’ skills following educational interventions. Surveys indicate that
American medical school graduates have low self-perceived comfort with EOL communication and that experience with dying patients contributed more strongly to perceived comfort and skill than classroom teaching.15 In critical care education, a single-center PC curriculum was designed and implemented for critical care fellows. The program included small group sessions, didactic sessions, and a PC rotation; it led to improvement in both knowledge and attitude.1 However, PC/EOLC education has not been compared among multiple specialties in the ICU, where educational opportunities may abound. Overall, PC/EOLC education is an important component of medical training for residents in many disciplines and should not be neglected in the ICU. In teaching hospitals with a wide range of residency programs and specialty ICUs, the PC/EOLC
1
Department of Medicine, Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA 2 Department of Medicine, Division of Geriatrics, Section of Pain and Palliative Medicine, Rush University Medical Center, Chicago, IL, USA 3 Rush University College of Nursing, Rush University Medical Center, Chicago, IL, USA 4 Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, IL, USA Corresponding Author: Elaine Chen, MD, 1750W Harrison Street, Jelke 204, Rush University Medical Center, Chicago, IL 60612, USA. Email: [email protected]
Downloaded from ajh.sagepub.com at NANYANG TECH UNIV LIBRARY on November 17, 2015
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experiences are likely to vary greatly.16 The purpose of this study was to assess the opinions, attitudes, and experiences of residents regarding PC/EOLC education during their ICU training. To our knowledge, this is the first study to simultaneously assess resident physicians in multiple specialties related to PC/EOLC in the ICU. We hoped to better understand (1) how residents perceive the importance of and need for PC/EOLC education in the ICU, (2) how they rate current PC/EOLC education in the ICU, and (3) how receptive they are to curricular reform.
Table 1. Response Rates. Program Neurology Anesthesia Surgery Internal Medicine Total
Invited
Responded
Response rate
16 65 65 158 304
7 37 23 90 157
43.8% 56.9% 35.4% 57.0% 51.6%
Table 2. Demographic Data for Respondents.a
Methods Literature review for surveys on PC/EOLC, medical education, and ICU experiences revealed no validated instruments. Survey questions were developed with the assistance of experienced survey designers using previous studies as a guide.17,18 The study population included all current residents in a single academic medical center who had completed at least 1 month-long dedicated adult ICU rotation in the past 2 years, which included all residents in internal medicine, anesthesia, neurology, and general surgery. The survey was approved by the institutional review board and administered in the last month of the academic year to maximize available patients. A Web-based survey tool (Survey Monkey) was used, and invitations to participate were distributed via e-mail. Although the survey was open, weekly e-mail reminders were sent through the survey tool to participants who had not yet responded. Responses were collected anonymously. Data analysis was performed using the SAS software program. The Likert-type questions were grouped to create 4 composite measures of opinions and attitudes related to (1) family meetings, (2) technical skill in PC/EOLC, (3) prior training in PC/EOLC, and (4) education on PC/EOLC. Initial analysis examined reliability, central tendency, and variability for the 4 composite measures and for the total measure. Stepwise multivariate regression analysis was conducted to examine whether physician demographic data or physician EOL experience was associated with the 4 composite measures. The criterion for variables to enter the stepwise regression model was significance at the 0.05 level; all variables retained in the model were significant at the 0.10 level.
Gender Ethnicity
Year of training
ICU months completed
Eventual career plans
Religious beliefs
Importance of religion
Male Female Caucasian Indian Asian Hispanic African American Middle Eastern Other PGY1 PGY2 PGY3 PGY 4 or greater 1 month 2 months 3 months 4 or more months General Critical Care Other subspecialty Unsure Christian Hindi/Sikh/Jain Agnostic Jewish Muslim Atheist Buddhist Extremely important Very important Somewhat important A little important Not at all important
Number
Percent
81 76 78 29 25 10 6 3 6 38 40 43 36 19 39 36 63 31 15 86 24 82 21 21 11 10 6 4 16 35 51 25 29
51.6 48.4 49.7 18.5 15.9 6.4 3.8 1.9 3.8 24.2 25.5 27.4 22.9 12.1 24.9 22.9 40.1 19.9 9.6 55.1 15.4 52.9 13.5 13.5 7.1 6.5 3.9 2.6 10.3 22.4 32.7 16.0 18.6
Abbreviations: ICU, intensive care unit; PGY, postgraduate year. a n ¼ 157.
Results End-of-Life-Care Experiences of Residents Of the 304 surveys distributed, 162 were returned for a response rate of 53.3%; 5 surveys had missing data resulting in an analytic sample of 157. Response rates were highest for residents in anesthesia and internal medicine (Table 1). Backgrounds and experiences of the respondents varied broadly (Table 2; Figure 1). Most (80%) residents agreed or strongly agreed that the most deaths they have been involved in during residency occurred in the ICU. Subgroup analyses using chi-square tests were performed by type of residency program on EOL experiences of the residents.
Neurology residents were excluded in subgroup analyses due to small sample size. More residents in internal medicine and surgery had encountered greater than 20 EOL cases than their counterparts in anesthesia (Figure 2). Chi-square analyses showed that compared with their counterparts in anesthesia and surgery programs, residents in internal medicine had more experience in all tested facets of death and dying. When comparing Internal Medicine residents to all other residents, chisquare analyses showed that internal medicine residents had significantly more encounters in family meetings, pronouncing death, and requesting autopsy. Chi-square analyses comparing
Downloaded from ajh.sagepub.com at NANYANG TECH UNIV LIBRARY on November 17, 2015
American Journal of Hospice & Palliative Medicine® 32(7)
740
Figure 1. End-of-life care experience of residents.
Figure 2. For how many dying patients have you been involved with provision of care?
year of training and number of dedicated ICU rotations showed a trend toward both being associated with greater number of encounters with death and dying.
Residents’ Opinions and Attitudes Toward PC/EOLC Questions in the opinions/attitudes section are shown in Table 3 with the mean Likert-type response and standard deviation along with the grouping for composite measure analysis. Overall, residents felt somewhat prepared to care for critically ill patients at the EOL (Table 3, Question 19). Average responses
for the composite measures were slightly above the mid-point indicating residents were only moderately comfortable dealing with EOL issues and with the training they received. Cronbach a values ranged from .42 to .71 (Table 4) indicating moderate internal consistency reliability for the questions in the composite measures and for the total measure. In step 1 of regression analysis, we examined the effect of gender and ethnicity on the 4 composite measures and on the total measure. Female residents had more positive views than male residents toward PC/EOLC education in an ICU setting (estimate ¼ 0.23; P value ¼ .004). Otherwise, gender and
Downloaded from ajh.sagepub.com at NANYANG TECH UNIV LIBRARY on November 17, 2015
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Table 3. Likert Scale Responses to Questions.a
Family meeting
Technical skill
Training
Education
1 2 3Rb 4 5 6 7 8 9 10 11 12 13 14 15Rb 16 17Rb 18Rb 19
Question
Mean (SD)
I am comfortable leading a family meeting to discuss goals of care regarding a patient with imminent death I am comfortable representing prognosis to a critically ill patient and/or family members of a critically ill patient If given a choice, I prefer to avoid discussions about end-of-life care with patients and families I am comfortable with the process of withdrawal of life support from a physician standpoint I know how to medically manage symptoms of distress, anxiety, and pain in a dying patient I am comfortable discussing organ donation with family members When approaching family to request an autopsy after a patient has died, I can accurately describe the procedure I am comfortable notifying family after a patient’s death I have had excellent previous training in end of life care during my medical training outside the ICU I have had excellent previous training in end of life care during my medical training in the ICU setting I have had adequate feedback on my end of life care skills during my training The most deaths I have been involved in during residency were in the ICU The fellows and attendings serve as good role models in the provision of end of life care in the ICU There is adequate time during a one month ICU rotation to incorporate more education on palliative and end of life care There is already too much education on palliative and end of life care in the ICU Learning to provide palliative and end of life care in an ICU has a significant impact on my future practice of medicine During an ICU rotation, it is more important to learn procedures and aggressive care than palliative care Providing aggressive care is more challenging than providing palliative care In general, I am well prepared to care for a critically ill patient at the end of life
3.3 (1.09) 3.5 (0.91) 2.4 (0.86) 4.0 (0.79) 3.7 (0.81) 3.6 (0.89) 3.0 (1.05) 3.6 (0.92) 2.8 (1.01) 2.9 (0.94) 2.4 (0.86) 3.9 (0.94) 3.8 (0.76) 3.3 (0.95) 2.0 (0.64) 3.7 (0.98) 2.7 (0.98) 2.9 (0.98) 3.5 (0.80)
Abbreviations: EOLC, end-of-life care; ICU, intensive care unit; PC, palliative care; SD, standard deviation. a Likert-type scale from 1 (Strongly disagree) to 5 (Strongly agree); higher values indicate greater comfort dealing with PC and EOLC issues, more positive training experiences, and more positive attitudes toward the need for PC and EOLC education. b Questions coded with ‘‘R’’ were reverse coded for composite variable calculations.
Table 4. Opinions/Attitudes of Residents Toward PC and EOLC Issues.a Standard deviation
Cronbach a reliability
3.48
0.77
.72
3.59
0.60
.70
3.15 3.48 3.43
0.53 0.50 0.37
.53 .42 .71
Composite Measuresb Mean Family meetings (3 items) Technical skill (5 items) Training (5 items) Education (5 items) Total measure
Abbreviations: EOLC, end-of-life care; ICU, intensive care unit; PC, palliative care. a N ¼ 157. b Likert-type scale from 1 (Strongly disagree) to 5 (Strongly agree); higher values indicate greater comfort dealing with PC and EOLC issues, more positive training experiences, and more positive attitudes toward the need for PC and EOLC education.
ethnicity were not significant predictors of any of the measures. In step 2, we retained gender and ethnicity and added the physician demographic variables (type of residency training, religion, importance of religion, and number of ICU months completed) using forward stepwise selection. In step 3, we examined the effect of physician EOL encounters (Figure 1) on the 4 composite measures and on the total measure. Results of steps 2 and 3 are reported for each outcome separately.
Comfort With Family Meetings In step 2, residency program and ICU months completed were significant predictors of comfort with family meetings. Anesthesia residents were significantly less comfortable with family meetings than internal medicine residents, and residents with only 1 month of ICU experience were significantly less comfortable than residents with 4 or more months of ICU experience. In step 3, all 5 variables reflecting physician EOL experiences were significantly positively associated with comfort in family meetings. However, only 1 variable (number of family meetings conducted) was retained in the final stepwise model (Table 5). Residency program and ICU months completed were also retained, and the amount of variance explained increased from 14% in step 2 to 31% in step 3.
Technical Skill In step 2, residency program and importance of religion were significant predictors of technical skill. Surgery residents had a significantly higher perception of their technical skill than internal medicine residents. Residents who described their religion as ‘‘somewhat important’’ had significantly lower scores in technical skill than residents who described their religion as ‘‘not important.’’ In step 3, all 5 variables reflecting physician EOL experiences were significantly positively associated with technical skill. However, only 1 variable (number of times
Downloaded from ajh.sagepub.com at NANYANG TECH UNIV LIBRARY on November 17, 2015
American Journal of Hospice & Palliative Medicine® 32(7)
742
Table 5. Results of Stepwise Multivariate Regression Analysis for Composite and Total Measures of Opinions and Attitudes Toward PC/EOLC.a
Predictors Residency program Internal Med (reference) Anesthesia Surgery ICU months completed 4þ months (reference) 3 months 2 months 1 month Importance of religion Not important (reference) Somewhat important Very important Physician PC/EOLC encounters No. of family meetings attended No. of family meetings conducted No. of dying patients cared for No. of dying patients pronounced No. of autopsy/organ donations R2 (P value)
Family meetings
Technical skill
Training
Education
Total measure
Estimate (P value)
Estimate (P value)
Estimate (P value)
Estimate (P value)
Estimate (P value)
0.42 (.001) NS
NS 0.42 (.002)
NS NS
NS NS
NS NS
NS NS 0.30 (.09)
NS NS NS
NS NS NS
NS NS NS
NS NS NS
NS NS
0.18 (.06) NS
NS 0.20 (.03)
NS NS
0.14 (.02) NS
NS 0.32 (
