EDITORIALS The Intensive Care Unit Family Conference Teaching a Critical Intensive Care Unit Procedure Caroline J. Hurd1,2 and J. Randall Curtis1,3 1
Cambia Palliative Care Center of Excellence, 2Division of Geriatrics and Gerontology, Harborview Medical Center, and 3Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
The intensive care unit (ICU) is a setting in which clinicians care for many of the sickest, most critically ill patients in our healthcare system. Unfortunately, many of our patients die in the ICU. Indeed, approximately 20% of Americans die in, or shortly after, a stay in the ICU, making the ICU a common location for end-of-life care (1). The majority of deaths that occur in ICUs in the United States are preceded by a decision to withhold or withdraw life-sustaining therapy (2), which means ICU clinicians are often making difficult decisions with patients or, more commonly, as patients often cannot participate, with the patients’ family members. Many of these decisions are made in the setting of an ICU family conference, and studies have used the ICU family conference as an important quality metric for patients at significant risk for death or prolonged ICU stay (3). Importantly, even if patients ultimately survive the ICU, their family members often have intense communication needs and are also at risk for consequences of stress and poor communication, including anxiety, depression, and posttraumatic stress disorder (4). In fact, family members of patients who survive the ICU rate ICU clinician communication more poorly than family members of patients who die in the ICU, attesting to the importance of communication for family members of all ICU patients (5). The consequences of poor communication with family members in the ICU are significant. A randomized trial showed that a relatively simple intervention designed to improve communication during family conferences and provide a bereavement packet to family members
was associated with dramatic reductions in symptoms of anxiety, depression, and post-traumatic stress disorder (6). Other studies have shown that improved communication with family members is associated with reductions in nonbeneficial treatment seen so commonly in our ICUs (7–9). In this context, we argue that the ICU family conference is a critical “ICU procedure” that needs to be effectively taught to all fellows training to be intensivists. The ICU is also an opportunity to teach this procedure to residents and others who need to learn this skill set for care across the healthcare continuum, including the acute care and outpatient settings. Although this skill set can also be taught in these other areas of medicine, there are few places where these conferences occur more frequently or have been studied so thoroughly. The ICU is our opportunity to teach and model effective and supportive family conferences to the next generation of physicians, as well as nurses, social workers, spiritual care providers, and other healthcare professionals. In this month’s issue of AnnalsATS, there appear two important reports of programs designed to teach critical care fellows to conduct effective and supportive ICU family conferences (10, 11). Both reports describe the development and implementation of a formal program for teaching this important skill set, although they apply somewhat different approaches. The program developed by McCallister and colleagues (pp. 520–525) uses a formal family conference checklist as a teaching guide to provide formative feedback to fellows about their performance during
actual family conferences in the ICU (11). Hope and coworkers (pp. 505–511) tested a targeted simulation training program, along with a list of directly observable family conference tasks, that was implemented in teaching sessions over the course of a month-long curriculum (10). Both of these programs were implemented successfully and were rated highly by critical care fellows. Both of these programs also showed improved communication ratings, as assessed by a third-party rater: either a faculty member teaching the course, who could not be blinded to whether fellows had received the training (10), or independent clinical psychologists who were blinded to pre- versus posttraining (11). The use of an independent rater blinded to training status greatly enhances our confidence in these assessments but can be difficult to accomplish. Although both studies demonstrate improvements in a fellow’s overall performance, as well as many individual aspects of the family conference, these studies also highlight significant remaining gaps in the attainment of key educational goals. A preintervention survey included in the McCallister study showed that only 40% of fellows reported ever being explicitly taught in residency how to respond to emotion (11). This lack of training and modeling in emotional content during early parts of medical education is widespread. This is evident in the report by Hope and colleagues, which showed poor performance in attending to emotion, accomplished in only about 20% of encounters both pre and postintervention, despite this being part of the curriculum
(Received in original form March 5, 2015; accepted in final form March 6, 2015 ) Correspondence and requests for reprints should be addressed to J. Randall Curtis, M.D., M.P.H., Cambia Palliative Care Center of Excellence, Harborview Medical Center, University of Washington, Box 359762, 325 Ninth Avenue, Seattle, WA 98104. E-mail: [email protected] Ann Am Thorac Soc Vol 12, No 4, pp 469–471, Apr 2015 Copyright © 2015 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201503-123ED Internet address: www.atsjournals.org
Editorials
469
EDITORIALS (10). As emotion often underpins much of medical decision-making under stress and addressing emotion is an essential skill in managing conflict and negotiating a plan of care during family conferences, we believe that at the fellow-training level, these and other advanced skills, such as aligning the treatment plan with goals and values, should be occurring in nearly every encounter. Within both studies, communication behaviors for family conferences can be nicely segmented into beginner, intermediate, and advanced skill levels. Medical students should be mastering beginner aspects of communication, progressing to intermediate skills as residents, and then demonstrating advanced communication skills sets as fellows. Unfortunately, in these studies, fellows fell short of this goal, with those in the study rated by psychologists as only completing about 65% of the key components even after the communication training program (11). This leaves nearly one third of communication skills out of the conversation, and we suspect these were some of the more complicated and nuanced aspects of family conferences. Because interpersonal communication is one of the six key competencies of the Accreditation Council for Graduate Medical Education, this really should be a call to action for all medical educators: We should be introducing an intentional and developmental curriculum for core communication skills earlier and more frequently along the training continuum. That way, by the time critical care fellows are leading ICU family conferences themselves, they are sharpening their skills as expert communicators instead of building a basic foundation. Both these studies, and many others in the medical education literature, use trainee self-evaluations to show improvement. Improvements in self-evaluation may be important, as it may reflect self-efficacy for performing the task, which may result in physicians who are more willing to take on this task (12). However, it is important to note that trainee self-assessments of communication do not necessarily correlate with assessments by patients and family members (13). In a recent randomized trial of an intensive simulation-based communication
training program for internal medicine and nurse practitioner trainees, we found that although the program was associated with improved communication skill acquisition, as assessed by blinded, trained raters, we were unable to demonstrate improvements in patient and family ratings of trainee communication (14, 15). We firmly believe, with our own intellectual and emotional conflict of interest fully acknowledged (as a study participant and an investigator) that this simulation training resulted in important improvements in trainee skill level. Nevertheless, we also acknowledge that demonstrating improvements in patient and family outcomes in our complex healthcare system can be extremely challenging. We believe it is important to continue to explore and study patient and family outcomes of communication training. However, we also recognize that those of us responsible for training the next generation of clinicians will often not have the luxury of patient and family outcome data to help us choose what programs to adopt and adapt. Of note, studies have shown that communications lead by palliative care specialists do improve family satisfaction (16). We argue that this observation represents proof of concept that, with adequate training in communication skills, patient outcomes can be directly improved. This further supports integrating more effective communication education into all levels of training, so that these skills build over time in a developmentally appropriate manner. As communication and family conference curricula continue to evolve, our assessment tools will also mature. At this time, our focus remains on whether family conferences occurred and whether key communication behaviors were observed. Over time, as the communication floor is raised for all healthcare professionals, the quality of these interactions must be better assessed. In our experience, family conferences in the ICU are still largely organized when a patient is doing poorly and the ICU team believes it is time to consider withdrawing life support. In this context, we run the risk of inadvertently encouraging a hidden
References 1 Angus DC, Barnato AE, Linde-Zwirble WT, Weissfeld LA, Watson RS, Rickert T, Rubenfeld GD; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group. Use of intensive care at the end of life in the
470
curriculum that implies that when family conferences are done well, patients and families elect to withdraw life-sustaining treatments. In actuality, we want our trainees to focus on the process, instead of the outcome. We want them to experience family conferences that are proactive and occur at regular intervals so they help us understand the patient’s and family’s perspectives, learn their values and preferences, and match the care plan to these values and preferences even if they are different from our own. This key step, aligning with our patients and families, allows us to walk together along an uncertain path. So what is the best approach to training critical care fellows and others in the skill set of family conferences? In 2015, this is an unanswered question. However, what is more important than which approach to use is the fact that each critical care training program develops an explicit family conference training program and implements it. These programs should be feasible, sustainable, and financially viable. To meet these three aims, we need faculty development within critical care that enables an embedded curriculum that is close to the point of care and clinically relevant. This is an essential skill our fellows must be trained in, and faculty members prepared to teach. The two reports in this month’s issue of the Annals provide program leadership with useful guidance for adoption and adaptation (10, 11). It seems likely to us that the best approach for an individual training program will depend on a number of factors, such as the baseline skills and prior training of the fellows, the resources available for such a program (such as an existing simulation program), and the expertise of the faculty. Our advice can be summarized by reflecting on the aphorism, popularized by Voltaire, that “the perfect is the enemy of the good.” Effective and supportive ICU family conferences are too important to leave to the untrained. n Author disclosures are available with the text of this article at www.atsjournals.org.
United States: an epidemiologic study. Crit Care Med 2004;32: 638–643. 2 Quill CM, Ratcliffe SJ, Harhay MO, Halpern SD. Variation in decisions to forgo life-sustaining therapies in US ICUs. Chest 2014;146: 573–582.
AnnalsATS Volume 12 Number 4 | April 2015
EDITORIALS 3 Black MD, Vigorito MC, Curtis JR, Phillips GS, Martin EW, McNicoll L, Rochon T, Ross S, Levy MM. A multifaceted intervention to improve compliance with process measures for ICU clinician communication with ICU patients and families. Crit Care Med 2013;41:2275–2283. 4 Azoulay E, Pochard F, Kentish-Barnes N, Chevret S, Aboab J, Adrie C, Annane D, Bleichner G, Bollaert PE, Darmon M, et al.; FAMIREA Study Group. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 2005;171:987–994. 5 Wall RJ, Curtis JR, Cooke CR, Engelberg RA. Family satisfaction in the ICU: differences between families of survivors and nonsurvivors. Chest 2007;132:1425–1433. 6 Lautrette A, Darmon M, Megarbane B, Joly LM, Chevret S, Adrie C, Barnoud D, Bleichner G, Bruel C, Choukroun G, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007;356:469–478. 7 Schneiderman LJ, Gilmer T, Teetzel HD, Dugan DO, Blustein J, Cranford R, Briggs KB, Komatsu GI, Goodman-Crews P, Cohn F, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA 2003;290:1166–1172. 8 Lilly CM, De Meo DL, Sonna LA, Haley KJ, Massaro AF, Wallace RF, Cody S. An intensive communication intervention for the critically ill. Am J Med 2000;109:469–475. 9 Curtis JR, Treece PD, Nielsen EL, Downey L, Shannon SE, Braungardt T, Owens D, Steinberg KP, Engelberg RA. Integrating palliative and critical care: evaluation of a quality-improvement intervention. Am J Respir Crit Care Med 2008;178:269–275.
Editorials
10 Hope AA, Hsieh SJ, Howes JM, Keene AB, Fausto JA, Pinto PA, Gong MN. Development and evluation of a communication skills training program for critical care fellows. Ann Am Thorac Soc 2015;12: 505–511. 11 McCallister JW, Gustin JL, Wells-Di Gregorio S, Way DP, Mastronarde JG. Communication skills training curriculum for pulmonary and critical care fellows. Ann Am Thorac Soc 2015;12:520–525. 12 Gulbrandsen P, Jensen BF, Finset A, Blanch-Hartigan D. Long-term effect of communication training on the relationship between physicians’ self-efficacy and performance. Patient Educ Couns 2013; 91:180–185. 13 Dickson RP, Engelberg RA, Back AL, Ford DW, Curtis JR. Internal medicine trainee self-assessments of end-of-life communication skills do not predict assessments of patients, families, or clinicianevaluators. J Palliat Med 2012;15:418–426. 14 Bays AM, Engelberg RA, Back AL, et al. Interprofessional communication skills training for serious illness: evaluation of smallgroup, simulated patient interventions. J Palliat Med 2014;17: 159–166. 15 Curtis JR, Back AL, Ford DW, Downey L, Shannon SE, Doorenbos AZ, Kross EK, Reinke LF, Feemster LC, Edlund B, et al. Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomized trial. JAMA 2013;310: 2271–2281. 16 Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage 2008;36:22–28.
471
Cambia Palliative Care Center of Excellence, 2Division of Geriatrics and Gerontology, Harborview Medical Center, and 3Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
The intensive care unit (ICU) is a setting in which clinicians care for many of the sickest, most critically ill patients in our healthcare system. Unfortunately, many of our patients die in the ICU. Indeed, approximately 20% of Americans die in, or shortly after, a stay in the ICU, making the ICU a common location for end-of-life care (1). The majority of deaths that occur in ICUs in the United States are preceded by a decision to withhold or withdraw life-sustaining therapy (2), which means ICU clinicians are often making difficult decisions with patients or, more commonly, as patients often cannot participate, with the patients’ family members. Many of these decisions are made in the setting of an ICU family conference, and studies have used the ICU family conference as an important quality metric for patients at significant risk for death or prolonged ICU stay (3). Importantly, even if patients ultimately survive the ICU, their family members often have intense communication needs and are also at risk for consequences of stress and poor communication, including anxiety, depression, and posttraumatic stress disorder (4). In fact, family members of patients who survive the ICU rate ICU clinician communication more poorly than family members of patients who die in the ICU, attesting to the importance of communication for family members of all ICU patients (5). The consequences of poor communication with family members in the ICU are significant. A randomized trial showed that a relatively simple intervention designed to improve communication during family conferences and provide a bereavement packet to family members
was associated with dramatic reductions in symptoms of anxiety, depression, and post-traumatic stress disorder (6). Other studies have shown that improved communication with family members is associated with reductions in nonbeneficial treatment seen so commonly in our ICUs (7–9). In this context, we argue that the ICU family conference is a critical “ICU procedure” that needs to be effectively taught to all fellows training to be intensivists. The ICU is also an opportunity to teach this procedure to residents and others who need to learn this skill set for care across the healthcare continuum, including the acute care and outpatient settings. Although this skill set can also be taught in these other areas of medicine, there are few places where these conferences occur more frequently or have been studied so thoroughly. The ICU is our opportunity to teach and model effective and supportive family conferences to the next generation of physicians, as well as nurses, social workers, spiritual care providers, and other healthcare professionals. In this month’s issue of AnnalsATS, there appear two important reports of programs designed to teach critical care fellows to conduct effective and supportive ICU family conferences (10, 11). Both reports describe the development and implementation of a formal program for teaching this important skill set, although they apply somewhat different approaches. The program developed by McCallister and colleagues (pp. 520–525) uses a formal family conference checklist as a teaching guide to provide formative feedback to fellows about their performance during
actual family conferences in the ICU (11). Hope and coworkers (pp. 505–511) tested a targeted simulation training program, along with a list of directly observable family conference tasks, that was implemented in teaching sessions over the course of a month-long curriculum (10). Both of these programs were implemented successfully and were rated highly by critical care fellows. Both of these programs also showed improved communication ratings, as assessed by a third-party rater: either a faculty member teaching the course, who could not be blinded to whether fellows had received the training (10), or independent clinical psychologists who were blinded to pre- versus posttraining (11). The use of an independent rater blinded to training status greatly enhances our confidence in these assessments but can be difficult to accomplish. Although both studies demonstrate improvements in a fellow’s overall performance, as well as many individual aspects of the family conference, these studies also highlight significant remaining gaps in the attainment of key educational goals. A preintervention survey included in the McCallister study showed that only 40% of fellows reported ever being explicitly taught in residency how to respond to emotion (11). This lack of training and modeling in emotional content during early parts of medical education is widespread. This is evident in the report by Hope and colleagues, which showed poor performance in attending to emotion, accomplished in only about 20% of encounters both pre and postintervention, despite this being part of the curriculum
(Received in original form March 5, 2015; accepted in final form March 6, 2015 ) Correspondence and requests for reprints should be addressed to J. Randall Curtis, M.D., M.P.H., Cambia Palliative Care Center of Excellence, Harborview Medical Center, University of Washington, Box 359762, 325 Ninth Avenue, Seattle, WA 98104. E-mail: [email protected] Ann Am Thorac Soc Vol 12, No 4, pp 469–471, Apr 2015 Copyright © 2015 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201503-123ED Internet address: www.atsjournals.org
Editorials
469
EDITORIALS (10). As emotion often underpins much of medical decision-making under stress and addressing emotion is an essential skill in managing conflict and negotiating a plan of care during family conferences, we believe that at the fellow-training level, these and other advanced skills, such as aligning the treatment plan with goals and values, should be occurring in nearly every encounter. Within both studies, communication behaviors for family conferences can be nicely segmented into beginner, intermediate, and advanced skill levels. Medical students should be mastering beginner aspects of communication, progressing to intermediate skills as residents, and then demonstrating advanced communication skills sets as fellows. Unfortunately, in these studies, fellows fell short of this goal, with those in the study rated by psychologists as only completing about 65% of the key components even after the communication training program (11). This leaves nearly one third of communication skills out of the conversation, and we suspect these were some of the more complicated and nuanced aspects of family conferences. Because interpersonal communication is one of the six key competencies of the Accreditation Council for Graduate Medical Education, this really should be a call to action for all medical educators: We should be introducing an intentional and developmental curriculum for core communication skills earlier and more frequently along the training continuum. That way, by the time critical care fellows are leading ICU family conferences themselves, they are sharpening their skills as expert communicators instead of building a basic foundation. Both these studies, and many others in the medical education literature, use trainee self-evaluations to show improvement. Improvements in self-evaluation may be important, as it may reflect self-efficacy for performing the task, which may result in physicians who are more willing to take on this task (12). However, it is important to note that trainee self-assessments of communication do not necessarily correlate with assessments by patients and family members (13). In a recent randomized trial of an intensive simulation-based communication
training program for internal medicine and nurse practitioner trainees, we found that although the program was associated with improved communication skill acquisition, as assessed by blinded, trained raters, we were unable to demonstrate improvements in patient and family ratings of trainee communication (14, 15). We firmly believe, with our own intellectual and emotional conflict of interest fully acknowledged (as a study participant and an investigator) that this simulation training resulted in important improvements in trainee skill level. Nevertheless, we also acknowledge that demonstrating improvements in patient and family outcomes in our complex healthcare system can be extremely challenging. We believe it is important to continue to explore and study patient and family outcomes of communication training. However, we also recognize that those of us responsible for training the next generation of clinicians will often not have the luxury of patient and family outcome data to help us choose what programs to adopt and adapt. Of note, studies have shown that communications lead by palliative care specialists do improve family satisfaction (16). We argue that this observation represents proof of concept that, with adequate training in communication skills, patient outcomes can be directly improved. This further supports integrating more effective communication education into all levels of training, so that these skills build over time in a developmentally appropriate manner. As communication and family conference curricula continue to evolve, our assessment tools will also mature. At this time, our focus remains on whether family conferences occurred and whether key communication behaviors were observed. Over time, as the communication floor is raised for all healthcare professionals, the quality of these interactions must be better assessed. In our experience, family conferences in the ICU are still largely organized when a patient is doing poorly and the ICU team believes it is time to consider withdrawing life support. In this context, we run the risk of inadvertently encouraging a hidden
References 1 Angus DC, Barnato AE, Linde-Zwirble WT, Weissfeld LA, Watson RS, Rickert T, Rubenfeld GD; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group. Use of intensive care at the end of life in the
470
curriculum that implies that when family conferences are done well, patients and families elect to withdraw life-sustaining treatments. In actuality, we want our trainees to focus on the process, instead of the outcome. We want them to experience family conferences that are proactive and occur at regular intervals so they help us understand the patient’s and family’s perspectives, learn their values and preferences, and match the care plan to these values and preferences even if they are different from our own. This key step, aligning with our patients and families, allows us to walk together along an uncertain path. So what is the best approach to training critical care fellows and others in the skill set of family conferences? In 2015, this is an unanswered question. However, what is more important than which approach to use is the fact that each critical care training program develops an explicit family conference training program and implements it. These programs should be feasible, sustainable, and financially viable. To meet these three aims, we need faculty development within critical care that enables an embedded curriculum that is close to the point of care and clinically relevant. This is an essential skill our fellows must be trained in, and faculty members prepared to teach. The two reports in this month’s issue of the Annals provide program leadership with useful guidance for adoption and adaptation (10, 11). It seems likely to us that the best approach for an individual training program will depend on a number of factors, such as the baseline skills and prior training of the fellows, the resources available for such a program (such as an existing simulation program), and the expertise of the faculty. Our advice can be summarized by reflecting on the aphorism, popularized by Voltaire, that “the perfect is the enemy of the good.” Effective and supportive ICU family conferences are too important to leave to the untrained. n Author disclosures are available with the text of this article at www.atsjournals.org.
United States: an epidemiologic study. Crit Care Med 2004;32: 638–643. 2 Quill CM, Ratcliffe SJ, Harhay MO, Halpern SD. Variation in decisions to forgo life-sustaining therapies in US ICUs. Chest 2014;146: 573–582.
AnnalsATS Volume 12 Number 4 | April 2015
EDITORIALS 3 Black MD, Vigorito MC, Curtis JR, Phillips GS, Martin EW, McNicoll L, Rochon T, Ross S, Levy MM. A multifaceted intervention to improve compliance with process measures for ICU clinician communication with ICU patients and families. Crit Care Med 2013;41:2275–2283. 4 Azoulay E, Pochard F, Kentish-Barnes N, Chevret S, Aboab J, Adrie C, Annane D, Bleichner G, Bollaert PE, Darmon M, et al.; FAMIREA Study Group. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 2005;171:987–994. 5 Wall RJ, Curtis JR, Cooke CR, Engelberg RA. Family satisfaction in the ICU: differences between families of survivors and nonsurvivors. Chest 2007;132:1425–1433. 6 Lautrette A, Darmon M, Megarbane B, Joly LM, Chevret S, Adrie C, Barnoud D, Bleichner G, Bruel C, Choukroun G, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007;356:469–478. 7 Schneiderman LJ, Gilmer T, Teetzel HD, Dugan DO, Blustein J, Cranford R, Briggs KB, Komatsu GI, Goodman-Crews P, Cohn F, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA 2003;290:1166–1172. 8 Lilly CM, De Meo DL, Sonna LA, Haley KJ, Massaro AF, Wallace RF, Cody S. An intensive communication intervention for the critically ill. Am J Med 2000;109:469–475. 9 Curtis JR, Treece PD, Nielsen EL, Downey L, Shannon SE, Braungardt T, Owens D, Steinberg KP, Engelberg RA. Integrating palliative and critical care: evaluation of a quality-improvement intervention. Am J Respir Crit Care Med 2008;178:269–275.
Editorials
10 Hope AA, Hsieh SJ, Howes JM, Keene AB, Fausto JA, Pinto PA, Gong MN. Development and evluation of a communication skills training program for critical care fellows. Ann Am Thorac Soc 2015;12: 505–511. 11 McCallister JW, Gustin JL, Wells-Di Gregorio S, Way DP, Mastronarde JG. Communication skills training curriculum for pulmonary and critical care fellows. Ann Am Thorac Soc 2015;12:520–525. 12 Gulbrandsen P, Jensen BF, Finset A, Blanch-Hartigan D. Long-term effect of communication training on the relationship between physicians’ self-efficacy and performance. Patient Educ Couns 2013; 91:180–185. 13 Dickson RP, Engelberg RA, Back AL, Ford DW, Curtis JR. Internal medicine trainee self-assessments of end-of-life communication skills do not predict assessments of patients, families, or clinicianevaluators. J Palliat Med 2012;15:418–426. 14 Bays AM, Engelberg RA, Back AL, et al. Interprofessional communication skills training for serious illness: evaluation of smallgroup, simulated patient interventions. J Palliat Med 2014;17: 159–166. 15 Curtis JR, Back AL, Ford DW, Downey L, Shannon SE, Doorenbos AZ, Kross EK, Reinke LF, Feemster LC, Edlund B, et al. Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomized trial. JAMA 2013;310: 2271–2281. 16 Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage 2008;36:22–28.
471
