The PULSES Project: Teaching the Vital Elements of Code Status Discussions to Postgraduate Oncology Trainees

Abstract

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.