P3C022: Development and Utilization of an Advance Care Planning Simulation Curriculum in the Med-peds Ambulatory Clinic

Purpose/Objectives: Our Med-Peds clinic is an ideal setting for advance care planning (ACP) conversations, however a needs assessment identified several barriers that impede successful ACP discussions. We previously implemented phase one of a resident ACP curriculum: a didactic lecture and team-based learning exercise, which resulted in overall improvement of resident comfort in having ACP discussions. We then developed a standardized patient (SP) simulation as phase two of our ACP curriculum so that residents could actively apply the knowledge learned in phase one during a standardized simulation experience.

Design/Methods: We developed two simulations. Case one focused on recognizing the need for, and then conducting, an ACP discussion with a patient who recently started dialysis. Residents were expected to counsel the SP on advance directives. Case two focused on readdressing ACP in a chronically ill patient with recent ICU hospitalization. Residents were expected to inquire about any changes in their goals of care and to document medical orders with the SP in the form of a POLST.

Simulations took place in the Gordon Center for Simulation and Innovation in Medical Education. Prior to working with residents, all SPs completed training sessions with the Gordon Center staff and QI project team. Each SP was given a case-defined persona and coached through a response algorithm for anticipated questions from the residents. Residents completed pre- and post-intervention self-efficacy surveys. SPs provided immediate post-encounter feedback and scored rubrics for each resident. Our QI team debriefed with the residents in small focus groups following each simulation session.

Results: Across all residency classes (n=16), the post-intervention survey showed improved attitudes and comfort with all aspects of an ACP clinical encounter, as delineated by our objectives, with an overall mean score of 3.56 (5-point likert scale) for the pre- survey and 4.09 (p < 0.01) for the post- survey. 75% of respondents felt more inclined to have ACP discussions in clinic following participation in the SP curriculum. SP feedback was cited as being instrumental in this increase in inclination.

Conclusion/Discussion: Our SP simulation improved resident comfort in: discussing goals of care with a patient, counseling a patient on appropriate advance care planning options, and constructing an advance care plan with a patient given their specific wishes. Lessons learned include the notion of “standardized” is not perfect pertaining to SPs, as some SPs may still have personal biases that influence the script of the clinical encounter. We are currently determining the overall impact of our curriculum in increasing the amount of ACP discussions conducted in our Med-Peds clinic.