P2A356: Case-based Medical Ethics Education for Pediatric Residents in the Critical Care Unit

Background: The accelerated growth of technology sits against a backdrop of a morally pluralistic society. When values collide and communication is weak, many healthcare providers struggle. Despite the 1997 mandate from the Accreditation Council for Graduate Medical Education to provide education in ethics, many pediatric residency programs have yet to implement an ethics curriculum. Decision-making and ethical reasoning are essential skills during resident’s training, especially in the critical care environment. Pediatric critical care practice often entails challenging and emotional communication with patients’ legal guardians. The continual interface with legal guardians on goals of care, quality and end of life discussions extends beyond the pediatric intensive care unit (PICU) into all dimensions of pediatric care, thereby making communication not just a practical skill, but an indispensable tool necessary for residents’ futures as practicing pediatricians. Poor ethics education is linked to low confidence in the end-of-life care decision-making. Pediatricians are also more likely than their peers to experience moral distress on issues surrounding death. No true consensus exists regarding the content of a resident ethical training program, nor how to best implement it into practice. Thus, in our PICU we devised and implemented a pedagogical, practical case-based teaching approach for trainees that also addresses moral distress. We hypothesize that our program creates not only improved attendance and participation but a more sustainable, and valuable curriculum that gives trainees essential tools they immediately incorporate into their daily practice.

Methods: This prospective pre-post mixed methods study utilizes proven tools including Kern’s framework, a moral distress map and Kirkpatrick’s levels of evaluation while implementing Jonsen et al.’s “Four-Box method” framework for ethical analysis. Multiple educational strategies were employed including problem and team-based learning, reflection, learner led discussions and clinical experience to create a curriculum based on established cases known to residents. These one-hour monthly sessions were designed to be freestanding. Focus group questionnaires and pre/post session questionnaires using a 5-point Likert scale were implemented assessing:

• Baseline knowledge and comfort in navigating ethical dilemmas
• Level of moral distress and potential for moral residue related to the case

We analyzed the differences between 2nd and 3rd year residents with chi square for binomial variable and Mann-Whitney U test for ordinal variables.

Results: In the focus group questionnaire, some words trainees use to describe ethical conflict included: “lose-lose situation,” “consuming,” and “challenging” (Fig 1). In the pre survey questionnaire, we evaluated 22 residents. No statistically significant differences were seen between classes (Table 1).

Conclusion: Our application of practical tools to build a curriculum centered around typical trainee patient encounters provides structure while allowing learners to navigate an ethical reasoning pathway. This enriches their future careers, in addition to fulfilling their educational requirements in their professional identity formation.