Empathetic end-of-life (EOL) communication is important for high quality pediatric patient and family outcomes. Trainees may have limited exposure and training in caring for patients at EOL which may impact communication-related stress. This study had 2 aims: (1) describe pediatric resident physician EOL exposure and training (2) measure objective and subjective stress during simulated critical communication encounters and the impact of prior communication training/exposures on stress responses.
Methods
We performed a prospective, pilot observational cohort study measuring physician exposure to caring for patients/families at EOL and simulated communication stress. Simulated stress was measured subjectively using the state-trait anxiety inventory (STAI) and objectively using heart rate variability (HRV) during a communication training intervention.
Results
85.7% (18/21) of residents reported seldom/never caring for patients at EOL and universally felt ill-prepared to provide care. Subjective and objective stress increased when directly communicating with the simulated parent/patient actor compared to baseline in all HRV domains. Residents with limited exposure to patients/families at EOL had a smaller stress response than those who cared for a substantial number.
Conclusions
Pediatric residents report limited opportunities to communicate with patients/families at EOL, which may impact stress responses when communicating life-altering news to families. Simulated communication encounters can be designed to evoke subjective and objective stress which can be measured using novel technology and may help address limited EOL opportunities.
LautretteADarmonMMegarbaneB, et al.A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007;356(5):469-478. doi:10.1056/NEJMoa063446
2.
KingAHoppeRB. “Best practice” for patient-centered communication: A narrative review. J Grad Med Educ. 2013;5(3):385-393. doi:10.4300/JGME-D-13-00072.1
3.
HojatMLouisDZMaioVGonnellaJS. Editorial: Empathy and health care quality. Am J Med Qual. 2013;28(1):6-7. doi:10.1177/1062860612464731
4.
CarlsonEBSpainDAMuhtadieLMcDade-MontezLMaciaKS. Care and caring in the intensive care unit: fFamily members’ distress and perceptions about staff skills, communication, and emotional support. J Crit Care. 2015;30(3):557-561. doi:10.1016/j.jcrc.2015.01.012
5.
WendlandtBCeppeAChoudhuryS, et al.Modifiable elements of ICU supportive care and communication are associated with surrogates’ PTSD symptoms. Intensive Care Med. 2019;45(5):619-626. doi:10.1007/s00134-019-05550-z
6.
MackJWCroninAMKangTI. Decisional regret among parents of children with cancer. J Clin Oncol. 2016;34(33):4023-4029. doi:10.1200/JCO.2016.69.1634
7.
CohenSTyrrellDASmithAP. Negative life events, perceived stress, negative affect, and susceptibility to the common cold. J Pers Soc Psychol. 1993;64(1):131-140. doi:10.1037/0022-3514.64.1.131
8.
MeertKLEgglySPollackM, et al.Parents’ perspectives on physician-parent communication near the time of a child’s death in the pediatric intensive care unit. Pediatr Crit Care Med. 2008;9(1):2-7. doi:10.1097/01.PCC.0000298644.13882.88
9.
ControNALarsonJScofieldSSourkesBCohenHJ. Hospital staff and family perspectives regarding quality of pediatric palliative care. Pediatrics. 2004;114(5):1248-1252. doi:10.1542/peds.2003-0857-L
10.
RapoportAObwangaCSirianniGLibrachSLHusainA. Not just little adults: palliative care physician attitudes toward pediatric patients. J Palliat Med. 2013;16(6):675-679. doi:10.1089/jpm.2012.0393
11.
RosenbergARWolfeJWienerLLyonMFeudtnerC. Ethics, emotions, and the skills of talking about progressing disease with terminally ill adolescents. JAMA Pediatr. 2016;170(12):1216. doi:10.1001/jamapediatrics.2016.2142
12.
RedmondBJosephMRayJ, et al.Stress as tool or toxin:Physiologic markers and subjective report in neonatal simulation. Pediatr Res. 2020;88(5):784-791. doi:10.1038/s41390-020-0806-9
13.
JohnsonEMHamiltonMFWatsonRS, et al.An intensive, simulation-based communication course for pediatric critical care medicine fellows. Pediatr Crit Care Med. 2017;18(8):e348-e355. doi:10.1097/PCC.0000000000001241
14.
TrowbridgeABamatTGriffisHMcConatheyEFeudtnerCWalterJK. Pediatric resident experience caring for children at the end of life in a children’s hospital. Acad Pediatr. 2020;20(1):81-88. doi:10.1016/j.acap.2019.07.008
15.
TrowbridgeABamatTGriffisHMcConatheyEFeudtnerCWalterJK. Pediatric resident experience caring for children at the end of life in a children’s hospital. Acad Pediatr. 2020;20(1):81-88. doi:10.1016/j.acap.2019.07.008
16.
RiderEAVolkanKHaflerJP. Pediatric residents’ perceptions of communication competencies: Implications for teaching. Med Teach. 2008;30(7):e208-e217. doi:10.1080/01421590802208842
17.
ReedSFrey-VogelAFrostM. Look who’s talking: A survey of pediatric program directors on communication skills education in pediatric residency programs. Acad Pediatr. 2020;20(1):9-13. doi:10.1016/j.acap.2019.05.005
18.
WolfeAHJHindsPSdu PlessisAJGordish-DressmanHArnoldRMSoghierL. Defining objective measures of physician stress in simulated critical communication encounters. Crit Care Explor. 2022;4(7):e0721. doi:10.1097/CCE.0000000000000721
19.
HarveyABandieraGNathensABLeBlancVR. Impact of stress on resident performance in simulated trauma scenarios. J Trauma Acute Care Surg. 2012;72(2):497-503. doi:10.1097/TA.0b013e31821f84be
20.
DeMariaJSBrysonEOMooneyTJ, et al.Adding emotional stressors to training in simulated cardiopulmonary arrest enhances participant performance. Med Educ. 2010;44(10):1006-1015. doi:10.1111/j.1365-2923.2010.03775.x
21.
TjønnåsMSGuzmán-GarcíaCSánchez-GonzálezPGómezEJOropesaIVåpenstadC. Stress in surgical educational environments: A systematic review. BMC Med Educ. 2022;22(1):791. doi:10.1186/s12909-022-03841-6
22.
JonesKIAmawiFBhallaAPeacockOWilliamsJPLundJN. Assessing surgeon stress when operating using heart rate variability and the State Trait Anxiety Inventory: Will surgery be the death of us?Colorectal Dis. 2015;17(4):335-341. doi:10.1111/codi.12844
23.
PorgesSW. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. 18th ed.W. W. Norton; 2011.
24.
LazarusRFolkmanS. Stress, Appraisal, and Coping. Springer Publishing Company; 1974:22-52.
25.
CherifNHMezghaniNGaudreaultNOuakrimYMouzouneIBoulayP. Physiological data validation of the hexoskin smart textile. In: BIODEVICES 2018 - 11th International Conference on Biomedical Electronics and Devices, Proceedings; Part of 11th International Joint Conference on Biomedical Engineering Systems and Technologies, BIOSTEC2018. Vol 1. doi:10.5220/0006588001500156
26.
SlamonNBPenfilSHNadkarniVMParkerRM. A prospective pilot study of the biometrics of critical care practitioners during live patient care using a wearable “smart shirt.”. J Intensive Crit Care. 2018;04(02):3. doi:10.21767/2471-8505.100112
27.
ThayerJFÅhsFFredriksonMSollersJJWagerTD. A meta-analysis of heart rate variability and neuroimaging studies: Implications for heart rate variability as a marker of stress and health. Neurosci Biobehav Rev. 2012;36(2):747-756. doi:10.1016/j.neubiorev.2011.11.009
28.
DeMariaSLevineAI. The use of stress to enrich the simulated environment. In: LevineAIDeMariaSSchwartzADSimAJ, eds. The Comprehensive Textbook of Healthcare Simulation. doi:10.1007/978-1-4614-5993-4_5. New York: Springer; 2013:65-72.
29.
LeblancVR. The effects of acute stress on performance: Implications for health professions education. Acad Med. 2009;84(Supplement):S25-S33. doi:10.1097/ACM.0b013e3181b37b8f
30.
LeBlancVRMcConnellMMMonteiroSD. Predictable chaos: A review of the effects of emotions on attention, memory and decision making. Adv Health Sci Educ. 2015;20(1):265-282. doi:10.1007/s10459-014-9516-6
31.
TremblayMLLafleurALeppinkJDolmansDHJM. The simulated clinical environment: Cognitive and emotional impact among undergraduates. Med Teach. 2017;39(2):181-187. doi:10.1080/0142159X.2016.1246710
32.
BrownRDunnSByrnesKMorrisRHeinrichPShawJ. Doctorsʼ stress responses and poor communication performance in simulated bad-news consultations. Acad Med. 2009;84(11):1595-1602. doi:10.1097/ACM.0b013e3181baf537
33.
van DulmenSTrompFGrosfeldFten CateOBensingJ. The impact of assessing simulated bad news consultations on medical students’ stress response and communication performance. Psychoneuroendocrinology. 2007;32(8-10):943-950. doi:10.1016/j.psyneuen.2007.06.016
34.
DiLallaLFHullSKDorseyJK. Effect of gender, age, and relevant course work on attitudes toward empathy, patient spirituality, and physician wellness. Teach Learn Med. 2004;16(2):165-170. doi:10.1207/s15328015tlm1602_8
ShanafeltTDWestCZhaoX, et al.Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005;20(7):559-564. doi:10.1111/j.1525-1497.2005.0108.x
37.
KirkpatrickHWasfieTLaykovaABarberKHellaJVogelM. Emotional intelligence, burnout, and wellbeing among residents as a result of the COVID-19 pandemic. Am Surg. 2022;88(8):1856-1860. doi:10.1177/00031348221086804
38.
GoldKJKuzniaALLaurieARWilliamsCB. Gender differences in stress and burnout: Department survey of academic family physicians. J Gen Intern Med. 2021;36(6):1811-1813. doi:10.1007/s11606-020-06287-y
39.
WestCPDyrbyeLNErwinPJShanafeltTD. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281. doi:10.1016/S0140-6736(16)31279-X
40.
RotensteinLSTorreMRamosMA, et al.Prevalence of burnout among physicians. JAMA. 2018;320(11):1131. doi:10.1001/jama.2018.12777
41.
TawfikDSProfitJMorgenthalerTI, et al.Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clin Proc. 2018;93(11):1. doi:10.1016/j.mayocp.2018.05.014
HarrisPATaylorRMinorBL, et al.The REDCap consortium: building an international community of software platform partners. J Biomed Inf. 2019;95:103208. doi:10.1016/j.jbi.2019.103208
44.
BongCLLeeSNgASBAllenJCLimEHLVidyarthiA. The effects of active (hot-seat) versus observer roles during simulation-based training on stress levels and non-technical performance: A randomized trial. Advances in Simulation. 2017;2(1):7. doi:10.1186/s41077-017-0040-7
45.
Electrophysiology TF of the ES of C the NA. Heart rate variability. Circulation. 1996;93(5):1043-1065. doi:10.1161/01.CIR.93.5.1043
46.
ShafferFGinsbergJP. An overview of heart rate variability metrics and norms. Front Public Health. 2017;5:1. doi:10.3389/fpubh.2017.00258
47.
WongMLAndersonJKnorrTJosephJWSanchezLD. Grit, anxiety, and stress in emergency physicians. Am J Emerg Med. 2018;36(6):1036-1039. doi:10.1016/j.ajem.2018.02.021
48.
VoultsosPKoungaliMPsaroulisKBoutouAK. Burnout syndrome and its association with anxiety and fear of medical errors among intensive care unit physicians: A cross-sectional study. Anaesth Intensive Care. 2020;48(2):134-142. doi:10.1177/0310057X20902780
49.
MarteauTMBekkerH. The development of a six‐item short‐form of the state scale of the Spielberger State—trait Anxiety Inventory (STAI). Br J Clin Psychol. 1992;31(3):301-306. doi:10.1111/j.2044-8260.1992.tb00997.x
50.
JoëlsMPuZWiegertOOitzlMSKrugersHJ. Learning under stress: how does it work?Trends Cognit Sci. 2006;10(4):152-158. doi:10.1016/j.tics.2006.02.002
51.
VogelSSchwabeL. Learning and memory under stress: Implications for the classroom. NPJ Sci Learn. 2016;1(1):16011. doi:10.1038/npjscilearn.2016.11
52.
VinceRA. Eradicating racial injustice in medicine—if not now, when?JAMA. 2020;324(5):451. doi:10.1001/jama.2020.12432
53.
PeelJLNolanRJ. You can’t start a central line? Supervising residents at different stages of the learning cycle. J Grad Med Educ. 2015;7(4):536-538. doi:10.4300/JGME-D-15-00025.1
54.
WolfeAHJHindsPSArnoldRMSoghierLTompkinsR. Vulnerability of inexperience: A qualitative exploration of physician grief and coping after impactful pediatric patient deaths. J Palliat Med. 2022;25(10):1476-1483. doi:10.1089/jpm.2022.0050
55.
BarnsleyLLyonPMRalstonSJ, et al.Clinical skills in junior medical officers: A comparison of self-reported confidence and observed competence. Med Educ. 2004;38(4):358-367. doi:10.1046/j.1365-2923.2004.01773.x
56.
O’DonoghueDDavisonGHannaLJMcNaughtenBStevensonMThompsonA. Calibration of confidence and assessed clinical skills competence in undergraduate paediatric OSCE scenarios: A mixed methods study. BMC Med Educ. 2018;18(1):211. doi:10.1186/s12909-018-1318-8
