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Introduction Early conversations about patients’ goals and values improve care, but clinicians struggle to conduct them. The systems-based Serious Illness Care Program (SICP) helps clinicians have more, better, and earlier conversations. Central to this approach is a clinician conversation guide for patient encounters. While the SICP works for practicing clinicians, it has not been tested with medical trainees. Methods We adapted the SICP training to emphasize assessing prognostic awareness and responding to emotion. We developed a 2.5-hour SICP workshop for medical students and medical interns that included large- and small-group work, practice with an actor, and interdisciplinary clinician facilitators. We trained 81 students and 156 interns and obtained anonymous quantitative and qualitative feedback. Results Eighty-six percent of students and 91% of residents rated the session as “very good” or “excellent” and >90% of all learners would either recommend this training or intended to apply this to their practice. Post-session learner confidence increased in all communication skills. Learners said the training provided a helpful framework and useful language for these conversations. Resident documentation of serious illness conversations in the medical record increased dramatically during the year following training commencement. Discussion Grounded in principles of adult learning theory, this training was rated highly by trainees and resulted in demonstrable practice change. These early learners were more flexible and willing to try this approach than practicing clinicians who tend to resist or revert to old habits. A Guide represents a new paradigm for teaching communication skills and is valued by early learners.

Palliative care specialists can aid in the care of patients with amyotrophic lateral sclerosis (ALS). In this article, we describe our 1-year experience incorporating a palliative care specialist into the ALS multidisciplinary team. We describe our integration model, patient selection, and visit content. Of 500 total clinic patients, 74 (14.8%) were seen by the palliative care specialist in 1 year. Referral was most often triggered by advance care planning needs (91%). In the initial visit with the palliative care specialist, topics most frequently covered included goals of care (84%), anxiety/depression (35%), and medical decision-making about feeding tubes (27%) or tracheostomy (31%). Symptom management comprised a relatively small number of the visits, and duration of visits was limited by patient fatigue. Patients with complex goals of care may benefit from the input of a palliative care specialist, and unique integration models may help to facilitate care delivery. Muscle Nerve 60: 137-140, 2019.

Palliative sedation therapy (PST) can be a challenging area of palliative medicine because of the complex ethical considerations involved. PST is a medical therapy used for refractory symptoms in terminally ill patients and is often considered ethically justified due to the principle of double effect. Even in cases where PST is clearly indicated such as refractory cancer pain, there is potential for moral distress among clinicians. Here, we present a unique case in which multiple therapeutic options were limited in a patient with overlapping diagnoses of catatonia, medication-induced extrapyramidal symptoms, and dementia with Lewy bodies. We review how existing frameworks can be applied to similar situations and offer practical strategies to support medical decision-making regarding PST and reduce the risk of moral distress among clinicians.

BackgroundThe communication process of preparing patients and families facing progressive neurodegenerative diseases for future illness has not been empirically elucidated; the goal of this qualitative study was to explore neurology interdisciplinary health professionals' communication experiences, including current approaches, facilitators, and challenges.MethodsThree focus groups were conducted with 22 clinicians representing a range of health professions from several multidisciplinary neurology outpatient clinics at a large academic medical center. A thematic analysis approach was used to develop a coding structure and identify overarching themes.ResultsNeurology clinicians highlighted that in their practice, (1) conversations are triggered by acute events and practical needs; (2) conversations occur routinely but are rarely documented; (3) loss of patient capacity and resultant surrogate decision-making can be ethically fraught, especially in times of family conflict; (4) prognostic uncertainty, unfamiliarity with disease trajectories, and patient or surrogate avoidance pose communication challenges; and (5) generalist- and specialty-level palliative care roles should be better defined.ConclusionsThere is a need for a systematic, structured approach to communication that can be applied early in the disease trajectory and considered when developing integrated neuro-palliative care programs.

Background Studies have shown that skilled nursing facilities (SNFs) are reservoirs for methicillin-resistant Staphylococcus aureus (MRSA). The extent to which resident-to-resident transmission accounts for the high burden of MRSA in these facilities remains poorly understood. The objective of this study was to estimate the frequency of intra-facility MRSA acquisition in a sample of SNFs participating in a longitduinal study in Wisconsin. Methods MRSA colonization among a cohort of 449 subjects residing in six SNFs in Southern Wisconsin was measured using serial, multi-anatomical surveillance culturing. Phenotypic acquisitions events (i.e., MRSA [-] to MRSA[+]) were identified and further characterized both temporally (calendar date) and genetically (pulse-field gel electrophoresis). An intra-facility acquisition event was defined as incident recovery of an MRSA isolate that was genetically identical to at least one other strain previously recovered in a study facility. A Marascuilo procedure for comparing multiple proportions was employed to determine whether the proportion of intra-facility MRSA acquisitions differed across study facilities. Linear regression was employed to assess if certain facility-level characteristics were associated with rates of intra-facility MRSA acquisition. Results 129 acquisition events were identified that met our criteria, of which 74 were determined to be intra-facility (57.4%) [95% CI: 45.5–67.6%]. Statistically significant differences were found between the intra-facility acquisition proportion of multiple SNFs. A facility’s baseline MRSA prevalence was significantly associated with its intra-facility MRSA acquisition rate (R2 = 0.784, P-value = 0.012). Conclusion Intra-facility acquisition represents a large proportion of the burden of MRSA observed in SNFs. The rate of intra-facility acquisition is variable between facilities but may, in part, be explained by the prevalent burden of MRSA in the facility (i.e., MRSA colonization pressure to characteristics of the facility). Whether other facility characteristics, including infection prevention practices are contributing to these transmission dynamics requires further study. Disclosures All authors: No reported disclosures.