A Workshop for First-year Residents on Discussing “Code Status” in Hospitals

Objective: This workshop is designed to enhance the communication skills of physicians in addressing end-of-life resuscitation wishes with patients, to increase their understanding of barriers to physician-initiated discussions about “code status” in the hospital, and to deepen their awareness of the personal impact of confronting mortality for themselves and their patients. Description: Family physicians responsible for the development of the Behavioural Medicine Curriculum of the Family Practice Residency Program located at St. Paul's Hospital, a tertiary care institution in downtown Vancouver, collaborated with colleagues in palliative care and educational and counseling psychology to develop a two-and-a-half-hour workshop for residents on establishing code status. Family doctors and doctoral students in counseling psychology with training in advanced group process and communication skills serve as facilitators. A small-group format is used, with one facilitator per two to four residents, to a maximum of 15 people. Participants are seated in a circle, without tables or empty chairs. Group safety and trust are essential, enhanced by explicitly establishing guidelines for participation (starting and finishing on time, turning pagers off, professionalism, confidentiality, and suspending judgment). All facilitators have participated in the same simulation exercises expected of the residents. Facilitators model active listening, express empathy, and offer constructive feedback throughout their interactions with the group. The participants are invited to describe their primary concerns and emotions when facing discussions of code status in the hospital. Their responses are recorded on a flip chart and considered in the context of the literature pertaining to barriers in discussing resuscitation. The research on patients' perspectives on the impact of end-of-life discussions is also presented. After a short break, which includes refreshments, the group leader describes and demonstrates a “broaching the topic” simulation exercise with a co-facilitator. A suggested template for the interaction, meant as a guide rather than an algorithm, is summarized. This includes a “self check” to identify the physician's emotions around broaching the topic, an opening statement with a rationale for “why discuss this now,” normalization and reassurance, definition of resuscitation in lay terms, checking for understanding, and establishing follow-up plans. Residents practice the scenario in pairs, with a facilitator coaching, giving supportive feedback, and teaching effective communication skills. We ask each resident to reflect on the affective experience of being in both the patient role and the doctor role. Finally, the participants are invited to offer scenarios from their own clinical encounters to be enacted by the facilitators or resident volunteers. After a debriefing of the exercises, the participants are asked in closing to “state one thing you'll take from today that you will put into practice on the wards.” Discussion: This workshop is based on the principles of behavioral rehearsal as a way to enhance communication skills and on reflection as a method to increase the physician's self-awareness and empathy. Attention to group process creates a safe learning environment and the opportunity for active participation. The residents' evaluations for the pilot workshop averaged 3.0 on a three-point scale. Future workshops will incorporate research on patients' views about resuscitation discussions, a bibliography on communication skills for establishing code status, and educational materials on our newly developed hospital “DNR” policy.

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