Three decades of research on end-of-life care in the U.S. indicate that patients frequently die with a significant burden of pain and other symptoms and often receive care that they would not choose. Patient- clinician communication about end-of-life care is an important focus for improving quality of patient-centered end-of-life care. Studies suggest that clinicians can improve their communication skills with experiential training, but no studies have shown that an intervention to improve clinician communication skill about end- of-life care improves patient outcomes. Furthermore, despite the knowledge that end-of-life care is best delivered in an interdisciplinary context, most studies do not incorporate interdisciplinary training. We propose to build on a state-of-the-art intervention, developed and implemented for oncology fellows through an R25 award funded by the National Cancer Institute, which is designed to improve clinician skills at communicating about end-of-life care. We will adapt the intervention for use in internal medicine and nurse practitioner training programs, one in the Northwest and one in the Southeast, and incorporate an innovative interdisciplinary training component. We will evaluate the intervention with patient-level outcomes using a questionnaire for assessing the quality of end-of-life care developed and validated in a prior RO1. The evaluation will target patients with cancer, patients with chronic heart, lung, or liver disease, and older adults. For internal medicine residents (n=291), the study design will be a randomized trial. For nurse practitioner (NP) students (n=96), we will use a before-after study design to accommodate sample size limitations. The primary aim is to evaluate the effectiveness of the communication intervention to improve the end-of- life care delivered by residents and NP students. The primary outcome measures are patient and family ratings of end-of-life care. As secondary outcomes, we will examine patient symptoms and end-of-life care as assessed by nurses. Secondary aims are: 1) to assess the intervention's success using process measures, including a validated knowledge test and attitudes survey, standardized patients, and learner self- assessment;and 2) to examine learner factors that facilitate or impede the effectiveness of the communication intervention to improve the quality of end-of-life care as assessed with both process (knowledge, attitudes, and behaviors) and outcome measures (patient and family ratings). This study will provide important information regarding the implementation and effectiveness of an interdisciplinary communication skills intervention for physicians and nurses with the goal of improving end- of-life care for patients and their families and reducing symptoms. The study will test the effectiveness of the intervention with patient- and family-level outcomes. If the intervention is effective, it offers the opportunity to improve the end-of-life care received by patients and their families throughout the US.
