Assessing competence of residents to discuss end-of-life issues

Residents are often responsible for eliciting patients' treatment preferences at the end of life (EOL), yet we have a limited understanding of their competence in this task.

To assess the competence of medical residents to discuss advance directives (AD) with patients using two measures: self-assessment (perceived competence) and self-reported behaviors (behavioral competence). To examine the relationship between educational experiences and these two measures of competence.

Cross-sectional self-report questionnaire.

Internal medicine residents from two university- and one community-based program.

The 282 respondents (84% response) had an average of 6.2 EOL discussions per month. Few residents reported having received useful feedback from a resident (8%) or an attending (7%) about their ability to discuss ADs. Even fewer reported that work rounds (4%) or attending rounds (5%) were frequently forums for learning about EOL care. Mean perceived competence was 3.8 (range, 1-5). In multivariable analyses, greater perceived competence was significantly associated with higher postgraduate year (p < 0.001), having residents demonstrate exemplary AD discussions (p < 0.001), and less formal education (p < 0.01). Behavioral competence was significantly associated with reporting that work rounds were useful for learning about EOL care (p = 0.002), less formal education (p = 0.02) and a greater number of EOL discussions per ward month (p = 0.009). The correlation between perceived and behavioral competence (r = 0.25, p = 0.001) was modest but statistically significant.

Many residents view themselves as competent to discuss ADs with patients but fail to engage in recommended behaviors for such discussions. Increasing experiential learning may be the most promising means of enhancing residents' abilities to discuss EOL issues with patients.