Training Residents in Advance Care Planning: A Task-Based Needs Assessment Using the 4-Component Instructional Design

A recent international consensus defined advance care planning (ACP) as “the ability to enable individuals to define goals and preferences for future medical treatment and care, to discuss these goals and preferences with family and health care providers, and to record and review these preferences if appropriate.”¹  ACP aims to ensure that people receive care that is medically appropriate and consistent with their personal values, which is an ethical imperative and improves patient safety and quality of care.^1–4  Health care professionals need to be trained in ACP because they are often unprepared to discuss ACP with patients.^5–7  Training is especially needed for resident physicians. In Switzerland, residents are typically patients' main interlocutors for ACP in the hospital setting and serve as liaison with other health care professionals caring for a patient.^8–10  Given the absence of ACP curriculum standards, internationally and nationally, training in ACP has traditionally been implicit.^11–14  Thus, residents' needs for training in ACP are poorly understood.

ACP is a complex process. It occurs within and outside of health care facilities, involves multiple stakeholders (patients, relatives, and health care professionals), and requires regular updates.^1–4  ACP encompasses both oral and written communication. It includes goals of care discussions with patients and their relatives (and documentation of these discussions) and decisions about the end of life that can be written by patients (such as advance directives), physicians (such medical orders for scope of treatment and do-not attempt cardiopulmonary resuscitation orders [DNACPR]), and other members of the health care team (such as care plans).^15,16  Given the complexity of ACP, scholars and policy makers have highlighted that training residents in ACP is critical.^13,14,16  The recent international consensus on ACP¹  provides a timely opportunity to develop such training.

Developing and implementing ACP training for residents, however, is difficult. First, the ACP-related tasks expected of residents in daily practice are ill-defined because ACP has traditionally been left to the informal curriculum.^11–14  Research on related tasks has, to date, focused on training residents for breaking bad news, discussing CPR code status, or talking about advance care plans.^14,17  Second, ACP requires a complex set of knowledge, skills, and attitudes^5,18  that residents need to develop.^11,14  Trainings published so far focused on specific aspects of ACP such as palliative care, end-of-life decision-making, or communication,^11,12,14,19  but we still need a comprehensive and explicit ACP competency-based curriculum. Third, existing and limited ACP trainings were not informed by task-based instructional designs,^20,21  though such designs may support integrated learning and transfer of complex competencies, such as ACP, into clinical practice. These considerations point to important research gaps that need to be filled to support residents in learning ACP. Furthermore, they suggest that innovative instructional design methods would be helpful in supporting residents' complex learning in ACP.

The aim of our study was to assess residents' training needs in ACP at the Geneva University Hospitals in Switzerland to inform the development of a training program. Specifically, we sought to address the following research questions: (1) What are the real-life tasks expected of residents when performing ACP with hospitalized patients? (2) What are the competencies needed by residents to perform these tasks? and (3) How can we support residents in the complex learning of these competencies?

This exploratory qualitative study took place at Geneva University Hospitals, in the French-speaking part of Switzerland, which includes 8 hospitals, with 1600 beds in 8 departments. There are approximately 750 residents in graduate medical education training in different specialties. Of note, in addition to Swiss residents, the hospitals have a long record of training residents from other European countries, especially from France, Belgium, Greece, Italy, and Portugal, which have different approaches to end-of-life decisions, DNACPR policies, and ACP.^9,22 

National guidelines support patients' empowerment and proxies' involvement in shared decision-making.¹⁰  Hospital guidelines recommend to discuss CPR with patients in goals of care discussions prior to document a DNACPR order, unless CPR is deemed futile near the end of life.¹⁰  However, previous studies conducted in Geneva have suggested that ACP is still underused and that residents experience difficulties with communication and decision-making during ACP.^8–10 

We used the definition of ACP as a framework and included code status discussions about DNACPR orders, goals of care discussions, medical decisions regarding the overall treatment plan, and documentation in electronic health records.^1,4  We focused on residents' training needs in ACP in the hospital.

We adopted the lens of task-centered learning, an approach underpinning several instructional design models, such as the first principles of instruction and the 4-Component Instructional Design (4C/ID).^20,21  In this approach, learners progress in learning complete tasks that are increasingly complex. They receive tailored guidance that diminishes as they gain more experience, and they learn through real-world practice to support complex learning.^23,24  Complex learning refers to “integrating knowledge, skills, and attitudes, coordinating qualitatively different constituent skills, and often transferring of what is learnt in the school or training setting to daily life and work setting.”²⁴  Among the most renowned task-centered instructional design methods, we chose the 4C/ID because it offers practical guidance on 4 main components to be elaborated: (1) the learning tasks (authentic whole-task experiences organized in simple-to-complex classes with variability); (2) the supportive information (supporting the learning and performance of nonrecurrent skills, such as mental models and cognitive feedback); (3) the corrective or “just-in-time” information (supporting the learning and performance of recurrent skills, such as information displays and corrective feedback); and (4) the part-task practice (additional practice for selected recurrent skills to be automated).^21,24  In addition, the 4C/ID allows for the involvement of all relevant stakeholders in needs assessment and to adapt training to the context.^21,24 

To illuminate residents' training needs in ACP, we used a qualitative research design to explore meanings and tasks associated with ACP in our setting.²⁵  We conducted focus groups and individual interviews with the main stakeholders involved in ACP in various departments of the hospitals and with researchers in the field of ACP in the French-speaking part of Switzerland. We collected and analyzed the data iteratively between December 2017 and September 2019. As residents' training in ACP has traditionally been implicit,^11–14  and as residents need to discuss ACP with the interprofessional health care team,^8–10  our needs assessment included multiple stakeholders involved in ACP. We recruited participants using purposive sampling of residents, fellows, attending physicians, nurses, and other members of the health care team, researchers with expertise on ACP, and members of the “Patients-as-Partners” program (developed at the hospitals to promote patient advocacy in care, research, and health professions education).²⁶  Involving members from the program in this study enabled us to elicit patient perspectives without interviewing hospitalized patients.

We conducted physician-only and interprofessional focus groups to understand the participants' perspectives on ACP, which enabled us to collect rich and contrasted data. However, focus groups require participants to feel at ease and speak freely with one another. To protect focus group dynamics, we conducted individual interviews with participants who had higher levels of seniority and with participants from the Patients-as-Partners program. We contacted participants by email with up to 2 reminders. Out of the 55 individuals we contacted, 51 agreed to participate, but 2 were not able to attend focus groups, resulting in 49 participants in this study (89%). We conducted focus groups in dedicated rooms close to participants' workplaces and interviews in the location of participants' choice, usually their offices. For both focus groups and interviews, we used a discussion guide based on the 4C/ID components (provided as online supplementary data).^21,24,27  We designed questions following principles of cognitive task analysis: participants first described recent ACP experiences, then were asked to explore mental models and cognitive strategies by discussing or drawing diagrams on a paper board.^28,29 

Three researchers who did not work with study participants conducted the interviews and focus groups—an intensivist in a geriatric emergency department with a background in public health and qualitative research (T.F.), a medical sociologist with experience in qualitative research (N.B.), and a research assistant in medical education (A.R.). We audiotaped and transcribed all focus group and interview data. We uploaded anonymized transcripts into Dedoose software for qualitative analysis (SocioCultural Research Consultants LLC, Manhattan Beach, CA).³⁰  We coded the data using 2 complementary approaches: deductively using content analysis with an a priori coding framework to identify the components of the 4C/ID, and inductively using thematic analysis to unveil potential themes beyond the deductive coding framework.²⁵  Two authors (T.F., N.B.) independently coded 2 interviews and 2 focus groups to develop an initial coding framework; 3 authors (T.F., N.B., A.R.) then coded the subsequent transcripts using this framework, which was consensually revised with the other researchers when new codes were integrated. The Standards for Reporting Qualitative Research guided our research design, data collection, and analysis.³¹ 

According to Swiss law, the Geneva Ethics Committee waived a complete review for this study. We provided participants with a letter summarizing the aim of the study and asked for their written consent to participate in the study.

We conducted 7 focus groups (median duration 68 minutes, IQR 54–78) and 10 individual interviews (45 minutes, IQR 40–54). As Table 1 shows, we involved 49 participants: 19 residents, 18 senior physicians, 4 nurses, 1 psychologist, 1 medical ethics consultant, 3 researchers, and 3 patients. Table 1 displays the participants' characteristics. Table 2 displays the 3 themes and codes with selected quotations detailed in the following sections. In brief, participants described 3 tasks expected of residents and discussed why training residents in ACP is complex. They identified knowledge, skills, and attitudes that residents need to integrate to become competent in ACP. They described the current training and identified priority needs for future training.

We identified 3 main task classes related to ACP for residents in the hospital: preparing, discussing, and documenting ACP. Preparing ACP involved gathering and evaluating prior ACP information (eg, advance directives or surrogate decision-maker) from diverse locations (eg, patient medical files at the hospital, nursing home, or family medicine physician office). It required residents to distinguish between simple and complex ACP situations, to determine the urgency, and to identify individuals to involve in the discussion. Discussing ACP involved different tasks depending on who participated in the conversation. Residents had to inform patients and their relatives about diagnosis and prognosis, explore end-of-life preferences, and ideally agree on realistic goals of care. They also had to discuss complex situations with their supervisors and other members of the health care team, such as primary care providers, nurses, or psychologists. Documenting ACP involved filling out a form in patients' electronic health records. At the time of the study, this meant checking 2 boxes (CPR/DNACPR order, discussed with patient “Yes/No”) and documenting the goals of care in a free text box. Supervisors stressed that documenting the form upon admitting a patient and updating it throughout hospitalization were important for patient safety and were elements of a physician's ethical duty to respect patient preferences. These tasks ranged from simple to complex, depending on a series of factors detailed in Table 3. The perceived level of complexity influenced the way residents reasoned, communicated, and made decisions. In simple situations (eg, elderly patients with dementia for whom palliative care was already initiated), residents tended to determine patients' code status by themselves with no or limited discussion with the patients and to leave what had previously been documented unchanged in the medical record. In contrast, in complex situations with a potential risk to patient safety (eg, older patients with life-threatening emergencies for whom intensive care may not be beneficial or even harmful), residents tended to work more collaboratively with patients and relatives and to call for help from senior physicians or palliative care consultants.

Competencies for residents to discuss ACP with hospitalized patients included knowledge, skills, and attitudes (Box). Residents needed knowledge about the legal and ethical principles used for ACP in Switzerland, which was often new to foreign residents. In addition, residents had to grapple with uncertainty and unclear information as to patients' status and prognosis. Residents also mentioned they needed deeper knowledge in palliative care, especially in life-threatening situations.

In terms of skills, residents needed skills in reasoning and communication (Box and Figure). Residents needed clinical reasoning skills to evaluate whether patients were able to have a conversation and make decisions, to establish diagnosis and prognosis, and to prescribe treatments. They also needed ethical reasoning skills to assess the extent to which patients or relatives wanted to be involved in ACP. Intertwined with clinical and ethical reasoning, residents needed decision-making skills to evaluate existing prior ACP, to initiate new discussions when needed, and to know when to refer to supervisors if the situation became too complex, for example with older patients with uncertain prognosis in life-threatening emergency conditions. Residents needed excellent communication skills to address critical points with patients and relatives (eg, diagnosis, prognosis, treatments, and patients' preference), to listen to patient needs, and to demonstrate empathy.

In terms of attitudes, residents needed be empathetic and tactful. They were also expected to be reflexive of how their own opinions and values influenced their approach to ACP and end-of-life care, as these represent sensitive topics. During focus groups, we noticed that participants often used humor when discussing these topics, suggesting their emotional involvement.

Participants identified developing competencies required for ACP as important learning objectives, although they described this as an educational challenge. Residents in our study reported learning ACP by shadowing more senior physicians. They also regretted not receiving any feedback from supervisors on how they managed ACP, which made them feel uncertain about what needed improvement. Some residents mentioned reading about ACP in their free time and attending workshops organized by the institution (eg, on breaking bad news, ethics).

All participants believed that residents' training in ACP was critical, particularly as residents were often left in charge of ACP even though most experienced participants acknowledged that it had taken them years to feel confident in managing complex ACP situations. Participants also noted that there were important barriers to overcome to develop residents' training in ACP. These barriers included limited time for learning, the high number of residents, the short duration of rotations, and the limited training of supervisors themselves. However, participants also believed that ACP training could be integrated into existing learning activities. Such activities included a patient-physician relationship module at the undergraduate level, a role-play for internal medicine residents at the postgraduate level, and a workshop on clinical supervision at the faculty development level. Another suggestion was to embed an introduction to ACP within an existing e-learning module on CPR, compulsory for every new health care professional at the hospitals.

In terms of educational strategies, many participants noted that simulation and role-play may be fruitful. In particular, they imagined a e-learning module with videotaped simulated goals of care discussions prior to a 2-hour practice session with role-play.

This qualitative study increased our understanding of current practices and training needs for residents in ACP; it revealed that residents perform 3 main task classes regarding ACP, namely preparing, discussing, and documenting ACP. To perform these tasks, this study showed that residents needed complex sets of skills and attitudes that include clinical and ethical reasoning. Finally, this study outlined suggestions for designing an innovative training in ACP using a whole-task instructional design.

Our proposed ACP skills hierarchy diagram (Figure) provides a hierarchical description of all constituent skills and their relationships²⁴  and fits well in competency-based residency programs endorsed worldwide, notably in Canada, the United States, and Switzerland.^32–34  This visual representation of our skills hierarchy can be used by instructional designers to guide the development of learning tasks, as well as by clinical supervisors and residents to share a common mental model of the skills to be integrated in the complex learning of ACP.^20,21  Our finding that residents need to acquire knowledge on disease prognosis and palliative care management is consistent with 2 reviews of the literature.^11,14  This need can be addressed through integration of palliative medicine and geriatrics competencies into postgraduate curricula.³⁵  Additionally, our skills hierarchy is helpful for including clinical and ethical reasoning into ACP postgraduate training.^11,36,37  In line with previous research,^38,39  our study shows that residents often struggle to integrate clinical and ethical reasoning because they tend to be taught in isolation. Research has suggested that learning ethical and clinical reasoning skills in a more integrated way requires a shared theoretical framework, assuming a balance between deductive (top down) and inductive (bottom up) reasoning.⁴⁰ 

Residents and senior physicians reported experiences of learning ACP-related tasks on the job through role modeling and informal curriculum rather than through formal trainings. This echoes the literature in Switzerland and in other settings.^8,9,14  Participants suggested that simulated role-play and clinical supervision could be starting points to improve the training, and that e-learning modules, journal clubs, and ACP guidelines or pocket-sized information sheets may be helpful. Some of these strategies are already described in the literature.^19,41  However, they are typically used during one-time training and focus on tasks at a single point in time, such as code status discussions, goals of care conversations, or breaking bad news.^17,42,43  We suggest that a whole-task approach is more consistent with the most recent approach to ACP, which promotes the integration of discussions and documentation of goals of care regularly updated along the ACP process.^5,15,16  In addition, a whole-task instructional design is expected to support residents' complex learning in ACP.^20,21  We provide suggestions for how to develop such an ACP training for learners in graduate medical education using the 4C/ID framework in the online supplementary data.

This study has several limitations. Due to time and budget constraints, we were limited in our ability to triangulate data collection methods. We conducted focus groups and semistructured interviews because we wanted to explore participants' perceptions of and experiences with ACP, but we did not conduct field observations.³¹  Our understanding of participants' behaviors and interactions during ACP-related tasks was limited from what they described, which may be different from what they actually do in real life. Another limitation of this study is that it focused primarily on physicians' perspectives. We attempted to involve patients' perspectives by interviewing members of the Patients-as-Partners program, but we still have limited insights into patients' needs, which may differ from professionals' needs and be relevant to residents' training in ACP.⁴³  Similarly, although we included one interprofessional focus group, we are still limited in understanding other health care professionals' potential role in training residents in ACP.⁴⁴ 

Future research could delve deeper into how residents perform ACP with patients by using ethnographic observations, which would allow to address underexplored phenomena in ACP such as barriers to patients' involvement in the decision-making process.^42,43,45  Furthermore, as we undertook this study to develop a program to train residents in ACP, we will conduct further research on the implementation and evaluation of the program.

In line with recent international consensus statements on ACP, this study provided a comprehensive description of tasks and competencies to train residents in ACP. It proposed a competency framework and a skills hierarchy for educators in graduate medical education to develop innovative trainings in ACP using the 4C/ID model.

The authors would like to thank all research participants for their involvement in the focus groups and individual interviews; members of the UDREM at the University of Geneva School of Medicine, members of the Interprofessional Simulation Center, and members of the Institute of Primary Care at the Geneva University Hospitals for their help in designing and conducting the study; the academic and administrative staff of the Master of Health Profession Education program at Maastricht University and the Association for Medical Education in Europe for a research scholarship granted to Dr Fassier; and the Swiss National Science Foundation for its Postdoctoral Fellowship grant for Dr Bochatay.