Author Interviews, Cognitive Issues, End of Life Care, Gender Differences, JAMA / 16.08.2019

MedicalResearch.com Interview with: [caption id="attachment_50851" align="alignleft" width="142"]Dr. Nathan Stall, MD Geriatrician and Research fellow Women’s College Research Institute Dr. Stall[/caption] Dr. Nathan Stall, MD Geriatrician and Research fellow Women’s College Research Institute   [caption id="attachment_50852" align="alignleft" width="133"]Dr. Paula Rochon, MD, MPH, FRCPC Periatrician and Vice-President of Research Women’s College Hospital Dr. Rochon[/caption]     Dr. Paula Rochon, MD, MPH, FRCPC Periatrician and Vice-President of Research Women’s College Hospital     MedicalResearch.com: What is the background for this study? Response: The advanced stages of the dementia are characterized by profound memory impairment, an inability to recognize family, minimal verbal communication, loss of ambulatory abilities, and an inability to perform basic activities of daily living. Nursing homes become a common site of care for people living with advanced dementia, who have a median survival of 1.3 years. In the advanced stages of the disease, the focus of care should generally be on maximizing quality of life. Our study examined the frequency and sex-based differences in burdensome interventions received by nursing home residents with advanced dementia at the very end of life. Burdensome interventions include a variety of treatment and procedures that are often avoidable, may not improve comfort, and are frequently distressing to residents and their families. We found that in the last 30 days of life, nearly one in 10 nursing home residents visited an emergency department, more than one in five were hospitalized, and one in seven died in an acute care setting. In addition, almost one in 10 residents received life-threatening critical care; more than one in four were physically restrained; and more than one in three received antibiotics.
Author Interviews, Cancer Research, Cannabis, End of Life Care, NYU / 28.03.2019

MedicalResearch.com Interview with: [caption id="attachment_48264" align="alignleft" width="200"]Arum Kim, MDAssistant professor of Medicine and Rehabilitation MedicineNYU School of MedicineDirector of the Supportive Oncology ProgramPerlmutter Cancer Center Dr. Kim[/caption] Arum Kim, MD Assistant Professor Medicine and Rehabilitation Medicine NYU School of Medicine Director of the Supportive Oncology Program Perlmutter Cancer Center MedicalResearch.com: What is the background for this study?   Response: There is increasing interest in medical marijuana and its applications for patients with cancers. Despite increasing access, little is known regarding doses of cannabinoids - specifically tetrahydrocannabinol (THC)  and cannabidiol (CBD), methods of drug delivery, and differences in patterns of use between cancer and non-cancer patients.
Author Interviews, Brigham & Women's - Harvard, Critical Care - Intensive Care - ICUs, End of Life Care, JAMA / 21.03.2019

MedicalResearch.com Interview with: Joanna Paladino, MD Director of Implementation, Serious Illness Care Program | Ariadne Labs Brigham and Women's Hospital | Harvard T.H. Chan School of Public Health Palliative Care | Dana-Farber Cancer Institute Instructor | Harvard Medical School and Dr. Rachelle Bernacki MD MS Director of Quality Initiatives Psychosocial Oncology and Palliative Care Senior Physician, Assistant Professor of Medicine Harvard Medical School Dr. Paladino's responses: MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Paladino: People living with serious illness face many difficult decisions over the course of their medical care. These decisions, and the care patients receive, should be guided by what matters most to patients, including their personal values, priorities, and wishes. These conversations don’t often happen in clinical practice or do so very late in the course of illness, leaving patients exposed to getting care they don’t want. Doctors and nurses want to have these important discussions, but there are real challenges, including insufficient training and uncertainties about when and how to start the conversation. We designed an intervention with clinical tools, clinician training, and systems-changes to address these challenges. When tested in a randomized clinical trial in oncology, we found that the intervention led to more, earlier, and better conversations between oncology clinicians and their patients with life-limiting cancer. These findings demonstrate that it is possible to ensure reliable, timely, and patient-centered serious illness conversations in an outpatient oncology practice.
Author Interviews, End of Life Care / 19.07.2018

MedicalResearch.com Interview with: [caption id="attachment_43298" align="alignleft" width="128"]Ann Cottingham Ann H Cottingham[/caption] Ann H Cottingham MA MAR Indiana University School of Medicine Indianapolis,IN. MedicalResearch.com: What is the background for this study? What are the main findings? Response: Advance care planning provides patients with cancer an opportunity to reflect on future care and treatment options with their physician and family and identify and document their preferences in preparation for a time when they may be unable to speak for themselves. Advance care planning increases both quality of life and satisfaction with care, however the majority of patients with cancer have not participated in these important conversations. Common emotional responses to cancer, such as feelings of anxiety, fear, and sadness, pose one barrier to planning as they can keep patients from thinking about or discussing sensitive topics related to their illness. We conducted a pilot study to explore whether training in mindfulness, the psychological process of bringing one's attention to experiences occurring in the present, could enhance the ability of patients and families to consider and discuss emotionally challenging topics -- such as end-of-life preparations -- and support timely advance care planning. Twelve patient-family caregiver pairs participated in a pilot study of Mindfully Optimizing Delivery of End-of-Life (MODEL) Care, which combined mindfulness meditation, mindful communication practices, and information about advance care planning. MODEL Care focused on developing emotional and communication capacities to enable patients and their family caregivers to respond to the experience of living with advanced cancer and to talk about the disease and future care preferences with greater ease. The study found that MODEL Care successfully supported patients and their family caregivers in thinking about and then talking about the care they would want to receive if they become unable to speak for themselves, enhancing their ability to respond to emotional challenges, and decreasing barriers to end-of-life planning. MODEL Care improved patient and caregiver ability to cope, lowered emotional reactivity, and enhanced ability to respond to issues that incited emotion. It also strengthened the patient-caregiver relationship and enhanced communication with each other. MODEL Care also improved both patient and family caregiver communication with the physicians caring for the patient.   Patients noted that the practices enabled them to cope more effectively with the symptoms of their disease, including pain. Caregivers reported changes in their loved one's ability to cope with their disease following the mindfulness sessions.
Author Interviews, End of Life Care / 06.05.2018

MedicalResearch.com Interview with: [caption id="attachment_41484" align="alignleft" width="128"]Mara Buchbinder, PhD Associate Professor Department of Social Medicine University of North Carolina at Chapel Hill Chapel Hill, NC 27599-7240  Dr. Buchbinder[/caption] Mara Buchbinder, PhD Associate Professor Department of Social Medicine University of North Carolina at Chapel Hill Chapel Hill, NC 27599-7240  MedicalResearch.com: What is the background for this study? What are the main findings? Response: The legal landscape of medical aid-in-dying in the United States is changing rapidly. Just a few weeks ago, Hawaii became the 8th jurisdiction in the US to permit a physician to prescribe a lethal dose of medication to a terminally ill patient for the purpose of ending the patient’s life. However, even in states where aid-in-dying is legal, patients still face substantial barriers to access. The Vermont Study on Aid-in-Dying, a qualitative, descriptive study of the implementation of Vermont’s assisted dying statute, found that patients encounter barriers concerning the safeguards built into the law, the cost of medication, the ability to find a physician willing to prescribe, and knowledge about the law.
Author Interviews, Cost of Health Care, End of Life Care, JAMA / 01.05.2018

MedicalResearch.com Interview with: [caption id="attachment_41387" align="alignleft" width="130"]R. Sean Morrison, MD Ellen and Howard C. Katz Professor and Chair Brookdale Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai New York, NY 10029 Dr. Morrison[/caption] R. Sean Morrison, MD Ellen and Howard C. Katz Professor and Chair Brookdale Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai New York, NY 10029 MedicalResearch.com: What is the background for this study? What are the main findings? Response: Palliative care is team based care that is focused on improving quality of life and reducing suffering for persons with serious illness and their families.  It can be provided at any age and in concert with all other appropriate medical treatments.  Palliative care has been shown to improve patient quality of life, patient and family satisfaction, and in diseases like cancer and heart failure, improve survival.  A number of individual studies have shown that palliative care can reduce costs by providing the right care to the right people at the right time. This study pooled data from six existing studies to quantify the magnitude of savings that high quality palliative care provides.
Author Interviews, End of Life Care, JAMA, UCSF / 20.11.2017

MedicalResearch.com Interview with: [caption id="attachment_38401" align="alignleft" width="103"]Kara Bischoff, MD Assistant Clinical Professor, Hospital Medicine & Palliative Care Director of Quality Improvement for the Palliative Care Service UCSF Department of Medicine Dr. Bischoff[/caption] Kara Bischoff, MD Assistant Clinical Professor, Hospital Medicine & Palliative Care Director of Quality Improvement for the Palliative Care Service UCSF Department of Medicine MedicalResearch.com: What is the background for this study? What are the main findings? Response: Care planning, which we define as including both advance care planning and goals of care discussions, are a common need in seriously ill patients and a key function of palliative care teams. However, few studies have looked at how often and how care planning is being done by inpatient palliative care teams throughout the United States, and similarly few studies have examined the precise impact of these care planning activities. Therefore, using data from a large quality improvement registry in palliative care called the Palliative Care Quality Network, we examined: 1) the characteristics of hospitalized patients who are referred to inpatient palliative care consult services, 2) the activities that occurred during those inpatient palliative care consults, and 3) the outcomes that resulted. In looking at data from 73,145 patients who referred for an inpatient palliative care consult, we found that care planning was the most common reason for inpatient palliative care consultation, requested for 71.9% of patients who were referred to palliative care. Further, care planning needs were found in more than half (58%) of palliative care patients even when the consult was requested for reasons other than care planning. Patients referred to palliative care for care planning were somewhat older than patients referred for other reasons, they were less likely to have cancer, and were more often full code at the time of referral. Through care planning conversations, palliative care clinicians frequently identified surrogates and clarified patients’ preferences for life-sustaining treatments (including code status). For instance, 31% more patients chose a code status of DNR/DNI after a conversation with the palliative care team. However, we also found that legal forms such as advance directives and Physician Orders for Life-Sustaining Treatments (POLST) forms were completed for just 3.2% and 12.3% of the patients see by palliative care teams, respectively. This highlights an important quality gap in need of improvement.
Author Interviews, End of Life Care, JAMA / 08.02.2017

MedicalResearch.com Interview with: [caption id="attachment_31813" align="alignleft" width="156"]Nathan A. Gray, M.D. Duke Palliative Care Durham, NC 27710 Dr. Nathan Gray[/caption] Nathan A. Gray, M.D. Duke Palliative Care Durham, NC 27710 MedicalResearch.com: What is the background for this study? What are the main findings? Response: The estimated number of undocumented immigrants living in the United States has been stable in recent years, but lengths of residence in the country are rising. This aging population of undocumented immigrants can expect to face an increasing burden of chronic disease and end-of-life needs, but may experience challenges in obtaining hospice care in the last months of life as many are uninsured and none are eligible for the Medicare Hospice Benefit. While hospice agencies do provide charity care, little is known about hospice agency approaches to caring for undocumented immigrants. We surveyed a national sample of hospice agencies and found that many hospice agencies do not enroll undocumented immigrants or place restrictions on the number enrolled. More than half of agencies sampled had received requests for enrollment of undocumented immigrants in the past year. Offering unrestricted enrollment was more common among larger, not-for-profit hospices in our sample.
Author Interviews, Cancer Research, End of Life Care / 23.12.2016

MedicalResearch.com Interview with: Yu Uneno, M.D. Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University Kyoto city, Kyoto Japan MedicalResearch.com: What is the background for this study? What are the main findings? Response: Prognosis prediction is one of the most important issues to make an optimal treatment decision for both cancer patients and health care professionals. Previous prognosis prediction models were developed using data from single time point (at the baseline, for example), limiting the use of the models at the similar situation. Recently, we have developed the Six Adaptable Prognostic (SAP) models which can be repeatedly used at any time point after the initiation of treatment for patients with cancer receiving chemotherapy. Those models use only three laboratory items (albumin, neutrophil, lactate dehydrogenase) which are routinely monitored in daily clinical practice.
Author Interviews, End of Life Care, JAMA, University of Pittsburgh / 30.11.2016

MedicalResearch.com Interview with: [caption id="attachment_29804" align="alignleft" width="120"]Dr. Dio Kavalieratos, PhD Assistant Professor of Medicine Section of Palliative Care and Medical Ethics Division of General Medicine Institute of Clinical Research University of Pittsburgh Dr. Dio Kavalieratos[/caption] Dr. Dio Kavalieratos, PhD Assistant Professor of Medicine Section of Palliative Care and Medical Ethics Division of General Medicine Institute of Clinical Research University of Pittsburgh MedicalResearch.com: What is the background for this study? What are the main findings? Response: The field of palliative care has seen a dramatic surge in research and clinical implementation over the past decade. The last systematic review of palliative care trials was published in 2008. In that review, the authors reported very weak evidence for palliative care, as well as major methodological limitations in the trials that had been done to date. Since then, several landmark trials have been published, some with very compelling findings such increased survival. Therefore, an up-to-date review was in order. There also had not previously been enough trials to perform a meta-analysis. A meta-analysis is the statistical process of combining the results of multiple trials, which gives you an overall effect for an intervention, in this case, palliative care. We were able to conduct the first meta-analysis of the effect of palliative care with three important outcomes: patient quality of life, patient symptom burden, and patient survival.
Author Interviews, Brigham & Women's - Harvard, Cancer Research, Colon Cancer, End of Life Care, Lung Cancer / 09.09.2016

MedicalResearch.com Interview with: [caption id="attachment_27780" align="alignleft" width="253"]Joseph A. Greer, Ph.D. Program Director, Center for Psychiatric Oncology & Behavioral Sciences Associate Director, Cancer Outcomes Research Program, Massachusetts General Hospital Cancer Center Yawkey Center, Boston, MA 02114 Dr. Joseph Greer[/caption] Joseph A. Greer, Ph.D. Program Director, Center for Psychiatric Oncology & Behavioral Sciences Associate Director, Cancer Outcomes Research Program, Massachusetts General Hospital Cancer Center Yawkey Center, Boston, MA 02114 MedicalResearch.com: What is the background for this study? What are the main findings? Response: Many patients with advanced cancer have a high symptom burden, increased depression symptoms, misperceptions about their prognosis, and difficulties in making decisions about care at the end of life. To address these challenges and improve care for this vulnerable population, our research team initially conducted a small, single-group pilot study of early palliative care integrated with standard oncology care for patients with advanced lung cancer. This study showed that the model of integrated care was feasible and acceptable to patients and their families. Specifically, the majority of patients in the study were able to meet with a palliative care clinician at least monthly from the time of diagnosis of metastatic lung cancer, in order to receive help with managing symptoms as well as support for coping with the disease and making decisions about treatment. We then conducted a follow-up randomized controlled trial of early, integrated palliative care in a sample of approximately 150 patients with metastatic non-small cell lung cancer. This study was published in the New England Journal of Medicine in 2010 and showed that those patients who received early palliative care reported significantly improved quality of life, mood, prognostic awareness, and end-of-life care compared to those who received standard oncology care alone. To confirm the findings of our prior research and to determine whether the benefits of early integrated palliative care would apply to a larger sample of patients with diverse malignancies, we recently completed another randomized trial of this same model of care in a sample of 350 patients with incurable lung and gastrointestinal cancers. In this trial, we observed that patients who received the early palliative care intervention reported higher quality of life and improved mood by 24 weeks but not at the primary end-point of 12 weeks. Our team was surprised to find that the trajectory of quality of life and depression symptoms over time was different for individuals with incurable lung versus gastrointestinal cancers in this study. As expected, the palliative care intervention positively buffered the decline in quality of life by 12 weeks for patients with incurable lung cancer, as we had seen in our prior trial. However, the group of patients with gastrointestinal cancers reported an improvement in their quality of life by the 12-week time point regardless of whether they received the palliative care intervention. We are still exploring possible reasons for this difference, such as whether changes in cancer therapy may have reduced symptoms and improved quality of life in the group of patients with gastrointestinal cancer. In addition, we were pleased to learn that the early integrated palliative care intervention led to improvements in how patients cope with their illness. For example, compared to patients in the usual oncology care group, those who received early, integrated palliative care were more likely to learn ways to accept their diagnosis and to take positive actions to make their lives better. So, in addition to treating patients’ symptoms, the palliative care clinicians in this study were bolstering people’s adaptive coping skills.
Author Interviews, End of Life Care, Heart Disease, JAMA / 24.05.2016

MedicalResearch.com Interview with: [caption id="attachment_24633" align="alignleft" width="161"]James N. Kirkpatrick, MD Director of the Echocardiography Laboratory Division of Cardiology Ethics Consultation Service University of Washington, Seattle Dr. James Kirkpatrick[/caption] James N. Kirkpatrick, MD Director of the Echocardiography Laboratory Division of Cardiology Ethics Consultation Service University of Washington, Seattle MedicalResearch.com: What is the background for this study? Dr. Kirkpatrick: With significant advances in technology, implanted cardiac devices like pacemakers and defibrillators, replacement heart valves, and mechanical pumps which assist or replace the pumping function of the heart have become standard therapies for patients with severe cardiac disease. Many patients who would previously have died after living with severe symptoms live longer and with improved quality of life. This is particularly true for elderly patients who receive transcatheter aortic valve replacement (TAVR—valve replacement that doesn’t require open heart surgery) and ventricular assist device (VAD—a durable mechanical heart pump) implantation. However, like everyone, these patients will die, and some of the patients will experience device complications which will shorten their lives. Elderly patients, in particular, are at risk for device complications, high symptom burden, and loss of the ability to make healthcare decisions, due to illnesses like strokes or dementia. Symptom management and advance care planning are the hallmarks of the medical specialty of Palliative Care and are particularly important in patients with TAVR and VADs, yet patients and clinicians don’t often think of Palliative Care when considering high tech, life-prolonging therapies. The Palliative Care Working Group of the American College of Cardiology’s Geriatrics Section therefore sought to gather data on the attitudes toward Palliative Care among cardiovascular clinicians and the current state of involvement of Palliative Care in the care of patients with TAVR and VAD.
Author Interviews, Cancer Research, CMAJ, End of Life Care / 20.04.2016

MedicalResearch.com Interview with: [caption id="attachment_23439" align="alignleft" width="143"]Camilla Zimmermann, MD, PhD, FRCPC Head, Division of Palliative Care, University Health Network Research Director, Lederman Palliative Care Centre, Princess Margaret Cancer Centre Associate Professor, Department of Medicine, University of Toronto Rose Family Chair in Supportive Care, Faculty of Medicine, University of Toronto Toronto, Canada Dr. Camilla Zimmermann[/caption] Camilla Zimmermann, MD, PhD, FRCPC Head, Division of Palliative Care, University Health Network Research Director, Lederman Palliative Care Centre, Princess Margaret Cancer Centre Associate Professor, Department of Medicine, University of Toronto Rose Family Chair in Supportive Care, Faculty of Medicine, University of Toronto Toronto, Canada Medical Research: What is the background for this study? Dr. Zimmermann: Early palliative care is increasingly recommended by national and international health agencies, and is in keeping with the definition of palliative care as being relevant throughout the course of life-threatening illness. We conducted a randomized controlled trial of early palliative care (referral and follow-up in a specialized outpatient palliative care clinic), versus routine oncology care, in 461 ambulatory patients with advanced cancer. The results showed that early palliative care improved quality of life and satisfaction with care. The current study was a follow-up study, where we conducted qualitative interviews with 71 patients and caregivers from the intervention and control arms of the larger trial. We asked them about their attitudes and perceptions of palliative care and whether these changed during the trial.
Author Interviews, End of Life Care / 23.06.2015

MedicalResearch.com Interview with: Gabrielle Rocque MD Division of Hematology & Oncology University of Alabama Birmingham, Alabama MedicalResearch: What is the background for this study? What are the main findings? Dr. Rocque: This study grew out of a retrospective study we conducted in 2010 in which we evaluated the characteristics of patients admitted to our solid tumor oncology service, what occurred during their hospitalization, and what their outcomes were after discharge.  We identified that the average life expectancy of the population was less than 4 months and therefore, inpatient admission was an opportunity for palliative care support.  Therefore, we conducted a sequential, prospective cohort study of patients before and after implementation of triggered palliative care consults for patients with advanced cancer. We found that patients’ prognostic awareness meaningfully and significantly improved after the implementation of consults, but there was little impact on utilization of health services. We did identify that providing consults to the entire population of patients was logistically challenging due to short stays, high-acuity symptoms, and individual provider resistance, but overall the oncology providers found the consults to be beneficial.
Author Interviews, Cancer, Cancer Research, End of Life Care / 09.09.2014

MedicalResearch.com Interview with: Karin Jors MA Department of Palliative Care, Comprehensive Cancer Center, University Medical Center Freiburg, Freiburg, Germany Medical Research: What are the main findings of the study? Answer: The findings of our study shed light on the current circumstances for dying in cancer centers. Physicians and nurses in our study reported that they rarely have enough time to care for dying patients. In addition, only a minority of staff members felt that they had been well-prepared during their training to care for dying patients and their families. Overall, only 56% of participants indicated that it is usually possible for patients to die in dignity on their ward. This is likely the result of various factors such as: inadequate rooms for dying patients and their families (i.e. shared rooms), poor communication with patients regarding burdensome treatments, an overuse of life-prolonging measures, etc. Striking differences were found between the responses of palliative care staff and staff from other wards (e.g. general care, oncology, intensive care). For example, palliative care staff reported that they usually have enough time to care for dying patients. In addition, 95% of palliative care staff indicated that it is usually possible for patients to die in dignity on their ward. Overall, nurses perceived the situation for dying patients more negatively than physicians. Whereas 72% of physicians reported that patients can usually die a dignified death on their ward, only 52% of nurses shared this opinion. Although only slightly more than half of participants believed that patients can usually die in dignity on their ward, this is a considerable improvement to the situation 25 years ago. In a similar study published in 1989, researchers found that 72% of physicians and nurses experienced the situation for patients dying on their hospital ward as undignified.
Author Interviews, BMJ, End of Life Care / 12.06.2014

MedicalResearch.com: Interview with: Dr. Hsien Seow PhD Cancer Care Ontario Research Chair in Health Services Research Asst Professor, Dept of Oncology, McMaster University Hamilton, OntarioDr. Hsien Seow PhD Cancer Care Ontario Research Chair in Health Services Research Asst Professor, Dept of Oncology, McMaster University Hamilton, Ontario   MedicalResearch: Why did you conduct this study? Dr. Seow: While palliative care has gained recognition as a service that can improve patient outcomes and reduce health care costs at the end of life, especially in hospitals and hospices, much less attention has focused on providing inter-disciplinary palliative care in the community and home. There have been several randomized trials that showed mixed evidence that inter-disciplinary teams of specialist palliative care providers can reduce acute care utilization in the community; however team size and team composition varied in prior trials. This variation has not been researched as a cause for the mixed outcomes.
Author Interviews, Depression, Education, End of Life Care, JAMA, Stanford / 06.12.2013

J. Randall Curtis, MD, MPH Professor of Medicine Director, UW Palliative Care Center of Excellence Section Head, Pulmonary and Critical Care Medicine, Harborview Medical CenterA. Bruce Montgomery, M.D. – American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine University of Washington, Seattle, WA 98104MedicalResearch.com Interview with: J. Randall Curtis, MD, MPH Professor of Medicine Director, UW Palliative Care Center of Excellence Section Head, Pulmonary and Critical Care Medicine, Harborview Medical CenterA. Bruce Montgomery, M.D. – American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA 98104 MedicalResearch.com: What are the main findings of the study? Dr. Curtis: We examined the effect of a communication-skills intervention for internal medicine and nurse practitioner trainees on patient- and family-reported outcomes.  The study was funded by the National Institutes of Nursing Research of the National Institutes of Heatlh.  We conducted a randomized trial with 391 internal medicine and 81 nurse practitioner trainees at two universities.  Participants were randomized to either an 8-session simulation-based, communication-skills intervention or to usual education.  We collected outcome data from a large number of patients with life-limiting illness and their families, including 1866 patient ratings and 936 family ratings.  The primary outcome was patient-reported quality of communication and, overall, this outcome did not change with the intervention.  However, when we restricted our analyses to only patients who reported their own health status as poor, the intervention was associated with increased communication ratings. Much to our surprise, the intervention was associated with a small but significant increase in depression scores among post-intervention patients.  Overall, this study demonstrates that among internal medicine and nurse practitioner trainees, simulation-based communication training compared with usual education improved communication skills acquisition, but did not improve quality of communication about end-of-life care for all patients.  However, the intervention was associated with improved patient ratings of communication for the sickest patients. Furthermore, the intervention was associated with a small increase in patients’ depressive symptoms, and this appeared most marked among patients of the first-year residents.