A. Teaching method: Group learning, teaching time 60 min.

B. Description: At the beginning of the h, the participants take a 15-item multiple-choice exam on advance directive knowledge (J.S. Weiner & S. Sarij, unpubl.). They then receive a 15-min lecture on basic concepts of advance directives. After the lecture, the group reviews the multiple-choice exam.

C. Educational rationale: Starting the workshop with a self-assessment examination demonstrates to learners their strengths and limitations in personal knowledge. This interactive session engages learners and helps ensure that all participants master basic concepts after the first h of the program.

A. Teaching method: Individual learning, teaching time 60 min.

B. Description: Learners conduct a videotaped advance care planning discussion with a trained actor or faculty member. Standardized vignettes are constructed so that the “simulated patient” (Maguire et al., 1986; Gordon et al., 1988) is in his/her 60s, with an incurable, but medically stable cancer, and the role play is scripted in an ambulatory setting (J.S. Weiner & R. Janicik, unpubl.). This forces the trainee to have the advance care planning discussion earlier than is generally done, but at a time that experts suggest it should be initiated. The scenarios have been constructed to elicit moderate and realistic emotional intensity from the simulated patient. The videotaped discussion is privately reviewed with the trainee immediately afterward. During this review, the educator facilitates learner-driven self-assessment and learner-centered goal setting for the training (Knowles, 1973, 1990).

C. Educational rationale: This simulated patient exercise provides the learner and the teacher with a snapshot of the participant's strengths and weaknesses. The moderate emotional intensity of the scenario also allows the trainees to experience some of their emotional and cognitive barriers. While providing an opportunity for feedback and individual learning, the educator encourages the learner to set more detailed goals for the next 6 h of training.

A. Teaching method: Group learning, teaching time 60 min.

B. Description: The group of 4–6 learners participate in the following exercise:

The trainees go around the room and exchange stories, facilitated by the faculty. The class develops a list of personal emotional challenges during end-of-life discussions, and the faculty supplements this list as appropriate (Weiner & Cole, 2004).

Trainees without much clinical experience, such as medical students, may not have participated in advance care planning. In this case, we ask trainees what it might feel like for them to have such a discussion. We have observed that it is generally better to conduct training sessions for clinicians with similar levels of experience as this will facilitate the openness necessary to share emotionally laden challenges.

After exchanging advance care planning vignettes and personal emotional responses, the class then discusses the specific precipitants that led to each clinician's response (Weiner & Cole, 2004). For example, a physician's anxiety about having advance care planning discussions with a terminally ill patient might stem from his or her conception that such a discussion would take away hope.

C. Educational rationale: This exercise, along with the previous simulated patient role play, provides learners and the teacher with invaluable information about individual emotional barriers to engaging in advance care planning. The group format helps participants appreciate the universality of emotional distress and the variety of challenges clinicians face. The group also discusses how common and understandable it is for the clinician to avoid discussions that elicit such distress. Many clinicians find relief in this common emotional ground (Bailint, 1972).

A. Teaching method: Group learning, 60 min.

B. Description: ACare training encourages the clinician to take an approach to advance care planning based on expert opinion (Lo et al., 1999; Larson & Tobin, 2000; Wenrich et al., 2001) and clinical experience.

Table A1 lists 10 elements we believe are fundamental to advance care planning discussion, along with sample questions or statements. Note that “advance care planning” goes beyond advance directive determination. The clinician acts as a guide to help the patient participate in a shared medical decision-making process throughout the illness trajectory (Teno & Lynn, 1996; Charles et al., 1999; Elwyn et al., 2000; Kolarik et al., 2002). This is helpful not only to sort out complex treatment planning issues, but it also facilitates the patients' efforts to construct meaning around their illness experience. This may have, in itself, therapeutic effects (Breitbart, 2002; Chochinov et al., 2002).

C. Most of these elements, list in the table in the Appendix, are self-explanatory. However, six deserve more attention:

1. With loved ones who have died.

2. With the patient's own prior medical illnesses, and

3. With the patient's own current medical illness.

[bull ] Help the patient actively link past experiences to the decisions he or she should ponder. Once such experiences are drawn out, it becomes a bit clearer for the patient to sort through decisions. The physician should help the patient by asking questions like, “You saw how your mother did on a breathing machine. What were the pros and cons of that experience for you? If you would ever be in a similar situation what would you want and not want for yourself?”

[bull ] Carefully listen for cues the patient gives that invite the clinician into a discussion about end-of-life issues. Clinicians are often reluctant to raise end-of-life issues, because they feel patients won't want to discuss it. This is usually an incorrect assumption. Data indicate patients commonly wait for physicians to raise the issue (Johnston et al., 1995). In practice, patients drop cues for physicians to discuss emotionally based topics, but these cues are frequently missed (Branch & Malik, 1993; Suchman et al., 1997). The ACare training helps clinicians pick up these cues by illustrating them during role play or a modeling videotaped interview that the class views.

[bull ] Help the patient and loved ones link the medical decisions they are making with losses they are suffering. Sometimes patients or family members refuse to accept imminent death. They might request ineffective treatments in the hope of a miracle. Sometimes they angrily demand constant attention from the medical staff or anxiously overinterpret small movements of a dying patient as a sign of recovery. These behaviors commonly cloak the grief of patients and family, which is rarely addressed in the acute care setting. Rather, the staff adapts by labeling people as “in denial,” “irrational,” or “difficult.” This establishes adversarial relationships that often escalate the demands of patient and family. Often the health care team unknowingly participates in “irrational denial,” by not acknowledging how painful it is for the patient and family to say goodbye. If this were more directly addressed, the maladaptive behaviors of patients, families, and staff might diminish.

[bull ] Provide accurate prognostic information and treatment recommendations, as requested by the patient or as needed by the patient to make adaptive decisions. In an attempt to protect patient hope and perhaps avoid emotionally upsetting bad news, clinicians may not share frank clinical information with patients. Providing this necessary information must be guided by the provider's assessment of the patient's desires and needs, not by the provider's personal distress (Buckman, 1992; Novack, 2000). By withholding crucial clinical opinion, the patient or family cannot exercise truely informed consent. Although it varies from patient to patient, studies have shown most patients would like to hear the truth (Buckman, 1996). Superimposing cultural preferences, however, must be taken into account (Crawley et al., 2002).

[bull ] Find opportunities for growth at the end of life. Clinicians sometimes narrowly frame patients into “treatable” and “terminal,” causing the misunderstanding that discussion about a noncurable condition may cause the patient or family to lose hope. Rather, the opposite has been amply described (Byock, 1997; Block, 2001). Patients and family members can hope for many other things besides a cure, including the hope for symptom reduction, to stay connected to and become closer with loved ones, to leave a legacy, and to emotionally grow (Nuland, 1994). With such a perspective, there is always the possibility for hope and growth near the end of life.

D. Educational rationale: A concrete, structured model for advance care planning discussion provides a framework for learners to develop skills. We believe having this structure also helps increase clinician comfort and confidence with this difficult task. This reduces their emotional distress.

A. Teaching method: Group Learning, 60 min.

B. Description: A videotaped advance care planning discussion with actual patients and families is used as a demonstration tool for the 10 elements of good advance care planning. The video is stopped many times to elicit trainees' thoughts and emotions. Counterproductive beliefs (see below) are challenged and reframing tasks are assigned.

C. Rationale: Modeling videotapes are used as a springboard to elicit group discussion. As discussed by Bandura (1977, 1992), modeling provides a template to improve clinician self-confidence.

A. Teaching method: Group learning, 60 min.

B. Description: Instead of trainees doing individual role play, we repeatedly utilize “rolling role play.” This is where the whole group assumes the role of the clinician: Group members sequentially ask one question or make one statement to the simulated patient (a faculty member). As role plays proceed, the facilitator will get a sense of specific situational-based skills each trainee needs to work on. For example, a nurse may have difficulty saying the word dying, when trying to ask, “Have you ever thought of dying?” This can be practiced within the context of a role play, and then given as an assignment to practice with the next appropriate patient in the clinical setting. When the nurse returns to the next class, the facilitator can follow up to see whether he or she was able to perform this skill. It is important to encourage participants to have advance care planning discussions with actual patients between classes, so they can bring in real vignettes to discuss and practice.

C. Rationale: This group role play effectively diffuses emotional discomfort among several people. As participants watch each other struggle during the role play, they feel validated in their shared distress, which facilitates open dialogue. And because the entire group participates in each role play, everyone remains involved in time-effective learning. Although these exercises and associated discussions about trainees' personal reactions are carefully controlled not to deflect into psychotherapy, they nevertheless can enable clinicians to overcome substantial personal anxieties related to discussions near the end of life (Bandura, 1977, 1992; Weiner & Cole, 2004).

A. Teaching method: Group learning, 60 min.

B. Description: The group format of the course allows trainees to examine and share their misconceptions about end-of-life care. We do not attempt to address unconscious conflict in the training. Rather we facilitate a group process to help trainees reevaluate their cognitive assumptions (Weiner & Cole, 2004). This approach is based on the cognitive-behavioral work of Beck et al. (1979) and Beck (1995). Table 3 illustrates common counterproductive beliefs clinicians have about end-of-life care and ways to reframe these misconceptions.

C. Rationale: Misconceptions can cloud clinical decision making. By clarifying and reframing counterproductive beliefs, we improve clinical effectiveness and reduce emotional distress. Clarification and reframing becomes part of the group process.

A. Teaching method: Individual learning, teaching time 60 min.

B. Description: Each trainee has a second advance care planning discussion with a simulated patient that is videotaped and reviewed immediately after. During private review of the videotape with the clinician, faculty facilitates a learner-driven self-assessment and learner-driven goal setting for the future.

C. Rationale: The trainee sees objective evidence of improvement, which increases motivation to put these skills into practice. The trainee also sees objective evidence of skills that he or she can continue to improve.