***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: CONTEXT Talking about death can be difficult . Without evidence that end-of-life discussion s improve patient outcomes , physicians must balance their desire to honor patient autonomy against a concern of inflicting psychological harm . OBJECTIVE To determine whether end-of-life discussion s with physicians are associated with fewer aggressive interventions . DESIGN , SETTING , AND PARTICIPANTS A US multisite , prospect i ve , longitudinal cohort study of patients with advanced cancer and their informal caregivers ( n = 332 dyads ) , September 2002-February 2008 . Patients were followed up from enrollment to death , a median of 4.4 months later . Bereaved caregivers ' psychiatric illness and quality of life was assessed a median of 6.5 months later . MAIN OUTCOME MEASURES Aggressive medical care ( eg , ventilation , resuscitation ) and hospice in the final week of life . Secondary outcomes included patients ' mental health and caregivers ' bereavement adjustment . RESULTS One hundred twenty-three of 332 ( 37.0 % ) patients reported having end-of-life discussion s before baseline . Such discussion s were not associated with higher rates of major depressive disorder ( 8.3 % vs 5.8 % ; adjusted odds ratio [ OR ] , 1.33 ; 95 % confidence interval [ CI ] , 0.54 - 3.32 ) , or more worry ( mean McGill score , 6.5 vs 7.0 ; P = .19 ) . After propensity-score weighted adjustment , end-of-life discussion s were associated with lower rates of ventilation ( 1.6 % vs 11.0 % ; adjusted OR , 0.26 ; 95 % CI , 0.08 - 0.83 ) , resuscitation ( 0.8 % vs 6.7 % ; adjusted OR , 0.16 ; 95 % CI , 0.03 - 0.80 ) , ICU admission ( 4.1 % vs 12.4 % ; adjusted OR , 0.35 ; 95 % CI , 0.14 - 0.90 ) , and earlier hospice enrollment ( 65.6 % vs 44.5 % ; adjusted OR , 1.65;95 % CI , 1.04 - 2.63 ) . In adjusted analyses , more aggressive medical care was associated with worse patient quality of life ( 6.4 vs 4.6 ; F = 3.61 , P = .01 ) and higher risk of major depressive disorder in bereaved caregivers ( adjusted OR , 3.37 ; 95 % CI , 1.12 - 10.13 ) , whereas longer hospice stays were associated with better patient quality of life ( mean score , 5.6 vs 6.9 ; F = 3.70 , P = .01 ) . Better patient quality of life was associated with better caregiver quality of life at follow-up ( beta = .20 ; P = .001 ) . CONCLUSIONS End-of-life discussion s are associated with less aggressive medical care near death and earlier hospice referrals . Aggressive care is associated with worse patient quality of life and worse bereavement adjustment IMPORTANCE Advance care planning can improve patient-centered care and potentially reduce intensification of care at the end of life . OBJECTIVES To inquire about patients ' advance care planning activities before hospitalization and preferences for care from the perspectives of patients and family members , as well as to measure real-time concordance between expressed preferences for care and documentation of those preferences in the medical record . DESIGN Prospect i ve study . SETTING Twelve acute care hospitals in Canada . PARTICIPANTS Elderly patients who were at high risk of dying in the next 6 months and their family members . MAIN OUTCOME MEASURES Responses to an in-person administered question naire and concordance of expressed preferences and orders of care documented in the medical record . RESULTS Of 513 patients and 366 family members approached , 278 patients ( 54.2 % ) and 225 family members ( 61.5 % ) consented to participate . The mean ages of patients and family members were 80.0 and 60.8 years , respectively . Before hospitalization , most patients ( 76.3 % ) had thought about end-of-life ( EOL ) care , and only 11.9 % preferred life-prolonging care ; 47.9 % of patients had completed an advance care plan , and 73.3 % had formally named a surrogate decision maker for health care . Of patients who had discussed their wishes , only 30.3 % had done so with the family physician and 55.3 % with any member of the health care team . Agreement between patients ' expressed preferences for EOL care and documentation in the medical record was 30.2 % . Family members ' perspectives were similar to those of patients . CONCLUSIONS AND RELEVANCE Many elderly patients at high risk of dying and their family members have expressed preferences for medical treatments at the EOL . However , communication with health care professionals and documentation of these preferences remains inadequate . Efforts to reduce this significant medical error of omission are warranted OBJECTIVE : To describe how medical residents discuss do-not-resuscitate ( DNR ) orders with patients . DESIGN : Prospect i ve observational study . SETTING : Inpatient medical wards of one university tertiary care center , one urban city public hospital , and one Veterans Affairs medical center . PARTICIPANTS : Thirty-one medical residents self-selected 31 of their English-speaking , competent patients , with whom they had DNR discussion s.  MEASUREMENTS : Three independent observers rated audiotaped discussion s about DNR orders between the medical residents and their patients . Ratings assessed whether the physicians met st and ard criteria for requesting informed consent ( e.g. , disclosed the nature , benefits , risks , and outcomes ) , addressed the patients ’ values , and attended to the patients ’ emotional concerns . MAIN RESULTS : The physicians often did not provide essential information about  cardiopulmonary resuscitation ( CPR ) . While all the physicians mentioned mechanical ventilation , only 55 % mentioned chest compressions and 32 % mentioned intensive care . Only 13 % of the physicians mentioned the patient ’s likelihood of survival after CPR , and no physician used a numerical estimate . The discussion s lasted a median of 10 minutes and were dominated in speaking time by the physicians . The physicians initiated discussion s about the patients ’ personal values and goals of care in 10 % of the cases , and missed opportunities to do so . CONCLUSIONS : Medical ethicists , professional societies , and the public recommend more frequent discussion s about DNR orders . Even when housestaff discuss resuscitation with patients , they may not be accomplishing the goal of increasing patient autonomy . Research and education must focus on improving the quality , as well as the quantity , of these discussion Objective : To evaluate the effect of an intervention on the underst and ing and use of DNR orders by physicians ; to assess the impact of underst and ing the importance of involving competent patients in DNR decisions . Design : Prospect i ve clinical interventional study . Setting : Internal medicine department ( 70 beds ) of the hospital of La Chaux-de-Fonds , Switzerl and . Participants : Nine junior physicians in postgraduate training . Intervention : Information on the ethics of DNR and implementation of new DNR orders . Measurements and main results : Accurate underst and ing , interpretation , and use of DNR orders , especially with respect to the patients ’ involvement in the decision were measured . Junior doctors writing DNR orders had an extremely poor underst and ing of what DNR orders mean . The correct underst and ing of the definition of a DNR order increased from 31 to 93 % ( p<0.01 ) after the intervention and the patients ’ involvement went from 17 % to 48 % ( p<0.01 ) . Physicians estimated that 75 % of their DNR patients were mentally competent at the time of the decision . Conclusion : An intervention aim ed at explaining the ethical principles and the definition of DNR orders improves underst and ing of them , and their implementation , as well as patient participation . Specific efforts are needed to increase the involvement of  mentally competent patients  in the decision PURPOSE To evaluate the effectiveness of binary content checklists in measuring increasing levels of clinical competence . METHOD Fourteen clinical clerks , 14 family practice residents , and 14 family physicians participated in two 15-minute st and ardized patient interviews . An examiner rated each participant 's performance using a binary content checklist and a global process rating . The participants provided a diagnosis two minutes into and at the end of the interview . RESULTS On global scales , the experienced clinicians scored significantly better than did the residents and clerks , but on checklists , the experienced clinicians scored significantly worse than did the residents and clerks . Diagnostic accuracy increased for all groups between the two-minute and 15-minute marks without significant differences between the groups . CONCLUSION These findings are consistent with the hypothesis that binary checklists may not be valid measures of increasing clinical competence ABSTRACT BACKGROUND The quality of code status discussion s ( CSDs ) is suboptimal as physicians often fail to discuss patients ’ goals of care and resuscitation outcomes . We previously demonstrated that internal medicine residents r and omized to a communication skills intervention  scored higher than controls on a CSD checklist using a st and ardized patient . However , the impact of this training on CSD content is unknown . OBJECTIVE Compare CSD content between intervention and control residents . DESIGN We conducted qualitative analysis of simulated CSDs . Augmenting a priori codes with constant comparative analysis , we identified key themes associated with resident determination of code status . We dichotomized each theme as present or absent . We used chi-square tests to evaluate the association between training and presence of each theme . PARTICIPANTS Fifty-six residents rotating on the internal medicine service in July 2010 were r and omized to intervention ( n = 25 ) or  control ( n = 31).INTERVENTIONIntervention residents completed CSD skills training ( lectures , deliberate practice , and self- study ) . Six months later , all 56 residents completed a simulated CSD.MAIN MEASUREComparison of key themes identified in CSDs among intervention and controls . KEY RESULTS Fifty-one transcripts were recorded and review ed . Themes identified included : exploration of patient values/ goals , framing code status as a patient decision , discussion of resuscitation outcomes and quality of life , and making a recommendation regarding code status . Intervention residents were more likely than controls to explore patient values/ goals ( p = 0.002 ) and make a recommendation ( p < 0.001 ) ; and less likely to frame the decision as one solely to be made by the patient ( p = 0.01 ) . Less than one-third of residents discussed resuscitation outcomes or quality of life . CONCLUSION Training positively influenced CSD content in key domains , including exploration of patient values/ goals , making a recommendation regarding code status , and not framing code status as solely a patient decision . However , despite the intervention , residents infrequently discussed resuscitation outcomes and quality of life Discussing end-of-life decisions with cancer patients is a crucial skill for physicians . This article reports findings from a pilot study evaluating the effectiveness of a computer-based decision aid for teaching medical students about advance care planning . Second-year medical students at a single medical school were r and omized to use a st and ard advance directive or a computer-based decision aid to help patients with advance care planning . Students ' knowledge , skills , and satisfaction were measured by self-report ; their performance was rated by patients . 121/133 ( 91 % ) of students participated . The Decision-Aid Group ( n = 60 ) outperformed the St and ard Group ( n = 61 ) in terms of students ´ knowledge ( p < 0.01 ) , confidence in helping patients with advance care planning ( p < 0.01 ) , knowledge of what matters to patients ( p = 0.05 ) , and satisfaction with their learning experience ( p < 0.01 ) . Likewise , patients in the Decision Aid Group were more satisfied with the advance care planning method ( p < 0.01 ) and with several aspects of student performance . Use of a computer-based decision aid may be an effective way to teach medical students how to discuss advance care planning with cancer patients BACKGROUND Internal medicine residents are largely unprepared to carry out end-of-life ( EOL ) conversations . There is evidence that these skills can be taught , but data from r and omized controlled trials are lacking . PURPOSE We studied whether a day-long communication skills training retreat would lead to enhanced performance of and confidence with specific EOL conversations . We also studied the effect of the retreat on residents ' ability to respond to patient emotions . METHODS PGY-2 resident volunteers were r and omly assigned to a retreat group or a control group . The retreat involved a combination of teaching styles and skills practice with st and ardized patients . All participants completed question naires and were evaluated carrying out two types of conversations ( breaking bad news or discussing direction of care ) with a st and ardized patient before ( T1 ) and after ( T2 ) the intervention phase . Conversations were audio-taped and later rated by a research er blinded to group assignment and time of assessment . RESULTS Forty-nine residents agreed to r and omization ( 88 % ) with 23 residents r and omized to the retreat group and 26 to the control group . Compared to controls , retreat participants demonstrated higher T2 scores for breaking bad news , discussing direction of care , and responding to emotion . Comparing T2 to T1 , the retreat group 's improvement in responding to emotion was statistically significant . The retreat group 's confidence improved significantly only for the breaking bad news construct . CONCLUSIONS A short course for residents can significantly improve specific elements of resident EOL conversation performance , including the ability to respond to emotional cues IMPORTANCE Communication about end-of-life care is a core clinical skill . Simulation-based training improves skill acquisition , but effects on patient-reported outcomes are unknown . OBJECTIVE To assess the effects of a communication skills intervention for internal medicine and nur 
    Output:
    
Conclusion Very low to low quality evidence suggests that end-of-life communication training may improve  healthcare professionals ’ self-efficacy , knowledge , and EoL communication scores compared to usual teaching .