P0542 - Holding Presence and Moving Forward: Pediatric Residents Lived Experience Providing Care for Dying Children

Background: Pediatric residents receive little formal training in the care of a dying patient and report feeling unprepared for this experience, despite recommendations from the American Academy of Pediatrics and other professional organizations that all pediatricians be trained in palliative care skills. This has negative effects on both the quality of end-of-life (EOL) care provided and resident wellbeing. Most published curricula address knowledge and skill gaps, and may overlook factors in the clinical environment that either empower or hinder residents from integrating skills into practice. The purpose of this study was to characterize the lived experience of pediatric residents caring for a dying patient to understand the impact of emotional, cultural, hierarchical and logistical factors on the clinical learning environment.

Methods: Pediatric residents or recent graduates with at least one experience caring for a dying patient were interviewed between June 2019 and February 2020. During a one-on-one, semi-structured interview, residents were asked to describe their most memorable experience(s) caring for a dying patient. Subsequent questions explored the resident’s (1) comfort, knowledge, and skills in EOL care, (2) emotional experience and coping, (3) role within the interdisciplinary team, and (4) perspective on how the experience could be improved. Initially, four coders reviewed all transcribed interviews using thematic content analyses. After initial codebook development, each transcript was coded by two investigators independently and reconciled; the full team adjudicated all discrepancies. Final themes were identified by consensus. Investigator team included three palliative medicine physicians, one palliative care social worker, and two health services researchers with expertise in palliative care and qualitative methods.

Results: Participants (n=8) found caring for dying patients intensely emotional and memorable. They coped with this through connection with the patient/family; finding support from their own community including family, friends outside of medicine and co-residents; and engaging in self-care activities. Many residents found it helpful to focus on areas of personal agency, particularly in their role providing presence and continuity. Conversely, residents were distressed by domains perceived to be outside of their control, such as complex medical decision making; perceived poor communication or mixed messages from the team; and logistical barriers related to the complexity of the overall medical system. Residents learned by observation, rather than through formal teaching sessions. Residents felt that more frequent team debriefing after intense experiences with dying patients would improve their experience.

Conclusions: The resident experience of caring for a dying patient is intense. The educational environment may be improved by better acknowledging the challenging aspects of EOL care, proactively incorporating debriefing sessions into clinical workflow, and enhancing opportunities for resident agency.