ORIGINAL REPORTS Resident Education and Management of End-of-Life Care: The Resident’s Perspective Zara Cooper, MD,* Michael Meyers, BS,* Nancy L. Keating, MD, † Xiangmei Gu, MS,* Stuart R. Lipsitz, ScD,* and Selwyn O. Rogers, MD* *Center for Surgery and the Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts and † Division of Health Policy, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts BACKGROUND: Twenty percent of Americans die in the intensive care unit of our nation’s hospitals. Many of those individuals die after life-sustaining therapy has been withdrawn or withheld. Surgeons should be competent in discussing the withholding and withdrawal of life sustaining therapy (WWLST) with their patients. We surveyed surgical residents to learn their perspectives and training experience with discuss- ing end-of-life care and WWLST with patients. METHODS: We mailed a survey to residents in all accredited surgical residency programs in New England. Nonresponders were contacted by mail at 3 and 6 weeks after the initial mailing. RESULTS: Nineteen of 20 (95%) programs participated in this study. Three hundred thirty-five residents were surveyed and 141 residents responded (response rate, 42%). Ninety-two percent (n = 129) of respondents had cared for patients where WWLST had occurred, and 74% (n = 104) had initiated a discussion about WWLST themselves. Most (n = 81, 60%) respondents felt competent to discuss WWLST, whereas 14% rarely (n = 13) or never (n = 6) felt comfortable discussing WWLST. Most (n = 119, 85%) respondents believed that they would be adequately trained at the end of their residencies; however, 39% (n = 53) felt they were inadequately trained in this area. Graduates before 2002 were significantly more likely to agree strongly or generally that they would be well trained in managing WWLST when they completed residency (p = 0.006). CONCLUSION: Almost all surgical residents will have to dis- cuss WWLST with patients and their families, yet a significant number feel inadequately trained to do so. Steps should be taken to ensure that surgical residents can discuss WWLST as part of their core competencies, and this training should be reinforced throughout residency. (J Surg 67:79-84. © 2010 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: end-of-life care, withdrawal of life-sustaining therapy, resident survey, communication training COMPETENCIES: Professionalism, Interpersonal and Com- munications skills, Systems Based Practice BACKGROUND Despite advances in critical care, the structural organization of intensive care units, and improved technology, death is a common outcome for patients after surgery or trauma and for those receiving intensive care. Twenty percent of patients die in the intensive care unit and up to 30% die within 12 months of an intensive care unit stay. 1 Deaths in the inten- sive care unit are often preceded by withholding or with- drawing of life-sustaining therapy (WWLST). 2 As older pa- tients with chronic illness use surgical services, surgeons find themselves caring for more chronically ill patients in whom a previous state of relative health is disrupted by a surgical emer- gency, followed by a postoperative course marked by unfore- seen complications and a precipitous decline. It is increasingly important for surgeons to manage terminally ill patients and discuss redirecting care from cure to comfort. Effective commu- nication and interpersonal skills have been recognized as core competencies, which residents should master during their train- ing. 3 The American College of Surgeons and the American Board of Surgery have set the expectation that surgeons should be knowledgeable about end-of-life issues. 4,5 Variation exists in how physicians manage end-of-life care. 6 Poorly managed disclosures have been associated with unfavor- able outcomes, such as depression and maladjustment in family members of dying patients. 7 In most of our teaching hospitals where surgical residents are trained, residents interface with patients and families in these difficult moments. Discussions about advanced directives, WWLST, and the implementation of do-not-resuscitate orders are imperative to Correspondence: Inquiries to Zara Cooper, MD, MSc, Center for Surgery and the Public Health, Department of Surgery, Brigham and Women’s Hospital, 75 Francis Street, Bos- ton, MA 02115; fax: (617) 566-9549; e-mail: zcooper@partners.org Journal of Surgical Education • © 2010 Association of Program Directors in Surgery 1931-7204/$30.00 Published by Elsevier Inc. All rights reserved. doi:10.1016/j.jsurg.2010.01.002 79