Journal of Education and Teaching in Emergency Medicine

Audience: This module was developed for emergency medicine (EM) residents, though may also be used for medical students on an emergency medicine clerkship or attending physicians.

Length of Curriculum: This frailty and end-of-life care module consists of two 60-minute small group sessions. 

Introduction: Emergency medicine physicians often care for patients with significant comorbidities, physical frailty, and acute and chronic life-limiting conditions, including those at end-of-life. Over 60% of emergency department (ED) patients older than 65 years old meet established criteria for physical frailty, and at least half of older adults present to the ED in their final month of life.^1,2 Therefore, it is critical that EM physicians understand end-of-life trajectories and adopt a thoughtful approach to end-of-life communication, clinical decision-making and symptom management to support both patients and their caregivers.³ To address this need, we developed a flipped-classroom case-based small group discussion session for emergency medicine learners that augments self-learning, followed by a small group discussion with peers. 

Educational Objectives: At the end of this module, learners should be able to: 1) recognize and classify end-of-life trajectories, 2) define physical frailty, including risk factors, prevalence and prognosis in ED patients, 3) develop a differential diagnosis and diagnostic and treatment plan for a patient with metastatic cancer presenting with fatigue, constipation, labile mood, and diffuse osseous pain, 4) review Medicare Hospice Benefit eligibility, 5) understand the differential diagnosis and medical management of chemotherapy-related nausea, 6) discuss the assessment and management of dyspnea in end-of-life patients, and 7) review how to estimate and communicate prognosis using practical timeframes.

Educational Methods: This exercise consists of two 60-minute small group sessions (two clinical cases per session) using a “flipped classroom” design.^4–20 The facilitator should distribute the learner responsible content one week in advance. Learners are instructed to complete the assigned readings and review four cases to prepare for an in-person discussion guided by the facilitator. Questions are included to guide their learning and structure the subsequent discussion. The facilitator uses the Physical Frailty and End-of-Life Care Preceptor Notes, which is organized around the handout questions, to stimulate discussion and answer questions.

Research Methods: Learners evaluated the content using end-of-session anonymous feedback forms. Faculty small-group facilitators assessed learner participation.

Results: We received open-ended responses from 11 learners. All felt the workload to prepare for the small-group session was reasonable and beneficial to their residency education. Some respondents requested additional sessions to discuss personal and/or difficult patient care experiences based on this “bite-sized” introduction to frailty and end-of-life care. 

Discussion: Overall, this split two-hour flipped classroom educational activity was an effective method to introduce the concept of frailty and end-of-life care to emergency medicine residents. Following the initial session, the authors added an additional case to expand the curriculum into two sessions to allow more time for free-form discussion.

Topics: Emergency medicine, flipped classroom, medical education, teaching, end-of-life, frailty, hospice, palliative care, terminal dyspnea, malignant hypercalcemia, chemotherapy-induced nausea.