Improving communication on ceilings of treatment among junior doctors: a pilot study on the introduction of a structured 5C framework

The coronavirus (COVID-19) pandemic has led to a global surge in mortality which is more apparent in the older and comorbid population. A quarter of COVID-19 hospital admissions died in the hospital over a 13-month period as shown in an observation study in England.(1) With intense pressure during pandemic, this has placed even a greater retrospective scrutiny on the decision-making of 'Do not attempt cardiopulmonary resuscitation (DNACPR) and its compliance with the legal and ethical frameworks.(2) This project aims to introduce a structured 5C framework (context, capacity, consultation, clear documentation and communication) as an aid to support decision-making where ceilings of treatment are being considered and enhance effective communication skills among junior doctors. A written questionnaire was distributed among foundation year (FY) doctors in North Wales to gather a baseline understanding on their knowledge on the All Wales DNACPR policy and advanced care planning and their confidence level about having conversation surrounding ceilings of treatment. Subsequently, we conducted a communication training workshop for the FY doctors. Complex simulated case studies were used for discussion, incorporating the practicability of using the 5C framework. Feedback was collected after the workshop to evaluate their knowledge and confidence level. A total of 27 responses were collected from the baseline questionnaire. Of the 27 responses, more than 60% said they were not familiar with the All Wales DNACPR policy and principles of advance care planning. A quarter said they did not receive formal training in DNACPR discussion. Only one-third feel confident to have conversation on DNACPR and ceilings of treatment with patient and their carers. There were 30 junior doctors attended communication workshop. All 30 of them completed the feedback following the training. There was a significant improvement (more than 90%) in their confident level. All of them felt that the 5C framework was concise and relevant to their training. The 5C framework has overall demonstrated a positive impact in improving communication skills and confidence level among junior doctors. Further learning package in the form of simulated case studies could be developed to enhance complex communication skills among junior doctors.