End-of-life communication in the intensive care unit

Live Well, Die Well: The Development of an Online, Arts-Based Palliative Care Programme in the Shadow of the COVID-19 Pandemic

The Covid-19 crisis led to an increase in the 'total pain' of many terminally ill patients who faced a reduction in support, due to the temporary closure of front-line palliative day therapy services. A hospice volunteer, I instigated an online day therapy programme for patients previously attending face-to-face day therapy. Participant feedback revealed the importance of providing a space for ongoing peer support for participants' changing sense of identity, an issue for time-limited day therapy programmes. An exploration of key concepts associated with palliative care established the multiple connections between such changing identity and arts-based approaches to living well. This article charts how I used this understanding to develop an alternative, online arts-based support programme, Live well, die well. It explores the links between ongoing mutual support, arts-based activity and the reactions to a shifting identity in patients with a life-limiting illness.

Role of patients' family members in end-of-life communication: an integrative review

OBJECTIVES

To synthesise empirical findings on the role of family in end-of-life (EOL) communication and to identify the communicative practices that are essential for EOL decision-making in family-oriented cultures.

SETTING

The EOL communication settings.

PARTICIPANTS

This integrative review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline. Relevant studies published between 1 January 1991 and 31 December 2021 were retrieved from four databases, including the PsycINFO, Embase, MEDLINE and Ovid nursing databases, using keywords with meanings of 'end-of-life', 'communication' and 'family'. Data were then extracted and coded into themes for analysis. The search strategy yielded 53 eligible studies; all 53 included studies underwent quality assessment. Quantitative studies were evaluated using the Quality Assessment Tool, and Joanna Briggs Institute Critical Appraisal Checklist was used for qualitative research.

PRIMARY AND SECONDARY OUTCOME MEASURES

Research evidence on EOL communication with a focus on family.

RESULTS

Four themes emerged from these studies: (1) conflicts in family decision-making in EOL communication, (2) the significance of timing of EOL communication, (3) difficulty in identification of a 'key person' who is responsible for decisions regarding EOL care and (4) different cultural perspectives on EOL communication.

CONCLUSIONS

The current review pointed towards the importance of family in EOL communication and illustrated that family participation likely leads to improved quality of life and death in patients. Future research should develop a family-oriented communication framework which is designed for the Chinese and Eastern contexts that targets on managing family expectations during prognosis disclosure and facilitating patients' fulfilment of familial roles while making EOL decision-making. Clinicians should also be aware of the significance of the role of family in EOL care and manage family members' expectations according to cultural contexts.

How to communicate with family members of the critically ill in the intensive care unit: A scoping review

OBJECTIVE

To map the existing approaches to communication with family members of the critically ill in the intensive care unit and the corresponding implementation requirements and benefits.

METHODS

We conducted a scoping review in February 2022 by searching PubMed, CINAHL, APA PsycINFO, and Cochrane Library for articles published between 2000 and 2022. We included records of all designs that met our inclusion criteria and applied frequency counts and qualitative coding.

RESULTS

The search yielded 3749 records, 63 met inclusion criteria. The included records were of an interventional (43 %) or observational (14 %) study design or review articles (43 %), and provided information in three categories: communication platforms, strategies, and tools. For implementation in the intensive care unit, the approaches required investing time and resources. Their reported benefits were an increased quality of communication and satisfaction among all parties involved, improved psychological outcome among family members, and reduced intensive care unit length of stay and costs.

CONCLUSION

The current approaches to communication with patients' family members offer insights for the development and implementation of communication pathways in the intensive care unit of which the benefits seem to outweigh the efforts. Structured interprofessional frameworks with standardised tools based on empathic communication strategies are encouraged.

Development and feasibility of a communication training to assist caregivers with advanced care planning

OBJECTIVE

Caregivers are critical in advanced care planning (ACP) discussions, which are difficult but necessary to carry out patients' goals of care. We developed and evaluated the feasibility and acceptability of a communication training to equip caregivers of patients with malignant brain tumors with skills to navigate ACP conversations.

METHOD

Caregivers completed a 2-h virtual training addressing ACP Discussions with Your Loved One and ACP Discussions with the Medical Team. A pre-training assessment was completed at baseline and a training evaluation was completed one day post-training. A subset of participants completed semi-structured interviews 2 months post-training.

RESULTS

Of 15 caregivers recruited, 9 attended the training and 4 completed qualitative interviews. Post-training, 40% felt confident in discussing ACP with loved ones and 67% felt confident doing so with healthcare professionals; 100% reported feeling confident in using skills learned in the training to facilitate these conversations. Data from qualitative interviews highlighted additional benefits of the training in empathic communication skills and fostering social support.

SIGNIFICANCE OF RESULTS

Our communication skills training shows promise in supporting caregivers' skills and confidence in engaging in ACP discussions with patients and healthcare providers. A future randomized controlled trial with a larger and more diverse caregiving sample is needed to determine training efficacy.

Withholding or withdrawing life support in long-term neurointensive care patients: a single-centre, prospective, observational pilot study

PURPOSE

Scarce evidence exists regarding end-of-life decision (EOLD) in neurocritically ill patients. We investigated the factors associated with EOLD making, including the group and individual characteristics of involved healthcare professionals, in a multiprofessional neurointensive care unit (NICU) setting.

MATERIALS AND METHODS

A prospective, observational pilot study was conducted between 2013 and 2014 in a 10-bed NICU. Factors associated with EOLD in long-term neurocritically ill patients were evaluated using an anonymised survey based on a standardised questionnaire.

RESULTS

8 (25%) physicians and 24 (75%) nurses participated in the study by providing their 'treatment decisions' for 14 patients at several time points. EOLD was 'made' 44 (31%) times, while maintenance of life support 98 (69%) times. EOLD patterns were not significantly different between professional groups. The individual characteristics of the professionals (age, gender, religion, personal experience with death of family member and NICU experience) had no significant impact on decisions to forgo or maintain life-sustaining therapy. EOLD was patient-specific (intraclass correlation coefficient: 0.861), with the presence of acute life-threatening disease (OR (95% CI): 18.199 (1.721 to 192.405), p=0.038) and low expected patient quality of life (OR (95% CI): 9.276 (1.131 to 76.099), p=0.016) being significant and independent determinants for withholding or withdrawing life-sustaining treatment.

CONCLUSIONS

Our findings suggest that EOLD in NICU relies mainly on patient prognosis and not on the characteristics of the healthcare professionals.

How doctors actually (do not) involve families in decisions to continue or discontinue life-sustaining treatment in neonatal, pediatric, and adult intensive care: A qualitative study

BACKGROUND

Intensive care doctors have to find the right balance between sharing crucial decisions with families of patients on the one hand and not overburdening them on the other hand. This requires a tailored approach instead of a model based approach.

AIM

To explore how doctors involve families in the decision-making process regarding life-sustaining treatment on the neonatal, pediatric, and adult intensive care.

DESIGN

Exploratory inductive thematic analysis of 101 audio-recorded conversations.

SETTING/PARTICIPANTS

One hundred four family members (61% female, 39% male) and 71 doctors (60% female, 40% male) of 36 patients (53% female, 47% male) from the neonatal, pediatric, and adult intensive care of a large university medical center participated.

RESULTS

We identified eight relevant and distinct communicative behaviors. Doctors' sequential communicative behaviors either reflected consistent approaches-a shared approach or a physician-driven approach-or reflected vacillating between both approaches. Doctors more often displayed a physician-driven or a vacillating approach than a shared approach, especially in the adult intensive care. Doctors did not verify whether their chosen approach matched the families' decision-making preferences.

CONCLUSIONS

Even though tailoring doctors' communication to families' preferences is advocated, it does not seem to be integrated into actual practice. To allow for true tailoring, doctors' awareness regarding the impact of their communicative behaviors is key. Educational initiatives should focus especially on improving doctors' skills in tactfully exploring families' decision-making preferences and in mutually sharing knowledge, values, and treatment preferences.

The burden they bear: A scoping review of physician empathy in the intensive care unit

PURPOSE

Research shows that physician empathy can improve patients' reporting of symptoms, participation in care, compliance, and satisfaction; however, success in harnessing these advantages in the ICU hinges on a myriad of contextual factors. This study describes the current state of knowledge about intensivists' empathy.

METHODS

A scoping review was conducted across six databases and grey literature to clarify intensivists' experiences of empathy and identify directions of future inquiries. The search had no date limits and was specific to empathy, intensivists, and ICU environments. Results were blindly and independently reviewed by authors.

RESULTS

The search yielded 628 manuscripts; 45 met inclusion criteria. Three overarching themes connected the manuscripts: (1) the risks and benefits of empathy, (2) the spectrum of connection and distance of intensivists from patients/families, and (3) the facilitators and barriers to empathy's development.

CONCLUSION

Empathy among intensivists is not a dichotomous phenomenon. It instead exists on continua. Four steps are recommended for optimizing empathy in the ICU: clearly defining empathy, addressing risks and benefits transparently, providing education regarding reflective practice, and developing supportive environments. Overall, this review revealed that the state of knowledge about empathy as experienced by intensivists still has room to grow and be further explored.

The Difficult Balance between Ensuring the Right of Nursing Home Residents to Communication and Their Safety

The COVID-19 epidemic has had a profound impact on healthcare systems worldwide. The number of infections in nursing homes for the elderly particularly is significantly high, with a high mortality rate as a result. In order to contain infection risks for both residents and employees of such facilities, the Italian government passed emergency legislation during the initial stages of the pandemic to restrict outside visitor access. On 30 November 2020, the Italian President of the Council of Ministers issued a new decree recognizing the social and emotional value of visits to patients from family and friends. In addition, it indicated prevention measures for the purposes of containing the infection risk within nursing homes for the elderly. This article comments on these new legislative provisions from the medicolegal perspective, providing indications that can be used in clinical practice.

"Managing uncertainty": Experiences of family members of burn patients from injury occurrence to the end-of-life period

BACKGROUND

Although mortality rates associated with burns have decreased, there is still a significant number of persons who may not survive severe forms of the injury and thus, undergo comfort/end of life care. The experiences of family members of persons whose injuries are deemed unsurvivable remain minimally explored and there is a general lack of practice guidelines and recommendations to support them at the end-of-life period.

AIM

To explore the experiences of family members whose relatives died in the burn unit to inform the development of practice recommendations.

METHODS

Qualitative description was employed for this study. Convenience sampling was used to recruit 23 family members of injured persons who died in the burn unit. Face to face semi-structured interviews were conducted and followed up with telephone interviews. The interviews were audio-recorded, transcribed verbatim and thematic analysis performed inductively.

RESULTS

Three themes emerged: reactions following injury occurrence, navigating through the experience, and managing uncertainties about survival. The sudden nature of the injury led to feelings of self-blame, guilt, helplessness, and grief and these escalated at the end of life. As the family members journeyed through their uncertainties regarding the outcomes of care, they had a feeling of being a part of the patient's suffering. Family members received little professional support in coming to terms with their loss in the post-bereavement period.

CONCLUSIONS

Family members experience distress following the occurrence of burns and at the endof-life period. Practice recommendations should focus on communication, bereavement, and post-bereavement support.

Critical Care Nurses’ Experiences of End-of-Life Care: A Qualitative Study

Background: Patients admitted to the intensive care unit (ICU) may face terminal illness situations, which may lead to death. In this case, the role of critical care nurses shifts from life-sustaining to end-of-life care (EOLC). Nurses’ involvement in EOLC varies between countries, even in one country due to differences in religion, culture, organization, laws, cases and patient quality. In Indonesia, research on EOLC in ICU has not been carried out.Purpose: This study aimed to explore the experiences of critical care nurses in providing EOLC.Methods: A qualitative study with a phenomenological approach was conducted. Ten critical care nurses having the experiences of caring for dying patients were recruited through a purposive sampling technique for in-depth interviews. Manual content analysis was used to identify themes.Results: The results of the study found five themes, including the challenge of communication with the family, support for the family, support for the patient, discussion and decision making, and nurses’ emotions. Conclusion: Most of EOLC provided by critical care nurses was focused on the family. They had some challenges in communication and decision making. Nurses need to get training and education about how to care for patients towards the end of life.

Nurse-facilitated reflective exercise post patient death in the ICU: a best practice implementation project

INTRODUCTION

ICUs are stressful environments where patient care is complex and demanding; death is not an unusual outcome. Nurses can become emotionally distressed from experiencing multiple, unexpected, or traumatic patient deaths. Performing a reflective exercise immediately post death is one coping strategy which encourages healthcare staff and family to debrief their feelings in a timelier manner.

OBJECTIVES

The aim of this project was to educate the nurses in the ICU with emotional coping skills pertaining to the effects of patient deaths. The objective was to implement a nurse-guided reflective exercise following each patient death in three adult ICUs in a quaternary academic medical center.

METHODS

The current change project used the Joanna Briggs Institute's Getting Research into Practice and Practical Application of Clinical Evidence Systems for auditing and strategy development. After standardizing the reflective exercise procedure, teaching methods were employed to support implementation. One follow-up audit measured compliance with completing a reflective exercise for all deaths occurring in the three ICUs. Contextual data were collected for completed exercises including type of death and words to describe nurses' emotions.

RESULTS

The reflective exercise script was revised and the standard procedure posted to the intranet for easy access. All ICU nurses received education on the use of this reflective exercise. For each of the two ICUs where this practice was new, compliance with nurses initiating and completing a reflective exercise was at a rate of 17 and 2%, respectively. For the ICU where reflective exercise was reintroduced, compliance was 30%. All deaths included in this study were anticipated (e.g., patient on comfort care) and calm, with the exception of one post cardiac arrest death.

CONCLUSION

Despite multipronged teaching for why, when, and how to use reflective exercise, there was minimal success in completing reflective exercises in the two units where the practice was new. This outcome was most likely due to higher than anticipated levels of needed support or the unpredictability of frequency of deaths on each unit. However, the main achievement was having the Minute of Silence procedure with a standardized script readily available at all times for nursing staff. Reimplementation success in the other ICU was attributed to more recently established reflective practices. Further exploration of barriers, such as type of death, and re-education are essential strategies to bolster and sustain practice and to provide support for our nursing staff to prevent emotional distress.

How to communicate with families living in complete isolation

IMPORTANCE

During the SARS-CoV-2 pandemic, a complete physical isolation has been worldwide introduced. The impossibility of visiting their loved ones during the hospital stay causes additional distress for families: in addition to the worries about clinical recovery, they may feel exclusion and powerlessness, anxiety, depression, mistrust in the care team and post-traumatic stress disorder. The impossibility of conducting the daily meetings with families poses a challenge for healthcare professionals.

OBJECTIVE

This paper aims to delineate and share consensus statements in order to enable healthcare team to provide by telephone or video calls an optimal level of communication with patient's relatives under circumstances of complete isolation.

EVIDENCE REVIEW

PubMed, Cochrane Database of Systematic Reviews, Database of Abstracts and Reviews of Effectiveness and the AHCPR Clinical Guidelines and Evidence Reports were explored from 1999 to 2019. Exclusion criteria were: poor or absent relevance regarding the aim of the consensus statements, studies prior to 1999, non-English language. Since the present pandemic context is completely new, unexpected and unexplored, there are not randomised controlled trials regarding clinical communication in a setting of complete isolation. Thus, a multiprofessional taskforce of physicians, nurses, psychologists and legal experts, together with some family members and former intensive care unit patients was established by four Italian national scientific societies. Using an e-Delphi methodology, general and specific questions were posed, relevant topics were argumented, until arriving to delineate position statements and practical checklist, which were set and evaluated through an evidence-based consensus procedure.

FINDINGS

Ten statements and two practical checklists for phone or video calls were drafted and evaluated; they are related to who, when, why and how family members must be given clinical information under circumstances of complete isolation.

CONCLUSIONS AND RELEVANCE

The statements and the checklists offer a structured methodology in order to ensure a good-quality communication between healthcare team and family members even in isolation, confirming that time dedicated to communication has to be intended as a time of care.

Reduction in Potentially Inappropriate Interventions in Trauma Patients following a Palliative Care Consultation

Background: Palliative care is expanding as part of treatment, but remains underutilized in trauma settings. Palliative care consultations (PCC) have shown to reduce nonbeneficial, potentially inappropriate interventions (PII), as decision for their use should always be made in the context of both the patient's prognosis and the patient's goals of care. Objective: To characterize trauma patients who received PCC and to analyze the effect of PCC and do-not-resuscitate (DNR) orders on PII in severely injured patients. Setting/Subjects: Retrospective cohort study of 864 patients admitted to two level 1 trauma centers: 432 patients who received PCC (PCC group) were compared with 432 propensity score match-controlled (MC group) patients who did not receive PCC. Measurements: PCC in a consultative palliative care model, PII (including tracheostomy and percutaneous endoscopic gastrostomy) rate and timing, DNR orders. Results: PCC rate in trauma patients was 4.3%, with a 5.3-day average time to PCC. PII were done in 9.0% of PCC and 6.0% of MC patients (p = 0.09). In the PCC group, 74.1% of PII were done before PCC, and 25.9% after. PCC compared with MC patients had significantly higher mechanical ventilation (60.4% vs. 18.1%, p < 0.001) and assisted feeding requirements (14.1% vs. 6.7%, p < 0.001). We observed a statistically significant reduction in PII after PCC (p = 0.002). Significantly less PCC than MC patients had PII following DNR (26.3% vs. 100.0%, p = 0.035). Conclusions: PCC reduced PII in severely injured trauma patients by factor of two. Since the majority of PII in PCC patients occurred before PCC, a more timely administration of PCC is recommended. To streamline goals of care, PCC should supplement or precede a DNR discussion.

[Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients in the coronavirus disease (COVID-19)]

On March 11, 2020, the Director-General of the World Health Organization (WHO) declared the disease caused by SARS-CoV-2 (COVID-19) as a pandemic. The spread and evolution of the pandemic is overwhelming the healthcare systems of dozens of countries and has led to a myriad of opinion papers, contingency plans, case series and emerging trials. Covering all this literature is complex. Briefly and synthetically, in line with the previous recommendations of the Working Groups, the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC) has prepared this series of basic recommendations for patient care in the context of the pandemic.

Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients in the coronavirus disease (COVID-19)

On March 11, 2020, the Director-General of the World Health Organization (WHO) declared the disease caused by SARS-CoV-2 (COVID-19) as a pandemic. The spread and evolution of the pandemic is overwhelming the healthcare systems of dozens of countries and has led to a myriad of opinion papers, contingency plans, case series and emerging trials. Covering all this literature is complex. Briefly and synthetically, in line with the previous recommendations of the Working Groups, the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC) has prepared this series of basic recommendations for patient care in the context of the pandemic.

Navigating the Transition from Advanced Illness to Bereavement: How Provider Communication Informs Family-related Roles and Needs

Person-centered, family-oriented services are integral to palliative and end-of-life care. Effective communication with providers informs the quality of the dying experience for patients and how families fare in bereavement. This paper reports findings from a study exploring how communication and care in the later stages of an advanced illness influence family caregivers' well-being in bereavement. A concurrent triangulation design was used to analyze data collected during semi-structured interviews with 108 recently bereaved caregivers from a single hospice agency in Western New York. Findings from this study suggest that family caregivers assume the role of interpreter and advocate while engaged in both formal and informal communication with health care providers at the end of care-recipients' lives. Findings also suggest that families are more likely to feel emotionally prepared for loss and grief when health care providers are available to communicate in a concise, consistent, and compassionate manner. The results illuminate the important connection between communication during the transition from late-stage illness to end-of-life care and preparation for bereavement. The paper concludes with a discussion of how findings from this study align with recent concerted efforts to establish standards and competencies for social work education and practice in palliative care.

European Psychiatric Association policy paper on ethical aspects in communication with patients and their families

BACKGROUND

Establishing a valid communication is not only a basic clinical need to be met but also a relevant ethical commitment.

METHODS

On the basis of the relevant literature, ethical issues arising from specific, important situations in clinical practice were identified.

RESULTS

The main ethical problems regarding communication about the disorder, both in general and in relation to prodromal stages, were described and discussed together with those regarding communication about voluntary and involuntary treatments, "dual roles" enacted in clinical practice, genetic counseling, and end-of-life conditions; on the basis of what emerged, ethically driven indications and suggestions were provided.

CONCLUSIONS

Several situations put the psychiatrist in front of relevant dilemmas and doubts which are no easy to face with; an ethically driven approach based upon the principle of the best interest of patients may support clinicians in their decisions.

COMSKIL Communication Training in Oncology-Adaptation to German Cancer Care Settings

Medical communication is a skill which can be learned and taught and which can substantially improve treatment outcomes, especially if patients' communication preferences are taken into account. Here, we give an overview of communication training research and outline the COMSKIL program as a state-of-the-art communication skills training in oncology. COMSKIL has a solid theoretical foundation and teaches core elements of medical communication in up to ten fully operationalized modules. These address typical situations ranging from breaking bad news to responding to difficult emotions, shared decision-making, and communicating via interpreters.

Surrogates' Perceptions of Service Quality While Making Decisions for ICU Patients

A qualitative secondary analysis was undertaken to identify aspects of health care service quality in an intensive care unit from the perspective of surrogate decision makers (N = 19) who were making decisions for relatives at end of life. Directed content analysis was guided by the Donabedian model of health care quality. Nineteen participants averaged 59 years old and were over half female (53%) and patients' spouses (53%) and adult children (32%). Salient aspects of quality service included surrogate perceptions that clinicians conveyed honesty about the patient's condition and in an easily understandable way; staff were sensitive and responsive to emotions and practical needs; clinicians demonstrated a clear, confident understanding of the patient's condition; and support by clinicians was given for surrogates' choices. Surrogates also commented on the hospital and intensive care unit environment, including cleanliness, comfort, privacy, and noise level. Further research is needed to explore how decision-support strategies might include service quality concepts.

Are Health-Care Providers Well Prepared in Providing Optimal End-of-Life Care to Critically Ill Patients? A Cross-Sectional Study at a Tertiary Care Hospital in the United States

It is important for health-care providers to be comfortable in providing end-of-life (EOL) care to critically ill patients and realizing when continuing aggressive measures would be futile. Therefore, there is a need to understand health-care providers' self-perceived skills and barriers to providing optimum EOL care. A total of 660 health-care providers from medicine and surgery departments were asked via e-mail to complete an anonymous survey assessing their self-reported EOL care competencies, of which 238 responses were received. Our study identified several deficiencies in the self-reported EOL care competencies among health-care providers. Around 34% of the participants either disagreed (strongly disagree or disagree) or were neutral when asked whether they feel well prepared for delivering EOL care. Around 30% of the participants did not agree (agree and strongly agree) that they were well prepared to determine when to refer patients to hospice. 51% of the participants, did not agree (agree and strongly agree) that clear and accurate information is delivered by team members to patients/family. The most common barrier to providing EOL care in the intensive care unit was family not accepting the patient's poor prognosis. Nursing staff (registered nurse) had higher knowledge and attitudes mean competency scores than the medical staff. Attending physicians reported stronger knowledge competencies when compared to residents and fellows. More than half of the participants denied having received any previous training in EOL care. 82% of the participants agreed that training should be mandatory in this field. Most of the participants reported that the palliative care team is involved in EOL care when the patient is believed to be terminally ill. Apart from a need for a stronger training in the field of EOL care for health-care providers, the overall policies surrounding EOL and palliative care delivery require further evaluation and improvement to promote better outcomes in caring patients at the EOL.

The Potential Role of Psychosocial Rehabilitation in Palliative Care

Palliative care is an approach to incurable and/or severe disease with limited prognosis, aiming to relieve the suffering and improve the quality of life of patients and their families. The existence of psychopathology is common in patients undergoing palliative care, and psychiatric comorbidities, such as depression and anxiety, are frequent and often underdiagnosed. This work constitutes a review of the literature and a reflection on the potential role of psychosocial rehabilitation in mental health in palliative care. Psychosocial rehabilitation may play a role in the mental health of patients undergoing palliative care, contributing to the minimisation of symptoms, support in daily life activities, the improvement of quality of life and the preparation for death.

Do physicians discuss end-of-life decisions with family members? A mortality follow-back study

OBJECTIVE

Deaths from chronic illness are often preceded by a potentially life-shortening end-of-life decision (ELD). Involving family in these ELDs may have psychosocial benefits for them and the dying person. This study aims to examine how often ELDs are discussed with relatives of the dying person and which characteristics determine their involvement in those ELDs.

METHODS

A questionnaire survey was conducted in 2013 among physicians attending a large, stratified and representative sample of deaths (n = 6188) in Flanders.

RESULTS

In 72.3% of ELDs preceding death, family of the dying person were involved. Discussion of an ELD with family members was more likely when the decision was also discussed with the dying person, the ELD was made with the explicit intention to shorten life, specialized palliative care was provided or death occurred in an ICU.

CONCLUSIONS

Involving family in end-of-life decision making appears to be related to the type of formal care services involved, communication with the dying person and the motives behind the decision.

PRACTICE IMPLICATIONS

Our findings suggest a need to further expand a palliative care approach with a focus on both the dying person and their family within and across a variety of health care services.

Improving Health Care Provider Communication in End-of-Life Decision-Making

Critical care providers are responsible for many aspects of patient care, primarily focusing on preserving life. However, nearly 40% of patients who are admitted to an adult critical care unit will not survive. Initiating a conversation about end-of-life decision-making is a daunting task. Often, health care providers are not trained, experienced, or comfortable facilitating these conversations. This article describes a quality improvement project that identified current views on end-of-life communication in the intensive care unit and potential barriers that obstruct open discussion, and offering strategies for improvement.

Communication Challenges of Oncologists and Intensivists Caring for Pediatric Oncology Patients: A Qualitative Study

CONTEXT

The families of oncology patients requiring intensive care often face increasing complexity in communication with their providers, particularly when patients are cared for by providers from different disciplines.

OBJECTIVE

The objective of this study was to describe experiences and challenges faced by pediatric oncologists and intensivists and how the oncologist-intensivist relationship impacts communication and initiation of goals of care discussions (GCDs).

METHODS

We conducted semi-structured interviews with a convenience sample of 10 physicians, including pediatric oncology and intensive care attendings and fellows.

RESULTS

We identified key themes (three barriers and four facilitators) to having GCDs with families of oncology patients who have received intensive care. Barriers included challenges to communication within teams because of hierarchy and between teams due to incomplete sharing of information and confusion about who should initiate GCDs; provider experiences of internal conflict about how to engage parents in decision-making and about the "right thing to do" for patients; and lack of education and training in communication. Facilitators included team preparation for family meetings; skills for partnering with families; the presence of palliative care specialists; and informal education in communication and willingness for further training in communication. Notably, the education theme was identified as both a barrier and resource.

CONCLUSION

We identified barriers to communication with families both within and between teams and for individual physicians. Formal communication training and processes that standardize communication to ensure completeness and role delineation between clinical teams may improve oncologists' and intensivists' ability to initiate GCDs, thereby fulfilling their ethical obligations of decision support.

Psychiatric and Palliative Care in the Intensive Care Unit

Palliative care is specialized medical care focused on patients with serious illness and their families. In the intensive care unit (ICU), palliative care encompasses core skills to support patients and their families throughout their ICU course and post-ICU stays. Psychiatric symptoms are common among patients approaching the end of life and require particular attention in the setting of sedating medications, typically used when patients require ventilators and other life-sustaining treatments. For patients with preexisting severe mental illness who have a concurrent serious medical illness, a palliative psychiatric approach can address complex symptom management and support ethical and value-based shared decision making.

The Impact of Resident Training on Communication with Families in the Intensive Care Unit. Resident and Family Outcomes

RATIONALE

In high-acuity settings such as intensive care units (ICUs), the quality of communication with patients' families is a particularly important component of care. Evidence shows that ICU communication is often inadequate and can negatively impact family outcomes.

OBJECTIVES

To assess the impact of a communication training program on resident skills in communicating with families in an ICU and on family outcomes.

METHODS

We conducted a prospective, single-site educational intervention study. The intervention featured a weekly required communication training program (4 h total) during the ICU rotation, which included interactive discussion, and role play with immediate feedback from simulated family members. All internal medicine residents on ICU rotation between July 2012 and July 2014 were invited to participate in the study. Family members who had a meeting with an enrolled resident were approached for a survey or interview. The primary outcome was family ratings of how well residents met their informational and emotional needs.

MEASUREMENTS AND MAIN RESULTS

The response rate for the resident baseline survey was 93% (n = 149 of 160), and it was 90% at postcourse and 84% at 3-month follow-up. Of 303 family members approached, 237 were enrolled. Enrolled family members who had a confirmed meeting with a resident were eligible to complete a survey or interview. The completion rate was 86% (n = 82 of 95). Family members were more likely to describe residents as having "fully met" (average rating of 10/10 on 0-10 scale) their informational and emotional needs when the resident had completed two or three course sessions (84% of family members said conversation with these residents "fully met" their needs), as compared with residents who had taken one session or no sessions (25% of family members said needs were "fully met") (P < 0.0001). Residents described improvements across all domains. All differences are statistically significant, most with large effect sizes.

CONCLUSIONS

At our institution, an on-site communication training program designed for integration into medical residency programs was associated with strongly positive family member outcomes and significant improvements in residents' perceived skills. This intervention may serve to prepare residents for optimal communications with patients and family members in ICUs and elsewhere.

An exploration of contextual dimensions impacting goals of care conversations in postgraduate medical education

Background

Postgraduate medical trainees are not well prepared difficult conversations about goals of care with patients and families in the acute care clinical setting. While contextual nuances within the workplace can impact communication, research to date has largely focused on individual communication skills. Our objective was to explore contextual factors that influence conversations between trainees and patients/families about goals of care in the acute care setting.

Methods

We conducted an exploratory qualitative study involving five focus groups with Internal Medicine trainees (n = 20) and a series of interviews with clinical faculty (n = 11) within a single Canadian centre. Thematic framework analysis was applied to categorize the data and identify themes and subthemes.

Results

Challenges and factors enabling goals of care conversations emerged within individual, interpersonal and system dimensions. Challenges included inadequate preparation for these conversations, disconnection between trainees, faculty and patients, policies around documentation, the structure of postgraduate medical education, and resource limitations; these challenges led to missed opportunities, uncertainty and emotional distress. Enabling factors were awareness of the importance of goals of care conversations, support in these discussions, collaboration with colleagues, and educational initiatives enabling skill development; these factors have resulted in learning, appreciation, and an established foundation for future educational initiatives.

Conclusions

Contextual factors impact how postgraduate medical trainees communicate with patients/families about goals of care. Attention to individual, interpersonal and system-related factors will be important in designing educational programs that help trainees develop the capacities needed for challenging conversations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-016-0107-6) contains supplementary material, which is available to authorized users.

The Conversations About Cancer (CAC) Project-Phase II: National findings from viewing When Cancer Calls…and implications for Entertainment-Education (E-E)

OBJECTIVE

We address cancer communication by creating and assessing the impacts of a theatrical production, When Cancer Calls…(WCC…), anchored in conversations from the first natural history of a patient and family members talking through cancer on the telephone.

METHODS

A national study was conducted using a multi-site and randomized controlled trial. An 80-minute video was produced to assess viewing impacts across cancer patients, survivors, and family members. Comparisons were made with a control video on cancer nutrition and diet. Pretest-posttest sample size was 1006, and 669 participants completed a 30-day follow-up impacts assessment.

RESULTS

All five family and communication indices increased significantly for WCC…. When compared to the placebo, average pretest-posttest change scores were higher for self-efficacy (775%), family fabric (665%), outside support (189%), and family communication (97%). One month following viewings, WCC…participants reported 30% more conversations about cancer among patients and family members about cancer.

CONCLUSION

A new genre of Entertainment-Education (E-E) was created that triggers positive reactions from audience members. Managing delicate and often complex communication about the trials, tribulations, hopes, and triumphs of cancer journeys is fundamentally important for everyday living.

PRACTICE IMPLICATIONS

Unique opportunities exist to make WCC… available to national and global audiences, create tailored curricula, and integrate these viewings into educational programs for patients, family members, and care-provider teams across diverse health, corporate, and governmental systems.

The value of uncertainty in critical illness? An ethnographic study of patterns and conflicts in care and decision-making trajectories

BACKGROUND

With increasingly intensive treatments and population ageing, more people face complex treatment and care decisions. We explored patterns of the decision-making processes during critical care, and sources of conflict and resolution.

METHODS

Ethnographic study in two Intensive Care Units (ICUs) in an inner city hospital comprising: non-participant observation of general care and decisions, followed by case studies where treatment limitation decisions, comfort care and/or end of life discussions were occurring. These involved: semi-structured interviews with consenting families, where possible, patients; direct observations of care; and review of medical records.

RESULTS

Initial non-participant observation included daytime, evenings, nights and weekends. The cases were 16 patients with varied diagnoses, aged 19-87 years; 19 family members were interviewed, aged 30-73 years. Cases were observed for <1 to 156 days (median 22), depending on length of ICU admission. Decisions were made serially over the whole trajectory, usually several days or weeks. We identified four trajectories with distinct patterns: curative care from admission; oscillating curative and comfort care; shift to comfort care; comfort care from admission. Some families considered decision-making a negative concept and preferred uncertainty. Conflict occurred most commonly in the trajectories with oscillating curative and comfort care. Conflict also occurred inside clinical teams. Families were most often involved in decision-making regarding care outcomes and seemed to find it easier when patients switched definitively from curative to comfort care. We found eight categories of decision-making; three related to the care outcomes (aim, place, response to needs) and five to the care processes (resuscitation, decision support, medications/fluids, monitoring/interventions, other specialty involvement).

CONCLUSIONS

Decision-making in critical illness involves a web of discussions regarding the potential outcomes and processes of care, across the whole disease trajectory. When measures oscillate between curative and comfort there is greatest conflict. This suggests a need to support early communication, especially around values and preferred care outcomes, from which other decisions follow, including DNAR. Offering further support, possibly with expert palliative care, communication, and discussion of 'trial of treatment' may be beneficial at this time, rather than waiting until the 'end of life'.

Experience of providing palliative care in critical care settings

BACKGROUND

Changing demographics and medical advances have led to an increased demand for beds in critical care units. Patients in critical care are at risk of physical and psychosocial suffering. The goal of palliative care is to achieve the best quality of life for patients and families irrespective of diagnosis or location of care. The delivery of high-quality end-of-life care in critical care units can be challenging.

OBJECTIVES

Our aim was to (1) identify patient characteristics and timing of referral to Hospital Palliative Care Team (HPCT) since admission to critical care unit; (2) assess the impact of HPCT on patient care and location of death; (3) describe challenges of providing input in this setting by HPCT.

METHODS

We retrospectively reviewed all referrals to HPCT from critical care units of a large teaching hospital over a 6-year period. Data were extracted from an electronic database storing details of all patient referrals and contacts.

RESULTS

As a proportion of all referrals to HPCT, those from critical care rose from 1.7% to 3.17%. The proportion of patients with non-malignant diagnoses referred has risen from 29% to 39%. Of total referrals, 96/144 (66.6%) patients died within the same episode of care. 65% of these died within 1 week. 51% of patients died on critical care. We also describe challenges encountered and impact of the HPCT on patient care.

CONCLUSIONS

The HPCT provide an important contribution to patients in critical care, through symptom control, family support, continuity of care and in end-of-life care. On the basis of our review, the challenge is to move from a sequential model of care to a more integrated approach.

Dying Care Interventions in the Intensive Care Unit

PURPOSE

Providing high-quality end-of-life care is a challenging area in intensive care practice. The aim of the current study was to assess the practice of registered nurses (RNs) with respect to dying care and spiritual support interventions in intensive care units (ICUs) in the Czech Republic (CR) and find correlations between particular factors or conditions and the frequency of NIC interventions usage.

DESIGN AND METHODS

A cross-sectional, descriptive study was designed. A questionnaire with Likert scales included the particular activities of dying care and spiritual support interventions and an evaluation of the factors influencing the implementation of the interventions in the ICU. The group of respondents consisted of 277 RNs working in 29 ICUs in four CR regions. The Mann-Whitney U test and Pearson correlation coefficient were used for statistical evaluation.

FINDINGS

The most and least frequently reported RN activities were "treat individuals with dignity and respect" and "facilitate discussion of funeral arrangements," respectively. The frequencies of the activities in the biological, social, psychological, and spiritual dimensions were negatively correlated with the frequency of providing care to dying patients. A larger number of activities were related to longer lengths of stay in the ICU, higher staffing, more positive opinions of the RNs regarding the importance of education in a palliative care setting, and attending a palliative care education course.

CONCLUSIONS

The psychosocial and spiritual activities in the care of dying patients are used infrequently by RNs in CR ICUs. The factors limiting the implementation of palliative care interventions and strategies improving implementation warrant further study.

CLINICAL RELEVANCE

Assessment of nursing activities implemented in the care of dying patients in the ICU may help identify issues specific to nursing practice.

Informal Caregivers of Palliative Oncohematologic Patients

Informal caregivers are crucial members of the teams that care for palliative patients with cancer, including those with oncohematological malignancies. Publications concerning specific aspects of this latter group of carers are limited. This literature review indicates that palliative oncohematologic patients’ caregivers do not differ from those of patients with solid tumors in ethical and related problems. However, there are specific problems for the former group with regard to negotiating the curative system, which are experienced as distressing, often without support from the health system and without offers of the possibility of being referred to palliative teams that they would have valued as very positive. Although this tendency seems to be changing, there is still considerable work to be done to improve the role of these carers.

Resolving Communication Challenges in the Intensive Care Unit

Communication in the intensive care unit (ICU) is challenging because of complexity, high patient acuity, uncertainty, and ethical issues. Unfortunately, conflict is common, as several studies and reviews confirm. Three types of communication challenges are found in this setting: those within the ICU team, those between the ICU team and the patient or family, and those within the patient’s family. Although specific evidence-based interventions are available for each type of communication challenge, all hinge on clinicians being culturally competent, respectful, and good communicators/listeners. Critical care advanced practice nurses promote a positive team environment, increase patient satisfaction, and model good communication for other clinicians. All advanced practice nurses, however, also need to be adept at having difficult conversations, handling conflict, and providing basic palliative care, including emotional support.

Talking with parents about end-of-life decisions for their children

BACKGROUND AND OBJECTIVE

Retrospective studies show that most parents prefer to share in decisions to forgo life-sustaining treatment (LST) from their children. We do not yet know how physicians and parents communicate about these decisions and to what extent parents share in the decision-making process.

METHODS

We conducted a prospective exploratory study in 2 Dutch University Medical Centers.

RESULTS

Overall, 27 physicians participated, along with 37 parents of 19 children for whom a decision to withhold or withdraw LST was being considered. Forty-seven conversations were audio recorded, ranging from 1 to 8 meetings per patient. By means of a coding instrument we quantitatively and qualitatively analyzed physicians' and parents' communicative behaviors. On average, physicians spoke 67% of the time, parents 30%, and nurses 3%. All physicians focused primarily on providing medical information, explaining their preferred course of action, and informing parents about the decision being reached by the team. Only in 2 cases were parents asked to share in the decision-making. Despite their intense emotions, most parents made great effort to actively participate in the conversation. They did this by asking for clarifications, offering their preferences, and reacting to the decision being proposed (mostly by expressing their assent). In the few cases where parents strongly preferred LST to be continued, the physicians either gave parents more time or revised the decision.

CONCLUSIONS

We conclude that parents are able to handle a more active role than they are currently being given. Parents' greatest concern is that their child might suffer.

Palliative care in the intensive care unit

Most patients who receive terminal care in the intensive care setting die after withdrawing or limiting of life-sustaining measures provided in the intensive care setting. The integration of palliative care into the intensive care unit (ICU) provides care, comfort, and planning for patients, families, and the medical staff to help decrease the emotional, spiritual, and psychological stress of a patient's death. Quality measures for palliative care in the ICU are discussed along with case studies to demonstrate how this integration is beneficial for a patient and family. Integrating palliative care into the ICU is also examined in regards to the complex adaptive system.

Ethical and clinical aspects of intensive care unit admission in patients with hematological malignancies: guidelines of the ethics commission of the French society of hematology

Admission of patients with hematological malignancies to intensive care unit (ICU) raises recurrent ethical issues for both hematological and intensivist teams. The decision of transfer to ICU has major consequences for end of life care for patients and their relatives. It also impacts organizational human and economic aspects for the ICU and global health policy. In light of the recent advances in hematology and critical care medicine, a wide multidisciplinary debate has been conducted resulting in guidelines approved by consensus by both disciplines. The main aspects developed were (i) clarification of the clinical situations that could lead to a transfer to ICU taking into account the severity criteria of both hematological malignancy and clinical distress, (ii) understanding the process of decision-making in a context of regular interdisciplinary concertation involving the patient and his relatives, (iii) organization of a collegial concertation at the time of the initial decision of transfer to ICU and throughout and beyond the stay in ICU. The aim of this work is to propose suggestions to strengthen the collaboration between the different teams involved, to facilitate the daily decision-making process, and to allow improvement of clinical practice.

Causes and consequences of disproportionate care in intensive care medicine

PURPOSE OF REVIEW

Increased use of advanced life-sustaining measures in patients with poor long-term expectations secondary to more chronic organ dysfunctions, comorbidities and/or a poor quality of life has become a worrying trend over the last decade. This can lead to futile, disproportionate or inappropriate care in the ICU. This review summarizes the causes and consequences of disproportionate care in the ICU.

RECENT FINDINGS

Disproportionate care seems to be common in European and North American ICUs. The initiation and prolongation of disproportionate care can be related to hospital facilities, healthcare providers, the patient and his/her representatives and society. This can have serious consequences for patients, their relatives, physicians, nurses and society.

SUMMARY

Disproportionate care is common in western ICUs. It can lead to violation of basic bioethical principles, suffering of patients and relatives and compassion fatigue and moral distress in healthcare providers. Avoiding inappropriate use of ICU resources and disproportionate care in the ICU should have high priority for ICU managers but also for every healthcare provider taking care of patients at the bedside.

Characteristics and trends in peer-reviewed publications in the field of psychosomatic medicine

BACKGROUND

The field of psychosomatic medicine/consultation-liaison psychiatry, now a subspecialty in psychiatry, has focused its efforts on clinical care, education, and research at the interface of psychiatry, medicine, and neurology.

OBJECTIVE

We sought to categorize characteristics and trends (over the past decade) in several journals intended primarily for practitioners of psychosomatic medicine.

METHODS

We reviewed all articles published in 3 peer-reviewed journals (i.e., Psychosomatics, General Hospital Psychiatry, and the Journal of Psychosomatic Research) in 2002 and 2012.

RESULTS

Each of the 3 journals has a different approach to publication of original research, clinical reviews, and case reports.

CONCLUSIONS

The 3 journals demonstrate differing levels of international involvement, publish a different number of articles of different types (e.g., case reports, reviews, and original research), and focus on different types of medical-psychiatric problems.

Physician-perceived contradictions in end-of-life communication: toward a self-report measurement scale

Communication is undoubtedly a critical element of competent end-of-life care. However, physicians commonly lack communication skills in this particular care context. Theoretically grounded, evidence-based guidelines are needed to enhance physicians' communication with patients and their families in this important time of their lives. To address this need, this study tests and validates a Contradictions in End-of-Life Communication (CEOLC) scale, which disentangles the relational contradictions physicians commonly experience when communicating with end-of-life patients. Exploratory factors analysis confirmed the presence of eight physician-perceived dialectical tensions, reflecting three latent factors of (1) integration, (2) expression, and (3) dominance. Furthermore, a number of significant intercultural differences were found in cross-cultural comparisons of the scale in U.S., Swiss, and Italian physician samples. Thus, this investigation introduces a heuristic assessment tool that aids a better understanding of the dialectical contradictions physicians experience in their interactions with end-of-life patients. The CEOLC scale can be used to gather empirical evidence that may eventually support the development of evidence-based guidelines and skills training toward improved end-of-life care.

Palliative Care in the Intensive Care Unit: Are Residents Well Trained to Provide Optimal Care to Critically ill Patients?

Palliative care (PC) and end-of-life (EOL) care are gaining importance in the management of critically ill patients in the ICU. Residents form a significant work force in the ICU and most often are the only group that provides round the clock coverage.

METHODS

We conducted a cross sectional study where residents were surveyed to assess their knowledge, skills and perceived barriers towards palliative care in the ICU.

RESULTS

The most common barrier identified by our residents was discrepancies in goals of care between the medical team and patients/families (18.7%). A palliative care consult was most commonly obtained when the patient was terminally ill (22.9%).

DISCUSSION

Teaching should focus on overcoming the identified barriers especially communication with patients and their families. More studies are needed to identify the best method to teach Palliative care in the ICU.

Acute and critical care nurses' perceptions of palliative care competencies: a pilot study

Competency development among acute and critical care nurses has focused primarily on the provision of life-sustaining care and less on the care of patients who fail to respond to life-prolonging treatments. Examining nurses' beliefs, perceptions, and experiences with patients' palliative care needs may improve continuing education programs, practice resources, educational curricula, and professional nursing practice. Survey methodology was used to conduct this pilot study. Forty-nine nurses completed a 33-item survey instrument in 2012. Respondents consisted of nurses attending a critical care continuing education event and graduate nursing students in an acute care nurse practitioner program. Statistical tests were used to examine differences in perceived importance of core competencies in palliative care. Findings from this study demonstrate variation in palliative care knowledge and perceived relative importance of core competencies needed in palliative care practice. This study provides preliminary data about knowledge differences among different nursing groups and a foundation for further study.

Determining the factors contributing to quality of life of patients at the last stage of life: a qualitative study

BACKGROUND

Quality- of- life of patients at their last stage of their life are different from that of other people.

OBJECTIVES

The aim of this study was to determine the factors contributing to the quality- of- life of patients at their last stage of their life and provide good cares for these patients.

PATIENTS AND METHODS

This qualitative study was performed by the thematic- framework method of analysis. Twenty three participants including patients, their families, nurses, physicians, psychologists and clergymen were selected sampling. Data were collected by semi - structured interview. We used the thematic framework method to analyze qualitative data.

RESULTS

Seven factors which needed to be considered in the patients' at last stage quality of life included stress reduction, participation, homecare, education, independency, support, recourses and facilities. According to the findings, the number of these factors may be more than what was mentioned above.

CONCLUSIONS

Paying attention to the quality of life at the last stage can be helpful for patients and their families and the special care can be taken for them.

Limiting intensive care therapy in dying critically Ill patients: Experience from a tertiary care center in United Arab Emirates

Background:

Limitations of life-support interventions, by either withholding or withdrawing support, are integrated parts of intensive care unit (ICU) activities and are ethically acceptable. The end-of-life legal aspects and practices in United Arab Emirates ICUs are rarely mentioned in the medical literature. The objective of this study was to examine the current practice of limiting futile life-sustaining therapies in our ICU, modalities for implementing of these decisions, and documentations in dying critically ill patients.

Materials and Methods:

This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected.

Methods:

This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected.

Results:

The electronic medical records of 67 patients were reviewed. The commonest method of limiting therapy was no escalation 53.6%. Interventions were withheld in 41.5%. “Do not resuscitate” order was documented in only 16.3%. The commonest method of documenting limitation of therapy was discussion with the family and documenting the prognosis and futility of additional therapy (73.3%). Patients who died early (<48 hrs) compared to patients who died late (>48 hrs) of ICU admission received terminal cardiopulmonary resuscitation more frequently (P < 0.007), had less frequent prognosis documentation (P < 0.009), and had more vasopressors administered (P < 0.006).

Conclusion:

Withholding therapy after discussion with the family was the preferred mode of limiting therapy in a dying patient.

Relational dialectics theory: Disentangling physician-perceived tensions of end-of-life communication

Existing literature evidences the centrality of interpersonal communication during end-of-life care, but several barriers currently compromise its effectiveness. One of them is a common lack of communication skills among physicians in this challenging context. Several strategies have been suggested to enhance end-of-life interactions; however, a solid theoretical framework is needed for the development of effective systematic guidelines and interventions that can facilitate this goal. The present research study addresses this gap, choosing to focus particularly on the physician's perspective. It relies on Baxter and Montgomery's (1996) Relational Dialectics Theory to illuminate the complexity of reality doctors commonly face in interactions with their patients during end-of-life care. Semistructured interviews were conducted with 11 physicians in a southern canton of Switzerland who had experienced at least one end-of-life encounter with a patient. The interviews probed whether and under what conditions Baxter and Montgomery's theoretical contradictions translate to physicians' end-of-life communication with their patients and the patients' family members. The results replicated and extended the original theoretical contradictions, evidencing that Relational Dialectics Theory is very applicable to end-of-life conversations. Thus, this study adds a theoretically framed, empirically grounded contribution to the current literature on the communicative challenges physicians commonly face during end-of-life interactions with their patients and their patients' family members.