Enhancing patient-professional communication about end-of-life issues in life-limiting conditions: a critical review of the literature

Feasibility and acceptability of facilitated advance care planning in outpatient clinics: A qualitative study of health-care professionals experience

OBJECTIVE

This study sought to determine the feasibility and acceptability of a facilitated advance care planning (ACP) intervention implemented in outpatient clinics, as perceived by health-care professionals (HCPs).

METHODS

Data from seven focus groups (n = 27) and nine semi-structured interviews with HCPs recruited as part of a pragmatic, randomised controlled trial (RCT) were analysed using qualitative descriptive methodology. Components of the intervention included HCP education and training, tools to assist HCPs with patient selection, hardcopy information, and ACP documentation, and specialised nurse-facilitators to support HCPs to complete ACP conversations and documentation with patients and caregivers.

RESULTS

Health-care professionals working in tertiary outpatient clinics perceived the facilitated ACP intervention as feasible and acceptable. Health-care professionals reported a high level of satisfaction with key elements of the intervention, including the specialised education and training, screening and assessment procedures and ongoing support from the nurse-facilitators. Health-care professionals reported this training and support increased their confidence and ACP knowledge, leading to more frequent ACP discussions with patients and their families. Health-care professionals noted their ability to conduct ACP screening and assessment in clinic was impeded by large clinical caseloads and patient-related factors (e.g., dementia diagnoses, and emotional distress). Additional barriers to ACP implementation identified by HCPs included poor collaboration, constrained time and clinical space, undefined roles and standardised recording procedures for HCPs.

CONCLUSIONS

Facilitated ACP intervention in outpatient clinics is perceived by HCPs as feasible and acceptable. Addressing barriers and tailoring implementation strategies may improve the delivery of ACP as part of tertiary outpatient care.

Talking about dying and death: Essentials of communicating about approaching death from the perspective of major stakeholders

OBJECTIVES

Although caring for dying patients and their family caregivers (FC) is integral to patient care, training in communication about approaching death is almost inexistent in medical and nursing curricula. Consequently, many health professionals have insufficient knowledge about conducting these conversations. In order to gain a broader insight into essential aspects of this communication from different perspectives, we conducted focus groups with key stakeholders.

METHODS

Medical specialists, nurses, medical students, bereaved FC and patient representatives participated in five focus groups (n = 30). Following a focus group schedule, we elicited relevant aspects of communication about approaching death, associated emotions, and appropriate communication frameworks. We analyzed data thematically.

RESULTS

Four main themes were central to conversations about approaching death: (1) embracing care within medical expertise, (2) preparing the conversation while remaining open to the unexpected, (3) recognizing and reflecting on own emotions and reactions, and (4) establishing a meaningful connection with others.

SIGNIFICANCE OF RESULTS

Communicating about approaching death with dying patients and their FC can be complex and challenging at a professional and personal level. With the recognition of the dying phase, a process is initiated for which health professionals need solid clinical knowledge about but also effective communication skills, constant self-reflection and self-care strategies. Comprehensive training and supervision while dealing with the challenges of communicating approaching death to dying patients and their FC are key, particularly for trainees, less experienced physicians and nurses. The essential components identified in this study can help health professionals to master these conversations.

A rapid umbrella review of the literature surrounding the provision of patient-centred end-of-life care

BACKGROUND

Patients have reported a broad range of unmet needs in their receipt of clinical care at the end of life. Therefore, enhancing the quality of end-of-life care through patient-centred healthcare interactions is warranted.

AIM

The aim of this rapid umbrella review was to synthesise previous literature reviews that have examined: (1) patient preferences for patient-centred end-of-life care; (2) barriers and enablers to patient-centred end-of-life care; (3) interventions designed to enhance patient-centred end-of-life care; and (4) patient-centred models of end-of-life care.

DESIGN

A rapid umbrella review was conducted and informed by the Joanna Briggs Institute's methodological guidance for conducting umbrella reviews.

DATA SOURCES

Three academic databases were searched for relevant literature in May 2022: MEDLINE, PsycINFO and CINAHL Plus. Inclusion criteria encompassed literature reviews that examined the topic of patient-centred care for any adult patients in end-of-life care.

RESULTS

A total of 92 literature reviews were identified. Findings suggest that there is often a discrepancy between patient preferences and the provision of care. These discrepancies have been associated with a range of barriers at the patient, staff and system levels. Common interventions included education and training for staff which were often met with improved patient outcomes. Patient-centred models of care were underrepresented across the literature.

CONCLUSIONS

This review highlighted a need for healthcare systems to support staff in providing a patient-centred end of life experience through the development of a co-designed patient-centred model of care, supplemented by professional development and a systematic approach to identifying and documenting patient preferences.

Managing Prognosis in Precision Medicine: Utility, Imagination, and Communication

Research on how physicians predict and communicate prognosis focuses primarily on end-of-life care. Unsurprisingly, as genomic technology gains traction as a prognostic tool, the focus has also been on terminality, with research focused on how genetic results may be used to terminate pregnancies or redirect care towards palliation for neonates. However, genomic results also have powerful impacts on how patients who live prepare for their futures. Genomic testing provides broad-reaching and early—albeit complex, uncertain, and shifting—prognostic information. In this essay, we argue that as genomic testing occurs earlier and increasingly in a screening context, researchers and clinicians must strive to understand and manage the prognostic implications of results. While our understanding of the psychosocial and communicational aspects of prognosis in symptomatic populations is incomplete, it has progressed further than our understanding in a screening context and therefore provides useful lessons and feasible opportunities for further research. By providing an interdisciplinary and inter-specialty perspective on the psychosocial and communicational aspects of prognosis in genetics, we discuss prognostication with respect to genetics from the neonatal period through adulthood, highlighting medical specialties and patient populations that are especially informative for considering the longitudinal management of prognostic information in genomic medicine.

Gynecologic oncology patient perspectives and knowledge on advance care planning: A quality improvement intervention

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Gynecologic oncology patients prefer advance care planning (ACP) communication outpatient with their gynecologic oncologist.

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A quality improvement intervention offering advance care planning resources increased ACP discussions.

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A quality improvement intervention offering advance care planning resources improved ACP document creation proficiency.

Objectives

Assess and improve advance care planning (ACP) awareness and uptake among gynecologic oncology patients.

Methods

Using a quality improvement Plan-Do-Check-Act framework, we completed a single institution needs assessment and intervention. The needs assessment was a 26-question survey assessing baseline ACP knowledge and preferences of gynecologic oncology patients. We used this survey to implement an outpatient intervention in which patients were offered ACP resources (pamphlet, discussion with their gynecologic oncologist, and/or social work referral). We conducted a post-intervention survey among patients who had and had not received ACP resource(s) to assess whether our intervention increased ACP knowledge, discussions, or uptake.

Results

Among 106 patients surveyed in the needs assessment, 33 % had ACP documents, 26 % had discussed ACP with a physician, and 82 % thought discussing ACP was important. The majority preferred these conversations in the outpatient setting (52 %) with their gynecologic oncologist (80 %) instead of nurses or trainees. In the intervention, 526 patients were offered ACP resources. Compared to women who did not receive resources (n = 324), patients who received ACP resource(s) (n = 202) were more likely to have ACP discussions with their gynecologic oncologist (38 % vs 68 %, P = 0.001) and had greater proficiency regarding how to create ACP documents (median score 5/10 vs 8/10, P = 0.048), although they were no more likely to have ACP documented in their electronic medical record (27 % vs 9 %, p = 0.08).

Conclusions

ACP uptake among gynecologic oncology patients is low, but ACP discussions with an oncologist during outpatient visits are important to patients and improve their knowledge regarding completing ACP documents.

RealTalk evidence-based communication training resources: development of conversation analysis-based materials to support training in end-of-life-related health and social care conversations

Training to enhance healthcare practitioners' capabilities in engaging people in sensitive and end-of life-related conversations is in demand. However, evaluations have either not measured, or found very limited impact on actual practice and patient experience. Training effectiveness is improved when it is based on in-depth evidence, reflects the complexity of real-life interactions, and instils principles adaptable to everyday practice. A relatively new source of in-depth evidence and practice-relevant insights on healthcare interactions is conversation analytic research, a form of observational analysis of real-life interactions. However, conversation analytic research findings have largely been disseminated by and for scientists, rather than clinicians and trainers. We used conversation analytic evidence to develop resources for use by healthcare trainers. The aim was to increase training's evidence-base and authenticity. We further aimed to develop resources applicable to working with learners ranging from novices to advanced practitioners.

METHODS

 Using an intervention development approach, we created online video-clips and supplementary written materials for professionals who deliver training, supervision, and support in healthcare communication for staff and students. The materials were reviewed by an advisory group comprising clinicians, lay consultees, educators, and researchers, and piloted by trainers in UK universities, NHS organisations and independent hospices. We refined materials based on their feedback.

RESULTS

 The resulting 'RealTalk' resources focus on practices for communicating with patients and their companions about end-of-life and prognosis. Two core training modules were developed, each comprising several patient case studies featuring video-clips from real-life healthcare consultations. The clips featured practices that patients and experienced practitioners use in approaching end-of-life matters. The case studies also included evidence-based descriptions of observable practices and the principles underlying these, alongside transcripts and case synopses.

CONCLUSIONS

 RealTalk training resources aim to facilitate evidence-based, experiential and reflective learning, focusing on communication challenges, practices and principles for end-of-life-related interactions. The resources are designed for use by trainers for delivering all levels of training, from introductory to advanced, in both formal and informal training settings. Our development process may serve as a blueprint for the production of future evidence-based training resources based on conversation analytic research.

Interventions for interpersonal communication about end of life care between health practitioners and affected people

BACKGROUND

Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes.

OBJECTIVES

To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing.

SELECTION CRITERIA

This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life,  we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes.

DATA COLLECTION AND ANALYSIS

Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies.

MAIN RESULTS

Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials.  Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication.  Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations.  Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions  (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life.  Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear.

AUTHORS' CONCLUSIONS

Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.

Developing a question prompt list for the oncology setting: A scoping review

OBJECTIVE

The purpose of this study was to provide an overview of existing methods used to develop a Question Prompt List (QPL) for an oncology setting.

METHODS

We conducted a search of the literature published between 1999 and 2019 in five online databases followed by a hand search, and extracted data on the methods used to develop a QPL.

RESULTS

A total of 21 studies were included. The review shows differences in the development of older QPLs (1999-2009) and current QPLs (2010-2019). However, most QPLs were developed using interviews or focus groups with patients and an expert session to review or adapt the QPL. Health professionals, patients, and researchers were included in nearly all the studies.

CONCLUSION

To develop a QPL, it is important to combine several information sources and at least to involve health professionals, patients, and researchers in the development process. Review or evaluation steps can improve the appropriateness and acceptance of a QPL.

PRACTICE IMPLICATIONS

Further research is needed to define the type of target population for new QPLs and to develop a framework for their development.

Instruments for the identification of patients in need of palliative care in the hospital setting: a systematic review of measurement properties

OBJECTIVE

The objective of this review was to provide a comprehensive overview of the measurement properties of the available instruments used by clinicians for identifying adults in need of general or specialized palliative care in hospital settings.

INTRODUCTION

Identification of patients in need of palliative care has been recognized as an area where many health care professionals need guidance. Differentiating between patients who require general palliative care and patients with more complex conditions who need specialized palliative care is particularly challenging.

INCLUSION CRITERIA

We included development and validation studies that reported on measurement properties (eg, content validity, reliability, or responsiveness) of instruments used by clinicians for identifying adult patients (>18 years and older) in need of palliative care in hospital settings.

METHODS

Studies published until March 2020 were searched in four databases: Embase.com, Medline Ovid, PubMed, and CINAHL EBSCO. Unpublished studies were searched in Google Scholar, government websites, hospice websites, the Library Network of Western Switzerland, and WorldCat. The search was not restricted by language; however, only studies published in English or French were eligible for inclusion. The title and abstracts of the studies were screened by two independent reviewers against the inclusion criteria. Full-text studies were reviewed for inclusion by two independent reviewers. The quality of the measurement properties of all included studies were assessed independently by two reviewers according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology.

RESULTS

Out of the 23 instruments identified, four instruments were included, as reported in six studies: the Center to Advance Palliative Care (CAPC) criteria, the Necesidades Paliativas (NECPAL), the Palliative Care Screening Tool (PCST), and the Supportive and Palliative Care Indicators Tool (SPICT). The overall psychometric quality of all four instruments was insufficient according to the COSMIN criteria, with the main deficit being poor construct description during development.

CONCLUSIONS

For the early identification of patients needing palliative care in hospital settings, there is poor quality and incomplete evidence according to the COSMIN criteria for the four available instruments. This review highlights the need for further development of the construct being measured. This may be done by conducting additional studies on these instruments or by developing a new instrument for the identification of patients in need of palliative care that addresses the current gaps in construct and structural validity.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020150074.

Educação em saúde e final de vida no hospital

Objetivo: identificar ações de educação em saúde direcionadas às pessoas em final da vida e seus cuidadores, informais e formais, no hospital, além de avaliar o nível de evidência de tais ações. Síntese do conteúdo: o estudo foi realizado entre dezembro de 2019 e janeiro de 2020, nas bases de dados Web of Science, Scopus e MEDLINE. Identificaram-se 6.762 artigos, dos quais 42 integram a análise por serem artigos originais ou de revisão escritos em português, espanhol, inglês ou francês; a amostra dos estudos foi composta por pacientes maiores de 19 anos, com doença avançada e/ou em final de vida ou cuidadores ou profissionais de saúde. Os dados foram agrupados por similaridade do tema das ações, conforme Polit e Beck, e o nível de evidência avaliado segundo Melnyk e Fineout-Overholt. O vídeo foi a ação com maior força de recomendação, seguida por cartilhas. As unidades temáticas foram “Ações para o controle da dor”, “Narrativas sobre o final da vida”, “Planejamento de cuidados”, “Dialogando sobre os cuidados paliativos” e “Comunicação e final de vida”. Conclusões: ações de educação em saúde no final da vida devem considerar as tecnologias da informação e da comunicação, além das condições socioculturais, clínicas e cognitivas dessa etapa do adoecimento.

An integrative literature review of the implementation of advance care planning in hospital settings

AIMS AND OBJECTIVES

To identify and synthesise existing literature about action research in the implementation of advance care planning in a hospital setting.

BACKGROUND

Despite the proven added value of advance care planning, there is a lack of wide integration of this concept. There are several obstacles known for the implementation but it remains unclear how these can be overcome. Action research is described in the literature as a plausible way to overcome obstacles to the implementation of quality enhancing projects.

DESIGN

An integrative literature review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) and reported in accordance with the PRISMA statement.

METHODS

We searched databases MEDLINE, EMBASE, CINAHL and Web of Science to identify executed action research for the implementation of advance care planning programs within a hospital setting, from January 2005 until November 2019. Studies were assessed for comprehensiveness and were supplemented by studies in reference lists of included articles. A quality appraisal and a thematic synthesis were performed on all included studies.

RESULTS

Five studies met inclusion criteria. Interventions focused on both nurses, physicians and hospitalised patients. Interventions targeted three different themes: identifying at-risk patients, adapting documentation to the local context and using communication improvement tools.

CONCLUSIONS

A Supportive and Palliative Care Indicators Tool is proposed to identify patients in need of advance care planning to work more efficiently. Furthermore, adapting documentation and instruments to a specific care context are shown to make advance care planning more effective. Communication challenges can be addressed by promoting communication skills and increase stakeholder self-confidence.

The impact of uncertainty on bereaved family's experiences of care at the end of life: a thematic analysis of free text survey data

Background

Inequities in the provision of palliative care for people with cardiac disease have been well documented in the literature. Despite experiencing significant palliative care needs, those with cardiac disease are less likely to be referred to specialist palliative care services and more likely to die in a hospital when compared to those with cancer. The unpredictable trajectory of heart failure has been identified as a key barrier to providing palliative care with many people experiencing a long period of stability with appropriate medical treatment. However, as the disease progresses and cardiac function deteriorates, exacerbations of acute decompensation can lead to what is often perceived to be ‘sudden’ death. The aim of this study is to explore the impact of uncertainty on how death is remembered by bereaved family members of people with heart disease.

Methods

Thematic analysis of free text collected during a postal survey of bereaved family’s experiences of healthcare services in the last 3 months of life using the New Zealand version of the VOICES questionnaire was undertaken. Data was analysed using a three-dimensional conceptual framework of “scientific uncertainty”.

Results

Eight hundred and twenty-seven completed questionnaires were received of which 12.6% (n = 105) indicated that they had cared for someone at the end of life with cardiac disease. Experiences of uncertainty were found to have a significant impact upon bereaved family. Four key themes were identified; distrust in healthcare professionals, stories left incomplete, loss, regret and missed opportunity and disempowerment.

Conclusions

This study highlights the ongoing impact on bereaved family when uncertainty is not made explicit in conversations regarding end of life for people with heart disease. Timely and sensitive conversations regarding the uncertainty of when death may occur is an important factor in ensuring that bereaved family are not left with unresolved narratives. Reframing how we think and talk about uncertainty in end of life care is important, as clinicians’ uncertainties may not always reflect or match up with families’ uncertainties. Being explicit about our inability to be certain about the timing of death may thus lead to a more positive and complete experience for bereaved family.

End-of-life conversation from both sides of the bed: voices of family and staff

PURPOSE

Prolonged living with chronic illness and disability expands the discussion of end-of-life conversation because of the complex role of intercommunication among patient, family, and healthcare staff. Little is known about such interaction from participants' different perspectives. This qualitative case study examined end-of-life conversation among patient, family, and staff during long-term hospitalization in a neurological rehabilitation department.

METHODS

After the patient's death, 18 participants responded to in-depth semi-structured interviews: 16 healthcare staff and two family members (the patient's wife and brother). In addition, we used the wife's autoethnographic documentation of her experiences during end-of-life conversation.

RESULTS

Thematic analysis produced three themes: (1) The Rehabilitation Department's Mission - Toward Life or Death? (2) The Staff's Perception of the Patient; (3) Containing Death: End-of-life Conversation from Both Sides of the Bed. These themes represented participants' different perspectives in the intercommunication in overt and covert dialogues, which changed over time. Death's presence-absence was expressed by movement between clinging to life and anticipating death.

CONCLUSION

The study findings emphasize the importance of practitioners' training to accept and openly discuss death as an inseparable part of life-long disability, and the implementation of this stance during end-of-life care via sensitive conversations with patients and their families.IMPLICATIONS FOR REHABILITATIONIt is vital for rehabilitation professionals to be trained to process and accept end-of-life issues as a natural and inseparable part of the life discourse among people with disabilities and their families.Rehabilitation professionals need to acquire tools to grasp the spoken and unspoken issues related to life and death, and to communicate their impressions and understandings with people with disabilities and their families.Rehabilitation professionals need to encourage an open dialogue when communicating with people with disabilities and their families on processes related to parting and death.

Improving Patient Preparedness and Confidence in Discussing Advance Directives for End-of-Life Care with Health Care Providers in the United States and Japan

BACKGROUND

The low completion rate of advance directives (ADs) has received attention in Japan and the United States, as policy makers and health care professionals face aging populations with multiple comorbidities. Among the barriers to AD planning, cultural values and attitudes appear to be particularly influential. A comparison of culturally distinct societies provides a deeper understanding of these barriers. Through such an approach, this study identifies strategies for increasing AD planning among late-middle-age Japanese and US individuals.

METHODS

After giving informed consent for the Institutional Review Board-approved study, Japanese and US respondents (45-65 y; 50% female) without ADs completed a language-appropriate online survey. Participants were asked to review a decision aid as part of a scenario-based physician consultation regarding artificial nutrition and hydration (ANH). Hypotheses were analyzed using multigroup structural equation modeling.

RESULTS

Important similarities were identified across the 2 groups. After reviewing the decision aid, both samples strongly preferred "no ANH." Respondents who strongly valued either self-reliance or interpersonal relationships experienced greater preparedness for AD planning. In both countries, greater decision preparedness and positive death attitude predicted greater confidence to discuss care options with a provider. Finally, cultural values predicted preference for family participation: respondents with a strong interdependent self-concept desired more family involvement, whereas high independents preferred less.

CONCLUSIONS

Findings indicate the importance of documenting care preferences and accounting for individual differences. To increase AD adoption, providers should identify patient segments likely to benefit most from the interventions. Targeting individuals in both countries who value self-reliance and interpersonal relationships appears to be a good place to begin. Such individuals can be identified clinically through administration of validated measures used in this study.

Experience of communication among cervical cancer patients in Kenya

Communication influences patient disclosure, treatment adherence, and outcome, adaptation to illness, and bereavement. Different cancer patients and caregivers communicate their various experiences in unique ways. These distinctive experiences are necessary to be told, because it empowers both the teller and everyone who hears and shares that experience. However, there is little research documenting the experiences of cervical cancer patients and caregivers in Kenya and the rest of Africa. This study therefore sought to assess the communication experience among cervical cancer patients and their caregivers. This study was a qualitative study employing the phenomenological method to obtain data from cervical patients and caregivers. It was carried out in Uasin Gishu County, Kenya, where a range of in-depth interviews were held with eight patients and eight caregivers purposively sampled. Data from the interviews were analysed thematically and presented in narrative form using paraphrases and quotations. Ethical issues such as informed consent, confidentiality and official authorisation were observed at all levels. To enrich this study, hermeneutic theory, which explains more about the individual's experience, was used. The findings of the study indicated that communication is therapeutic, although most of the patients and the caregivers were reluctant to talk about their illness. The findings of this study will be of interest to scholars, policy-makers and caregivers of terminally ill patients.

Nursing facility residents' cardiopulmonary resuscitation decisions

CONTEXT

As many as one-quarter of all residents in nursing facilities have cardiopulmonary resuscitation (CPR) as a documented choice in the medical record, despite the likelihood of limited medical benefit in this setting.

OBJECTIVES

The aim of this study was to understand the perspectives of healthcare providers and nursing facility residents regarding CPR decisions.

METHODS

We used qualitative interviews to examine the perspectives of residents with a documented decision for CPR in the medical record. We then compared residents' views with those of healthcare providers who routinely conduct advance care planning (ACP) conversations in the nursing facility setting.

RESULTS

Five themes emerged from the interviews: (a) Resident versus Provider Concerns, (b) Offering Information versus Avoidance, (c) Lack of Understanding of CPR, (d) Lack of Awareness, and (e) 'Don't Keep Me on Machines'. Residents held misconceptions about CPR and/or exhibited an overall poor understanding of the relationship between their own health status and the likelihood of a successful CPR attempt. Although healthcare providers offer information and health education in an attempt to address knowledge gaps, these efforts are not always successful or even accepted by residents. Resident viewpoints and priorities differed from healthcare providers in ways that affected communication about CPR.

CONCLUSIONS

Unrecognised differences in perceptions between providers and residents affect key aspects of ACP communication that can impact CPR decision-making. The concerns and priorities of institutionalized older adults may differ from those of healthcare providers, creating challenges for engaging some residents in ACP.

IMPLICATIONS FOR PRACTICE

ACP communication models and training should be designed not only to explore nursing facility residents' goals, values, and preferences, but also to elicit any underlying differences in perceptions that may affect communication. Healthcare providers can identifying the primary concerns of residents and assist them with integrating or reframing these issues as a part of ACP discussions.

The effectiveness of training interventions on nurses' communication skills: A systematic review

OBJECTIVES

The objective of this systematic review was to identify, critically appraise and synthesise evidence for the effectiveness of communication skills training interventions in nursing practice.

DESIGN

A systematic review of literature.

DATA SOURCES

Randomised controlled trials published in English from 1998 to 2018, identified in five computerised databases (Medline, Cinahl, Embase, Psychinfo and Cochrane Database). Studies were included if they reported an educational intervention to enhance nurses' communication with patients and contained an objective measure of communication skills and/or patient outcome measures.

REVIEW METHODS

The Preferred reporting Items for Systematic reviews and Meta-Analyses guided the review. Data were extracted regarding study design and effectiveness on nurses' communication skills. Trial quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The heterogeneity of the included studies prohibited meta-analysis.

RESULTS

Of the 7811 papers identified, seven trials met the eligibility criteria. The quality was modest. Training programs varied significantly in duration, structure, location and use of outcome measurement tools. Five trials focused on communication with cancer patients using simulated patients. All trials found at least one statistically significant improvement for nurses' communication skills.

CONCLUSIONS

Educational interventions to enhance nurses' capacity to communicate with patients show promise. The paper reports the first systematic review of randomised controlled trials concerning the effect of communication skills training on nurses' abilities to communicate with patients, inclusive of non-cancer settings. The direct impact of educational interventions on nurses' communication skills is difficult to measure arising from non-standardised outcome measurement tools. Further research is particularly needed in acute, chronic illness, aged care and community settings.

Integrating nurse-facilitated advance care planning for patients newly diagnosed with advanced lung cancer

BACKGROUND

Advance care planning (ACP) is well recognised as an important component of palliative care. However, there is still a need to explore ways in which it can become a part of routine practice, ensuring a timely and person-centred discussion.

OBJECTIVES

To explore patients newly diagnosed with advanced lung cancer and their family members' experiences of engaging in a person-centred and structured ACP discussion facilitated by palliative care nurses in an outpatient oncology clinic at the University Hospital of Iceland.

METHODS

An exploratory qualitative design employing semi-structured interviews and thematic analysis. The intervention included a structured ACP discussion, aided by a booklet.

RESULTS

Key themes emerged describing families' and patients' experiences and highlighted that the timing and approach of the ACP discussion was appropriate and helpful, even though the discussion was sensitive and difficult. Using a routine approach with a flexible structure normalised the discussion and made it easier for the patients to take the lead in the discussion.

CONCLUSIONS

ACP discussion can be part of an integrated palliative care and oncology service if implemented in a systematic way.

Do published patient decision aids for end-of-life care address patients' decision-making needs? A systematic review and critical appraisal

BACKGROUND

Many decisions are made by patients in their last months of life, creating complex decision-making needs for these individuals. Identifying whether currently existing patient decision aids address the full range of these patient decision-making needs will better inform end-of-life decision support in clinical practice.

AIMS AND DESIGN

This systematic review aimed to (a) identify the range of patients' decision-making needs and (b) assess the extent to which patient decision aids address these needs.

DATA SOURCES

MEDLINE, PsycINFO and CINAHL electronic literature databases were searched (January 1990-January 2017), supplemented by hand-searching strategies. Eligible literature reported patient decision-making needs throughout end-of-life decision-making or were evaluations of patient decision aids. Identified decision aid content was mapped onto and assessed against all patient decision-making needs that were deemed 'addressable'.

RESULTS

Twenty-two studies described patient needs, and seven end-of-life patient decision aids were identified. Patient needs were categorised, resulting in 48 'addressable' needs. Mapping needs to patient decision aid content showed that 17 patient needs were insufficiently addressed by current patient decision aids. The most substantial gaps included inconsistent acknowledgement, elicitation and documentation of how patient needs varied individually for the level of information provided, the extent patients wanted to participate in decision-making, and the extent they wanted their families and associated healthcare professionals to participate.

CONCLUSION

Patient decision-making needs are broad and varied. Currently developed patient decision aids are insufficiently addressing patient decision-making needs. Improving future end-of-life patient decision aid content through five key suggestions could improve patient-focused decision-making support at the end of life.

How Should End-of-Life Advance Care Planning Discussions Be Implemented According to Patients and Informal Carers? A Qualitative Review of Reviews

CONTEXT

The goal of advance care planning (ACP) is to help ensure that the care people receive during periods of serious illness is consistent with their preferences and values. There is a lack of clear understanding about how patients and their informal carers feel ACP discussions should be implemented.

OBJECTIVES

The objective of this study was to synthesize literature reviews pertaining to patients' and informal carers' perspectives on ACP discussions.

METHODS

This is a systematic review of reviews.

RESULTS

We identified 55 literature reviews published between 2007 and 2018. ACP discussions were facilitated by a diverse range of formats and tools, all of which were acceptable to patients and carers. Patients and carers preferred health professionals to initiate discussions, with the relationships they had with the professionals being particularly important. There were mixed feelings about the best timing, with many people preferring to defer discussions until they perceived them to be clinically relevant. ACP was felt to bring benefits including a greater sense of peace and less worry, but it could also be disruptive and distressing. Patients and carers perceived many benefits from ACP discussions, but these may differ from the dominant narratives about ACP in health policy and may move away from the narratives of RCTs and standardization in research and practice.

CONCLUSION

Researchers and clinicians may need to adjust their approaches as current practices are not aligned enough with patients' and carers' preferences. Future research may need to test implementation strategies of ACP interventions to elucidate how benefits from standardization and flexibility might both be realized.

A training needs analysis of admiral nurses to facilitate advance care planning in dementia

Education of health and social care professionals is essential in preparation to confidently and effectively support families affected by dementia to undertake advance care planning. This article describes a training needs analysis of Admiral Nurses, dementia specialists, in facilitating advance care planning for future care.

METHODS

A questionnaire survey was completed by Admiral Nurses attending end-of-life care masterclasses in 2017 and 2018. Both quantitative (years registered as a nurse, years as an Admiral Nurse and subjective level of confidence in completing advance care plannings) and qualitative data (interventions perceived to increase confidence) were collected.

FINDINGS

There were 75 completed responses (two incomplete returns). There was no correlation between levels of confidence and years registered as a nurse. However, there was a small positive correlation between confidence and number of years as an Admiral Nurse (r = 0.23; p < 0.05). Themes identified qualitatively to enhance practice were advanced communication skills, supervised practice, resources to frame conversations and a guide and template for advance care planning.

CONCLUSION

Although Admiral Nurses are specialists in dementia, several educational initiatives could be employed to better enable them to support advance care planning for families affected by dementia. This training needs analysis is contributed towards developing an educational intervention for Admiral Nurses to improve advance care planning support.

Meaningful connections in dementia end of life care in long term care homes

BACKGROUND

Most persons with dementia die in long term care (LTC) homes, where palliative approaches are appropriate. However, palliative approaches have not been widely implemented and there is limited understanding of staff and family experiences of dying and bereavement in this context.

METHOD

This descriptive qualitative study explored family and staff experiences of end of life and end of life care for persons with dementia in LTC homes. Eighteen focus groups were conducted with 77 staff members and 19 relatives of persons with dementia at four LTC homes in four Canadian provinces.

RESULTS

Three themes emerged: knowing the resident, the understanding that they are all human beings, and the long slow decline and death of residents with dementia.

DISCUSSION

Intimate knowledge of the person with dementia, obtained through longstanding relationships, was foundational for person-centred end of life care. Health care aides need to be included in end of life care planning to take advantage of their knowledge of residents with dementia. There were unmet bereavement support needs among staff, particularly health care aides. Persons with dementia were affected by death around them and existing rituals for marking deaths in LTC homes may not fit their needs. Staff were uncomfortable answering relatives' questions about end of life.

CONCLUSIONS

Longstanding intimate relationships enhanced end of life care but left health care aides with unmet bereavement support needs. Staff in LTC homes should be supported to answer questions about the trajectory of decline of dementia and death. Further research about residents' experiences of deaths of other residents is needed.

Managing clinical uncertainty: An ethnographic study of the impact of critical care outreach on end-of-life transitions in ward-based critically ill patients with a life-limiting illness

Rapid response teams, such as critical care outreach teams, have prominent roles in managing end-of-life transitions in critical illness, often questioning appropriateness of treatment escalation. Clinical uncertainty presents clinicians with dilemmas in how and when to escalate or de-escalate treatment.

AIMS AND OBJECTIVES

To explore how critical care outreach team decision-making processes affect the management of transition points for critically ill, ward-based patients with a life-limiting illness.

METHODS

An ethnographic study across two hospitals observed transition points and decisions to de-escalate treatment, through the lens of critical care outreach. In-depth interviews were carried out to elucidate rationales for practices witnessed in observations. Detailed field notes were taken and placed in a descriptive account. Ethnographic data were analysed, categorised and organised into themes using thematic analysis.

FINDINGS

Data were collected over 74 weeks, encompassing 32 observation periods with 20 staff, totalling more than 150 hr. Ten formal staff interviews and 20 informal staff interviews were undertaken. Three main themes emerged: early decision-making and the role of critical care outreach; communicating end-of-life transitions; end-of-life care and the input of critical care outreach. Findings suggest there is a negotiation to achieve smooth transitions for individual patients, between critical care outreach, and parent or ward medical teams. This process of negotiation is subject to many factors that either hinder or facilitate timely transitions.

CONCLUSIONS

Critical care outreach teams have an important role in shared decision-making. Associated emotional costs relate to conflict with parent medical teams, and working as lone practitioners. The cultural contexts in which teams work have a significant effect on their interactions and agency.

RELEVANCE TO PRACTICE

There needs to be a cultural shift towards early and open discussion of treatment goals and limitations of medical treatment, particularly when facing serious illness. With training and competencies, outreach nurses are well placed to facilitate these discussions.

Are older long term care residents accurately prognosticated and consequently informed about their prognosis? Results from SHELTER study data in 5 European countries

BACKGROUND

Informing residents in long term care facilities (LTCFs) about their prognosis can help them prepare for the end of life. This study aimed to examine which proportion of European LTCF residents, close to death, are accurately prognosticated and consequently informed about their prognosis; and to examine factors related to accurate prognostication and discussion of prognosis.

METHODS

A subsample of SHELTER study data was used, consisting of: 500 residents from 5 European countries, who died within 6 months after their last assessment, and had a valid answer on the item 'End stage disease, 6 or fewer months to live'. This item was used to indicate whether an accurate prognosis was established and discussed with residents. Generalized estimating equations were used to examine factors related to establishment and discussion of accurate prognosis.

RESULTS

86.4% of residents close to death did not receive an accurate prognosis. Residents with cancer; fatigue; dehydration; and normal mode of nutritional intake were more likely to have an accurate prognosis established and discussed. Accurate prognostication and prognosis discussion was less likely for residents who: had a diagnosis under 'other'; initiated interactions; and residents from Germany, Italy and the Netherlands.

CONCLUSIONS

The great majority of residents close to death did not receive an accurate prognosis. Prognostication tools might help clinicians to increase their prognostic accuracy and communication training might help to discuss prognosis with residents.

Advance care planning (ACP) for specialists managing cirrhosis: A focus on patient-centered care

Advance care planning (ACP) and goals of care designation (GCD) are being integrated into modern health care. In cirrhosis, uptake and adoption of these practices have been limited with physicians citing many perceived barriers and limitations. Recognizing the many tangible benefits of ACP and GCD processes in patients with life-limiting chronic diseases, the onus is on health practitioners to initiate and direct these conversations with their patients and surrogates. Drawing upon the literature and our experiences in palliative care and cirrhosis, we provide an actionable framework that can be readily implemented into a busy clinical setting by a practitioner. Conversation starters, visual aids, educational resources (for patients and practitioners), and videos of mock physician-patient scenarios are presented and discussed. Importantly, we have customized each of these tools to meet the unique health care needs of patients with cirrhosis. The inherent flexibility of our approach to ACP discussions and GCD can be further modified to accommodate practitioner preferences.

CONCLUSION

In our clinics, this assemblage of "best practice tools" has been well received by patients and surrogates enabling us to increase the number of outpatients with cirrhosis who have actively contributed to their GCD before acute health events and are supported by well-informed surrogates. (Hepatology 2018;67:2025-2040).

Development and testing of a goals of care intervention in advanced heart failure

AIM

The purpose of this paper is to describe the conceptual framework for a goals of care (GoC) intervention, elements, and findings of intervention feasibility, acceptability, and benefits from both patients with heart failure (HF) and their providers.

BACKGROUND

Receiving care at a mechanical circulatory support center for advanced HF offers new opportunities for treatment, making the implementation of a GoC intervention timely and crucial in helping patients determine next steps in HF treatment.

METHODS

The GoC intervention was designed using a self-management framework, incorporating the concepts of self-efficacy, patient activation, and patient motivation. At the conclusion of the study, open-ended exit interviews were conducted with patients and providers. Content analysis was used to derive the feasibility, acceptability, and benefits of the intervention.

RESULTS

Forty-one patients with HF, with average age 58.2±11.3years, LVEF=30.3±9.7%, and New York Heart Association Functional Class (NYHA FC)=2.4±0.8, and nine HF providers participated in the study. Patient benefits from the intervention included enhanced communication with their provider and family members, increased confidence to have a conversation with the provider, and refreshed HF knowledge. Provider benefits from the intervention were facilitating a conversation with the patient and learning new information about the patient's goals and values.

CONCLUSION

The GoC intervention provides an avenue to align patient goals and values with treatment choices in the context of advanced heart failure, so that patient quality of life is enhanced and costs of care can be reduced.

Decline of Physical Activity in Terminally Ill Patients Could Be Useful for Predicting Short-Term Survival

BACKGROUND

Although it is recommended that all terminally ill patients receive advance care planning (ACP), this is occasionally challenging because of the difficulty in predicting survival. There are some indexes for predicting survival, but few are accurate, especially at the terminal stages of illness.

METHODS

Twenty-two patients at the terminal stages of cancer were retrospectively analyzed. We assessed their physical activity and condition using activities of daily living (ADL) scores for 1 month before the death. The ADL scores included 7 items: walking, bathing, grooming, dressing, eating, transferring, and toileting.

RESULTS

Survival time after the first decline of physical activity was calculated (median: 13 days, 95% confidence interval [95% CI]: 5.6-20.4 days). Survival time after the second (median: 5 days, 95% CI: 0-10.9 days), third (median: 5 days, 95% CI: 0-13.4 days), and fourth (median time: 1 day, 95% CI: not applicable due to small size) decline of physical activity was also calculated.

CONCLUSION

Change in physical activity seems helpful for estimating survival time, especially at the end of life, and this index could be useful for coordinating final ACP.

How do healthcare practitioners talk about end-of-life conversations? A poetic inquiry

Despite agreement that end-of-life conversations should happen early on in the illness trajectory, it is widely acknowledged that healthcare practitioners often engage in these conversations when death is imminent or avoid the conversation altogether. Healthcare practitioners’ feelings of distress influence how end-of-life conversations are approached, yet thorough exploration of this emotional experience and its impact are largely missing from the literature. The aims of this preliminary scoping literature review using poetic inquiry were to examine physicians’ and nurses’ emotional distress in their accounts of how they approach end-of-life conversations, and to map key concepts relevant to exploring barriers to these conversations. The poetic findings highlight the differing nature of distress for physicians and nurses. Physicians’ distress appears to stem from adhering to their role of ‘curer’ when communicating with terminally ill adult patients at the end of life, whereas the sources of nurses’ distress appear to be interprofessional hierarchies and conflicts. Future research and training that uses methods to decentre and disrupt hierarchies and ingrained practices will be important to nursing practice and in improving end-of-life conversations. Arts-based approaches are one such method that could be pursued.

Facing Death in Medical Training

This study explores how medical students feel about caring for terminally ill patients as well as how their medical courses prepare them for addressing end-of-life (EOL) issues with patients. Four hundred and five Mexican medical students were surveyed through the Student Views on Death questionnaire. The vast majority of students (94%) felt that physicians should inform patients of their impending death. Most students said they felt comfortable talking with (61%) or examining (76%) terminally ill patients. However, only half the students actually talked with patients about death. Participants in our study were interested in learning about EOL medical attention, yet most considered themselves poorly prepared to offer this type of care to terminally ill patients. The study provides objective data on a topic that has scarcely been explored in Mexico, data that will be useful in designing educational activities to improve EOL medical training.

A Systematic Review of End-of-Life Care Communication Skills Training for Generalist Palliative Care Providers: Research Quality and Reporting Guidance

CONTEXT

End-of-life care (EoLC) communication skills training for generalist palliative care providers is recommended in policy guidance globally. Although many training programs now exist, there has been no comprehensive evidence synthesis to inform future training delivery and evaluation.

OBJECTIVES

To identify and appraise how EoLC communication skills training interventions for generalist palliative care providers are developed, delivered, evaluated, and reported.

METHODS

Systematic review. Ten electronic databases (inception to December 2015) and five relevant journals (January 2004 to December 2015) were searched. Studies testing the effectiveness of EoLC communication skills training for generalists were included. Two independent authors assessed study quality. Descriptive statistics and narrative synthesis are used to summarize the findings.

RESULTS

From 11,441 unique records, 170 reports were identified (157 published, 13 unpublished), representing 160 evaluation studies of 153 training interventions. Of published papers, eight were of low quality, 108 medium, and 41 high. Few interventions were developed with service user involvement (n = 7), and most were taught using a mixture of didactics (n = 123), reflection and discussion (n = 105), and role play (n = 86). Evaluation designs were weak: <30% were controlled, <15% randomized participants. Over half (n = 85) relied on staff self-reported outcomes to assess effectiveness, and 49% did not cite psychometrically validated measures. Key information (e.g., training duration, participant flow) was poorly reported.

CONCLUSIONS

Despite a proliferation of EoLC communication skills training interventions in the literature, evidence is limited by poor reporting and weak methodology. Based on our findings, we present a CONSORT statement supplement to improve future reporting and encourage more rigorous testing.

The Effect of Communication Skills Training for Generalist Palliative Care Providers on Patient-Reported Outcomes and Clinician Behaviors: A Systematic Review and Meta-analysis

CONTEXT

As most end-of-life care is provided by health care providers who are generalists rather than specialists in palliative care, effective communication skills training for generalists is essential.

OBJECTIVES

To determine the effect of communication training interventions for generalist palliative care providers on patient-reported outcomes and trainee behaviors.

METHODS

Systematic review from searches of 10 databases to December 2015 (MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, CENTRAL, Web of Science, ICTRP, CORDIS, and OpenGrey) plus hand searching. Randomized controlled trials of training interventions intended to enhance generalists' communication skills in end-of-life care were included. Two authors independently assessed eligibility after screening, extracted data, and graded quality. Data were pooled for meta-analysis using a random-effects model. PRISMA guidelines were followed.

RESULTS

Nineteen of 11,441 articles were eligible, representing 14 trials. Eleven were included in meta-analyses (patients n = 3144, trainees n = 791). Meta-analysis showed no effect on patient outcomes (standardized mean difference [SMD] = 0.10, 95% CI -0.05 to 0.24) and high levels of heterogeneity (chi-square = 21.32, degrees of freedom [df] = 7, P = 0.003; I² = 67%). The effect on trainee behaviors in simulated interactions (SMD = 0.50, 95% CI 0.19-0.81) was greater than in real patient interactions (SMD = 0.21, 95% CI -0.01 to 0.43) with moderate heterogeneity (chi-square = 8.90, df = 5, P = 0.11; I² = 44%; chi-square = 5.96, df = 3, P = 0.11; I² = 50%, respectively). Two interventions with medium effects on showing empathy in real patient interactions included personalized feedback on recorded interactions.

CONCLUSIONS

The effect of communication skills training for generalists on patient-reported outcomes remains unclear. Training can improve clinicians' ability to show empathy and discuss emotions, at least in simulated consultations. Personalized feedback on recorded patient interactions may be beneficial.

REGISTRATION NUMBER

CRD42014014777.

Nurse-led navigation to provide early palliative care in rural areas: a pilot study

Background

Few services are available to support rural older adults living at home with advancing chronic illness. The objective of this project was to pilot a nurse-led navigation service to provide early palliative support for rural older adults and their families living at home with advancing chronic illness.

Methods

Twenty-five older adults and 11 family members living with advancing chronic illness received bi-weekly home visits by a nurse navigator over a 2-year period. Navigation services included symptom management, education, advance care planning, advocacy, mobilization of resources, and psychosocial support. The nurse navigator collected longitudinal data on older adult and family needs, and older adult quality of life and healthcare utilization.

Results

Satisfaction with the service was high. There was no attrition over the 2-year period except through death, and few cancelled visits, indicating a high degree of acceptability of the intervention. The navigator addressed complex, multi-faceted needs through connecting health, social, and informal community resources. Participants who indicated a preferred place of death were able to die in that preferred place (n = 7). Emergency room use by participants was minimal and largely unpreventable by the nurse navigator. Longitudinal health-related quality of life scores for many participants were poor, lending further support to the need for more focused attention to this upstream palliative population.

Conclusions

Using a nurse navigator to facilitate early palliative care for rural older adults living with advanced chronic illness is a promising innovation for meeting the needs of this population. Further research is required to evaluate outcomes on a larger scale.

End-of-life care decisions for haemodialysis patients - 'We only tend to have that discussion with them when they start deteriorating'

BACKGROUND

Haemodialysis patients receive very little involvement in their end-of-life care decisions. Issues relating to death and dying are commonly avoided until late in their illness. This study aimed to explore the experiences and perceptions of doctors and nurses in nephrology for involving haemodialysis patients in end-of-life care decisions.

METHODS

A semi-structured qualitative interview study with 15 doctors and five nurses and thematic analysis of their accounts was conducted. The setting was a large teaching hospital in Wales, UK.

RESULTS

Prognosis is not routinely discussed with patients, in part due to a difficulty in estimation and the belief that patients do not want or need this information. Advance care planning is rarely carried out, and end-of-life care discussions are seldom initiated prior to patient deterioration. There is variability in end-of-life practices amongst nephrologists; some patients are felt to be withdrawn from dialysis too late. Furthermore, the possibility and implications of withdrawal are not commonly discussed with well patients. Critical barriers hindering better end-of-life care involvement for these patients are outlined.

CONCLUSIONS

The study provides insights into the complexity of end-of-life conversations and the barriers to achieving better end-of-life communication practices. The results identify opportunities for improving the lives and deaths of haemodialysis patients.

Preconditions for successful advance care planning in nursing homes: A systematic review

OBJECTIVES

There is growing evidence of the potential effectiveness of advance care planning. Yet important knowledge gaps remain regarding the preconditions for successful implementation of advance care planning in the nursing home setting. We aim to identify the preconditions related to successful advance care planning in the nursing home setting. By specifying those, we would be able to make well-founded choices for the future design and planning of advance care planning intervention programs.

DESIGN

A systematic review.

DATA SOURCES

PubMed, PsycINFO, EMBASE and CINAHL.

REVIEW METHODS

Two authors independently screened publications. One author assessed methodological quality and extracted textual data, which was double-checked for a random sample. We extracted textual data and used thematic synthesis to identify "preconditions", defined as requirements, conditions and elements necessary to achieve the desired outcome of advance care planning, i.e. attaining concordance between residents' preferences and actual care or treatment received at the end of life.

MAIN FINDINGS

Based on 38 publications, we identified 17 preconditions at five different levels: resident, family, health-care professional, facility and community. Most preconditions were situated on multiple levels but the majority addressed professionals and the nursing home itself. We summarized preconditions in five domains: to have sufficient knowledge and skills, to be willing and able to participate in advance care planning, to have good relationships, to have an administrative system in place, and contextual factors supporting advance care planning within the nursing home.

CONCLUSION

There are multiple preconditions related to successfully implementing advance care planning in the complex nursing home setting that operate at micro, meso and macro level. Future interventions need to address these multiple domains and levels in a whole-system approach in order to be better implementable and more sustainable, while simultaneously target the important role of the health-care professional and the facility itself.

An Intervention to Enhance Goals-of-Care Communication Between Heart Failure Patients and Heart Failure Providers

CONTEXT

Heart failure patients contend with a markedly impaired quality of life, experiencing emotional distress and severe physical discomfort that increases in frequency in the last months of life. Improving communication between patients and providers about goals of care has the potential to improve patient-provider communication and patient outcomes.

OBJECTIVES

To determine the effects of a goals-of-care (GoC) intervention compared to usual care on the number of GoC conversations, quality of communication between patients and providers, referrals to palliative care services and completion of advance care directives.

METHODS

A two-group randomized study (n = 40/group) compared a GoC intervention to usual care, conducted in an academic heart failure (HF) clinic. The GoC intervention was a previsit patient activation-education, telephone-based intervention delivered by a nurse. The primary outcome of the study was number of GoC conversations between HF patients and HF providers. Secondary outcomes were quality of communication, number of referrals to palliative care, and completion of advance directives.

RESULTS

Patients averaged 58.15 ± 11.26 years of age, with mean left ventricular ejection fraction = 30.31 ± 9.72% and Seattle Heart Failure Model scores = 95.1 ± 1.60. There was a significant increase in goals-of-care conversations (58% vs. 2.6%, P < 0.001) and quality of end-of-life communication (P = 0.03) in the GoC group compared to usual care after the intervention. There were no differences between groups on the other outcomes.

CONCLUSION

The GoC intervention resulted in more GoC conversations and higher quality communication between HF patients and providers without increased anxiety or depression. Further studies are needed to assess impact on longer term quality of care and patient outcomes.

End-of-life planning with frail patients attending general practice: an exploratory prospective cross-sectional study

Background

End-of-life planning means decision making with patients, formulating and recording decisions regarding their end-of-life care. Although clearly linked with benefits including improved quality of life, reduced hospital admissions, and less aggressive medical care, it is still infrequently undertaken and is regarded as challenging by healthcare professionals.

Aim

To ascertain the feasibility of improving the identification of patients at high risk of dying in general practice and the acceptability of providing patients identified with an end-of-life planning tool.

Design and setting

Exploratory prospective cross-sectional study in four general practices.

Method

Patients at high risk of dying were identified during routine consulting by their GP, using the Supportive and Palliative Care Indicators Tool (SPICT). Patients identified were invited to participate, and provided with Think Ahead — an end-of-life planning tool, which has been used previously in general practice. Participants completed telephone surveys, assessing their response to Think Ahead, and the acceptability of the GP raising end-of-life issues during routine consulting.

Results

Provision of Think Ahead to a purposive sample of preterminal patients identified by GPs was feasible, acceptable to most patients, and somewhat effective in increasing discussion among families and in practice on end-of-life planning.

Conclusion

The SPICT and Think Ahead tools were mostly acceptable, effective, and enabling of discussions on end-of-life care in general practice.

Discussing end-of-life issues in nursing homes: a nationwide study in France

BACKGROUND

discussing end-of-life issues with nursing home residents and their relatives is needed to ensure patient-centred care near the end of life.

OBJECTIVES

this study aimed to estimate the frequency of nursing home physicians discussing end-of-life issues with residents and their relatives and to investigate how discussing end-of-life issues was associated with care outcomes in the last month of life.

METHODS

post-mortem cohort study in a nationwide, representative sample of 78 nursing home facilities in France. Residents who died from non-sudden causes between 1 October 2013 and 31 May 2014 in these facilities were included (n = 674).

RESULTS

end-of-life issues were discussed with at most 21.7% of the residents who died during the study period. In one-third of the situations (32.8%), no discussion about end-of-life-related topics ever occurred, either with the resident or with the relatives. Older people with severe dementia were less likely to have discussed more than three of the six end-of-life topics we investigated, compared with residents without dementia (OR = 0.17, 95% CI = 0.08-0.22). In the last month of life, discussing more than three end-of-life issues with the residents or their relatives was significantly associated with reduced odds of dying in a hospital facility (adjusted OR = 0.51, 95% CI = 0.33-0.79) and with a higher likelihood of withdrawing potentially futile life-prolonging treatments (adjusted OR = 2.37, 95% CI = 1.72-3.29).

CONCLUSION

during the last months of life, discussions about end-of-life issues occurred with only a minority of nursing home decedents, although these discussions may improve end-of-life care outcomes.

Endosonographers' approach to delivering a diagnosis of pancreatic cancer: obligated but undertrained

BACKGROUND AND STUDY AIMS

No data are available on the practice patterns of endosonographers as they pertain to the disclosure of a pancreatic cancer diagnosis. We sought to understand the current practice and coping strategies of physicians who perform endoscopic ultrasound (EUS) procedures in patients with suspected pancreatic cancer.

METHODS

This study used a nonexperimental, cross-sectional survey design. A total of 707 endosonographers were contacted and asked to complete an online survey encompassing both demographic and practice data. In addition, participants had the option to complete a second survey assessing common coping strategies.

RESULTS

A total of 152 physicians (22 %) participated in the study. The sample was split between community (47 %) and academic centers (53 %). A total of 92 % of the respondents felt an obligation to share a cancer diagnosis when it was available to them; however, only 45 % felt they were adequately trained to do so. Comfort levels were higher in those who performed more than 200 EUS procedures annually and in those practicing for longer than 5 years (P = 0.044). A total of 98 physicians (64.5 %) also completed the Brief COPE questionnaire, and the results indicated that the more experienced endosonographers were less likely to experience emotional distress when disclosing a cancer diagnosis.

CONCLUSION

The comfort level for disclosing a pancreatic cancer diagnosis after EUS appears to be higher in experienced endosonographers (> 5 years in practice) and in those who conduct a higher volume of procedures. Although the majority of endosonographers feel obligated to disclose a cancer diagnosis, the lack of time and proper training is limiting. Formal communication skills training within a gastrointestinal fellowship should be considered.

Development of a complex intervention to support the initiation of advance care planning by general practitioners in patients at risk of deteriorating or dying: a phase 0-1 study

Background

Most patients with life-limiting illnesses are treated and cared for over a long period of time in primary care and guidelines suggest that ACP discussions should be initiated in primary care. However, a practical model to implement ACP in general practice is lacking. Therefore, the objective of this study is to develop an intervention to support the initiation of ACP in general practice.

Methods

We conducted a Phase 0-I study according to the Medical Research Council (MRC) Framework. Phase 0 consisted of a systematic literature review about the barriers and facilitators for GPs to engage in ACP, focus groups with GPs were held about their experiences, attitudes and concerns regarding initiating ACP in general practice and a review of ACP interventions to identify potential components for the development of our intervention. In Phase 1, we developed a complex intervention to support the initiation of ACP in general practice in patients at risk of deteriorating or dying, based on the results of Phase 0. The complex intervention and its components were reviewed and refined by two expert panels.

Results

Phase 0 resulted in the identification of the factors inhibiting or enabling GPs’ initiation of ACP and important components underpinning existing ACP interventions. Based on these findings, an intervention was developed in Phase 1 consisting of: (1) a training for GPs in initiating and conducting ACP discussions, (2) a register of patients eligible for ACP discussions, (3) an educational booklet on ACP for patients to prepare the ACP discussions that includes general information on ACP, a section on the role of GPs in the process of ACP and a prompt list, (4) a conversation guide to support GPs in the ACP discussions and (5) a structured documentation template to record the outcomes of discussions.

Conclusion

Taking into account the barriers and facilitators for GPs to initiate ACP as well as the key factors underpinning successful ACP intervention in other health care settings, a complex intervention for general practice was developed, after gaining feedback from two expert panels. The feasibility and acceptability of the intervention will subsequently be tested in a Phase II study.

The effectiveness of communication-skills training interventions in end-of-life noncancer care in acute hospital-based services: A systematic review

OBJECTIVE

A systematic review was conducted in order to explore the effectiveness of communication-skills training interventions in end-of-life care with noncancer acute-based healthcare staff.

METHOD

Articles were included if they (1) focused on communication-skills training in end-of-life/palliative care for noncancer acute-based staff and (2) reported an outcome related to behavior change with regard to communication. Sixteen online databases were searched, which resulted in 4,038 potential articles. Screening of titles left 393 articles that met the inclusion criteria. Abstracts (n = 346) and full-text articles (n = 47) were reviewed, leaving 10 papers that met the criteria for our review. All articles explored the effect of communication-skills training on aspects of staff behavior; one study measured the effect on self-efficacy, another explored the impact on knowledge and competence, and another measured comfort levels in discussing the end of life with patients/families. Seven studies measured a number of outcomes, including confidence, attitude, preparedness, stress, and communication skills.

RESULTS

Few studies have focused on end-of-life communication-skills training in noncancer acute-based services. Those that do have report positive effects on staff behavior with regard to communication about the end of life with patients and families. The studies varied in terms of the population studied and the health services involved, and they scored only moderately or weakly on quality. It is a challenge to draw a definite conclusion about the effectiveness of training interventions in end-of-life communication because of this. However, the findings from our review demonstrate the potential effectiveness of a range of training interventions with healthcare professionals on confidence, attitude, self-efficacy, and communication skills.

SIGNIFICANCE OF RESULTS

Further research is needed to fully explore the effectiveness of existing training interventions in this population, and evidence using objective measures is particularly needed. Ideally, randomized controlled trials or studies using control groups and longer follow-ups are needed to test the effectiveness of interventions.