A Scoping Review of End-of-Life Communication in International Palliative Care Guidelines for Acute Care Settings

Applying the Generalizability Theory to Identify the Sources of Validity Evidence for the Quality of Communication Questionnaire

Effective doctor-patient-family communication is an integral and sensitive part of health care, assessing its quality is essential to identify aspects needing disclosure and, if necessary, improvement. Cross-sectional study aimed to analyze the sources of evidence of validity and the number of participants needed to reliably apply the Quality of Communication Questionnaire (QoC) through Generalizability Theory (GT). The mean age of the 150 patients hospitalized at the end of life was 50.5 (SD = 13.8) years, the mean hospital length of stay was 7.5 (SD = 10.2) days, 56.9% were male. Regarding the 105 patients' family members of patients whose mean length of hospital stay was 9.5 (SD = 9.1) days, their mean age was 42.2 (SD = 14.7) years, 69.5% were female. GT was used to quantify the minimum number of questionnaires needed, with the aim of reaching a reliable estimate of QoC with G-coefficients. To reach a reliability of .90, there is a need for 25 for the Eρ2 questionnaires and 35 for the Φ. The exact estimation identified the minimum number of questionnaires required for the evaluation of physicians by patients. To obtain a reliability of .90, there is a need for 30 and 40 questionnaires for the G-coefficients. A practical and fast application makes it possible to use QoC in its entirety or alone to evaluate general communication or communication about palliative care. Furthermore, based on these results, it was possible to identify which aspects were effective or ineffective in these contexts.

Patients', families' and healthcare providers' perspectives on end-of-life communication in Chinese hospital settings: A qualitative study protocol

BACKGROUND

Perspectives of key stakeholders should be fully considered to enhance culturally appropriate strategies in end-of-life communication and strengthen healthcare service delivery. So far, little research evidence is available on Chinese patients', families', and healthcare professionals' experiences with and perspectives of end-of-life communication in hospital settings.

AIM

The current study aims to explore experiences, perceptions and suggestions of end-of-life communication among Chinese terminally ill patients, their families and healthcare providers.

METHODS

The phenomenology qualitative approach will be adopted. Semi-structured in-depth interviews and focus group discussions will be used to collect relevant data. Eligible terminally ill patients, family caregivers and healthcare providers will be recruited in two hospitals in Mainland China via purposive sampling. Thematic analysis will be performed to analyse data. The Standards for Reporting Qualitative Research (SRQR) checklist will be followed for reporting. This study has been registered at ClinicalTrials.gov (NCT05734781).

DISCUSSION

This qualitative study is, as far as we are aware, the first to specifically address patient/family-provider end-of-life communication in the Chinese social-cultural context. The results hold the potential to enrich current knowledge of end-of-life communication, navigate culturally appropriate communication strategies, and inform the development of related training programs for healthcare providers in hospital settings.

Barriers and facilitators that hospital clinicians perceive to discuss the personal values, wishes, and needs of patients in palliative care: a mixed-methods systematic review

Background

The exploration and monitoring of the personal values, wishes, and needs (VWN) of patients in the palliative phase by hospital clinicians is essential for guiding appropriate palliative care.

Objective

To explore the barriers and facilitators concerning communication with patients in the palliative phase about their VWN as perceived by hospital clinicians.

Design

A mixed-methods systematic review following the Joanna Briggs Institute guidelines for mixed-method systematic reviews and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted (PROSPERO ID: CRD42021216693).

Data sources and methods

Eight databases, including PubMed, Embase, and CINAHL, were searched without time restrictions. The search string was built using the search Palliative cAre Literature rEview iTeraTive mEthod (PALETTE) framework. Eligible studies focused on (1) hospital clinicians and (2) perceived barriers and facilitators regarding the exploration and monitoring of the VWN of adult patients in the palliative phase. Two researchers independently selected articles and evaluated the quality. Findings were synthesized using a convergent integrated approach.

Results

In total, 29 studies were included: 14 quantitative, 13 qualitative, and 2 mixed methods. Five synthesized findings were identified: (1) the clinician's professional manners, (2) the image formed of the patient and loved ones, (3) the human aspect of being a clinician, (4) the multidisciplinary collaboration, and (5) the contextual preconditions. Most studies seemed focused on communication about treatment decision making.

Conclusion

A patient-centered approach seems lacking when clinicians discuss the patient's VWN, since most studies focused on treatment decision making rather than on the exploration and monitoring of the multidimensional well-being of patients. This review emphasizes the need for the development and integration of a systematic approach to explore and monitor the patients' VWN to improve appropriate palliative care in hospitals.

The Duality of "Goals of Care" Language: A Qualitative Focus Group Study With Frontline Clinicians

CONTEXT

The phrase "goals of care" (GOC) is common in serious illness care, yet it lacks clarity and consistency. Understanding how GOC is used across healthcare contexts is an opportunity to identify and mitigate root causes of serious illness miscommunication.

OBJECTIVES

We sought to characterize frontline palliative and critical care clinicians' understanding and use of the phrase GOC in clinical practice.

METHODS

We conducted a secondary qualitative thematic analysis of focus group transcripts (n = 10), gathered as part of a parent study of care delivery for patients with respiratory failure. Participants (n = 59) were members of the palliative and critical care interprofessional teams at two academic medical centers.

RESULTS

Clinicians primarily use GOC as a shorthand signal among team members to indicate a patient is nearing the end of life. This signal can also indicate conflict with patients and families when clinicians' expectations-typically an expected "transition" toward a different type of care-are not met. Clinicians distinguish their clinical use of GOC from an "ideal" meaning of the phrase, which is broader than end of life and focused on patients' values. Palliative care specialists encourage other clinicians to shift toward the "ideal" GOC concept in clinical practice.

CONCLUSION

Frontline palliative and critical care clinicians understand a duality in GOC, as an idealized concept and as an expeditious signal for clinical care. Our findings suggest ambiguous phrases like GOC persist because of unmet needs for better ways to discuss and address diverse and complex priorities for patients with serious illness.

Translating Knowledge Into Clinical Practice: A Unique End-of-Life Nursing Education Consortium Teleconferencing Program

For learning to influence change in palliative clinical practice, education needs to be ongoing, incorporating specific interventions targeted to the learner, in a format that enhances knowledge and networking. This novel, online, interactive, case-based educational offering provided a method to allow ongoing integration of palliative care principles for health care professionals who attended the End-of-Life Nursing Education Consortium/Open Medical Institute courses in Salzburg during 2019-2022. Eight monthly teleconferences based on challenging clinical cases allowed discussion between palliative care professionals from 9 countries, serving as a mechanism for deepening theoretical information, allowing incorporation of best practice into the clinical setting, and, ultimately, improving care for all with serious illness. Many of the challenges encountered providing palliative care are universal. Through case vignettes, the group has been able to offer specific interventions, advances in practice, and discussions of approaches toward family and other health care professionals to provide optimal care. The participants report that the opportunity to learn from and support peers in other countries has been a rewarding and emotionally uplifting experience. These discussions were highly rated by participants who strongly voiced that the interactions would change their clinical practice to positively impact patient 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.

The Development of a Communication Tool to Aid Parent-Centered Communication between Parents and Healthcare Professionals: A Quality Improvement Project

Good communication is central to good healthcare. As a result of poor communication between parents and healthcare professionals (HCPs) in clinical settings, this study aimed to address this problem by developing a communication tool to empower parents and act as a prompt for HCPs to talk about the child's care and gather information at the point of admission to hospital about what is important to families, therefore supporting patient-centered communication. A design thinking process was used to develop a physical copy of Chloe's card and evaluate its use. Design thinking is a problem-solving approach, which uses an empathetic lens to integrate viewpoints of different stakeholders throughout the process of creating solutions. Design thinking involves five processes: (1) empathise-including a literature review and data synthesis, (2) define-by completing semi-structured interviews with parents about their experience of communication and HCPs perceptions of parent's experience of communication, (3) ideate-iterate the design of Chloe's card with parents and HCPs, (4) prototype-develop the design of Chloe's card, and (5) test-pilot test in clinical practice. Results from this initial study suggest that a small hand-held card, with emoticons and a place to write concerns, was acceptable to parents and feasible to use in clinical practice. Parents do not always feel heard by HCPs and a tool such as Chloe's card may help facilitate sharing of information about matters important to them and their child. However, some HCPs felt the need for a communication tool undermined their clinical skills. Feedback from HCP participants suggests that the idea of Chloe's card was acceptable and perceived as potentially being useful in clinical practice. Further work is required, as part of a larger study, to further refine this communication tool, identify those parents who would benefit most from Chloe's card, as well as to further refine the HCP process prior to implementing it into clinical settings. It was noted future iterations would benefit from a digital version linked with a child's electronic record, as well as multi-language versions and information for parents.

Social and healthcare professionals' experiences of end-of-life care planning and documentation in palliative care

AIM

To explore social and healthcare professionals' experiences of end-of-life (EOL) care planning and documentation in palliative care.

DESIGN

A qualitative study with narrative methodology.

METHODS

A narrative method with interviews was used. Data were collected from purposively selected registered nurses (n = 18), practical nurses (n = 5), social workers (n = 5) and physicians (n = 5) working in palliative care unit in five hospitals in three hospital districts. Content analysis within narrative methodologies was undertaken.

RESULTS

Two main categories - patient-oriented EOL care planning and multi-professional EOL care planning documentation- were formed. Patient-oriented EOL care planning included treatment goals planning, disease treatment planning and EOL care setting planning. Multi-professional EOL care planning documentation included healthcare professionals' and social professionals' perspectives. Healthcare professionals' perspectives on EOL care planning documentation included benefits of structured documentation and poor support of electronic health record (EHR) for documentation. Social professionals' perspective on EOL care planning documentation included usefulness of multi-professional documentation and externality of social professionals in multi-professional documentation.

CONCLUSION

The results of this interdisciplinary study demonstrated a gap between what healthcare professionals consider important in Advance Care Planning (ACP), that is, proactive, patient-oriented and multi-professional EOL care planning and the ability to access and document this in a useful and accessible way in the EHR.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of the patient-centered EOL care planning and multi-professional documentation processes and their challenges are prerequisites for documentation to be supported by technology.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research checklist was followed.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Interventions to Promote End-of-Life Conversations: A Systematic Review and Meta-Analysis

CONTEXT

Although several interventions aimed to promote end-of-life conversations are available, it is unclear whether and how these affect delivery of end-of-life conversations. Measuring the processes associated with high-quality end-of-life care may trigger improvement.

OBJECTIVES

To estimate the effect of interventions aimed to promote end-of-life conversations in clinical encounters with patients with advanced chronic or terminal illness or their family, on process indicators of end-of-life conversations.

METHODS

Systematic review with meta-analysis (PROSPERO no. CRD42021289471). Four databases (PubMed, CINAHL, PsycINFO, and Scopus) were searched up to September 30, 2021. The primary outcomes were any process indicators of end-of-life conversations. Results of pairwise meta-analyses were presented as Risk Ratio (RR) for occurrence, standardized mean difference (SMD) for quality and ratio of means (ROM) for duration. Meta-analysis was not performed when fewer than four studies were available.

RESULTS

A total of 4,663 articles were scanned. Eighteen studies were included in the systematic review and 16 entered at least one meta-analysis: documented occurrence (n = 8), patient-reported occurrence (n = 4), patient-reported-quality (n = 4), duration (n = 4). There was significant variability in settings, patients' clinical conditions, and professionals. No significant effect of interventions on documented occurrence (RR 1.54, 95% CI 0.84-2.84; I2 91%), patient-reported occurrence (RR 1.52, 95% CI 0.80-2.91; I2 95%), patient-reported quality (SMD 0.83, 95% CI -1.06 to 2.71; I2 99%), or duration (ROM 1.20, 95% CI 0.95-1.51; I2 65%) of end-of-life conversations was found. Data on frequency were conflicting. Interventions targeting multiple stakeholders promoted earlier and more comprehensive conversations.

CONCLUSION

Heterogeneity was considerable, but findings suggest no significant effect of interventions on occurrence, patient-reported quality and duration of end-of-life conversations. Nevertheless, we found indications for interventions targeting multiple stakeholders to promote earlier and more comprehensive conversations.

End-of-life communication strategies for healthcare professionals: A scoping review

BACKGROUND

Timely and effective communication about end-of-life issues, including conversations about prognosis and goals of care, are extremely beneficial to terminally ill patients and their families. However, given the context, healthcare professionals may find it challenging to initiate and facilitate such conversations. Hence, it is critical to improving the available communication strategies to enhance end-of-life communication practices.

AIM

To summarise the end-of-life communication strategies recommended for healthcare professionals, identify research gaps and inform future research.

DESIGN

A scoping review performed in accordance with the Arksey and O'Malley framework.

DATA SOURCES

A literature search was conducted between January 1990 and January 2022 using PubMed, CINAHL, Embase, PsycINFO, Web of Science, Scopus, Cochrane Library and China National Knowledge Infrastructure databases and Google, Google Scholar and ProQuest Dissertations & Theses Global. Studies that described recommended end-of-life communication strategies for healthcare professionals were included.

RESULTS

Fifty-nine documents were included. Seven themes of communication strategies were found: (a) preparation; (b) exploration and assessment; (c) family involvement; (d) provision and tailoring of information; (e) empathic emotional responses; (f) reframing and revisiting the goals of care; and (g) conversation closure.

CONCLUSIONS

The themes of communication strategies found in this review provide a framework to integrally promote end-of-life communication. Our results will help inform healthcare professionals, thereby promoting the development of specialised training and education on end-of-life communication.

Facilitators and Barriers for Initiating Conversations About End of Life

Background

Conducting a conversation about wishes for treatment at end of life (EOL) has been shown to improve EOL care for patients and relatives. Still, only a minority of physicians conduct the conversation, which might lead to unwanted interventions and treatments.

Objectives

The purpose of this survey was to examine which factors facilitate and hinder physicians across a wide range of health care facilities to initiate the conversation about wishes for treatment at EOL.

Design

A questionnaire survey based on a Delphi-developed questionnaire.

Setting/Subjects

The questionnaire was sent to both hospital physicians and general practitioners (GPs) in a Danish region.

Results

More than 3000 physicians were invited to participate in the survey. Of these, 782 responded, 622 working at a hospital department, and 160 from general practice clinics. Results showed that senior physicians, GPs, and physicians working in a medical department feel best equipped to conduct the conversation. Moreover, senior physicians pointed to their experience as physicians as being of great importance for conducting the conversation, whereas junior physicians found training in conducting the conversation as an important factor.

Conclusion

Our study indicates that different factors depending on the health care setting and the seniority of the physician facilitate or hinder physicians from conducting the conversation about wishes for treatment at EOL. Being aware of these differences and making a concerted effort depending on setting and seniority might help implement and conduct the conversation.

Characterizing the Language Used to Discuss Death in Family Meetings for Critically Ill Infants

Importance

Communication during conversations about death is critical; however, little is known about the language clinicians and families use to discuss death.

Objective

To characterize (1) the way death is discussed in family meetings between parents of critically ill infants and the clinical team and (2) how discussion of death differs between clinicians and family members.

Design, Setting, and Participants

This longitudinal qualitative study took place at a single academic hospital in the southeast US. Patients were enrolled from September 2018 to September 2020, and infants were followed up longitudinally throughout their hospitalization. Participants included families of infants with neurologic conditions who were hospitalized in the intensive care unit and had a planned family meeting to discuss neurologic prognosis or starting, not starting, or discontinuing life-sustaining treatment. Family meetings were recorded, transcribed, and deidentified before being screened for discussion of death.

Main Outcomes and Measures

The main outcome was the language used to reference death during family meetings between parents and clinicians. Conventional content analysis was used to analyze data.

Results

A total of 68 family meetings involving 36 parents of 24 infants were screened; 33 family meetings (49%) involving 20 parents (56%) and 13 infants (54%) included discussion of death. Most parents involved in discussion of death identified as the infant's mother (13 [65%]) and as Black (12 [60%]). Death was referenced 406 times throughout the family meetings (275 times by clinicians and 131 times by family members); the words die, death, dying, or stillborn were used 5% of the time by clinicians (13 of 275 references) and 15% of the time by family members (19 of 131 references). Four types of euphemisms used in place of die, death, dying, or stillborn were identified: (1) survival framing (eg, not live), (2) colloquialisms (eg, pass away), (3) medical jargon, including obscure technical terms (eg, code event) or talking around death with physiologic terms (eg, irrecoverable heart rate drop), and (4) pronouns without an antecedent (eg, it). The most common type of euphemism used by clinicians was medical jargon (118 of 275 references [43%]). The most common type of euphemism used by family members was colloquialism (44 of 131 references [34%]).

Conclusions and Relevance

In this qualitative study, the words die, death, dying, or stillborn were rarely used to refer to death in family meetings with clinicians. Families most often used colloquialisms to reference death, and clinicians most often used medical jargon. Future work should evaluate the effects of euphemisms on mutual understanding, shared decision-making, and clinician-family relationships.

Quality of information transferred to palliative care

AIMS AND OBJECTIVES

To describe the quality of information coming from previous care units to palliative care.

BACKGROUND

Information quality is an interconnected concept that includes different dimensions and can be viewed from different perspectives. More knowledge is needed from a multi-professional perspective on the information quality coming to palliative care.

DESIGN

Descriptive qualitative study.

METHODS

Altogether 33 registered nurses, practical nurses, social workers and physicians working in palliative care were purposively selected to participate in thematic interviews. The research was carried out in six palliative care units in three hospital districts. The data were analysed by using deductive and inductive content analysis. The COREQ checklist was used.

RESULTS

Three main categories with thirteen categories were identified in connection with the deductive analysis based on the Clinical Information Quality framework: (1). Informativeness of information coming from previous care units to palliative care included accuracy, completeness, interpretability, plausibility, provenance and relevance. (2). Availability of information coming from previous care units to palliative care included accessibility, portability, security and timeliness. (3). Usability of information coming from previous care units to palliative care included conformance, consistency and maintainability. Each category is divided into sub-categories followed by narratives of their content.

CONCLUSIONS

This study provides new knowledge on the quality of information coming to palliative care from a multi-professional perspective. Professionals working in palliative care units highlight issues describing good information quality, but also point out quality issues and areas for improvement.

RELEVANCE TO CLINICAL PRACTICE

The results can guide the development of documentation practices and Health Information System development as well as be used in the generation of a new audit instrument of information quality.

Quality of Communication Questionnaire for Patients Hospitalized in Intensive and Palliative Care: Validity Evidence for Use in Brazil

The Quality of Communication Questionnaire (QoC) was culturally adapted for Brazil due to its importance and use in several studies and different scenarios. The objective of this study was to evaluate the validity evidence of the Brazilian version of the QoC. A validation study was carried out involving 253 patients admitted to five public hospitals in Southern Brazil. Data were analyzed using descriptive analysis, Cronbach's alpha (α) to assess internal consistency, exploratory factor analysis, and goodness-of-fit index. One hundred and three patients were in intensive care (IC), and 150 were in palliative care (PC). The participants' mean age was 51 years (SD = 14.2). QoC,and its general communication subscale, and end-of-life communication subscale means were 5.5 (SD = 1.6), 8.8 (SD = 1.5), and 5.5 (SD = 1.6) respectively. Among patients in IC, QoC Cronbach's alpha was .75, and .84 in the general communication subscale and .51 in the end-of-life communication subscale. Among patients in PC, QoC Cronbach's alpha was .83, and .88 in the general communication subscale, and .71 in the end-of-life communication subscale. The root mean square error of approximation was .07 (90% CI: .04 - .08); Tucker-Lewis index was .97 (95% CI: .95 - .98); comparative fit index was .98 (95% CI: .97 - .99), and χ²/df ratio was 1.33 (χ²[53] = 70.858, p = .05). The authors conclude that the general communication subscale of QoC Brazilian version has good validity evidence for patients in IC and PC, whereas the end-of-life communication subscale is only valid for patient in PC.

Advance Care Plans and the Potentially Conflicting Interests of Bedside Patient Agents: A Thematic Analysis

AIM

People diagnosed with a neurodegenerative disorder often contend with a threat to independence and control, leading some to complete an advance care plan. Advance care plans are commonly associated with treatment limitations; however, key patient agents (such as doctors, allied health, nurses and family) may instead make temporal, best interests or good medical practice decisions on behalf of the patient. Accordingly, there is a need to better understand ancillary decision-maker's perspectives, particularly of doctors.

PURPOSE

To explain how the potentially conflicting interests of bedside patient agents operates as a factor which influences doctors' application of advance care plans of people with a neurodegenerative disorder.

PARTICIPANTS AND METHODS

Using a constructivist grounded theory informed thematic analysis, 38 semi-structured interviews were conducted with hospital-based doctors, allied health, nurses and family of people with a neurodegenerative disorder who had an advance care plan. Data were inductively analysed using open and focused coding.

RESULTS

Analysis revealed two main themes: dynamics of discerning best interests; and avoiding conflict. Rather than applying advance care plans, doctors largely involved families to attempt best interests decision-making partnerships on patients' behalf. Bedside agents demonstrated significant intra and interpersonal challenges associated with their roles as patient agents. Doctors appeared protective of families and patients with neurodegenerative disorder.

CONCLUSION

Although bedside agents value advance care plans, doctors often favour temporal healthcare decisions in consultation with family. We suggest there are limitations to the effectiveness of advance care plans in practice, with application typically only occurring close to death. Despite the intentions of advance care planning, bedside agents may still experience considerable dissonance.