Preparing professionals for family conferences in palliative care: evaluation results of an interdisciplinary approach

Palliative Family Conference Reduces the Risk of Death in Intensive Care Units and Cardiopulmonary Resuscitation at End of Life

Background: Palliative family conference (PFC) was included in the reimbursement of National Health Insurance to promote palliative care in Taiwan in 2012. Objectives: This study aimed to evaluate the impact of PFC on death in intensive care unit (ICU) and receiving cardiopulmonary resuscitation (CPR) within three days before death. Design: This is a cross-sectional study. Subjects: All patients who died in a public hospital and were admitted to ICU within 30 days before death, from 2013 to 2018, were included. Measurements: The medical records were analyzed to identify information on causes of death, receiving PFC, receiving palliative care consultation, death in ICU, and receiving CPR within three days before death. Multivariate logistic regression was used to assess the independent effects of receiving PFC on the risk of death in ICU and receiving CPR within three days before death. Results: For patients who died and those who did not die in ICU, the proportion of receiving PFC was 45.8% (1818/3973) and 55.0% (808/1468), respectively. For patients who received and those who did not receive CPR within three days before death, the proportion of receiving PFC was 23.9% (140/585) and 51.2% (2486/4856), respectively. PFC was associated with a reduced risk of death in ICU (adjusted odds ratio [AOR]: 0.842; 95% confidence interval [CI]: 0.717-0.988) and a reduced risk of receiving CPR within three days before death (AOR: 0.361; 95% CI: 0.286-0.456). Conclusion: PFC reduces the risk of receiving nonbeneficial aggressive intervention and may improve the quality of end-of-life care.

AD-LAST! An interdisciplinary clinical workshop to improve cultural and spiritual awareness in advance care planning skills

OBJECTIVES

Clinicians report training deficits in advance care planning (ACP), including limits to their understanding of cultural/spiritual influences on patient decision-making and skills in interdisciplinary teamwork. This study describes Advance Directives-Live Action Simulation Training (AD-LAST), an interdisciplinary experiential and didactic training program for discussing ACP and end-of-life (EOL) care. AD-LAST highlights cultural/spiritual variations in medical decision-making.

METHODS

Prospective educational cohort study with pre-post intervention survey. AD-LAST incorporated standard curricular tools for didactic and experiential training in ACP/EOL communication. Study conducted in an urban community teaching hospital in Queens, NY, one of the most diverse counties in the USA. Participants included physicians, house staff, nurses, therapists, and other disciplines. AD-LAST format was a one-day workshop. The morning focused on didactic teaching using widely available curricular tools. The afternoon involved experiential practice with standardized patient-actors. Pre-post intervention questionnaires assessed ACP operational knowledge and self-efficacy (i.e., self-confidence in skills) in ACP and EOL communication. Repeated measure ANOVAs evaluated changes from pretest to posttest in knowledge and self-efficacy.

RESULTS

A total of 163 clinical staff participated in 21 AD-LAST training sessions between August 2015 and January 2019. Participants displayed a significant increase from pretest to posttest in total knowledge (p < 0.001), ACP procedural knowledge (p < 0.001), ACP communication/relationships knowledge (p < 0.001), and self-efficacy (p < 0.001). Knowledge and self-efficacy were not correlated and represented independent outcomes. Postprogram evaluations showed greater than 96% of participants were highly satisfied with AD-LAST, especially the opportunity to practice skills in real-time and receive feedback from members of other professional groups.

SIGNIFICANCE OF RESULTS

AD-LAST, a multifaceted training program deployed in an interdisciplinary setting, is effective for increasing ACP knowledge and self-efficacy, including the capacity to address cultural/spiritual concerns. The use of standard tools facilitates dissemination. The use of case simulations reinforces learning.

Family Conference Simulation Designed for Physician Assistant Students and Chaplain Residents

Background: Physician Assistants (PAs) are increasingly likely to work in clinical areas where family conference skills are needed, but there is currently a lack of family conference education in PA program curricula. Objectives: To (1) describe a novel interprofessional education (IPE) event for PA students and chaplain residents; (2) examine whether participating in the IPE event is associated with improvements in attitudes and knowledge regarding interprofessional teams; and (3) describe participant perceptions about the event. Design: Two cohorts of PA students and chaplain residents completed a required interprofessional simulation activity involving a critically ill patient and a family conference. All participants completed pre- and postsimulation activity questionnaires. Bivariate tests were utilized to analyze the quantitative data. Setting/Subjects: Over two years, 171 PA students and 20 chaplain residents completed the activity at a school of medicine in the United States. Measurements: Pre- and postactivity measurements included role-specific questions plus overlapping sections regarding roles and responsibilities of the other discipline, comfort facilitating end-of-life discussions, and the value of IPE. Results: For PA students, there was a statistically significant increase for all questionnaire items. The largest effect size increases were in PA students' confidence in provider-patient communication at the end of life (Cohen's d > 1.1). Chaplain data demonstrated increases in knowledge of the PA role and likelihood of consulting with PAs in the future. Conclusion: This simulation event improved participant attitudes and knowledge relating to interprofessional interactions in the setting of an end-of-life family conference, and may contribute to more effective collaboration between PAs and chaplains in the clinical setting.

Top Ten Tips Palliative Care Clinicians Should Know About Psychosocial and Family Support

Palliative care (PC) is perhaps the most inherently interdisciplinary specialty within health care. Comprehensive PC is delivered by a core team of physicians, nurses, social workers, spiritual care providers, pharmacists, and others who address the broad range of medical, psychosocial, and spiritual needs of those living with serious illness. While PC clinicians are typically skilled in screening for distress, the best path to follow when patients screen positive for psychosocial distress or exhibit mental health challenges may not always be clear. This article brings together the perspectives of experienced social workers practicing across PC and hospice settings. It seeks to identify opportunities and rationale for the integration of palliative social work (PSW) in the provision of quality, person-centered, family-focused, and culturally congruent care for the seriously ill. Increasing recognition of the impact of social determinants of health highlights the critical importance of including PSW if we are to better understand and ultimately address the broad range of factors that influence people's quality of life.

Communication skills training for healthcare professionals working with people who have cancer

BACKGROUND

This is the third update of a review that was originally published in the Cochrane Library in 2002, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress, which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective.

OBJECTIVES

To assess whether communication skills training is effective in changing behaviour of HCPs working in cancer care and in improving HCP well-being, patient health status and satisfaction.

SEARCH METHODS

For this update, we searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid, Embase via Ovid, PsycInfo and CINAHL up to May 2018. In addition, we searched the US National Library of Medicine Clinical Trial Registry and handsearched the reference lists of relevant articles and conference proceedings for additional studies.

SELECTION CRITERIA

The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In updated versions, we limited our criteria to RCTs evaluating CST compared with no CST or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real or simulated people with cancer or both, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects method. For continuous data, we used standardised mean differences (SMDs).

MAIN RESULTS

We included 17 RCTs conducted mainly in outpatient settings. Eleven trials compared CST with no CST intervention; three trials compared the effect of a follow-up CST intervention after initial CST training; two trials compared the effect of CST and patient coaching; and one trial compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists, residents, other doctors, nurses and a mixed team of HCPs. Overall, 1240 HCPs participated (612 doctors including 151 residents, 532 nurses, and 96 mixed HCPs).Ten trials contributed data to the meta-analyses. HCPs in the intervention groups were more likely to use open questions in the post-intervention interviews than the control group (SMD 0.25, 95% CI 0.02 to 0.48; P = 0.03, I² = 62%; 5 studies, 796 participant interviews; very low-certainty evidence); more likely to show empathy towards their patients (SMD 0.18, 95% CI 0.05 to 0.32; P = 0.008, I² = 0%; 6 studies, 844 participant interviews; moderate-certainty evidence), and less likely to give facts only (SMD -0.26, 95% CI -0.51 to -0.01; P = 0.05, I² = 68%; 5 studies, 780 participant interviews; low-certainty evidence). Evidence suggesting no difference between CST and no CST on eliciting patient concerns and providing appropriate information was of a moderate-certainty. There was no evidence of differences in the other HCP communication skills, including clarifying and/or summarising information, and negotiation. Doctors and nurses did not perform differently for any HCP outcomes.There were no differences between the groups with regard to HCP 'burnout' (low-certainty evidence) nor with regard to patient satisfaction or patient perception of the HCPs communication skills (very low-certainty evidence). Out of the 17 included RCTs 15 were considered to be at a low risk of overall bias.

AUTHORS' CONCLUSIONS

Various CST courses appear to be effective in improving HCP communication skills related to supportive skills and to help HCPs to be less likely to give facts only without individualising their responses to the patient's emotions or offering support. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', the mental or physical health and satisfaction of people with cancer.

Supporting home hospice family caregivers: Insights from different perspectives

ABSTRACTObjective:Our intention was to describe and compare the perspectives of national hospice thought leaders, hospice nurses, and former family caregivers on factors that promote or threaten family caregiver perceptions of support.

METHOD

Nationally recognized hospice thought leaders (n = 11), hospice nurses (n = 13), and former family caregivers (n = 14) participated. Interviews and focus groups were audiotaped and transcribed. Data were coded inductively, and codes were hierarchically grouped by topic. Emergent categories were summarized descriptively and compared across groups.

RESULTS

Four categories linked responses from the three participant groups (95%, 366/384 codes): (1) essentials of skilled communication (30.6%), (2) importance of building authentic relationships (28%), (3) value of expert teaching (22.4%), and (4) critical role of teamwork (18.3%). The thought leaders emphasized communication (44.6%), caregivers stressed expert teaching (51%), and nurses highlighted teamwork (35.8%). Nurses discussed teamwork significantly more than caregivers (z = 2.2786), thought leaders discussed communication more than caregivers (z = 2.8551), and caregivers discussed expert teaching more than thought leaders (z = 2.1693) and nurses (z = 2.4718; all values of p < 0.05).

SIGNIFICANCE OF RESULTS

Our findings suggest differences in priorities for caregiver support across family caregivers, hospice nurses, and thought leaders. Hospice teams may benefit from further education and training to help cross the schism of family-centered hospice care as a clinical ideal to one where hospice team members can fully support and empower family caregivers as a hospice team member.

Communicating Effectively in Pediatric Cancer Care: Translating Evidence into Practice

Effective communication is essential to the practice of pediatric oncology. Clear and empathic delivery of diagnostic and prognostic information positively impacts the ways in which patients and families cope. Honest, compassionate discussions regarding goals of care and hopes for patients approaching end of life can provide healing when other therapies have failed. Effective communication and the positive relationships it fosters also can provide comfort to families grieving the loss of a child. A robust body of evidence demonstrates the benefits of optimal communication for patients, families, and healthcare providers. This review aims to identify key communication skills that healthcare providers can employ throughout the illness journey to provide information, encourage shared decision-making, promote therapeutic alliance, and empathically address end-of-life concerns. By reviewing the relevant evidence and providing practical tips for skill development, we strive to help healthcare providers understand the value of effective communication and master these critical skills.

The VOICE Study: Valuing Opinions, Individual Communication and Experience: building the evidence base for undertaking Patient-Centred Family Meetings in palliative care - a mixed methods study

Background

Despite family meetings being widely used to facilitate discussion among patients, families, and clinicians in palliative care, there is limited evidence to support their use. This study aims to assess the acceptability and feasibility of Patient-Centred Family Meetings in specialist inpatient palliative care units for patients, families, and clinicians and determine the suitability and feasibility of validated outcome measures from the patient and family perspectives.

Methods

The study is a mixed-methods quasi-experimental design with pre-planned Patient-Centred Family Meetings at the intervention site. The patient will set the meeting agenda a priori allowing an opportunity for their issues to be prioritised and addressed. At the control site, usual care will be maintained which may include a family meeting. Each site will recruit 20 dyads comprising a terminally ill inpatient and their nominated family member. Pre- and post-test administration of the Distress Thermometer, QUAL-EC, QUAL-E, and Patient Health Questionnaire-4 will assess patient and family distress and satisfaction with quality of life. Patient, family, and clinician interviews post-meeting will provide insights into the meeting feasibility and outcome measures. Recruitment percentages and outcome measure completion will also inform feasibility.

Descriptive statistics will summarise pre- and post-meeting data generated by the outcome measures. SPSS will analyse the quantitative data. Grounded theory will guide the qualitative data analysis.

Discussion

This study will determine whether planned Patient-Centred Family Meetings are feasible and acceptable and assess the suitability and feasibility of the outcome measures. It will inform a future phase III randomised controlled trial.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12616001083482 on 11 August 2016

Family conference in palliative care: concept analysis

ABSTRACT Objective: to analyze the attributes, antecedents and consequents of the family conference concept. Method: Walker and Avante's method for concept analysis and the stages of the integrative review process, with a selection of publications in the PubMed, Cinahl and Lilacs databases focusing on the family conference theme in the context of palliative care. Results: the most cited antecedents were the presence of doubts and the need to define a care plan. Family reunion and working instrument were evidenced as attributes. With respect to consequents, to promote the effective communication and to establish a plan of consensual action were the most remarkable elements. Final considerations: the scarcity of publications on the subject was observed, as well as and the limitation of the empirical studies to the space of intensive therapy. Thus, by analyzing the attributes, antecedents and consequents of the concept it was possible to follow their evolution and to show their efficacy and effectiveness as a therapeutic intervention.

Pre-registration interprofessional clinical education in the workplace: a realist review

CONTEXT

The inclusion of interprofessional education opportunities in clinical placements for pre-registration learners has recently been proposed as a strategy to enhance graduates' skills in collaborative practice.

OBJECTIVES

A realist review was undertaken to ascertain the contexts, mechanisms and outcomes of formal interprofessional clinical workplace learning.

METHODS

Initial scoping was carried out, after which Ovid MEDLINE, CINAHL and EMBASE were searched from 2005 to April 2016 to identify formal interprofessional workplace educational interventions involving pre-registration learners. Papers reporting studies conducted in dedicated training wards were excluded, leaving a total of 30 papers to be included in the review.

RESULTS

Several educational formats that combined students from medicine, nursing, pharmacy and allied health professions were identified. These included: the use of engagement by student teams with a real patient through interview as the basis for discussion and reflection; the use of case studies through which student teams work to promote discussion; structured workshops; ward rounds, and shadowing. Meaningful interprofessional student discussion and reflection comprised the mechanism by which the outcome of learners acquiring knowledge of the roles of other professions and teamwork skills was achieved. The mechanism of dialogue during an interaction with a real patient allowed the patient to provide his or her perspective and contributed to an awareness of the patient's perspective in health care practice. Medication- or safety-focused interprofessional tasks contributed to improved safety awareness. In the absence of trained facilitators or in the context of negative role-modelling, programmes were less successful.

CONCLUSIONS

In the design of workplace education initiatives, curriculum decisions should take into consideration the contexts of the initiatives and the mechanisms for achieving the education-related outcomes of interest.

Transforming Students' Attitudes and Anxieties Toward Death and Loss: The Role of Prior Death Experiences

This study examines the impact of a death and dying course on 39 undergraduate students' attitudes and anxieties about death. Authors outline key aspects of the curriculum used in the course and discuss how the approach lends itself to a transformative learning experience related to death and loss, preparing students who will face clients with a variety of needs in these areas across practice settings. The majority of students ( n = 34) experienced a decrease in death avoidance, fear of death, and overall death anxiety. Students with a history of multiple violent, traumatic, or unexpected deaths ( n = 5) did not experience any significant changes but demonstrated increased scores of death anxiety suggesting that they may be in need of greater support while engaging in death education.

Advancing Hospice and Palliative Care Social Work Leadership in Interprofessional Education and Practice

The importance of interprofessional collaboration in achieving high quality outcomes, improving patient quality of life, and decreasing costs has been growing significantly in health care. Palliative care has been viewed as an exemplary model of interprofessional care delivery, yet best practices in both interprofessional education (IPE) and interprofessional practice (IPP) in the field are still developing. So, too, is the leadership of hospice and palliative care social workers within IPE and IPP. Generating evidence regarding best practices that can prepare social work professionals for collaborative practice is essential. Lessons learned from practice experiences of social workers working in hospice and palliative care can inform educational efforts of all professionals. The emergence of interprofessional education and competencies is a development that is relevant to social work practice in this field. Opportunities for hospice and palliative social workers to demonstrate leadership in IPE and IPP are presented in this article.

Hospice Core Professions' Views on Interdisciplinary Teams: A Qualitative Investigation

The hospice interdisciplinary team (IDT) has been recognized as an ideal model for interprofessional collaboration. To address the manner in which interdisciplinary practices are perceived by team members, this study explored profession-based similarities and differences in perceptions among the four core hospice IDT members (physicians, nurses, social workers, and spiritual care providers) as well as experiences on the IDT. Semistructured interviews with 20 hospice professionals, 5 from each profession, were completed. Findings suggested that while hospice professions share some perceptions and experiences about hospice team membership, strengths of and barriers to teamwork, and individual members' contribution to the team, significant profession-based differences exist largely in the area of hospice team membership beyond the core members, type of language and descriptions used, perceptions of causes and effects of barriers to teamwork, and understandings of how team effectiveness is evaluated. Changes at the team-based, organizational, policy, and educational levels are needed to further maximize strengths of individual hospice IDT member and team qualities.

Family conferences in palliative care: a survey of health care providers in France

CONTEXT

Family conferences are conducted to assist with end-of-life discussions and discharge planning.

OBJECTIVES

This study describes the current practices of family conferences in palliative care units (PCUs) in France.

METHODS

A cross-sectional descriptive survey was sent to each PCU in France (n = 113). Members of the interdisciplinary health care team (palliative care physician, nurse, psychologist, and social worker) who were active in each PCU at the time of the survey were asked to respond.

RESULTS

Two hundred seventy-six of 452 responses (61%) were obtained from members of the health care team in 91 units (81%). Two hundred seventy-two of 276 health care providers (HCPs) (99%) reported conducting family conferences in their clinical practice. Only 13 participants (5%) reported that they followed a structured protocol. Most respondents completed the questionnaire: palliative care physicians (n = 225; 82%), nurses (n = 219; 79%), and psychologists (n = 181; 66%). The three primary goals of family conferences were to allow family members to express their feelings (n = 240; 87%), identify family caregivers (n = 233; 84%), and discuss the patient's plan of care (n = 219; 79%). The primary reasons for conducting a family conference were: the patient's illness was terminal (n = 216; 78%), family caregivers requested a conference (n = 208; 75%), or terminal sedation was required (n = 189; 69%). One hundred six of 452 HCPs (38%) reported that patients were not invited to participate. The primary indications and goals for a family conference were significantly different among the four health care disciplines.

CONCLUSION

Most HCPs in our study conducted family conferences. However, most of the family conferences had no structured protocol, half of the participants preferred no patient participation, and a significant variation was noted in the primary indications and goals among disciplines.

Similarities and Differences in Perspectives on Interdisciplinary Collaboration Among Hospice Team Members

This study surveyed 4 core hospice professionals (physicians, nurses, social workers, and chaplains) on their perceived level of interdisciplinary collaboration, the influences of interdisciplinary collaboration, and job satisfaction to determine potential similarities and differences based on profession and various demographic characteristics of the members or member hospices. Analysis found that there are overall no differences based on demographic characteristics. Differences between professions, while few, were largely in the area of perceptions on relationships between members of the hospice team. Specifically, social workers appear to perceive themselves as less connected to the other members of the interdisciplinary team, an area theorized to influence interdisciplinary collaboration. Difference between professions was also found in job satisfaction. Implications for hospice practice and interdisciplinary education are discussed.

The elderly patient on dialysis: geriatric considerations

The burgeoning population of older dialysis patients presents opportunities to provide personalized care. The older dialysis population has a high burden of chronic health conditions, decrements in quality of life and a high risk of death. In order to address these challenges, this review will recommend routinely establishing prognosis through the use of prediction instruments and communicating these findings to older patients. The challenges to prognosis in adults with end-stage renal disease (ESRD) include the subjective nature of clinical judgment, application of appropriate prognostic tools and communication of findings to patients and caregivers. There are three reasons why we believe these conversations occur infrequently with the dialysis population. First, there have previously been no clinically practical instruments to identify individuals undergoing maintenance hemodialysis (HD) who are at highest risk for death. Second, nephrologists have not been trained to have conversations about prognosis and end-of-life care. Third, other than hospitalizations and accrual of new diagnoses, there are no natural milestone guidelines in place for patients supported by dialysis. The prognosis can be used in shared decision-making to establish goals of care, limits on dialysis support or parameters for withdrawal from dialysis. As older adults with ESRD benefit from kidney transplantation, prognosis can also be used to determine who should be referred for evaluation by a kidney transplant team. The use of prognosis in older adults may determine approaches to optimize well-being and personalize care among older adults ranging from hospice to kidney transplantation.

Communication skills training for healthcare professionals working with people who have cancer

BACKGROUND

This is an updated version of a review that was originally published in the Cochrane Database of Systematic Reviews in 2004, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses have been proposed and are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective.

OBJECTIVES

To assess whether CST is effective in improving the communication skills of HCPs involved in cancer care, and in improving patient health status and satisfaction.

SEARCH METHODS

We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2012, MEDLINE, EMBASE, PsycInfo and CINAHL to February 2012. The original search was conducted in November 2001. In addition, we handsearched the reference lists of relevant articles and relevant conference proceedings for additional studies.

SELECTION CRITERIA

The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In this updated version, we limited our criteria to RCTs evaluating 'CST' compared with 'no CST' or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real and/or simulated patients with cancer, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects model and, for continuous data, we used standardised mean differences (SMDs).

MAIN RESULTS

We included 15 RCTs (42 records), conducted mainly in outpatient settings. Eleven studies compared CST with no CST intervention, three studies compared the effect of a follow-up CST intervention after initial CST training, and one study compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists (six studies), residents (one study) other doctors (one study), nurses (six studies) and a mixed team of HCPs (one study). Overall, 1147 HCPs participated (536 doctors, 522 nurses and 80 mixed HCPs).Ten studies contributed data to the meta-analyses. HCPs in the CST group were statistically significantly more likely to use open questions in the post-intervention interviews than the control group (five studies, 679 participant interviews; P = 0.04, I² = 65%) and more likely to show empathy towards patients (six studies, 727 participant interviews; P = 0.004, I² = 0%); we considered this evidence to be of moderate and high quality, respectively. Doctors and nurses did not perform statistically significantly differently for any HCP outcomes.There were no statistically significant differences in the other HCP communication skills except for the subgroup of participant interviews with simulated patients, where the intervention group was significantly less likely to present 'facts only' compared with the control group (four studies, 344 participant interviews; P = 0.01, I² = 70%).There were no significant differences between the groups with regard to outcomes assessing HCP 'burnout', patient satisfaction or patient perception of the HCPs communication skills. Patients in the control group experienced a greater reduction in mean anxiety scores in a meta-analyses of two studies (169 participant interviews; P = 0.02; I² = 8%); we considered this evidence to be of a very low quality.

AUTHORS' CONCLUSIONS

Various CST courses appear to be effective in improving some types of HCP communication skills related to information gathering and supportive skills. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', patients' mental or physical health, and patient satisfaction.

Challenges in providing family-centered support to families in palliative care

BACKGROUND

Supporting the family-as-a-whole presents challenges in palliative care, although family meetings are increasingly used in routine practice. The Family Focused Grief Therapy (FFGT) Model guides clinicians in using a range of intervention strategies.

AIM

To examine the therapists' techniques used in assessing 'at risk' families in palliative care to better illuminate what helps and what remains challenging.

METHOD

Recorded sessions 1 and 2 were coded using the FFGT fidelity coding measure, with its glossary of definitions. Inter-rater reliability between three coders was satisfactory at 88%. Frequencies of strategy utilization were computed, with extraction of examples of both successful and problematic approaches.

SETTING/PARTICIPANTS

From within a larger study of family therapy during palliative care at a comprehensive cancer center, the first two sessions (n = 144) delivered to 74 families (299 individuals) by 32 therapists were coded and analyzed.

RESULTS

Therapists readily explored the story of illness and families' ways of coping (97%) and assessed communication and cohesiveness in the majority. Exploration of relational patterns occurred in 89% of sessions, use of a genogram in 80%, understanding members' roles in 65% and family values and beliefs in 62%. Less use was made of summaries (39%), family mottos (34%), exploration of family conflict (35%) and the formalization of a comprehensive family treatment plan (20%).

CONCLUSIONS

Challenges exist in therapy with difficult families. Therapy in the home brings special issues. Therapists can apply most of the interventions prescribed by the FFGT model.

Meeting the family: Measuring effectiveness of family meetings in a specialist inpatient palliative care unit

Objective:

The World Health Organization (WHO) definition of palliative care as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness …” recognizes the importance of family members in this setting. In practice, family meetings account for a significant amount of the weekly workload in a specialist inpatient palliative care unit. Despite this, there is little empirical evidence to support the benefits of family meetings from the perspective of family members.

Method:

A prospective study over 6 months, invited a designated family member to complete a self-report instrument (SRI) and the Family Inventory of Needs (FIN) questionnaire prior to, immediately following, and 48 hours after a planned family meeting attended by several members of the multidisciplinary team.

Results:

Thirty-one designated family members completed the study. The SRIs completed prior to a family meeting identified particular areas of concern and worry for family members, and also helped to generate an agenda based on the family's particular needs. The pre-meeting FIN identified areas of patient care of greatest importance to each family member, and asked them to rate whether particular care needs were presently met or unmet, in their opinion, by the healthcare team caring for the patient. Following the family meeting, repeat SRIs showed an overall reduction in concerns and increased confidence in dealing with those issues raised. Post-family meeting FIN scores confirmed a greater number of met care needs compared with pre-meeting scores, all of which were sustained over time.

Significance of results:

This study confirms the value of planned multidisciplinary family meetings for patients in specialist inpatient palliative care units. It identifies the often unmet needs of family members and the sustained benefits associated with formal family meetings.

Palliative care curriculum for speech-language pathology students

This paper reports on the experience of undergraduate speech-language pathology students at one university chosen for the implementation stage of the Palliative Care Curriculum for Undergraduates (PCC4U) Project. Funded by a government department for health and ageing through a national palliative care programme, the project was managed by a team of researchers from the discipline of nursing. The PCC4U project championed the inclusion of palliative care education as an integral part of medical, nursing, and allied healthcare undergraduate training. Of the pilot sites chosen for the PCC4U project, only one site, reported here, included both speech-language pathology and social work disciplines, providing an important opportunity for interdisciplinary collaboration on novel curriculum development in an area of mutual interest. This synergy served as an excellent foundation for ongoing opportunities for interdisciplinary teaching and learning in the university. Speech-language pathology students reported that the project was an invaluable addition to their education and preparation for clinical practice.

Communication with families facing life-threatening illness: a research-based model for family conferences

BACKGROUND

Communication is an ongoing challenge for clinicians working with people facing life-threatening illnesses and end of life. Family conferences offer patient-focused, family-oriented care that brings together patients, family members, and health care providers.

OBJECTIVE

The aim of this study was to develop a research-based model for family conferences to help physicians and other health care providers conduct such conferences effectively and improve communication with patients and families.

DESIGN

We prospectively studied family conferences for patients facing life-threatening illness in two inpatient medical centers. We videotape and audiotape recorded real-life conferences and postconference interviews with participants.

PARTICIPANTS

Twenty-four family conferences were included in the study. Participants consisted of 24 patients, 10 of whom took part in the family conferences, 49 family members, and 85 health care providers.

APPROACH

A multidisciplinary team conducted a qualitative analysis of the videotaped and audiotaped materials using thematic analysis. The team used a multistage approach to independently and collectively analyze and integrate three data sources.

MAIN RESULTS

The resulting theoretical model for family conferences has 4 main components. These include the underlying structural context of conference organization and the key process components of negotiation and personal stance. Emotional engagement by health care providers, emotion work, appears central to the impact of these components on the successful outcome of the conference. In addition to the theoretical model, the authors found that family conference participants place specific value on the "simultaneous presence" of conference attendees that leads to being on the "same page."

CONCLUSIONS

Physicians and other health care professionals can use the model as a guide for conducting family conferences and strengthening communication with patients, families and colleagues.

Concept analysis of interdisciplinary collaboration

PURPOSE

The study aims to explore the meaning of interdisciplinary collaboration within the context of health care.

ORGANIZING FRAMEWORK

Rodgers' Evolutionary View of Concept Analysis was employed to identify attributes, antecedents, and consequences of interdisciplinary collaboration.

METHODS

Utilizing an inductive approach, a systematic review of the literature was undertaken in August 2007 to clarify the current use of interdisciplinary collaboration in health care.

FINDINGS

Interdisciplinary collaboration is commonly described using the terms problem-focused process, sharing, and working together. The elements that must be in place before interdisciplinary collaboration can be successful are interprofessional education, role awareness, interpersonal relationship skills, deliberate action, and support. Consequences of interdisciplinary collaboration are beneficial for the patient, the organization, and the healthcare provider.

CONCLUSIONS

A comprehensive definition of interdisciplinary collaboration within the context of health care is presented as an outcome of this analysis. It is recommended that further inquiry in this area focus on the development of valid measures to accurately evaluate interdisciplinary collaboration in health care.

Family meetings in palliative care: Multidisciplinary clinical practice guidelines

Background

Support for family carers is a core function of palliative care. Family meetings are commonly recommended as a useful way for health care professionals to convey information, discuss goals of care and plan care strategies with patients and family carers. Yet it seems there is insufficient research to demonstrate the utlility of family meetings or the best way to conduct them. This study sought to develop multidisciplinary clinical practice guidelines for conducting family meetings in the specialist palliative care setting based on available evidence and consensus based expert opinion.

Methods

The guidelines were developed via the following methods: (1) A literature review; (2) Conceptual framework; (3) Refinement of the guidelines based on feedback from an expert panel and focus groups with multidisciplinary specialists from three palliative care units and three major teaching hospitals in Melbourne, Australia.

Results

The literature review revealed that no comprehensive exploration of the conduct and utility of family meetings in the specialist palliative care setting has occurred. Preliminary clinical guidelines were developed by the research team, based on relevant literature and a conceptual framework informed by: single session therapy, principles of therapeutic communication and models of coping and family consultation. A multidisciplinary expert panel refined the content of the guidelines and the applicability of the guidelines was then assessed via two focus groups of multidisciplinary palliative care specialists. The complete version of the guidelines is presented.

Conclusion

Family meetings provide an opportunity to enhance the quality of care provided to palliative care patients and their family carers. The clinical guidelines developed from this study offer a framework for preparing, conducting and evaluating family meetings. Future research and clinical implications are outlined.

An interactive educational workshop to improve end of life communication skills

INTRODUCTION

An understanding of legal, ethical, and cultural concerns and an ability to communicate when faced with clinical dilemmas are integral to the end of life decision-making process. Yet teaching practicing clinicians these important skills in addressing conflict situations is not strongly emphasized.

METHODS

A one-day interactive continuing education workshop was designed to improve interactions among multiprofessional intensive care unit (ICU) clinicians, their colleagues, and families in a range of end of life situations using standardized families and colleagues (SF/SCs). Workshop participants completed preworkshop and postworkshop evaluations. Data were analyzed using the McNemar test for paired categorical data to evaluate changes in comfort, knowledge, and skill.

RESULTS

The majority of evaluation respondents were nursing professionals, while only one physician (of two in attendance) responded. Statistically significant improvement was seen in all comfort levels, except when approaching cultural differences. Expectations were exceeded according to 76.2% of responses, while 82.4% rated SF/SCs "excellent" for improving communication skills and comfort levels with ethical and legal dilemmas. Peer discussions were highly valued in meeting educational objectives (95.2% good or excellent), and 95.2% rated achievement of personal learning objectives good or excellent. Qualitative data supported a high overall perception of success and achievement of educational objectives.

DISCUSSION

An interactive workshop can be a valuable educational intervention for building capacity and confidence in end of life communication skills and ethical and legal knowledge for health care providers; further physician involvement is required to extrapolate results to this population.

Palliative care and psychosocial contributions in the ICU

Psychosocial domains and palliative care medicine are the connective tissue of our fragmented health care system. The psychosocial domains of palliative care are central to creating new partnerships with physicians, patients, and their caregivers in emotionally charged medical environments, especially Intensive Care Units. Managing the psychological, social, emotional, spiritual, practical and existential reactions of patients and their loved ones supports effective action and problem-solving. Practical aspects to establishing realistic goals of care among the health care team and other specialists, communicating effectively with patients and families in crisis, using the diverse and ambiguous emotional responses of patients, families, faculty and staff therapeutically, and helping to create meaning in the experience is essential to whole-patient and family care centered. The family conference is an excellent vehicle to create an environment of honest and open communication focused on mobilizing the resources of the patient, family and health care team toward a mutually agreed upon plan of action resulting in clearly defined goals of care.

Curriculum factors influencing knowledge of communication skills among medical students

BACKGROUND

Communication training builds on the assumption that understanding of the concepts related to professional communication facilitates the training. We know little about whether students' knowledge of clinical communication skills is affected by their attendance of communication training courses, or to what degree other elements of the clinical training or curriculum design also play a role. The aim of this study was to determine which elements of the curriculum influence acquisition of knowledge regarding clinical communication skills by medical students.

METHODS

The study design was a cross-sectional survey performed in the four Norwegian medical schools with different curricula, spring 2003. A self-administered questionnaire regarding knowledge of communication skills (an abridged version of van Dalen's paper-and-pencil test) was sent to all students attending the four medical schools. A total of 1801 (59%) students responded with complete questionnaires.

RESULTS

At the end of the 1st year of study, the score on the knowledge test was higher in students at the two schools running communication courses and providing early patient contact (mean 81%) than in the other two medical schools (mean 69-75%, P < or = 0.001), with students studying a traditional curriculum scoring the lowest. Their scores increased sharply towards the end of the 3rd year, during which they had been subjected to extensive patient contact and had participated in an intensive communication course (77% vs. 72% the previous year, P <or = 0.01). All students scored generally lower in academic years in which there was no communication training. However, at the end of the final year the difference between the schools was only 5% (81% vs. 86%, P < or = 0.001).

CONCLUSION

The acquisition of knowledge regarding communication skills by medical students may be optimised when the training is given together with extensive supervised patient contact, especially if this teaching takes place in the initial years of the curriculum.

An interdisciplinary workshop to improve palliative care: Advanced heart failure— Clinical guidelines and healing words

Objective: Effective communication is recognized as an essential process to providing quality care, including palliative and end-of-life care. Discussion of prognosis and support needs of patients with heart failure is particularly challenging given the nature of the condition and care across several settings. The objective was to design, implement, and evaluate an interdisciplinary workshop aimed at improving attitudes and skills related to communication with patients and family, health team communication and documentation, and assessment of physical and emotional symptoms.

Methods: A pretest, delayed posttest evaluation design was used to evaluate two 4-h workshops offered to nurses, social workers, and other nonphysician clinicians.

Results: Although baseline reports of skills were high for the participants, significant improvement was noted for objectives emphasized in the workshop.

Significance of results: This project demonstrated the feasibility of designing, marketing a brief workshop, and positively impacting communication and documentation skills.