Core elements of serious illness conversations: an integrative systematic review

Breaking the Cycle: Using Serious Illness Communication to Optimize Care Transition Planning in Serious Illness

It is widely recognized that many older adults in their last year of life will cycle between hospitals and skilled nursing facilities-a phenomenon described as "rehabbing to death." Several strategies to address this complex problem have been proposed, including developing and testing serious illness communication models to provide goal-concordant care by aligning what matters most to patients with how they spend their time in the last months of life. Serious illness communication (SIC) includes structured skills clinicians can use with patients and caregivers to assess illness understanding, goals and values, share information, and make recommendations. Despite the potential of SIC models, there is a lack of literature focused on developing and testing SIC strategies in the context of care transition planning for older adults with serious illness. Our interprofessional team developed "Rehabbing to Death: Practical Strategies to Optimize Care Transitions for Patients with Serious Illness," an evidence-based, interprofessional SIC training curriculum for hospital-based rehabilitation clinicians. This 3-session curriculum was designed to enable rehabilitation clinicians to acquire knowledge of trajectories and outcomes for patients living with serious illness and communication skills to use with patients, families, and interprofessional colleagues. Nine rehabilitation clinicians (n = 3 equally from Physical Therapy, Occupational Therapy, and Speech-Language Pathology) participated in our pilot. Sessions were highly attended [100% (n = 9) sessions 1 and 2, 89% (n = 8) session 3]. Participants who completed the curriculum reported increased self-rated confidence in knowledge of serious illness and ability to communicate prognostic information and recommendations for care transitions with patients, families, and colleagues. In addition, 78% of participants would recommend the curriculum to a colleague and strongly agreed that curricular content and skills were relevant to their clinical practice. Pilot results suggest that implementing an SIC curriculum for hospital-based rehabilitation clinicians is feasible, given high rates of completion and satisfaction.

Clinicians' Perspectives on the Telehealth Serious Illness Care Program for Older Adults With Myeloid Malignancies: Single-Arm Pilot Study

BACKGROUND

Serious illness conversations may help patients avoid unwanted treatments. We previously piloted the telehealth Serious Illness Care Program (SICP) for older adults with acute myeloid leukemia and myelodysplastic syndrome.

OBJECTIVE

In this study, we aimed to understand the experience of the telehealth SICP from the clinician's perspective.

METHODS

We studied 10 clinicians who delivered the telehealth SICP to 20 older adults with acute myeloid leukemia or myelodysplastic syndrome. Quantitative outcomes included confidence and acceptability. Confidence was measured using a 22-item survey (range 1-7; a higher score is better). Acceptability was measured using an 11-item survey (5-point Likert scale). Hypothesis testing was performed at α=.10 (2-tailed) due to the pilot nature and small sample size. Clinicians participated in audio-recorded qualitative interviews at the end of the study to discuss their experience.

RESULTS

A total of 8 clinicians completed the confidence measure and 7 clinicians completed the acceptability measure. We found a statistically significant increase in overall confidence (mean increase of 0.5, SD 0.6; P=.03). The largest increase in confidence was in helping families with reconciliation and goodbye (mean 1.4, SD 1.5; P=.04). The majority of clinicians agreed that the format was simple (6/7, 86%) and easy to use (6/7, 86%). Clinicians felt that the telehealth SICP was effective in understanding their patients' values about end-of-life care (7/7, 100%). A total of three qualitative themes emerged: (1) the telehealth SICP deepened relationships and renewed trust; (2) each telehealth SICP visit felt unique and personal in a positive way; and (3) uninterrupted, unrushed time optimized the visit experience.

CONCLUSIONS

The telehealth SICP increased confidence in having serious illness conversations while deepening patient-clinician relationships.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04745676; https://www.clinicaltrials.gov/study/NCT04745676.

Perils and payoffs for patients in serious illness conversations as described by physicians: a qualitative study

BACKGROUND

The Serious Illness Care Programme was developed to promote more, better and earlier serious illness conversations. Conversations about goals and values are associated with improved experiences and outcomes for seriously ill patients. Clinicians' attitudes and beliefs are thought to influence the uptake and performance of serious illness conversations, yet little is known about how clinicians perceive the impact of these conversations on patients. This study aimed to explore physicians' perceptions regarding the impact of serious illness conversations for patients.

METHODS

The Serious Illness Care Programme was implemented as a quality improvement project in two hospitals in Southern Sweden. Focus group evaluation discussions were conducted with 14 physicians and inductive thematic analysis was undertaken.

RESULTS

The results revealed that physicians considered potential perils and optimised potential payoffs for patients when engaging in serious illness conversations. Potential perils encompassed inappropriate timing, damaging emotions and shattering hopes. Potential payoffs included reflection time, secure space, and united understandings.

CONCLUSIONS

Physicians depicted a balance in evaluating the perils and payoffs of serious illness conversations for patients and recognised the interrelation of these possibilities through continual assessment and adjustment.

Beyond translation: Transcreation of a clinicians' guide to structure discussions about health-related values with Latinx patients throughout cancer

OBJECTIVE

This study aimed to ensure accurate translation and cultural appropriateness of a guide designed to help oncology clinicians provide person-centered care to Spanish-speaking Latinx patients with cancer.

METHODS

Initial translation of a clinician-patient values discussion guide in open-ended question format ("Guide") was pretested in interviews with 27 Spanish-speaking individuals, followed by national expert panel review. At three sites, semi-structured, in-depth, audio-recorded interviews in the participant's preferred language (Spanish/English) were then conducted with Latinx patients receiving systemic treatment for a solid tumor malignancy and family joining them at clinic.

RESULTS

Interviews of 43 patient/family participants representing diverse Latinx communities addressed the Guide's understandability, acceptability, relevance and responsiveness. Rapid analysis of interviews contributed to cultural adaptation/transcreation of the Guide for a pilot interventional trial.

CONCLUSION

Moving beyond translation to transcreation can help promote inclusion, equity, and cultural sensitivity in oncologic care/communication.

PRACTICE IMPLICATIONS

Clinicians now have a linguistically- and culturally-adapted guide including questions and prompts to help structure discussions in Spanish or English of health-related values with Latinx patients receiving oncologic care.

Advance Directives in Portugal: A Qualitative Survey

(1) Background: Advance directives (ADs) in Portugal have been legalized since 2012. What has been observed over time, from the few studies carried out, is that despite the positive attitudes in the population, there is a low level of adherence to ADs. To try to understand the reasons for these data, the current study aimed to explore and describe the experiences of the Portuguese population regarding AD. (2) Methods: For this exploratory and descriptive qualitative study, the researchers conducted open (unstructured) interviews with a convenience sample aged over 18 years until data saturation was achieved. (3) Results: A total of fifteen interviews were conducted-eight with women and seven with men. The following four categories emerged from the content analysis of the interviews: (1) AD literacy, (2) AD relevance, (3) AD attitudes, and (4) conditionalities for compiling the ADs. (4) Conclusions: The study pointed out the good receptivity of the participants to the ADs; however, literacy on this subject was low, and identifying the conditionalities in the development of ADs could contribute to improvements in implementation in the population. The data from this study suggest the need to implement measures to increase the literacy of the Portuguese population on ADs and review the legal framework for improving the accessibility of the citizen population. There is also a need to continue researching and obtain more evidence about the ways in which the Portuguese population perceives ADs; thus, in this way, a society can better respond to its citizens' right to freely exercise their prospective autonomy at the end of their lives.

Physicians' perceptions of the implementation of the serious illness care program: a qualitative study

BACKGROUND

Conversations about goals, values and priorities with patients that are seriously ill are associated with improved palliative healthcare. The Serious Illness Care Program is a multi-component program that can facilitate more, better, and earlier conversations between clinicians and seriously ill patients. For successful and sustainable implementation of the Serious Illness Care Program, it is important to consider how stakeholders perceive it. The aim of our study was to explore physicians' perceptions and experiences of implementing the Serious Illness Care Program.

METHODS

Data were collected through four focus group discussions with physicians (n = 14) working at a hospital where the Serious Illness Care program was in the process of being implemented. Data were analyzed with inductive thematic analysis.

RESULTS

Physicians' perceptions of the implementation encompassed three thematic areas: hovering between preparedness and unpreparedness, being impacted and being impactful, and picking pieces or embracing it at all.

CONCLUSIONS

This study identified key aspects related to the individual physician, the care team, the impact on the patient, and the organizational support that were perceived to influence the implementation and sustainable integration of the Serious Illness Care Program. Describing these aspects provides insight into how the Serious Illness Care Program is implemented in practice and indicates areas for future training and development.

TRIAL REGISTRATION

Not applicable.