Efficacy of a training intervention on the quality of practitioners' decision support for patients deciding about place of care at the end of life: A randomized control trial: Study protocol

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.

Creation of a Nursing Intervention Model to Support Decision Making by Elderly Advanced Cancer Patients and Their Families About the Place of Death, and Evaluation of the Model's Appropriateness and Clinical Applicability

Elderly patients with advanced cancer and their families need to be supported in the process of making a decision about a place to die. The objective of this research was to evaluate the appropriateness and clinical applicability of a nursing intervention model we developed to support decision making by elderly advanced cancer patients and their families about the place of death. We created the Nursing Intervention Model using the framework of the nursing intervention model reported by McEvoy and Egan (1979). Our survey was performed on 5 physicians and 9 nurses engaged in decision making about the place of terminal care and death for cancer patients. Focus group interviews were conducted to determine the appropriateness of the model. A content analysis technique was used to analyze the data obtained. Survey participants expressed an overall view that the contents of "Intervention Focus" and "Nursing Activity" are generally appropriate. On the other hand, the challenges to be addressed include clarification of which patients the model is applicable to support their decision making, positioning within the model of factors that influence the decision-making process, and further identification of the roles of nurses in an interdisciplinary approach to health care.

Decision-Making about the Place of Death for Cancer Patients: A Concept Analysis

Objective:

The objective of the study was to conduct a concept analysis of “decision-making about the place of death for cancer patients” to develop a theoretical definition of the concept and identify its attributes, antecedents, and outcomes.

Methods:

The Rodgers' evolutionary model of concept analysis was used. A literature search for papers published from 2000 to 2017 was conducted using the keywords: “cancer,” “place,” “death,” and “decision-making” for the search of the electronic databases.

Results:

Thirty articles were selected for this analysis. As a result, five attributes, six antecedents, and five consequences were extracted. [options to choose as a place of death], [wishes of the patients themselves], [consideration of the burden on the family], [open discussions with other persons concerned], and [best choice according to circumstances] are considered to be the characteristics in the decision-making about the place of death for cancer patients.

Conclusions:

This concept is defined as “The best choice according to circumstances of the cancer patients among different options for a place of death, resulting from a careful evaluation of the wishes of these patients and the burden on the family, as well as through open discussions with other persons concerned.” Nurses need to assist patients discuss deaths with important others, such as family members, in making decisions about the place of death. Further studies are necessary to elucidate the details of the categories and relationships shown in the attributes in this study, investigating the actual conditions of the patients and their families.

Skills Training to Support Patients considering place of End-Of-Life Care: A Randomized Control Trial

The effect of a program to train clinicians to support patients making decisions about place of end-of-life care was evaluated. In all, 88 oncology and/or palliative care nursing and allied health providers from three Ontario health networks were randomly assigned to an education or control condition. Quality of decision support provided to standardized patients was measured before and after training, as were participants’ perceptions about the acceptability of the training program and their intentions to engage in patient decision support. Compared to controls, intervention group members improved the quality of decision support provided and were more likely to address a wider range of decision-making needs. Intervention group members scored higher on a knowledge test of decision support than controls and rated the components as acceptable. Improvements in the quality of decision support can be made by providing training and practical tools such as a patient decision aid.

Evaluation of nurses' perceptions on providing patient decision support with cardiopulmonary resuscitation

The decision whether to receive cardiopulmonary resuscitation (CPR) is a decision in which the personal values of the patient must be considered along with information about the risks and benefits of the treatment. A decision aid can be used to provide patient decision support to a patient who is seriously ill and needs to consider CPR options. The goal of this project was to identify the barriers and facilitators to using a CPR decision aid, through evaluating nursing perceptions on providing patient decision support. Using a needs assessment, it was determined that implementing a patient decision aid for CPR status in the Acute Monitor Area (AMA) of The Ottawa Hospital would be an excellent quality improvement project. The nurses who chose to participate were given an education session regarding patient decision support. Questionnaires were distributed to evaluate their views of patient decision support and decision aids before and after the education session and implementation of the CPR decision aid. Questionnaire results did not indicate a significant change between before or after education session and decision aid implementation. Qualitative reports did indicate that nurses generally have positive attitudes toward patient decision support and decision aids. The nurses identified specific barriers and facilitators in their commentaries. This clinically relevant data supports the idea that patient decision support should be integrated into daily nursing practice.

Crossword puzzles: self-learning tool in pharmacology

Students of the second professional MBBS course of the Indian medical curriculum (II MBBS) perceive pharmacology as a 'Volatile Subject' because they often find it difficult to remember and recall drug names. We evaluated the usefulness of crossword puzzles as a self-learning tool to help pharmacology students to remember drug names. We also measured the students' satisfaction with this learning method. This was an open-label randomized, two-arm intervention study, conducted with II MBBS students (n = 70), randomly selected and assigned to two groups A (n = 35) and B (n = 35). Two self-learning modules containing crossword puzzles with antihypertensive and antiepileptic drug terms were prepared and pre-validated. Hard copies of both crossword puzzles were administered to Group A (Intervention group) on two different occasions. One hour was allotted to solve a puzzle. Students were allowed to refer to their textbooks. Group B (Control group) underwent the self-learning module without the crossword puzzles. In both groups, pre- and post-test knowledge was assessed. Students' perceptions of the crossword puzzles were assessed using a pre-validated 10-item questionnaire. Responses to items 1-8 were recorded using a 5-point Likert scale. Responses to item 9 were recorded on a 10-point rating scale while item 10 was an open-ended question. The crossword completion index was 92.86 %. In group A, the average pre-test score was 6.09 whereas the average post-test score was 12.87 (p < 0.05). In group B, average pre- and post-test scores were 6.03 and 9.74, respectively. A significant difference (p < 0.001) was observed between the post-test scores of the two groups. The absolute learning gain was 33.9 % in Group A and 18.55 % in Group B. The response rate for the questionnaire was 100 %. Of the students, 71.43 % strongly agreed that crossword puzzles enhanced their knowledge of antihypertensive and antiepileptic drugs and were helpful for remembering and recalling the drug names, 60 % students found it challenging and a good problem solving activity and 85.71 % students opined that it was a good self-learning, recreational activity. The test scores improved when crossword puzzles, designed to improve retention of drug names, were incorporated in the self-study modules of pharmacology training. Students rated the crossword puzzles as a challenging and effective self-learning tool. Students' acceptability for crossword puzzles further favours their usefulness as a self-learning tool. The crossword puzzle is an effective tool for 'recreational learning' and can be used as an active learning strategy to promote self-directed learning.

Training health professionals in shared decision-making: an international environmental scan

OBJECTIVE

To identify and analyze training programs in shared decision-making (SDM) for health professionals.

METHODS

We conducted an environmental scan looking for programs that train health professionals in SDM. Pairs of reviewers independently analyzed the programs identified using a standardized data extraction sheet. The developers of the programs validated the data extracted.

RESULTS

We identified 54 programs conducted between 1996 and 2011 in 14 countries and 10 languages. Thirty-four programs targeted licensed health professionals, 10 targeted pre-licensure health professionals, and 10 targeted both. Most targeted only the medical profession (n=32); six targeted more than one health profession. The five most frequently mentioned teaching methods were case-based discussion, small group educational session, role play, printed educational material, and audit and feedback. Thirty-six programs reported having evaluated their impacts but evaluation data was available only for 17.

CONCLUSIONS

Health professional training programs in SDM vary widely in how and what they deliver, and evidence of their effectiveness is sparse.

PRACTICE IMPLICATIONS

This study suggests there is a need for international consensus on ways to address the variability in SDM training programs. We need agreed criteria for certifying the programs and for determining the most effective types of training.

Development of PRIDe: a tool to assess physicians' preference of role in clinical decision making

OBJECTIVE

To develop and evaluate items for inclusion in PRIDe (Preferred Role in Decision Making), a new tool to assess changes of role preference among professionals exposed to training in shared decision making (SDM).

METHODS

This study was part of a pilot trial to evaluate the effectiveness of SDM training on the doctors' prescription of antibiotics for acute respiratory infections. Thirty-nine family physicians were randomized to immediate exposure to training or to delayed exposure. Potential items for PRIDe and a questionnaire about physicians' intention to engage in SDM were administered at baseline and at follow-up.

RESULTS

Following analysis, we retained five items that captured a change in physicians' preference. The items' scores were pooled and the resulting tool showed limited internal consistency (Cronbach's alpha = 0.41) but significant test-retest reliability (immediate group: P = 0.03; delayed group: P = 0.008) and acceptable discriminant validity, with patients involved in decision making more actively after training than before (Fisher's test, P = .02).

CONCLUSION

This initial step to develop an evaluation tool to assess changes in doctors' preference of role in decision making following SDM training shows promising results. The next step is to develop more clinical vignettes followed by questions inspired from this analysis.

PRACTICE IMPLICATIONS

The PRIDe instrument can be used in the assessment of health professionals' attitude towards shared decision making after training in shared decision making. Additional research is needed to evaluate its validity before it can be recommended for use.

Effects of online palliative care training on knowledge, attitude and satisfaction of primary care physicians

Background

The Spanish Palliative Care Strategy recommends an intermediate level of training for primary care physicians in order to provide them with knowledge and skills. Most of the training involves face-to-face courses but increasing pressures on physicians have resulted in fewer opportunities for provision of and attendance to this type of training. The effectiveness of on-line continuing medical education in terms of its impact on clinical practice has been scarcely studied. Its effect in relation to palliative care for primary care physicians is currently unknown, in terms of improvement in patient's quality of life and main caregiver's satisfaction. There is uncertainty too in terms of any potential benefits of asynchronous communication and interaction among on-line education participants, as well as of the effect of the learning process.

The authors have developed an on-line educational model for palliative care which has been applied to primary care physicians in order to measure its effectiveness regarding knowledge, attitude towards palliative care, and physician's satisfaction in comparison with a control group.

The effectiveness evaluation at 18 months and the impact on the quality of life of patients managed by the physicians, and the main caregiver's satisfaction will be addressed in a different paper.

Methods

Randomized controlled educational trial to compared, on a first stage, the knowledge and attitude of primary care physicians regarding palliative care for advanced cancer patients, as well as satisfaction in those who followed an on-line palliative care training program with tutorship, using a Moodle Platform vs. traditional education.

Results

169 physicians were included, 85 in the intervention group and 84 in the control group, of which five were excluded. Finally 82 participants per group were analyzed. There were significant differences in favor of the intervention group, in terms of knowledge (mean 4.6; CI 95%: 2.8 to 6.5 (p = 0.0001), scale range 0-33), confidence in symptom management (p = 0.02) and confidence in terms of communication (p = 0.038). Useful aspects were pointed out, as well as others to be improved in future applications. The satisfaction of the intervention group was high.

Conclusions

The results of this study show that there was a significant increase of knowledge of 14%-20% and a significant increase in the perception of confidence in symptom management and communication in the intervention group in comparison with the control group that received traditional methods of education in palliative care or no educational activity at all. The overall satisfaction with the intervention was good-very good for most participants.

This on-line educational model seems a useful tool for palliative care training in primary care physicians who have a high opinion about the integration of palliative care within primary care. The results of this study support the suggestion that learning effectiveness should be currently investigated comparing different Internet interventions, instead of Internet vs. no intervention.

Trial Registration

German Clinical Trials Register DRKS00000694

Nurses' perceptions of factors influencing patient decision support for place of care at the end of life

Although patients have more choices about where to receive care as death approaches, they often need help with decision making. This study identified factors that influence nurses' provision of decision support. A total of 22 nurses, from 3 health networks, participated in semistructured interviews. Overall, nurses held favorable attitudes toward providing decision support for place of care at end of life. Overlap between other professionals' roles and nurses' clinical experience affected nurses' decision support behaviors. Although nurses considered decision support to be part of patient-centered care, they report a lack of skills, confidence, and tools to help them provide it. These findings confirm the need to develop practical postlicensure education strategies and ways to embed patient decision support tools into systems of care.