Enhancing Oncologists' Comfort with Serious Illness Conversations: The Impact of Serious Illness Conversation Guide (SICG) Training

Providers oftentimes need to have difficult conversations with patients facing a poor prognosis. Research indicates that providers generally feel ill prepared for these conversations and that bad conversations may lead to more anxiety for patients. Communication skills development training programs have shown improvement in providers' skills. Our cancer center embarked on skills development training to help providers improve their skills and comfort in having serious illness conversations. During our phased approach, about 500 physicians and advanced practice providers in the Division of Oncology were trained for over a year. Their level of comfort with serious illness conversations was measured before and after the training by using both quantitative and qualitative methods. We found that mean and median comfort scores increased from pre-training to post-training. The findings suggest that the improved comfort and confidence observed among providers who undergo communications skills training can lead to better provider-patient communication, more patient-centered care, and improved patient satisfaction.

Emergency Nurses' Perceived Barriers and Solutions to Engaging Patients With Life-Limiting Illnesses in Serious Illness Conversations: A United States Multicenter Mixed-Method Analysis

INTRODUCTION

This study aimed to assess emergency nurses' perceived barriers toward engaging patients in serious illness conversations.

METHODS

Using a mixed-method (quant + QUAL) convergent design, we pooled data on the emergency nurses who underwent the End-of-Life Nursing Education Consortium training across 33 emergency departments. Data were extracted from the End-of-Life Nursing Education Consortium post-training questionnaire, comprising a 5-item survey and 1 open-ended question. Our quantitative analysis employed a cross-sectional design to assess the proportion of emergency nurses who report that they will encounter barriers in engaging seriously ill patients in serious illness conversations in the emergency department. Our qualitative analysis used conceptual content analysis to generate themes and meaning units of the perceived barriers and possible solutions toward having serious illness conversations in the emergency department.

RESULTS

A total of 2176 emergency nurses responded to the survey. Results from the quantitative analysis showed that 1473 (67.7%) emergency nurses reported that they will encounter barriers while engaging in serious illness conversations. Three thematic barriers-human factors, time constraints, and challenges in the emergency department work environment-emerged from the content analysis. Some of the subthemes included the perceived difficulty of serious illness conversations, delay in daily throughput, and lack of privacy in the emergency department. The potential solutions extracted included the need for continued training, the provision of dedicated emergency nurses to handle serious illness conversations, and the creation of dedicated spaces for serious illness conversations.

DISCUSSION

Emergency nurses may encounter barriers while engaging in serious illness conversations. Institutional-level policies may be required in creating a palliative care-friendly emergency department work environment.

Serious illness communication skills training for emergency physicians and advanced practice providers: a multi-method assessment of the reach and effectiveness of the intervention

BACKGROUND

EM Talk is a communication skills training program designed to improve emergency providers' serious illness conversational skills. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, this study aims to assess the reach of EM Talk and its effectiveness.

METHODS

EM Talk consisted of one 4-h training session during which professional actors used role-plays and active learning to train providers to deliver serious/bad news, express empathy, explore patients' goals, and formulate care plans. After the training, emergency providers filled out an optional post-intervention survey, which included course reflections. Using a multi-method analytical approach, we analyzed the reach of the intervention quantitatively and the effectiveness of the intervention qualitatively using conceptual content analysis of open-ended responses.

RESULTS

A total of 879 out of 1,029 (85%) EM providers across 33 emergency departments completed the EM Talk training, with the training rate ranging from 63 to 100%. From the 326 reflections, we identified meaning units across the thematic domains of improved knowledge, attitude, and practice. The main subthemes across the three domains were the acquisition of Serious Illness (SI) communication skills, improved attitude toward engaging qualifying patients in SI conversations, and commitment to using these learned skills in clinical practice.

CONCLUSION

Our study showed the extensive reach and the effectiveness of the EM Talk training in improving SI conversation. EM Talk, therefore, can potentially improve emergency providers' knowledge, attitude, and practice of SI communication skills.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT03424109; Registered on January 30, 2018.

The Role of Nurse Practitioners in the Management of Heart Failure Patients and Programs

PURPOSE OF REVIEW

The goal of this paper is to highlight the multifaceted approach heart failure (HF) nurse practitioners (NPs) use to manage patients. We were seeking to answer if NPs have the scope of clinical skills to manage the complexity of HF patients.

RECENT FINDINGS

NP care in HF has been shown to reduce readmissions, improve timeliness of visits, decrease cost, and improve quality outcomes in small heterogeneous studies. The evidence supports that NPs provide multifaceted, patient-centered care for at all stages on the continuum of HF. Our goals as NPs are to reduce the healthcare financial strain and improve access to high quality care. Telehealth is an emerging technology that shows promise in HF management by improving access and decreasing readmissions. Telehealth use and recognition increased with the COVID-19 pandemic. Future research should focus on NP run clinics, cost effectiveness, and quality of care.

Communication strategies during the COVID-19 pandemic: Unforeseen opportunities and drawbacks

The current coronavirus pandemic has forced a dramatic shift in the way clinicians practice medicine, including the way we communicate with our patients. The pandemic has both facilitated and challenged serious illness conversations between providers and patients. Furthermore, telemedicine has emerged as a major practice across the globe. Benefits of which include greater involvement of supporting family members while drawbacks involve socioeconomic barriers that limit high quality interactions between provider and patient. This commentary aims to highlight the evolution of communication strategies over this unique time in hopes of promoting reflection and change to improve our communication strategies at the individual and institutional level.

Behavioral economic implementation strategies to improve serious illness communication between clinicians and high-risk patients with cancer: protocol for a cluster randomized pragmatic trial

BACKGROUND

Serious illness conversations (SICs) are an evidence-based approach to eliciting patients' values, goals, and care preferences that improve patient outcomes. However, most patients with cancer die without a documented SIC. Clinician-directed implementation strategies informed by behavioral economics ("nudges") that identify high-risk patients have shown promise in increasing SIC documentation among clinicians. It is unknown whether patient-directed nudges that normalize and prime patients towards SIC completion-either alone or in combination with clinician nudges that additionally compare performance relative to peers-may improve on this approach. Our objective is to test the effect of clinician- and patient-directed nudges as implementation strategies for increasing SIC completion among patients with cancer.

METHODS

We will conduct a 2 × 2 factorial, cluster randomized pragmatic trial to test the effect of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Participants will include 166 medical and gynecologic oncology clinicians practicing at ten sites within a large academic health system and their approximately 5500 patients at high risk of predicted 6-month mortality based on a validated machine-learning prognostic algorithm. Data will be obtained via the electronic medical record, clinician survey, and semi-structured interviews with clinicians and patients. The primary outcome will be time to SIC documentation among high-risk patients. Secondary outcomes will include time to SIC documentation among all patients (assessing spillover effects), palliative care referral among high-risk patients, and aggressive end-of-life care utilization (composite of chemotherapy within 14 days before death, hospitalization within 30 days before death, or admission to hospice within 3 days before death) among high-risk decedents. We will assess moderators of the effect of implementation strategies and conduct semi-structured interviews with a subset of clinicians and patients to assess contextual factors that shape the effectiveness of nudges with an eye towards health equity.

DISCUSSION

This will be the first pragmatic trial to evaluate clinician- and patient-directed nudges to promote SIC completion for patients with cancer. We expect the study to yield insights into the effectiveness of clinician and patient nudges as implementation strategies to improve SIC rates, and to uncover multilevel contextual factors that drive response to these strategies.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04867850 . Registered on April 30, 2021.

FUNDING

National Cancer Institute P50CA244690.

Goals of Care: Development and Use of the Serious Veterinary Illness Conversation Guide

Goals of care (GOC) conversations and resulting goal-concordant treatment are the heart of palliative medicine. Despite repeated evidence that GOC conversations offer significant benefit and minimal harm, barriers to widespread and high-quality implementation persist in human medicine. One strategy to overcoming these barriers has been utilization of a structured checklist format for serious illness conversations. The Serious Illness Conversation Guide was developed for human patients and has been modified for use in the veterinary profession. The guide promotes individualized, goal-concordant care planning even when conflict and emotional demands are high.