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Communication Skills

Key Messages

  • Clear communication is an essential ingredient of quality palliative care. [1-3]
  • Ongoing refresher training can help palliative care staff to improve their skills in discussing end-of-life (EoL). [2,4,5]
  • Communication education should include discussions of life expectancy and imminent mortality, care options and preferences, dealing with conflict and empathetic communication. [2,6]
  • Strategies such as ‘Fishing’ and ‘Hypothetical’ questions framed in a general context can smooth the initiation of end-of-life discussions. [7]
  • Sensitivity is important in balancing the sincerity and gravity of end-of-life issues. [7]
  • Written prompt questions seem to be the only effective tool in helping EoL discussions. [4,8]
  • Advance care planning (ACP) and documenting of preferences is best facilitated by a trained health professional. Multiple discussions may be needed. [9]

 

Background

Health professionals not specialised in palliative care service, frequently report finding end-of-life discussions uncomfortable and hard to initiate. [3-5,7] Clinicians seek evidence-based guidance on strategies for discussing end-of-life matters with people and their significant others. [5,7,8]

Evidence Summary

Good communication at the end of a person’s life involves the ability to both give and receive information at a time where strong emotions and stress can affect even the most experienced clinician. [4,8,9] Strong communication skills can be valuable. For health professionals, having as much information as possible from the patient is vital to ensure any plans and decisions are inclusive and that staff are advocating appropriately for them. [2,4,5,7,8]

There is consensus that people who have a terminal diagnosis should be provided with opportunities to discuss their future care and treatment preferences in the form of advance care planning (ACP) discussions (see also Advance Care Planning and Communication at End-of-Life pages). [6,7,9] People and their families dealing with a life-limiting illness rarely raise the topic of end-of-life preferences, and often look to their medical team to initiate these discussions. [4,7] However, health professionals frequently report finding these discussions uncomfortable and hard to initiate, [4,7] particularly where there is uncertainty as to whether the person and their family are ready or willing to accept the information. [4,7] In addition, there is an increasing need for provision of palliative care services to older adults, often in a community or residential aged care context, from non-specialist health professionals. As such, ambiguity regarding roles and anxiety over ability to communicate sensitive information to people is partially responsible for end-of-life planning and discussion being delayed or not occurring at all. [1,4]

Currently there are no standard definitions of a communication intervention for upskilling health professionals and there is substantial variation in delivery, content and measurable outcomes in the literature. General consensus is that training should include strategies for effectively communicating prognostic information, mediating disagreement, supporting people and their family by acting on their statements and nonverbal cues and responding to their needs to facilitate shared decision making. [6] The use of role-playing as part of an educational approach with refresher training is thought to have favourable outcomes for increased confidence and knowledge. [4,5,7]

Communication tools such as prompt questions have been shown to assist with initiation of end-of-life discussions in one review [4], but otherwise tools have not demonstrated significant difference to usual care. Conversely, a review of how language is used in such discussions found a number of questioning techniques that were successful in initiating conversations while promoting clinician sincerity and empathy. [7]

In the care of people with dementia, communication skills play an important role in quality of care, the emotional and physical wellbeing of the care givers and care recipients [10-13] and discussion about future care. [10,11] Effective interventions involved active participation by carers and care staff and were generally skills-based (including practicing skills, discussion, hands-on training with counselling and feedback on real interactions between the participating carers and people with dementia). [11-13]

In summary, there is evidence that communication training for health care professionals in palliative care is warranted. Common features of successful interventions are that they should include combined components of training, patient discussion, education and written documentation that is delivered via mixed teaching methods e.g. didactic, role-playing etc. [3,11-13] Key outcomes should be that training facilitates patient understanding of their condition, prognosis where possible and promoting of ACP discussions. ACP conversations should focus on goals of care rather than specific treatments and clinicians should be responsive to the emotional reaction to discussions. [9] Further research in an aged care and palliative context is needed. [1-5,9-13]

Quality Statement

Overall the quality of the evidence was found to be low with limitations generally from the lack of reporting on the quality of the studies included and the paucity of robust study design in the primary studies.
 

Page updated 16 June 2021

 

  • References

  • About PubMed Search

  1. Gardiner C, Gott M, Ingleton C. Factors supporting good partnership working between generalist and specialist palliative care services: a systematic review. Br J Gen Pract. 2012 May;62(598):e353-62.
  2. Brighton LJ, Koffman J, Hawkins A, McDonald C, O'Brien S, Robinson V, et al. A Systematic Review of End-of-Life Care Communication Skills Training for Generalist Palliative Care Providers: Research Quality and Reporting Guidance. J Pain Symptom Manage. 2017 Sep;54(3):417-425. doi: 10.1016/j.jpainsymman.2017.04.008. Epub 2017 Aug 4.
  3. Selman LE, Brighton LJ, Hawkins A, McDonald C, O'Brien S, Robinson V, et al. The Effect of Communication Skills Training for Generalist Palliative Care Providers on Patient-Reported Outcomes and Clinician Behaviors: A Systematic Review and Meta-analysis. J Pain Symptom Manage. 2017 Sep;54(3):404-416.e5. doi: 10.1016/j.jpainsymman.2017.04.007. Epub 2017 Aug 1.
  4. Walczak A, Butow PN, Bu S, Clayton JM. A systematic review of evidence for end-of-life communication interventions: Who do they target, how are they structured and do they work? Patient Educ Couns. 2016 Jan;99(1):3-16.
  5. Chung HO, Oczkowski SJ, Hanvey L, Mbuagbaw L, You JJ. Educational interventions to train healthcare professionals in end-of-life communication: a systematic review and meta-analysis. BMC Med Educ. 2016 Apr 29;16:131.
  6. Schram AW, Hougham GW, Meltzer DO, Ruhnke GW. Palliative Care in Critical Care Settings: A Systematic Review of Communication-Based Competencies Essential for Patient and Family Satisfaction. Am J Hosp Palliat Care. 2016 Jan 1:1049909116667071.
  7. Parry R, Land V, Seymour J. How to communicate with patients about future illness progression and end of life: a systematic review. BMJ Support Palliat Care. 2014 Dec;4(4):331-41.
  8. Oczkowski SJ, Chung HO, Hanvey L, Mbuagbaw L, You JJ. Communication tools for end-of-life decision-making in the intensive care unit: a systematic review and meta-analysis. Crit Care. 2016 Apr 9;20:97.
  9. Barnes S, Gardiner C, Gott M, Payne S, Chady B, Small N, et al. Enhancing patient-professional communication about end-of-life issues in life-limiting conditions: a critical review of the literature. J Pain Symptom Manage. 2012 Dec;44(6):866-79.
  10. Lai M, Jeon YH, McKenzie H. The key factors for the engagement of primary stakeholders in decision-making for the future care of people with dementia living in the community: a systematic integrative review. Int Psychogeriatr. 2019 Dec;31(12):1731-1746. doi: 10.1017/S104161021900005X. Epub 2019 Feb 14.
  11. Machiels M, Metzelthin SF, Hamers JP, Zwakhalen SM. Interventions to improve communication between people with dementia and nursing staff during daily nursing care: A systematic review. Int J Nurs Stud. 2017 Jan;66:37-46. doi: 10.1016/j.ijnurstu.2016.11.017. Epub 2016 Nov 30.
  12. Morris L, Horne M, McEvoy P, Williamson T. Communication training interventions for family and professional carers of people living with dementia: a systematic review of effectiveness, acceptability and conceptual basis. Aging Ment Health. 2018 Jul;22(7):863-880. doi: 10.1080/13607863.2017.1399343. Epub 2017 Nov 10. Erratum in: Aging Ment Health. 2018 Jul;22(7):920.
  13. Nguyen H, Terry D, Phan H, Vickers J, McInerney F. Communication training and its effects on carer and care-receiver outcomes in dementia settings: A systematic review. J Clin Nurs. 2019 Apr;28(7-8):1050-1069. doi: 10.1111/jocn.14697. Epub 2018 Nov 20.

Definition

The focus of this topic is on the learning, teaching or current communication skills of health care staff.

Searches

Final search

(((ed[sh] OR education[mh]) AND communication[mh]) OR (Communicat*[ti] AND (train*[ti] OR educat*[ti] OR workshop*[ti] OR module*[ti] OR teach*[ti] OR curricul*[ti] OR learn*[ti] OR course*[ti] OR program*[ti] OR skill[ti] OR skills[ti] OR competenc*[ti])))