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Communication Issues

What is known

A number of reviews address aspects of communication that are relevant to advance care planning. Discussing the transition from a curative to a palliative approach is often seen as difficult, and evidence based guidance is available to assist with this. [1-2] A key element of advance care planning conversations relates to patients’ goals of care.

A structured literature review from studies of end of life decision-making has identified six major types of patient goals: to be cured; to live longer; to improve or maintain function / quality of life; to be comfortable; to achieve life goals; and to provide support for family / caregiver. [3] Another review identified three domains of patient concern that are relevant for advance care planning conversations – feelings about the disease, feelings about suffering, and feelings about the circumstances of death. [4]

A systematic review of the emotional impact of discussions about end of life decisions showed that the patients involved experienced positive benefits from the process. [5] However few studies have looked methodically for possible adverse outcomes related to advance care planning.

Patients from non-English speaking backgrounds or minority cultural groups may have very different concerns about end-of- life care. Differences may relate to whether the most usual cultural approach to end of life decisions is family-based, or focused on individual autonomy (which is the philosophy underlying the medicolegal system in Australia). Communication difficulties as well as cultural differences can be a barrier to good care. [6]

Increasingly, evidence is available that advance care planning facilitated by appropriately skilled facilitators can be effective. [7] The participation of nurses in end of life decision-making, and some aspects of the doctor-nurse relationship, have been shown to have an impact on the outcome of a “good death”. [8] However, a review of studies of junior doctors’ involvement in end of life decisions suggests that many misunderstand the implications of “not for resuscitation” choices, or the concept of medically futile treatment. It also showed that many have difficulty discussing patients’ wishes about resuscitation and end of life care. [9]

A systematic review showed that patient-focused educational efforts are helpful in increasing the rate of completion of written advance directives [10] and the best strategy appears to be provision of oral information over multiple sessions. [11] Passive educational approaches eg, written materials alone were less useful. [12] 

What it means in practice

  • Use of evidence-based guidelines and specific skills training can improve the quality of communication by health care professionals, which is an essential component of advance care planning. NH&MRC guidelines on discussing prognosis suggest some simple, practical strategies to improve communication. [2,13]
  • Doctors in training are often involved in conversations about end of life decisions, and they require support, supervision and mentoring in this area.
  • As a result of their involvement with patients’ day to day care, nursing staff can make an important contribution to discussions about end of life decision making, and team processes which formally include nursing input may improve outcomes.
  • Social workers have valuable skills to contribute to discussions about goals of care and to assist with difficult conversations. [14]
  • Cultural differences are extremely significant in relation to advance care planning and can sometimes be a cause of conflict. General guidelines to improve care suggest use of trained interpreters, and education to improve the cultural competence of health care workers. Strategies like active listening, checking understanding and checking preferences for approaches to decision-making are likely to improve cross-cultural communication.
  1. Schofield P, Carey M, Love A, Nehill C, Wein S. 'Would you like to talk about your future treatment options'? Discussing the transition from curative cancer treatment to palliative care. Palliat Med. 2006 Jun;20(4):397-406.
  2. Clayton JM, Hancock KM, Butow PN, Tattersall MHN, Currow DC. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Med J Aust. 2007;186(12 Suppl):S77-S108.
  3. Kaldjian LC, Curtis AE, Shinkunas LA, Cannon KT. Goals of care toward the end of life: a structured literature review. Am J Hosp Palliat Care. 2008 Dec-2009 Jan;25(6):501-11.
  4. Knops KM, Srinivasan M, Meyers FJ. Patient desires: a model for assessment of patient preferences for care of severe or terminal illness. Palliat Support Care. 2005 Dec;3(4):289-99.
  5. Song MK. Effects of end-of-life discussions on patients' affective outcomes. Nurs Outlook. 2004 May-Jun;52(3):118-25. No abstract available.
  6. Thomas R, Wilson DM, Justice C, Birch S, Sheps S. A literature review of preferences for end-of-life care in developed countries by individuals with different cultural affiliations and ethnicity. J Hosp Palliat Nurs. 2008 May-Jun;10(3):142-63.
  7. Lorenz KA, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA, et al. Evidence for improving palliative care at the end of life: a systematic review. Ann Intern Med. 2008 Jan 15;148(2):147-59.
  8. Frank RK. Shared decision making and its role in end of life care. Br J Nurs. 2009 May 28;18(10):612-8.
  9. Gorman TE, Ahern SP, Wiseman J, Skrobik Y. Residents' end-of-life decision making with adult hospitalized patients: a review of the literature. Acad Med. 2005 Jul;80(7):622-33.
  10. Patel RV, Sinuff T, Cook DJ. Influencing advance directive completion rates in non-terminally ill patients: a systematic review. J Crit Care. 2004 Mar;19(1):1-9.
  11. Bravo G, Dubois MF, Wagneur B. Assessing the effectiveness of interventions to promote advance directives among older adults: a systematic review and multi-level analysis. Soc Sci Med. 2008 Oct;67(7):1122-32. Epub 2008 Jul 20.
  12. Ramsaroop SD, Reid MC, Adelman RD. Completing an advance directive in the primary care setting: what do we need for success? J Am Geriatr Soc. 2007 Feb;55(2):277-83.
  13. National Breast Cancer Centre and National Cancer Control Initiative. Clinical practice guidelines for the psychosocial care of adults with cancer. (838kb pdf) Camperdown, NSW: National Breast Cancer Centre; 2003.
  14. Street A, Ottmann G. State of the science review of advance care planning models. (291kb pdf)Bundoora VIC: La Trobe University; 2006.

Guidelines

Overview articles (free full text)

Last updated 15 February 2017