Communication Interventions to Improve Goal-Concordant Care of Seriously Ill Patients

An Integrative Review

Frank Bennett, MDiv, BS; Susan O'Conner-Von, PhD, RN-BC, CNE

Disclosures

Journal of Hospice and Palliative Nursing. 2020;22(1):40-48. 

In This Article

Abstract and Introduction

Abstract

Effective communication between clinicians and seriously ill patients and their families about a patient's goals of care is essential to patient-centered, goal-concordant, end-of-life care. Effective goals-of-care communication between clinicians and patients is associated with improved patient and family outcomes, increased clinician satisfaction, and decreased health care costs. Unfortunately, clinicians often face barriers in goals-of-care communication and collaboration, including a lack of education, time constraints, and no standardized protocols. Without clear goals-of-care communication, patients may not be able to provide guidance to clinicians about their end-of-life preferences. The purpose of this integrative review was to examine the efficacy of goals-of-care communication interventions between patients, families, and clinicians in randomized controlled trials published between 2009 and 2018. Twenty-three studies met the inclusion criteria with an overall sample (N = 6376) of patients, family members, and clinicians. Results revealed of the 6 different intervention modes, patient decision aids and patient-clinician communication consistently increased comprehension and communication. Twelve of the studies had nurses facilitate or support the communication intervention. Because nurses are a critical, trusted nexus for communication about end-of-life care, focusing on nurse interventions may significantly improve clinical outcomes and the patient experience.

Introduction

Effective communication that clarifies, defines, and documents a patient's goals of care (GOCs) between clinicians, seriously ill patients, and their family decision makers supports patient-centered end-of-life (EOL) care. Effective GOC communication between clinicians and patients is associated with the triple aims of improved patient outcomes, increased clinician satisfaction, and decreased health care costs.[1] Although advance care planning documentation is often used as a proxy for measuring GOCs,[2] the need for in-depth GOC communication between clinicians and patients and their families is unlikely to be met by advance directives alone.[3] Patients and their families in GOC communication lack prognostic comprehension, EOL care communication skills, and collaborative health care experience.[4–6] Clinicians also face barriers to GOC communication and collaboration, including workflow constraints and a lack of standardized protocols or education.[4,7] Without GOC communication, patients may not be able to provide guidance to clinicians about their EOL care preferences and choices, and their family decision makers may be unable or unwilling to make GOC choices for the patient.

For the purposes of this integrative review, several terms were defined. Patients were seriously ill persons with at least 1 advanced stage disease or multimorbidity frailty. Family was the social group, including surrogates, designated by the patient to make their health care decisions if they become incapacitated. End of life refers to the timespan from months to years that patients live in a state of declining health. Clinicians include registered nurses, advanced practice nurses, nurse practitioners, and medical doctors. Goals of care are the nomenclature framework used to guide a patient's future EOL health care, generally divided into 3 categories: (1) life-prolonging care, using any and all medical treatments to extend a patient's life; (2) limited care, restricting the scope or time frame for employing medically appropriate life-prolonging treatments; and (3) comfort care, restricting the scope of a patient's medical care to palliative symptom management.

There is a current, pressing need to evaluate the relative efficacy of GOC communication interventions due to projected demographic trends and a lack of future EOL care planning by most American adults.[5,8,9] Thus, an integrative review of experimental interventions to improve GOC communication published between 2009 and 2018 was undertaken to examine the evidence. This review focused solely on randomized controlled trial (RCT) experimental studies whose outcomes included clarifying and communicating patients' EOL care preferences to their family and clinicians. The objective of this integrative review was to answer 2 questions about the efficacy of GOC communication interventions: (1) What is the evidence of the efficacy of GOC communication interventions between patients, family, and clinicians in RCT studies published between 2009 and 2018? (2) What is the evidence about the relative efficacy for different modes of GOC communication interventions between patients, family, and clinicians in RCT experimental studies published between 2009 and 2018?

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