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

Discussion

Summary

This review examined evidence in 23 RCT GOC communication studies, grouping them into 6 modalities of intervention: Early Palliative Care, Clinician Communication Training, Patient Communication Support, Family Communication Support, Patient-Clinician Communication, and Patient Decision Aids. The reviewers compared the relative efficacy of each mode as a means of improving GOC comprehension, communication, and collaboration. The Patient Decision Aids and Patient-Clinician Communication modes appear to produce consistently significant results in increasing patient comprehension and communication of patient EOL care treatment preferences, while the Early Palliative Care mode did not seem to significantly improve GOC communication, although some indicated significant improvement in patients' quality of life, family depression, and EOL care satisfaction. The other GOC modes appear to produce some specific significant improvements. The Clinician Communication Training mode is associated with some improvement in GOC communication skills when rated by their peers, but it was noteworthy that intervention patients did not perceive significant change in clinicians' communication behaviors. The interventions in the Family Communication Support mode appear to increase EOL care satisfaction and patient-family GOC concordance, both of which were important outcomes for collaboration in shared decision making and communication about EOL care. Interventions in Patient Communication Support mode were not uniform in their evidence, but 2 studies' approach to formalizing advance care planning appeared to increase electronic documentation of patients' GOC preferences and goal-concordant EOL care.[22,34]

Patients' and families' lack of health condition and prognostic comprehension is a significant barrier to GOC communication.[38–40] Similarly, clinicians do not adequately comprehend patients' GOCs, negatively impacting patient EOL care outcomes.[41] The dearth of clinicians' GOC communication skills and experience has a bilateral impact, with clinicians, patients, and families each waiting for the other to initiate GOC communication about EOL care.[6,42] The paucity of education in GOC communication and EOL care planning leads to clinicians' stress and burnout and patients' and families' dissatisfaction with EOL care.[43]

As supported by this integrative review, increasing the likelihood of goal-concordant, patient-centered EOL care outcomes depends on efficacious GOC comprehension, communication, and collaboration between patients, their family, and clinicians. The primary author created a GOC communication process conceptual model, graphically represented in Figure 2, for use in education, research, and clinical practice. The 3 domains of GOC communication are all essential, interrelated, and succedent. Comprehension of health prognosis and EOL care treatment options by patients and their clinicians and family is often the first step in GOC elucidation. Communication about patient GOC preferences, EOL care options, risks, and benefits between patients and their clinicians and family follows from mutual comprehension between all stakeholders. Collaboration to achieve patient-centered EOL care between clinicians and patients and their families as patients' health changes and GOCs evolve is supported by effective communication. Operative collaboration leads to deeper comprehension by every person engaged in the EOL care process, which in turn stimulates further communication and collaboration. When the GOC communication process is active and supported, it becomes generative, with each step leading to the next in a circular process. These 3 domains align with the EOL care components perceived as essential by patients and their family: effective communication and shared decision making with respectful, compassionate, expert clinicians in whom they have trust and confidence.[13]

Figure 2.

Goals-of-care communication process model. © Frank Bennett, 2018.

We draw several conclusions from this integrative review. First, recognizing that GOC communication is a continuous process and ensuring that it addresses all 3 domains of comprehension, communication, and collaboration could improve EOL care patient outcomes, goal-concordant care, and clinician resiliency. Most of the included studies' designs measured 1 or 2 of these domains, addressing gaps in comprehension, such as Patient Decision Aids; communication, such as Patient-Clinician Communication, Patient Communication Support, or Clinician Communication Training modes; or collaboration, such as the Early Palliative Care or Family Communication Support modes. It should be noted that the demarcation between modes and the included studies' aims and methods was not definitive, with most studies possessing some component of the other 2 domains, as represented in Figure 3.

Figure 3.

Efficacious modes in goals-of-care communication process model. © Frank Bennett, 2019.

However, none incorporated all 3 domains and thus were missing at least 1 essential step that contributes to an effective GOC communication process. Second, electronic Patient Decision Aids appear to increase patient and family knowledge of EOL care treatment risks and benefits and thus comprehension, improving congruence between their treatment choices and expressed values, and increasing their satisfaction in communicating with their clinicians, but they need to be accompanied by communication and collaboration.[12,44] Third, standardized GOC protocols between patients, clinicians, and families appear to be efficacious in increasing communication. Incorporating requisite patient or family and clinician interviews and forms into care planning procedures will increase frequency of GOC discussions. Communication skills education for clinicians prepares them to facilitate effective interactions with patients and families, promoting collaboration. Fourth, clinicians can use specific modes of communication, such as employing Patient Decision Aids to support comprehension, to sequentially address each domain within the GOC communication process, according to the conceptual model in Figures 2 and 3 above. Finally, it is noted that long-term-care, rural, and minority populations were underrepresented in the included studies, which is not surprising, given that most interventions were evaluated in urban, academic acute care settings. However, this limits the utility of these studies' findings and application of their interventions with populations not represented in the research.

Strengths and Limitations

The included studies have several limitations. First, the long-term impact of the interventions on both stability of patients' GOC preferences and quality of their EOL care was unclear because the studies' measurements averaged less than 7 weeks. Second, many of the studies lacked standardized, validated measurements for their outcomes, decreasing their generalizability or comparisons to other studies' results.[6] Third, education interventions by their nature have potential internal validity threats posed by contamination between intervention and control groups, increasing risk of bias. This integrative review also has several limitations. First, the included studies' heterogeneity of measurement and outcomes limits the depth of analysis and thus strength of conclusions. Second, this review was limited to studies published since 2009; prior evidence was not included. Third, identifying eligible studies for inclusion was dependent on the researchers' judgment as there were few objective categories for organizing research on GOC communication for goal-concordant EOL care. Ovid MEDLINE, Mendeley, or Cochrane databases did not have MeSH headings for "goals of care," "seriously ill patients," or "goal concordant care." Given that studies of GOC communication research are spread among disease specialists, palliative care, clinical educators, and patient care researchers, it is likely that this review could have missed existing evidence. Despite these limitations, this review possesses strengths. First, its data are drawn from RCT studies, the highest quality of evidence.[45] Second, all studies were published in the last 10 years, and 14 of the 23 studies were published in the last 5 years; thus, the evidence represents the most recent research in GOC communication. Third, the researchers compared results from studies in all 6 modes of GOC communication.

Implications for Nursing Research

There is a need to refine measurement of methods in GOC communication research. Establishing a common set of validated, reliable measurement tools represents a significant opportunity to move GOC communication research forward, improve outcomes, and enhance patient care.[46] Goals-of-care communication frequency, quality, and assurance of goal-concordant care will need to be assessed.[47]

With the exception of 1 study that evaluated GOC discussions between all 3 stakeholders: nurse-facilitators, patients, and families,[48] the included studies' intervention designs included only 1 or 2 stakeholders (see Supplemental Digital Content 2, http://links.lww.com/JHPN/A43). Singular or dyadic intervention designs do not accommodate the dynamic, multifocal nature of GOC communication and EOL care decision making. Designing multifocal GOC communication interventions into future research may increase the efficacy of and remove barriers to GOC communication.[6]

Most studies measured the effects of their intervention only up to 6 weeks. The short duration and frequency of most GOC communication interventions do not reflect the timespan of patient care, which often lasts more than 12 months. Designing GOC communication interventions with a longer duration and greater frequency of measurement will align research with clinical experience, yielding more insightful, valuable data to clinicians. Long-term-care, rural, and minority populations need effective GOC communication interventions to improve goal-concordant EOL care. To become ubiquitous, GOC communication interventions will have to broaden their designs to be inclusive of all patient populations.

Implications for Nursing Practice

Most GOC communication interventions were targeted at specific disease populations of adults who have established EOL care trajectories, simplifying their GOC communication process. Yet, patients often live for months or years with multiple diagnoses, resulting in complex, dynamic EOL care planning, prognosis, and treatment choices. Many GOC communication interventions were proprietary and not publicly available, limiting their potential clinical use.[49] Several GOC communication tools that recognize multiple comorbidities may prove effective and efficient in GOC communication and decision making and are available to all clinicians. These tools include a validated short, 4-question survey for all seriously ill patients that measured their readiness to discuss and document their EOL care preferences,[50] a standardized patient-clinician GOC communication protocol for EOL care decision making,[51] and a concise guide for patient-clinician GOC communication.[52] A 2017 study using this concise GOC communication guide resulted in a significant increase in the frequency and documentation of GOC discussions between primary care clinicians and their patients.[53] Clinicians and health care leaders need to standardize GOC communication using universal, succinct protocols to incorporate the GOC process into organizational standards of care.

All of the included studies of Clinician Communication Training interventions focused on educating medical doctors, although 1 study's intervention included nurse practitioners.[54] However, 12 of the 23 included studies' interventions used nurses to facilitate or support their intervention with patients and families. This reflects another clinical reality: GOC communication and decision making are a time-consuming process that requires a trust-based relationship between clinician, patient, and family. Time and workflow constraints create a challenge for medical doctors to bear all responsibility for GOC comprehension, communication, and collaboration. Because of their unique professional role and proximity to and relationship with patients, nurses are a critical, trusted nexus for communication about EOL care with patients and their families. Consistent with the Code of Ethics for Nurses,[55] nurses must act to minimize patient suffering. Conversations with patients and their families about goals of care and advance care planning help make this possible. Moreover, empowering nurses to lead GOC communication interventions may improve collaboration because of their role in care coordination. Nurses may need additional support and formal education, through established programs such as the End-of-Life Nursing Education Consortium to sustain initiatives to improve GOC communication and patient EOL care outcomes.

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