How do we teach clinicians to talk about the end of life?

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Image credit: Doctor and patient – Government of Alberta. Creative Commons License 2.0 (Non-commercial No Derivatives). Source: Flickr

By Dr Lucy Selman Research Fellow (Qualitative Research in Randomised Trials) Centre for Academic Primary Care  University of Bristol

In a systematic review published this month, we identified 153 communication skills training interventions for generalists in end of life care. In randomised controlled trials, training improved showing empathy and discussing emotions in simulated interactions (i.e. with actor patients) but evidence of effect on clinician behaviours during real patient interactions, and on patient-reported outcomes, was inconclusive.

The global increase in the proportion of older people and length of life means providing end of life care is now increasingly the responsibility of generalist as well as specialist palliative care providers. But many clinicians find communicating about end of life issues challenging: how do you best discuss imminent mortality, limited treatment options, what to expect when you’re dying, or a patient’s preferences for end of life care?

When this communication is done poorly, or not done at all, patients are confused and less satisfied with their care, experience inadequate symptom relief, and have worse quality of life. Staff who feel insufficiently trained in communication skills are more likely to provide depersonalised care and suffer from burnout.

While research in clinical communication has grown in recent years, there is little consensus on optimal training strategies and the most effective teaching methods.

What we did

We conducted a systematic review on communication skills training for generalist end of life care providers. We knew that most studies measured effectiveness using clinicians’ own assessment of their confidence and competence, neither of which necessarily translates into changed behaviour or patient benefit. We therefore pooled the statistical results from randomised controlled trials (RCTs), to examine the effect of training interventions on patient-reported outcomes and staff behaviours.

What we found

  • Overall, 160 studies evaluated 153 different training interventions.
  • Only 7 (5%) were developed with the involvement of patients or their family members
  • 27 per cent of studies used a controlled design (e.g. compared trainees with people who did not receive the training), 13 per cent randomised participants.
  • Only 6 per cent of studies assessed the impact of staff training on patient or family outcomes.
  • Reporting and methodology were often weak; we developed a CONSORT statement supplement to improve future reporting and encourage more rigorous testing.
  • Of the 160 studies identified, 19 were RCTs assessing the effect of communication training for clinicians on patient-reported outcomes and/or clinician behaviours in either real or simulated encounters with patients.
  • There was a significant effect of training on showing empathy and discussing emotions in simulated interactions (i.e. with actor patients), but evidence of effect on clinician behaviours measured during real patient interactions was inconclusive (Figures 1 and 2).
  • The two interventions with effects on showing empathy in real patient interactions included feedback on a recorded interaction.
  • Evidence regarding the effect of training on patient-reported outcomes or experiences (anxiety, depression, perceived empathy and satisfaction with communication skills) was inconclusive.

An intriguing result

Training generalist staff in end of life care communication skills can improve their ability to show empathy and discuss emotions, and the use of feedback on a recorded patient interaction can be especially effective. However, we found that the effects of training on clinicians’ behaviours during simulated interactions are not reflected as strongly in their behaviours when interacting with real patients. More research is needed to understand this intriguing finding. Few studies assessed the effect of training clinicians on the outcomes or experiences of the people they care for. While this is what we expected, it is nonetheless disappointing and should be rectified in future research.


References

Selman et al. The effect of communication skills training for generalist palliative care providers on patient-reported outcomes and clinician behaviours: a systematic review and meta-analysis. Journal of Pain and Symptom Management. September 2017 Volume 54, Issue 3, Pages 404–416.e5

Brighton et al. A systematic review of end of life care communication skills training for generalist palliative care providers: research quality and reporting guidance. Journal of Pain and Symptom Management. September 2017 Volume 54, Issue 3, Pages 417–425

Brighton et al. End of life care communication skills training for generalist palliative care providers: a systematic review [protocol]. PROSPERO.

More about the author

Dr Lucy Selman is a Research Fellow at the University of Bristol. Her research focuses on communication, decision-making, and psychosocial and spiritual aspects of palliative and end of life care. She co-chairs the Palliative and End of Life Care South West Research Group. Follow her on Twitter at @Lucy_Selman

Related links:

Blog: How do we support GPs providing end of life care?

Blog: Dying in the UK?: Lucky you.

This blog was first published by the Centre for Academic Primary Care.

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