Health professionals not specialised in palliative care, frequently report finding end-of-life discussions uncomfortable and hard to initiate particularly if there is uncertainty as to the readiness or willingness of people to accept the information. Clinicians want and need more evidence-based guidance and education on how best to discuss end-of-life matters with people and their significant others.
A total of eight systematic reviews [1-8] were found examining communication interventions, tools or competencies but rarely in cohorts of older adults or in an aged care setting.
Overall the quality of the majority of the literature was low, [1,5,7,8] or adequate [4,6] with only two papers rating highly. [2,3] Reviews scored poorly due to the lack of reporting on the quality of the included studies and synthesis of findings with relation to bias. None of the reviews were conducted with an aged care context and therefore applicability of the research to this domain should be considered with this in mind.
Facilitating good communication for advance care planning
As discussed in Workforce, there is an increasing need for palliative care services for older adults in a community or residential aged care setting to be provided by non-specialist health professionals. 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 missed.  The UK’s ‘End of Life Strategy’ states that any member of a UK palliative care multidisciplinary team must attend an advanced communication skills course. In the systematic review by Barnes et al.  the authors note the inequity in advance care planning (ACP) for non-oncology diagnoses and call for an urgent need to identify strategies to enhance professional communication for ACP.
A review by Schram et al.  set out to identify components that might be used to develop a competency framework for communication skills in end-of-life care. Within the review four domains of competency were identified for clinicians to provide high-quality palliative care:
- Prognostication – the ability to effectively communicate prognostic information
- Conflict mediation – the ability to detect and mediate disagreement
- Empathic communication – the ability to support people and their family using statements and nonverbal cues
- Family-centred aspects of care – the ability to respect families and response to their needs/facilitate shared decision making
These competencies have similarly been identified as components of communication that the person and their family also value.  Although the review notes that the research primarily focuses on physician interactions, the competencies could be more widely applicable to other members of the palliative care team and could be effectively taught to clinicians.  To the knowledge of the authors this framework has not yet been tested, and how this research might also be applicable to an aged care context also requires further study.
Barriers to communication and end-of-life discussions
This theme is also discussed from the perspective of the person receiving palliative care in Communication at End-of-Life. Barriers identified include knowledge, attitudes and practices; while these are also discussed in Communication at End-of-Life and Workforce, this summary will focus on the strong evidence for the lack of training in skills in communication.
Education and training: As part of a wider review looking at supporting partnership working between generalist and specialist palliative care services, reviews by Gardiner et al.  and Garland et al.  identified the importance of education and training in delivering effective palliative care. Strategies included study days for aged care staff and decision support for GPs. The review recognised the importance of face-to-face communication networks and collaborative work as key components of a shared learning approach.  Further research is required to validate the efficacy of this approach. Garland et al.  noted that poor interdisciplinary communication, time and role ambiguity as organisational barriers to timely end-of-life discussion with people.
A systematic review by Walczak et al.  recognised a substantial body of communication intervention evaluated in the palliative care context. The included studies lacked robust methodology and suffered from poor design. These limitations should be borne in mind despite the review suggesting that healthcare professionals can derive useful insights into effective end-of-life communication strategies. The findings suggest that training via role playing may be useful, and clarification of roles and responsibilities to remove ambiguity in the responsibility of initiating discussions have shown impressive outcomes. Question prompt sheets used in consults have also been found to be a successful strategy.  Conversely, in a review by Oczkowski et al.,  communication tools were not found to be used routinely in the acute care/ICU setting. While the review found that the use of communication tools for end-of-life preferences reduced the number of days in hospital, there was minimal to no difference to other outcomes of usual care.  This would suggest that the context of end-of-life discussion may be critical to positive outcomes which would support findings discussed in Communication at End-of-Life.
Returning to look at an educational approach to communications styles, a systematic review by Chung et al.  reviewed studies for collective outcomes of self-efficacy, increased knowledge, improved communication and patient satisfaction with end-of-life planning. The included studies were of very poor quality with significant heterogeneity. While the review concluded that a modest number of studies suggest end-of-life (EoL) communication training may improve self-efficacy, knowledge and communication, it is important to note the significant confounding variables and limitations of the studies.  Earlier studies have found that doctor confidence and knowledge does not indicate actual ability to hold EoL discussions. Further research as to the exact instructional composition and contextually relevant outcome data compared against other active educational comparators is required.  In the review by Barnes et al.,  favourable outcomes for confidence and performance in empathetic communication were improved in a simulated environment but it is unknown how much these results are transferable to conversations with people in a real world setting.  Evaluation of two small studies utilising written information to stimulate discussion regarding end-of-life issues were not reliable methods of communication and there was a need to ensure additional opportunities to ask questions were provided.
An earlier systematic review by Parry et al.  is the only one to provide immediately practical findings. This review looked at studies where conversation and discourse analysis had been conducted on interviews where there were prognostic discussions with adults with terminal diseases and their doctor or counsellor. Through doing so, eight conversational styles were identified that may improve effectiveness at opening such dialogue and how information might be disseminated effectively (Fishing questions, Indirect talk, Hypothetical questions, Framing, Linking questions, Pausing, Silence after posing a question and Shifting to the positive).
- ‘Fishing’ questions and ‘indirect talk’ were found to demonstrate sensitivity and to open up discussion of difficult topics while also making it easy for a person to avoid engagement. This approach was deemed more useful when a clinician is unsure as to how receptive a person may be to discussing end-of-life planning.  ‘Hypothetical’ questions more strongly oblige an on-topic discussion and ‘framing’ the discussion, generally can be used when a clinician senses that it is in the interest of the person to have the discussions e.g. where treatment decisions need to be made.
- When a person refers to the future, the clinician is in a strong position to pose a ‘linking’ question, which demonstrates active listening but also steers the conversation to difficult topics. By then providing information in a measured way with pauses or silence to allow information to be digested or questions asked, the gravity of the discussion is conveyed in what is perceived a sensitive manner. Finally, some clinicians preferred to end conversations on a hopeful or positive note, which while helps with fostering a stronger relationship with the clinician, can detract from all that has been discussed. 
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 delivered via mixed teaching methods e.g. didactic, role-playing etc. Key outcomes should be that training facilitates patients to understand their condition, and, where possible, prognosis and even promotes of advance care planning (ACP) discussions. ACP conversations should focus on goals of care and clinicians should be responsive to the emotional reaction to discussions.
Gaps in the Evidence
- Identifying barriers to effective palliative care in health professionals working in an aged care setting
- Communication strategies specifically in an aged care and palliative context
- Testing communication competency frameworks in aged care and palliative context
- Educational strategies with appropriate outcomes i.e. improvement in person satisfaction
- Evaluating models of shared learning between specialists and generalist clinicians in palliative care
- Cost savings of health professionals enhanced communication skills i.e. as a result of dying in place, fewer acute care admissions or unnecessary treatment
Page updated 24 May 2017