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 person concerned to accept the information. [1-4] Clinicians want and need more evidence-based guidance and education on how best to discuss end-of-life matters with people in their care and their significant others. [1,4,5]
The five reviews conducted in an aged care context focussed on dementia [6-9] and heart failure . Other reviews focussed on general palliative care for adults [1-4,11,12], the partnership between general and specialist palliative care , and critical and intensive care [5,14] Eight reviews focussed on communication training interventions [2-4,7-9,11,12], three on enablers and barriers [6,10,13], two on skills and competencies [1,14], and one on tools. 
Overall, the quality of the literature was mixed with four reviews of low quality, five of acceptable quality and five of high quality. [3-5,9,12] Reviews scored poorly due to the lack of reporting on the quality of the included studies and synthesis of findings with relation to bias.
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. [2,13] 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 at end-of-life 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.
Communication skills training
Eight systematic reviews focussed on research of communication interventions in the palliative care context. The included primary studies lacked robust methodology and suffered from poor design. [2-4,7-9,12,13]
In a review of randomised controlled trials (RCTs) Selman et al. found that training interventions appear to improve doctors’ ability to show empathy and discuss emotions.  However, the effects of training on doctors’ behaviours during simulated interactions are not reflected in their behaviours when interacting with real patients.  This systematic review was the only one to restrict its analysis to RCTs. Others reviewed studies of various methodologies. [1,2,4-9,11-14]
Brighton et al. propose a 10-item checklist to improve reporting of training interventions which is currently of poor quality.  They also note the absence of input from patients, families, and carers in the development of communication skills training and that training is commonly not multidisciplinary.
The findings of Walczak et al.  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. The review found that the use of communication tools for end-of-life preferences reduced the number of days of mechanical ventilation, length of ICU stay, number of hospital days, and financial costs of care. However, there was minimal to no difference to other outcomes such as the number of patients with documented code status or DNR status, or decisions to withdraw or withhold treatment.  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, findings from a systematic review by Chung et al.  suggest that structured end-of-life (EoL) communication training may improve self-efficacy, knowledge, and communication. . 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. 
Communication skills and dementia
Healthcare professionals’ (HCPs) communication skills contribute significantly to the quality of healthcare, palliative care and dementia care [6-9] and have been identified as one of six key factors influencing decision-making related to future care.  The communication skills of HCPs are critical especially when tackling challenging topics such as mortality and institutionalisation. Skill in discussing future care is also influenced by engagement of people with dementia and their family in the decision-making process; understanding and respecting the preparedness of the person with dementia and their family to broach these topics.  Often HCPs report limited competence and confidence in communicating with people with dementia and in initiating and/or holding discussions about future care. [6,7] As communication problems are mostly verbal, people with dementia often express themselves in a behavioural way and understand non-verbal information better.  Aggressive and agitated behaviour in people with dementia can also be an attempt to communicate.  This can compromise the quality of care, place stress on the physical and emotional health carers (formal and informal) [7-9] and possibly contributes to behavioural and psychological symptoms among people with dementia. 
Communication between people with dementia and nurses is important in meeting social and care needs as part of daily care but may be challenging [7,9] For people living with dementia, their cognitive impairments can affect communication in varying ways; unable to find words to express their intentions, difficulty retrieving memories or processing the contextual information they need to understand the motivations of others. [8,9]
The effectiveness of interventions to improve communication between nurses or formal carers and people with dementia is uncertain. [7,8]
Communication training interventions for family carers have been found to improve communication, knowledge and understanding of dementia for informal carers with most reporting an improvement in skills and competencies. [8,9] Effective interventions involved active participation by carers and were generally skills-based (including practicing skills and discussion). [8,9]
A review by Nguyen et al. included interventions delivered face-to-face by researchers and trained professionals.  This included delivery to groups within residential aged care, and either small groups or to individuals in home care settings. The strongest effects were on carer communication skills, knowledge and attitudes and these effects lasted beyond the intervention period.  Effective residential care interventions were those which incorporated constructive feedback and counselling on real interactions between the care staff and people with dementia, as well as follow-up reinforcement or consultations as part of their training programmes. 
A reduction in carer burden or anxiety or depression was not demonstrated in a review by Morris et al. but interventions that had a significant impact on family carer burden were those which were skills based and included regular home visits over a number of weeks. 
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 advance care planning (ACP) discussions. ACP conversations should focus on goals of care and clinicians should be responsive to the emotional reaction to discussions.
- 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
- Involvement of patients, families, and carers in the development of training interventions to know what types of communication are valued
- The impact of training on patients, families, and carers
- Stronger methodology in evaluating training interventions (communication skills and decision-making) is required as is research into ‘the active ingredients' of what contributes to the effectiveness of training interventions
- 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 16 June 2021