Care not cure: dialogues at the transition

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Abstract

Physicians and patients find it hard to communicate when treatment fails to cure or control cancer. Communication barriers include fear of “giving up,” losing the medical team, and discussing death. The quality of physician–patient communication affects important outcomes including patient distress, coping, and quality of life, and physician burnout. Communication skills that can be taught, learned, and maintained for physicians at all levels of training, and effective educational programs have been described. Research on communication skills training should focus on the best method of delivery, the “dose–response” effect, and how to measure success of training in complex health care environments.

Introduction

People living with serious progressive disease face multiple communication challenges including receiving the diagnosis, choosing and starting treatment, modifying treatment in response to failure or disease progression, and arranging end of life care. However, few guidelines exist to help clinicians talk with patients and families when the burdens or risks of treatment outweigh the benefits, and the focus of care shifts from prolonging survival to improving quality of life [1], [2]. This conversation may take place over several encounters until the patient, family, and medical team are all in agreement regarding the goals, methods, and expected results of treatment.

The goal of this article is to highlight some challenges to effective communication at transitions to palliative care, review communication skills training for physicians, and raise questions for further research.

Section snippets

Communication challenges at the transition

Conversations about care when treatment fails to cure or control the disease can be extraordinarily difficult for doctors, patients, and families. Immediate and urgent issues for communication include (1) prognostic uncertainty (“How much time do I have?”), (2) death and dying (“Where and how will I die?”), and (3) the definition of hope (“I can not lose hope, but what am I hoping for?”). Discussing prognostic uncertainty is problematic because physicians: (1) have trouble estimating when a

Communication skills training for physicians

Communication skills are linked to important outcomes such as greater satisfaction (patient and physician), greater patient understanding and acceptance of treatment plans, reduced patient distress, and fewer lawsuits [19], [20]. Interventions to improve physician–patient communication improve patient outcomes in hypertension, diabetes, and post-operative recovery [21], [22], [23]. In oncology, benefits of effective communication include improved patient coping, quality of life, and distress,

What is the “dose–response” effect for communication skills training?

What kind of teaching, for how long, is optimal for improving clinicians’ communication skills? Medical student and resident programs last 2–4 h; residential workshops for practitioners last 2–3 days. Workshops of several sessions followed by ongoing coaching may be more effective than single training events. We need to know more about the optimal “dose” (amount and frequency) of teaching, the impact of “boosters” to revisit and reinforce learning, and appropriate “responses” or outcome measures

Conclusion

Medical educators are implementing competency-based assessment and certification of individuals and training programs, including communication and interpersonal skills [51]. At the same time, health care organizations increasingly view communication as an essential element of patient safety and quality of care [52]. These initiatives will provide new opportunities for collaborative research on patient-centered and systems-based teaching and practice, including communication around management of

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