Care not cure: dialogues at the transition
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
References (53)
Effects of framing and level of probability on patients’ preferences for cancer chemotherapy
J. Clin. Epidemiol.
(1989)Improving communication with cancer patients
Eur. J. Cancer
(1999)- et al.
Helping cancer patients disclose their concerns
Eur. J. Cancer
(1996) - et al.
Helping health professionals involved in cancer care acquire key interviewing skills—the impact of workshops
Eur. J. Cancer
(1996) - et al.
Efficacy of a Cancer Research UK communication skills training model of oncologists: a randomized controlled trial
Lancet
(2002) - et al.
Patient–physician communication assessment instruments: 1986–1996 in review
Pat. Educ. Couns.
(1998) - et al.
Physician expressions of uncertainty during patient encounters
Pat. Educ. Couns.
(2000) - et al.
Collusion in doctor–patient communication about imminent death: an ethnographic study
BMJ
(2000) - et al.
Working toward consensus: providers’ strategies to shift patients from curative to palliative treatment goals
Res. Nurs. Health
(2001) How gravely ill becomes dying: a key to end-of-life care
JAMA
(1999)
Prognostic disclosure to patients with cancer near the end of life
Ann. Intern. Med.
Patients’ interpretations of verbal expressions of probability: implications for securing informed consent to medical interventions
Behav. Sci. Law
Uncertainty and control: learning to live with medicine’s limitations
Hum. Med.
Serving patients who may die soon and their families: the role of hospice and other services
JAMA
Discrepancies between patient and physician estimates for the success of stem cell transplantation
JAMA
Fostering hope in terminally ill people
J. Adv. Nurs.
Truth may hurt but deceit hurts more: communication in palliative care
Palliat. Med.
Discussing disease progression and end-of-life decisions
Oncology
Discussing palliative care with patients
Ann. Intern. Med.
“I wish things were different.” Expressing wishes in response to loss, futility, and unrealistic hopes
Ann. Intern. Med.
Perspectives on care at the close of life. Psychological considerations, growth, and transcendence at the end of life: the art of the possible
JAMA
The inner life of physicians and care of the seriously ill
JAMA
Meta-analysis of correlates of provider behavior in medical encounters
Med. Care
Evidence on doctor–patient communication
Cancer Prev. Control
Cited by (25)
Supporting Supportive Care in Cancer: The ethical importance of promoting a holistic conception of quality of life
2018, Critical Reviews in Oncology/HematologyCitation Excerpt :The consequent trauma can in turn feed the fear and stigma towards death. The difficulty in planning SCC and discussing prognostic uncertainty is often underpinned by such stigma (Gordon, 2003). Clinicians tend to view disclosing uncertainty as potentially damaging to the doctor-patient relationship and often give falsely optimistic prognosis to dying patients (McCartney, 2014).
Communication as a Core Skill of Palliative Surgical Care
2012, Anesthesiology ClinicsCommunication Skills in Palliative Surgery: Skill and Effort Are Key
2011, Surgical Clinics of North AmericaCitation Excerpt :Forthright and compassionate discussions about terminal disease, including prognosis and treatment options, further allow patients and families to prepare for the final stages of life. Good communication can help providers, families, and patients to “clarify and achieve their hopes and goals within the constraints of progressive disease.”46 Using well-defined communication tools and systematic approach can facilitate this challenging task.
End of Life Decision-Making for Cancer Patients
2009, Primary Care - Clinics in Office PracticeCitation Excerpt :What does the literature tell about this concept of hope? Physicians often think of hope in terms of cancer response to treatment or improved survival.80 Patients, however, often can find other hopes as their illness progresses.80
Coping with Medical Illness and Psychotherapy of the Medically Ill
2008, Massachusetts General Hospital Comprehensive Clinical PsychiatryA Qualitative Study on the Needs of Women with Metastatic Breast Cancer
2022, Journal of Cancer Education
Symposium on Consumer/Provider Communication Research, National Cancer Institute, 14–15 September 2001, Bethesda, MD, USA.