Interventions for interpersonal communication about end of life care between health practitioners and affected people
- PMID: 35802350
- PMCID: PMC9266997
- DOI: 10.1002/14651858.CD013116.pub2
Interventions for interpersonal communication about end of life care between health practitioners and affected people
Abstract
Background: Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes.
Objectives: To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL.
Search methods: We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing.
Selection criteria: This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life, we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes.
Data collection and analysis: Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies.
Main results: Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials. Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication. Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations. Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life. Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear.
Authors' conclusions: Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.
Trial registration: ClinicalTrials.gov NCT00331877 NCT00325611 NCT01245621 NCT01990742 NCT02261935 NCT02606149 NCT02723799 NCT02730858 NCT02944344 NCT03099746 NCT03548142 NCT03626402 NCT03770481.
Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Conflict of interest statement
Rebecca Ryan: completed this work as part of her role as Joint Co‐ordinating Editor with the Cochrane Consumers and Communication Group. Her position is funded by a Cochrane Infrastructure Grant provided by the National Health and Medical Research Council (NHMRC).
Michael Connolly: completed this work as part of his Evidence Synthesis Ireland Fellowship.
Natalie Bradford: none to declare.
Simon Henderson: none to declare.
Anthony Herbert: received funding from Australia Research Council (2018 to 2020) and Gilead Sciences (2016).
Lina Schonfeld: none to declare.
Jeanine Young: none to declare.
Josephine Bothroyd: none to declare.
Amanda Henderson: none to declare.
Figures







Update of
- doi: 10.1002/14651858.CD013116
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- Curtis JR, Downey L, Back A, Nielsen E, Treece P, Engelberg R. A patient and clinician communication-priming intervention increases patient-reported goals-of-care discussions between patients with serious illness and clinicians: a randomized trial. Palliative Medicine 2018;32(1 Supplement 1):9. [DOI: ] - PMC - PubMed
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- Flannery MA, Culakova E, Poh Loh K, Epstein RM, Kamen CS, Obrecht S. Improving person-centered communication of goals, proxy, and advance directives in older patients with advanced cancer: secondary analysis from a University of Rochester NCI Community Oncology Research Program (NCORP) cluster randomized controlled trial (CRCT). Journal of Clinical Oncology 2019;37(15 Supplement):11523. [DOI: 10.1200/JCO.2019.37.15_suppl.11523] - DOI
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- Flannery MA, Mohile S, Culakova E, Norton S, Kamen C, Dionne-Odom JN, et al. Completion of patient-reported outcome questionnaires among older adults with advanced cancer. Journal of Pain and Symptom Management 2022;63(2):301-10. [DOI: 10.1016/j.jpainsymman.2021.07.032] [PMID: ] - DOI - PMC - PubMed
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Fujimori 2014 {published data only}
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- Fujimori M, Shirai Y, Asai M, Kubota K, Katsumata N, Uchitomi Y. Effect of communication skills training program for oncologists based on patient preferences for communication when receiving bad news: a randomized controlled trial. Journal of Clinical Oncology 2014;32:2166-72. [DOI: 10.1200/JCO.2013.51.2756] - DOI - PubMed
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Goldstein 2019 {published data only}
Gramling 2016 {published data only}
Graul 2019 {published data only}
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Graul 2020 {published data only}
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- Graul A, Haggerty A, Stickley C, Kumar P, Morales K, Bogner H, et al. Effect of patient education on palliative care knowledge and acceptability of outpatient palliative care services among gynecologic oncology patients: a randomized controlled trial. Gynecologic Oncology 2020;156(2):482-7. - PubMed
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Hanson 2019 {published data only}
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- ISRCTN36040085. ImproveCare - The management of clinical uncertainty in hospital settings. www.isrctn.com/ISRCTN36040085 (first received 18 January 2017).
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- Johnson S, Vaccaro L, Butow PN, Kiely BE, Silvester W, Detering K, et al. Advance care planning increases communication between cancer patients, their oncologists and their family: an RCT. Asia-Pacific Journal of Clinical Oncology 2016;12(Supplement 5):93. [ACTRN12613001288718]
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- Lee Brittney C, Houston PE, Rana SR, Kimmel AL, D'Angelo LJ, Lyon ME. Who will speak for me? Disparities in palliative care research with ''unbefriended'' adolescents living with HIV/AIDS. Journal of Palliative Medicine 2017;20:1135-8. [DOI: ]
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NCT00580515 {unpublished data only}
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- NCT00580515. Trial of family focused grief therapy in palliative care and bereavement. clinicaltrials.gov/show/nct00580515 (first received 24 December 2007).
NCT01160367 {unpublished data only}
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NCT01245621 {unpublished data only}
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- NCT01245621. Study of palliative care intervention for advanced cancer patients and their caregivers - Educate Nurture Advise Before Life Ends (ENABLE III). clinicaltrials.gov/ct2/show/NCT01245621 (first received 22 November 2010). [NCT01245621]
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NCT01828775 {unpublished data only}
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- NCT01828775. Palliative care intervention in improving quality of life, psychological distress, and communication in patients with solid tumors receiving treatment. clinicaltrials.gov/show/nct01828775 (first received 11 April 2013).
NCT01914848 {unpublished data only}
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- NCT01914848. Multiprofessional advance care planning and shared decision making for end of life care (MAPS). clinicaltrials.gov/show/nct01914848 (first received 2 August 2013).
NCT01944813 {unpublished data only}
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- NCT01944813. Advance care planning: a way to improve end-of-life care life care. clinicaltrials.gov/show/nct01944813 (first received 18 September 2013).
NCT01990742 {unpublished data only}
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- NCT01990742. Improving Palliative Care Through Teamwork (IMPACTT). clinicaltrials.gov/ct2/show/NCT01990742 (first received 21 November 2013). [NCT01990742]
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- NCT02112461. Hospice and end-of-life symptom monitoring & support using an automated system designed for family caregivers (SCP). clinicaltrials.gov/show/nct02112461 (first received 14 April 2014).
NCT02261935 {unpublished data only}
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- NCT02261935. Supporting family caregivers of palliative patients at home: the carer support needs assessment intervention (CSNAT). clinicaltrials.gov/ct2/show/NCT02261935 (first received 10 October 2014). [NCT02261935]
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- NCT02349412. Early palliative care with standard care or standard care alone in improving quality of life of patients with incurable lung or non-colorectal gastrointestinal cancer and their family caregivers. clinicaltrials.gov/show/nct02349412 (first received 28 January 2015).
NCT02445937 {unpublished data only}
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- NCT02445937. PARTNER II: improving patient and family centered care in advanced critical illness. clinicaltrials.gov/show/nct02445937 (first received 15 May 2015).
NCT02463162 {unpublished data only}
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- NCT02463162. Trial of advance care planning (ACP) & goals of care designations (GCD) discussions. clinicaltrials.gov/show/nct02463162 (first received 4 June 2015).
NCT02606149 {unpublished data only}
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- NCT02606149. Truthful information on chemotherapy and its impact on chemotherapy at the end of life (HIPPOCRATE). clinicaltrials.gov/ct2/show/NCT02606149 (first received 17 November 2015). [NCT02606149]
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- NCT02730858. Palliative and oncology care model in breast cancer. clinicaltrials.gov/ct2/show/NCT02730858 (first received 7 April 2016).
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- NCT02917603. Shared decision making to improve palliative care in the nursing home. clinicaltrials.gov/show/nct02917603 (first received 28 September 2016).
NCT02944344 {unpublished data only}
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- NCT03068013. Managing Cancer and Living Meaningfully (CALM) adapted to Italian cancer care setting (CALM-IT). clinicaltrials.gov/show/nct03068013 (first received 1 March 2017).
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- NCT03099746. Decision support among surrogate decision makers of the chronically critically ill (INVOLVE) [A clinical trial of decision support for end of life care among surrogate decision makers of the chronically critically ill]. clinicaltrials.gov/ct2/show/NCT03099746 (first received 4 April 2017). [NCT03099746]
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- NCT03138564. An effectiveness-implementation trial of SPIRIT in ESRD. clinicaltrials.gov/show/nct03138564 (first received 3 May 2017).
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- NCT03387436. The "Hand-in-Hand Study": improvement of quality of life in palliative cancer patients through collaborative advance care planning (COLAP). clinicaltrials.gov/show/nct03387436 (first received 2 January 2018).
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- NCT03506087. Advance care planning coaching for patients with chronic kidney disease (MY WAY). clinicaltrials.gov/show/nct03506087 (first received 23 April 2018).
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Parker 2017 {published data only}
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