Delphi-endorsed Communication Skills Clinicians Need to Care for Hospitalized Incapacitated Patients

Abstract

Background: The National Academy of Medicine recently identified improving clinicians' serious illness communication skills as a necessary step in improving patient and family outcomes near the end of life, but there is not an accepted set of core communication skills for engaging with surrogate decision makers.

Objective: To determine the core serious illness communication skills clinicians should acquire to care for incapacitated, hospitalized patients with acute, life-threatening illness, including patients with Alzheimer's disease and related dementias.

Methods: From January 2019 to July 2020, we conducted a modified Delphi study with a panel of 79 experts in the field of serious illness communication. We developed a preliminary list of candidate communication skills through a structured literature review. We presented the candidate skills to the panelists in the context of three prototypical serious illness conversations. Over three rounds, panelists first augmented the list of candidate skills, then voted on the skills. The final set included skills deemed "very important" or "essential" by 70% of panelists. For external validation, we engaged 11 practicing clinicians and 7 community stakeholders for their perspectives on the expert-endorsed list of skills.

Results: The panelists' ratings indicate the importance of a diverse set of communication skills related to providing clear information exchange as well as emotional and psychological support to surrogates. The final set included 33 skills, 12 of which were endorsed for all three prototypical serious illness conversations. Practicing clinicians and community stakeholders supported the expert-endorsed framework with only minor additions.

Conclusion: We generated a stakeholder-endorsed list of skills that can inform the content of communication skills training programs for clinicians who care for incapacitated patients in the inpatient setting. The skills go beyond those required to provide traditional cognitive decision support and suggest the need for a paradigm shift in curricular content for communication training.

Keywords: Alzheimer disease; Delphi technique; communication; dementia; shared decision making.

Figure 1.

Our methods consisted of five distinct phases, with phases 5A and 5B happening concurrently. ADRD = Alzheimer’s disease and related dementias; NIH = National Institutes of Health; REDCap = Research Electronic Data Capture; RePORTER = Research Portfolio Online Reporting Tools Expenditures and Results.

Figure 2.

These skills were important across all three serious illness conversations. Conversation 1 is the first conversation with a patient’s surrogate(s) shortly after the patient has been admitted to the hospital. Conversation 2 is a follow-up conversation with a patient’s surrogate(s) when a patient is improving and progressing toward hospital discharge. Conversation 3 is a follow-up conversation with a patient’s surrogate(s) when a patient is clinically deteriorating. ADRD = Alzheimer’s disease and related dementias.