Many Americans with serious illness receive health care that is mismatched with their goals and priorities. This gap between an individual’s priorities and the medical treatment they receive, stands at the center of a network of problems with far-reaching consequences that involve the patient, the patient’s family and caregivers, health care providers, health care systems, and national spending on health care.
For many people, serious illness and dying may seem to be an intrinsically and unavoidably terrible and terrifying experience. However, for patients with serious illness, in many cases the process of illness and death is one that they expect, can accept, and are willing to prepare and discuss in depth. Patients often experience the most suffering and anguish because their preferences for care are never elicited, documented, or honored; their families and caregivers struggle with decisions that leave them with regret and post-traumatic distress; clinicians experience moral distress and burnout; and healthcare systems face increasing utilization with suboptimal outcomes. Nationally, this results in health care expenses in the United States that surpass every other country in the world as a proportion of gross national product (GDP), even as our nation lags in quality measures.
Clinicians and patients are not having enough serious illness conversations.
To improve medical care to make it more concordant with patient goals requires multiple interventions. A key component is the ability of physicians, nurses, and other clinicians to communicate effectively about values and goals, and then to translate those values into clinical care plans.
Patients want to be heard, feel cared for, and share with their clinicians what is most important when faced with serious illness. Healthcare professionals agree: 99 percent of clinicians studied nationally say they should be having serious illness conversations with patients (Fulmer et al., 2018). However, only 14 percent of clinicians have these conversations and 46 percent of clinicians reported they were uncertain of what to say (Fulmer et al., 2018).
Most practicing clinicians have never received effective communication training, and as a result, data shows that clinicians often fail to elicit values from patients, miss empathic cues that are critical for establishing patient trust, and are unable to connect patient values to a medical action plan. Inadequate clinician communication skills impact not only patients from intake to discharge but the entire health ecosystem.
Many clinicians do not receive adequate training in serious illness conversations.
Reasons clinicians cite for this “conversation gap” include lack of time, worry about provoking emotions, fear of prognostication, uncertainty about what to say, and lack of formal training. In fact, only 29 percent of clinicians reported having formal training conducting these conversations (Fulmer et al., 2018).
Communication skills training improves clinicians’ likelihood and ability to have serious illness conversations.
Serious illness conversations improve goal-concordance, care experience, and patient quality of life and outcomes. When goals of care and advanced care planning conversations happen, studies report higher patient-rated quality of life, longer survival, fewer depressive symptoms, and improved spiritual wellbeing (Temel et al., 2010; Bakitas, Lyons & Hegel, 2009; Rogers et al., 2017). Serious illness communication interventions positively impact health care systems as well, including shorter lengths of stay, lower rates of 30-day readmissions, reduced acute care utilization, and earlier hospice enrollment (Norton et al., 2017; Temel et al., 2010; Sharma, Freeman, Zhang & Goodwin, 2009). Communication training has a positive effect on clinician burnout as well. 60 percent of physicians who report having specific training in end-of-life discussions say they rarely feel unsure about what to say when having conversations about end-of-life care and 46 percent of physicians are more likely (than those who have not) to find those conversations rewarding (Fulmer et al., 2018).
Effective, empathic and honest conversations between a clinician, patient and their family are the cornerstones of patient-centered care. Just as performing surgery is a learned skill, the same is true for communicating with patients and their families experiencing serious illness. Communication skills training programs can and do bridge the costly gaps between patients, their families, and their healthcare teams. With better communication there is a future in which every seriously ill patient will be surrounded by clinicians who can speak about what matters most and match care to values.
References
1. Fulmer T, Escobedo M, Berman A, Koren MJ, Hernández S, Hult A. Physicians’ Views on Advance Care Planning and End-of-Life Care Conversations. J Am Geriatr Soc. 2018;66(6):1201-1205. https://doi.org/10.1111/jgs.15374
2. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic nonsmall-cell lung cancer. The New England Journal of Medicine. 2010;363:733-742. https://doi.org/10.1056/NEJMoa1000678
3. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a Palliative Care Intervention on Clinical Outcomes in Patients With Advanced Cancer: The Project ENABLE II Randomized Controlled Trial. JAMA. 2009;302(7):741–749. https://doi.org/10.1001/jama.2009.1198
4. Rogers JG, Patel CB, Mentz RJ, et al. Palliative Care in Heart Failure: The PAL-HF Randomized, Controlled Clinical Trial. J Am Coll Cardiol. 2017;70(3):331-341. https://doi.org/10.1016/j.jacc.2017.05.030
5. Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ, Quill TE. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Critical Care Medicine. 2007;35:1530-5. https://doi.org/10.1097/01.CCM.0000266533.06543.0C
6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic nonsmall-cell lung cancer. The New England Journal of Medicine. 2010;363:733-42. https://doi.org/10.1056/NEJMoa1000678
7. Sharma G, Freeman J, Zhang D, Goodwin JS. Continuity of care and intensive care unit use at the end of life. JAMA. 2009;169:81-6. https://doi.org/10.1001/archinternmed.2008.514
For more research regarding the effects of communication skills training in healthcare, please visit: https://www.vitaltalk.org/evidence/
Tessie October, M.D., M.P.H., is a board-certified physician in pediatrics, pediatric critical care and palliative and hospice medicine. She blends expertise from these three areas to transform the communication healthcare experience for patients with serious illness and their families. Dr. October currently serves as a board member for VitalTalk.
