The Meaning of Words and Why They Matter During End-of-Life Conversations

Communication Skills Training

Every member of the health care team should be equipped with the basic skills to have these conversations. The academic curricula for members of the health care team focuses on developing communication skills, but there has been a lack of content on palliative and EOL care.⁹

Due to time constraints and limited opportunities in the clinical setting, there has been an increasing use of simulation-based learning activities (SBLA) to enhance communication skills among nursing students.⁹ At this time, the impact of SBLA in enhancing communication competency is not fully known, but given the lack of clinical opportunities for students, this option is worth considering.⁹ When asked, nurses recognized the need for improved EOL communication education, training, and guidelines.¹⁰ They also felt that a multidisciplinary approach in EOL communication is beneficial. The inclusion of the End-of-Life Nursing Education Consortium (ELNEC) Core training in Bachelor of Science in Nursing programs have led to improved insight on palliative care and nurses’ role in palliative care and hospice among nursing students.¹¹

The Palliative Care and Hospice Education and Training Act of 2017 amended the Public Health Service Act to include improving EOL training for health care providers, including talking about death and dying.¹² Even though the Liaison Committee of Medical Education asked medical schools to incorporate EOL care education in the medical school curricula, there is still a lack of developmentally appropriate and supervised EOL education in medical schools.¹² Training on grief also has been lacking and less likely to be mandatory among medical students and residents: Workshops are mostly conducted before they can be applied in the clinical setting.¹³ Meanwhile, resources are available to assist physicians in EOL conversations with patient and families, such as the Serious Illness Conversation Guide, The Conversation Project, and Stanford’s Letter Project.¹²

Conclusions

Palliative consultation is associated with an overall improvement in EOL care, communication, and support, according to families of deceased patients.¹⁴ It has also been shown to enhance patients’ quality of life and mood, improve documentation of resuscitation preferences, and lead to less aggressive care at the EOL, including less chemotherapy.¹⁵ Integration of palliative care in the care of patients hospitalized with acute heart failure has been associated with improved quality of life, decreased symptom burden and depressive symptoms, and increased participation in advance care planning.¹⁶

The involvement of palliative care in the care of patients and their families at EOL enhances goals of care discussions that improve understanding for everyone involved. It helps provide consistency with the message being delivered by the rest of the health care team to patients and families regarding prognosis and recommendations. Palliative care can provide an alternative when all other aggressive measures are no longer helpful and allow for the continuation of care with a shift in focus from prolonging life to promoting its quality. Furthermore, palliative care involvement for care of patients with life-limiting illness also has been found to improve symptom control, decrease hospitalizations and health care costs, and even improve mortality.¹⁷A multidisciplinary approach to palliative care EOL conversations is beneficial, but every member of the health care team should have the training, education, and skills to be ready to have these difficult conversations. These health care team members include physicians, advance practice clinicians, nurses, social workers, and chaplains, among others. Patients and families are likely to be in contact with different members of the health care team who should be able to carry out therapeutic conversations. Using validated tools and resources on communication techniques through evidence-based practice is helpful and should be encouraged. This provides a framework on how EOL conversations should be conducted in the clinical setting to augment the identified lack of training on EOL communication in schools. Repeated opportunities for its use over time will help improve the ability of clinicians to engage in effective EOL communication.