Communicating a terminal prognosis in a palliative care setting: Deficiencies in current communication training protocols

doi:10.1016/j.socscimed.2008.01.042

Social Science & Medicine

Volume 66, Issue 11, June 2008, Pages 2356-2365

https://doi.org/10.1016/j.socscimed.2008.01.042 Get rights and content

Abstract

The goal of this study was to understand the use and effectiveness of current communication protocols in terminal prognosis disclosures. Data were gathered from an interdisciplinary palliative care consultation service team at a Veterans Hospital in Texas, USA. Medical communication guidelines, a consistent component in United States palliative care education, propose models for delivery of bad news. However, there is little empirical evidence that demonstrates the effectiveness of these guidelines in disclosures of a terminal prognosis. Based on ethnographic observations of terminal prognosis meetings with dying patients, palliative care team meetings, and semi-structured interviews with palliative care team practitioners, this study notes the contradictory conceptualizations of current bad news communication guidelines and highlights that communicating a terminal prognosis also includes (1) adaptive communication based on the patient's acceptability, (2) team based/family communication as opposed to physician–patient dyadic communication, and (3) diffusion of topic through repetition and definition as opposed to singularity of topic. We conclude that environmentally based revision to communication protocol and practice in medical school training is imperative.

Section snippets

Current medical communication guidelines

Current U.S. communication guidelines for end-of-life training are included in the Education for Physicians on End-of-Life Care (EPEC; Emanuel, von Gunten, & Ferris, 1999). Module two of the curriculum contains a six-step protocol for delivering bad news. The first step involves getting started and preparing for the interaction. Second, physicians are encouraged to assess the patient's knowledge about his/her illness, followed by the third step: gauging and determining the amount of information

Setting

Our study was conducted at the South Texas Veterans Health Care System (STVHS) in San Antonio TX, USA. The STVHS, in conjunction with the University of Texas Health Science Center, has a training program to educate interdisciplinary fellows including physicians, nurses, chaplains, psychologists and social workers. On average, palliative care services are delivered to more than 150 patients per month. We conducted inpatient geriatric palliative care team observations between January 2006 and May

Flawed conceptualizations of communicating a terminal prognosis in palliative care

We extend the interpretive insight of Eggly, Penner, Albrecht, et al., 2006 who offer a critique of medical communication guidelines in general as a departure point to further explore the quagmires of communicating a terminal prognosis. Eggly, Penner, Albrecht, et al. (2006) suggest three of the assumptions undergirding current communication prescripts may not reflect the intricacies and complexities of physician–patient interaction in the challenging context of delivering and receiving

Discussion and future directions

Our ethnographic observations contribute to the larger dialogue about palliative and end-of-life care issues. The literature suggests that medical care for patients with advanced illness is typified by inadequately treated physical distress, fragmented care systems, poor communication between health care professionals, patients, and families, and enormous strain on family caregiver and support systems (National Hospice and Palliative Care Organization, 2007). In a recent article in the Journal

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Communicating a terminal prognosis in a palliative care setting: Deficiencies in current communication training protocols

Abstract

Section snippets

Current medical communication guidelines

Setting

Flawed conceptualizations of communicating a terminal prognosis in palliative care

Discussion and future directions

Social Science & Medicine

The Lancet

Breaking bad news: learning through experience

Journal of Clinical Oncology

SPIKES – a six step protocol for delivering bad news: application to the patient with cancer

Oncologist

Delirium in older adults with cancer: implications for practice and research

Oncology Nursing Forum

Making sense of qualitative data analysis: Complementary strategies

Trends in the aggressiveness of cancer care near the end of life

Journal of Clinical Oncology

Discussing bad news in the outpatient oncology clinic: rethinking current communication guidelines

Journal of Clinical Oncology

Interdisciplinary health care teamwork in the clinic backstage

Journal of Applied Communication Research

Doctor's strategies when breaking bad news to terminally ill patients

Journal of Palliative Medicine

Concerns about losing control when breaking bad news to terminally ill patients with cancer: physician's perspective

Journal of Palliative Medicine