Effective communication is a fundamental part of patient care and integral in a palliative and End of Life ‘EOL’ setting. Effective communication assist healthcare providers to discuss prognosis, establish and manage patients and their relatives’ expectations, create a shared understanding of goals and ensuring care co-ordination between services (Im et al, 2019; Gelfman et al, 2017 Mason and Ellershaw, 2004). Good communication is the foundation to good quality end of life care where patients’ choices and wishes are respected and facilitated (De Caestecker, 2012).
Literature shows effective communication at palliative stage and later at EOL phase enhances the rapport between the healthcare professionals, patients and their families by increasing their concordance of goals, managing patients and families’ expectations whilst increasing their satisfaction of care or service delivered (National Palliative and EOL Care Partnership, 2021; You et al, 2014).
Effective communication and timely discussions around poor prognosis and EOL improves multidisciplinary approach, co-ordination between services and person centred care (NHS England, 2021). At the same time, poor or lack of communication is found to be one of the most common barriers to achieving a well-planned and well-co-ordinated EOL Care (Teunissen, 2007; Jerant et al, 2004; Yabroff, Mandelblatt & Ingham, 2004).
Barriers influencing effective communication include lack or limited exposure to EOL care, and therefore, often avoidance of EOL conversations (Hancock et al, 2007). Unfamiliarity of the healthcare professionals due to different speciality or role and lack of knowledge about early identification of those rapidly deteriorating and approaching EOL are amongst these barriers (Pattison, 2020; Powell and Sileira, 2020; Barnes, 2019). In addition, some healthcare professionals avoid EOL discussions as they often hope patients or their relatives approach this topic and initiate EOL conversations and ask questions (Clayton, Butow and Tattersall, 2005). Finally, professionals’ lack of clarity or confusion around which speciality or care provider such as primary, secondary or community care should have open and honest conversations where patients approaching EOL and their relatives are informed, reassured and well-supported (Im et al, 2019). An effective EOL care requires a team approach where it can offer a holistic and patient centred care (Pfeifer and Head, 2018).
There seems to be an increasing awareness around the importance of communication in palliative and EOL care with a recognition around healthcare professionals’ need for further education and practice. This is to help clinicians prepare for challenging conversations and raise their confidence in having sensitive discussions or delivering bad news (Ekberg et al, 2021; WHO, 2014; Quill and Abernathy, 2013). Lack or limited exposure to palliative and EOL encounter during healthcare professionals’ training can lead to professionals’ avoidance in discussions about palliative and EOL as they may find it challenging (Hancock et al, 2007). This avoidance could also be due to clinicians’ unfamiliarity as they may not encounter routine palliative and EOL patients due to their specialities or roles (Pattison, 2020; Powell and Sileira, 2020). Lack of knowing or using Gold Standards to identify terminally ill patient, those who are deteriorating rapidly and reaching EOL are amongst other reasons for not communicating with patients and their families (Barnes, 2019).
In a study by Brighton and Bristowe (2016) they found a number of barriers responsible for the lack, or poor and ineffective communication between clinicians and patients or relatives which included uncertainty around prognosis and patients’ readiness to accept the prognosis, clinician’s fear of causing harm or distress as well as their unpreparedness for such challenging discussions. Clayton et al (2007) reported that clinicians may avoid challenging discussions around EOL due to not being certain how rapidly patient may or has been deteriorating. Clinicians may wait for cues from patients or relatives to have an honest discussion around poor prognosis and EOL (Clayton, Butow and Tattersall, 2005). Whilst some clinicians may rely on patients and their families to begin such challenging discussions, this can result in an unhealthy and unending cycle of poor communication which ultimately leads to poor patient and family satisfaction and poor care experience for patients and their relatives (You et all, 2015; Almack et al, 2012; Pfeil et al, 2015).
Additional barriers preventing effective EOL communication amongst healthcare professionals include physicians’ lack of certainty or clarity as to which speciality or care provider should have the challenging discussion with patients and relative (Im et al, 2019). This challenging discussions could include, severity of the illness especially in patients with poor prognosis and, therefore, each care provider assumes another speciality could or should deliver such a news and initiate discussions (Im et al, 2019). Often the responsibility of delivering sensitive news or initiating discussions around illness trajectory and poor prognosis is delegated to specialist healthcare providers such as palliative care teams (Dunlay et al, 2015). This is mainly due to clinicians feeling underprepared to initiate discussions around rapid deterioration and EOL (De Vleminck et al, 2014; Barclay et al, 2011). While communication has been highlighted as a fundamental competency that clinicians must have in order to be effective healthcare professionals and yet, clinicians repeatedly report being underprepared to initiate or lead discussions around end of life and managing EOL symptoms (Bernacki and Block, 2014; Ahluwalia et al, 2012).
One of the most common expressed reasons for clinicians avoiding these discussions has been reported as the patients and their families’ lack of understanding of the prognosis, unrealistic expectations and disagreement about the care goals and plans around end of life (Feder et al, 2018; Abdul-Razzak et al, 2019). Healthcare professionals’ lack of skill in identifying patients who have entered the last year of life and having the sensitive and honest conversation with patients and their relatives is recognised as one of the biggest barriers in poor EOL care and experience (NICE, 2019). Therefore, it is integral for healthcare professionals to initiate discussions where questions could be answered, and ambiguities clarified to reduce fear and anxiety and to encourage patients and their families to engage in the end of life discussions (NICE, 2019). Understanding the illness, diagnosis, prognosis and options or benefits of treatment available is a critical foundation that can help the physician to encourage patients and their families to engage more with end of life discussions (Im et al, 2019).
It has been highlighted that another reason for healthcare professionals’ lack of engagement with challenging discussions around EOL is their perception that patients and families are coping well with the situation as they may seem they are coping well and adapting to living with life limiting condition or choosing to keep positive (Davison,2010). Although it is important to acknowledge patients’ positive thinking and coping strategies, it is still the healthcare professionals’ responsibility to find ways to engage with patients and relatives by gauging their true understating of the illness. It is also their duty of care to adapt their communication style and approach to ensure open and honest message has been delivered so as to avoid false hope or misunderstandings (Klindtworth et al, 2015; Kendall et al, 2015). It is stated that when communication is adapted to individual’s needs, it facilitates a therapeutic relationship which, could provide mutual respect thereby promoting a better care where patients and their families’ needs, worries, wishes and preferences are identified and addressed (Kwame and Petrucka, 2021).
EOL Communication and discussions are considered time consuming but essential and although each healthcare professional has the responsibility to ensure they are able to initiate and hold such discussions, a team-based effort tends to facilitate the effective communication that is needed to provide information which then allows patients and their relatives to explore options that can help them develop plans which, ultimately facilitates holistic, patient-centred care. Subsequently, enhancing communication skills can have a significant positive impact on the patients and their relatives’ journey and experiences (Pfeifer and Head, 2018).
Communication has been identified as fundamental in healthcare especially in palliative and end of life care (Im et al, 2019). Effective communication assists the clinicians to engage with patients and their families and to support them by facilitating open and honest conversations so patients and their relatives can express their wishes and their needs (Park et al, 2015).
Although initiating or holding sensitive discussions especially around poor prognosis and end of life is not without its challenges, ultimately healthcare professionals should take responsibility to overcome these challenges as part of their duty of care and their accountability (General Medical Council, 2023; NMC, 2018). Effective communication is paramount in ensuring care is co-ordinated and person-centred where all services and care sectors are prepared to provide seamless care (NHS England, 2021).
While there may be number of barriers affecting good communication between patients and the clinicians, healthcare professionals should be proactive in identifying these barriers and aim to facilitate therapeutic rapport in accordance with patients’ needs. A person-centred care and effective communication have been highlighted as a continuum that needs to be present and in balance if patient satisfaction and positive experience is to be achieved (Kwame and Petrucka, 2021).
Finally, EOL conversations requires a team-effort to facilitate an environment that is patient- centred and holistic where patients and their relatives can explore options and develop advanced care plan (Pfeifer and Head, 2018).
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