Victoria Land

How to communicate with patients about future illness progression and end of life: a systematic review

Background Conversation and discourse analytic research has yielded important evidence about skills needed for effective, sensitive communication with patients about illness progression and end of life. Objectives To: ▸ Locate and synthesise observational evidence about how people communicate about sensitive future matters; ▸ Inform practice and policy on how to provide opportunities for talk about these matters; ▸ Identify evidence gaps. Design Systematic review of conversation/discourse analytic studies of recorded interactions in English, using a bespoke appraisal approach and aggregative synthesis. Results 19 publications met the inclusion criteria. We summarised findings in terms of eight practices: ‘fishing questions’—open questions seeking patients’ perspectives (5/19); indirect references to difficult topics (6/19); linking to what a patient has already said—or noticeably not said (7/19); hypothetical questions (12/19); framing difficult matters as universal or general (4/19); conveying sensitivity via means other than words, for example, hesitancy, touch (4/19); encouraging further talk using means other than words, for example, long silences (2/19); and steering talk from difficult/negative to more optimistic aspects (3/19). Conclusions Practices vary in how strongly they encourage patients to engage in talk about matters such as illness progression and dying. Fishing questions and indirect talk make it particularly easy to avoid engaging—this may be appropriate in some circumstances. Hypothetical questions are more effective in encouraging on-topic talk, as is linking questions to patients’ cues. Shifting towards more ‘optimistic’ aspects helps maintain hope but closes off further talk about difficulties: practitioners may want to delay doing so. There are substantial gaps in evidence.

Systematically reviewing and synthesizing evidence from conversation analytic and related discursive research to inform healthcare communication practice and policy: an illustrated guide

BackgroundHealthcare delivery is largely accomplished in and through conversations between people, and healthcare quality and effectiveness depend enormously upon the communication practices employed within these conversations. An important body of evidence about these practices has been generated by conversation analysis and related discourse analytic approaches, but there has been very little systematic reviewing of this evidence.MethodsWe developed an approach to reviewing evidence from conversation analytic and related discursive research through the following procedures:• reviewing existing systematic review methods and our own prior experience of applying these• clarifying distinctive features of conversation analytic and related discursive work which must be taken into account when reviewing• holding discussions within a review advisory team that included members with expertise in healthcare research, conversation analytic research, and systematic reviewing• attempting and then refining procedures through conducting an actual review which examined evidence about how people talk about difficult future issues including illness progression and dyingResultsWe produced a step-by-step guide which we describe here in terms of eight stages, and which we illustrate from our ‘Review of Future Talk’. The guide incorporates both established procedures for systematic reviewing, and new techniques designed for working with conversation analytic evidence.ConclusionsThe guide is designed to inform systematic reviews of conversation analytic and related discursive evidence on specific domains and topics. Whilst we designed it for reviews that aim at informing healthcare practice and policy, it is flexible and could be used for reviews with other aims, for instance those aiming to underpin research programmes and projects. We advocate systematically reviewing conversation analytic and related discursive findings using this approach in order to translate them into a form that is credible and useful to healthcare practitioners, educators and policy-makers.

Engaging Terminally Ill Patients in End of Life Talk: How Experienced Palliative Medicine Doctors Navigate the Dilemma of Promoting Discussions about Dying

Objective To examine how palliative medicine doctors engage patients in end-of-life (hereon, EoL) talk. To examine whether the practice of “eliciting and responding to cues”, which has been widely advocated in the EoL care literature, promotes EoL talk. Design Conversation analysis of video- and audio-recorded consultations. Participants Unselected terminally ill patients and their companions in consultation with experienced palliative medicine doctors. Setting Outpatient clinic, day therapy clinic, and inpatient unit of a single English hospice. Results Doctors most commonly promoted EoL talk through open elaboration solicitations; these created opportunities for patients to introduce–then later further articulate–EoL considerations in such a way that doctors did not overtly ask about EoL matters. Importantly, the wording of elaboration solicitations avoided assuming that patients had EoL concerns. If a patient responded to open elaboration solicitations without introducing EoL considerations, doctors sometimes pursued EoL talk by switching to a less participatory and more presumptive type of solicitation, which suggested the patient might have EoL concerns. These more overt solicitations were used only later in consultations, which indicates that doctors give precedence to patients volunteering EoL considerations, and offer them opportunities to take the lead in initiating EoL talk. There is evidence that doctors treat elaboration of patients’ talk as a resource for engaging them in EoL conversations. However, there are limitations associated with labelling that talk as “cues” as is common in EoL communication contexts. We examine these limitations and propose “possible EoL considerations” as a descriptively more accurate term. Conclusions Through communicating–via open elaboration solicitations–in ways that create opportunities for patients to volunteer EoL considerations, doctors navigate a core dilemma in promoting EoL talk: giving patients opportunities to choose whether to engage in conversations about EoL whilst being sensitive to their communication needs, preferences and state of readiness for such dialogue.

Communication practices that encourage and constrain shared decision making in health-care encounters: Systematic review of conversation analytic research

Shared decision making (SDM) is generally treated as good practice in health‐care interactions. Conversation analytic research has yielded detailed findings about decision making in health‐care encounters.

ENCOURAGING AND DISCOURAGING TALK ABOUT ILLNESS PROGRESSION, DYING AND DEATH: A SYSTEMATIC REVIEW OF COMMUNICATION RESEARCH

Introduction Communicating with patients about their feelings and preferences for the future is a challenging element of palliative care. Useful evidence exists, but most is embedded in social-scientific rather than clinical research. Aims and Methods To collate evidence about communication practices used in addressing sensitive future issues, from studies where patient/professional conversations have been recorded and analysed. To inform communication policy, practice and training. This innovative systematic review spanned social science, clinical and linguistics research. Using explicit criteria, we searched electronic databases and specialist sources. We used review and synthesis techniques appropriate for social-science research. Results 2203 publications were initially identified. Of the 18 meeting the inclusion criteria, 5 were social science, five clinical and eight linguistics publications. Strong evidence (11/18) indicates hypothetical questions are effective in encouraging people to address feelings and plans for uncertain and difficult futures. Moderate evidence (5/18) indicates that another way to create such opportunities entails using cautious, euphemistic language; and that this provides distinctive opportunities for people to deflect or avoid the topic. Moderate evidence (3/21) indicates that people often steer such conversations towards more optimistic statements, which tends to stop further talk about difficult events. Conclusions Social-science, linguistic and clinical evidence is available to inform this skilled, often problematic element of care. There are different ways to provide opportunities to discuss feelings and plans in relation to end of life. Different ways have different results: better understandings of these will facilitate evidence-based communication. To fill gaps in knowledge, further research using recordings of authentic palliative care consultations is needed.