Illness Communication Research Articles

Human-centered design to improve clinical decision support systems (CDSS) to engage in serious illness communication (SIC) with patients with cancer in a gastrointestinal oncology clinic.

433 Background: We previously reported the implementation of a machine learning (ML) model for mortality prediction that was integrated into a CDSS encouraging clinicians to have a SIC with at-risk cancer patients. The clinical utility of a ML model can change after implementation due to fluctuations in the organization’s patient population and clinical practices. It is important to establish a workflow to monitor and continually reinforce ML-powered CDSS to ensure that it continues to benefit patients. We report a workgroup structure that incorporates data driven evaluation of ML model performance and feedback from CDSS end users to optimize the acceptability of the CDSS. Methods: The workflow was piloted in the gastrointestinal (GI) oncology clinic from 11/2021-5/2022. A workgroup including members of the implementation team and end-users of the CDSS met monthly to review 1) a dashboard that displays model performance, 2) an electronic health record (EHR) report that summarizes use of the CDSS, 3) feedback from end users regarding their opinion of the CDSS and any barriers to implementation. We evaluated the accuracy of model predictions among subgroups as defined by mortality and unplanned hospital admissions or ED visit rates. Fisher’s Exact Test was used to identify differences between categorical variables. Numeric values including incidence rate ratios (IRRs) adjusted for age, sex, race, and gender with 95% confidence intervals (CIs) were calculated using Poisson regression. Results: 119 patients were evaluated by the model and 50 (42%) were assessed as high-risk. In the high-risk group, the oncology team evaluated 39 (78%) patients for appropriateness of a SIC; SIC was completed with 5 (10%) patients. During workgroup meetings, physicians shared that some of the high-risk predictions were for patients undergoing curative intent therapy. 0 out of 24 patients who received curative treatment died and 5 out of 26 patients who receive palliative treatment died. The log-rank p-value of 0.03 indicates that the survival distribution differs significantly over time between two groups. The adjusted IRR for unplanned hospital visits (palliative vs curative) was 2.55 (1.3-5.0). Adjusted mean hospital visits per month were 0.34 (0.21-0.51) vs 0.13 (0.06-0.21). Conclusions: The workgroup format is a feasible method to continuously review acceptability of a ML-powered CDSS. It may evaluate critical feedback from end users in a holistic manner that can augment a data driven evaluation of the model performance. The data implies that patients undergoing curative therapy have a decreased risk for mortality and unplanned hospital admissions or ED visits. The CDSS may be optimized by excluding these patients; however, longer follow up of this sub-population is needed to confirm that they have no additional risk factors.

Palliative Care and Movement Disorders.

This article reviews the role of palliative care in the treatment of patients with life-limiting neurodegenerative movement disorders. Growing evidence indicates that palliative care significantly improves quality of life and symptom burden for people with Parkinson disease and other serious movement disorders, while reducing caregiver burnout. An emphasis on advance care planning guides goal-directed treatment recommendations. Serious illness communication skills are evidence-based methods of relaying bad medical news to patients and mapping out values and goals in a way that provides comfort, emphasizes patient autonomy, and builds coping and resiliency strategies. Palliative care, when offered alongside primary medical and neurologic teams, provides an extra layer of support for people with serious illnesses. The goal of palliative care is to intensively treat total pain, which includes all of the physical, emotional, social, and spiritual distress caused by serious illness. Serious illness communication skills are key to providing empathic and goal-concordant care.

Goals-of-care and serious illness conversations for patients with cancer with inpatient mortality.

184 Background: Goals-of-care (GOC) and serious illness conversations are an integral part of personalized cancer care, particularly toward the end of life (EOL). Eliciting patients (pts)’ preferences and values facilitates informed decision-making throughout the disease course and enables oncologists to provide patient-centered care. Many aspects of GOC discussions and advance care planning (ACP) are inadequately understood, particularly during transitions of care when pts are hospitalized. Methods: We administered surveys to inpatient and outpatient medical oncologists of pts who died while hospitalized from 5/1/2020 to 5/31/2021. Survey items included oncologists’ knowledge of inpatient death, anticipation of pt death within six months of admission, recollection of GOC discussions taking place, and perceived barriers to GOC discussions. To better characterize EOL planning for these pts, retrospective data was collected to identify documentation of GOC discussions, advance directives, and hospice consideration in pts’ electronic health records. Results: For 75 cancer pts who died while hospitalized, 158 surveys were electronically administered with 104 responses (response rate: 66%). Pts characteristics: median age 62 (range 25-89); 63% men; 79% white; median length of hospital stay 7 days (range 1-45). Primary cancer disease type varied: 26.7% gastrointestinal, 18.7% non-small cell lung, 14.7% hematologic, 10.7% sarcoma, 9.3% genitourinary, and 19.9% other cancers. Of 104 completed surveys, responses were received from 40 inpatient and 64 outpatient oncologists. 81 oncologists (77.9%) were aware of the pt’s death prior to survey communication, 68 (65.4%) anticipated the pt’s death within six months of admission, and 67 (64.4%) recalled having a GOC discussion prior to or during the terminal hospitalization. Only 21.3% of pts had documented GOC discussions prior to admission, 33.3% had advance directives, and 22.7% had prior documentation of hospice consideration. Oncologist-reported barriers to GOC discussions included unrealistic expectations from pts or family (25%) and inability for pts to participate due to their clinical condition (15%). Oncologists commented on lack of time, lack of communication between inpatient and outpatient teams, and discordance among multiple inpatient providers as additional barriers. Conclusions: Most oncologists recalled having GOC discussions and anticipated six-month mortality for cancer pts who died while hospitalized. However, documentation of ACP and serious illness communication remained sub-optimal. Ongoing analyses are examining potential associations between patient, provider, and patient-provider relationship factors and oncologists’ survey responses. Addressing barriers to serious illness conversations across different healthcare settings is crucial to providing high-quality EOL care for cancer pts.

Paving the way for universal medical student training in serious illness communication: the Massachusetts Medical Schools’ Collaborative

BackgroundPatients with serious illness look to their clinicians for discussion and guidance on high-stakes treatment decisions, which are complex, emotional and value-laden. However, required training in serious illness communication is rare in U.S. medical schools, with efforts at curricular reform stymied by competing institutional demands, lack of resources and accreditation requirements. We describe an approach to building and scaling medical student training in serious illness communication through the creation of a statewide collaborative of medical schools.MethodsThe Massachusetts Medical Schools’ Collaborative is a first-of-its-kind group that promotes longitudinal, developmentally-based curricula in serious illness communication for all students. Convened externally by the Massachusetts Coalition for Serious Illness Care, the collaborative includes faculty, staff, and students from four medical schools.ResultsThe collaborative started with listening to member’s perspectives and collectively developed core competencies in serious illness communication for implementation at each school. We share early lessons on the opportunities, challenges and sustainability of our statewide collective action to influence curricular reform, which can be replicated in other topic areas.ConclusionsOur next steps include curriculum mapping, student focus groups and faculty development to guide successful and enduring implementation of the competencies to impact undergraduate medical education in Massachusetts and beyond.

Development of Patient-centered Communication Curriculum for Radiation Oncology Residents

<h3>Background</h3> Radiation oncologists often speak with patients who are terminally ill and may be near the end of their life. In fact, up to 63% of patients who died of cancer receive palliative radiation in their last year of life. Despite this, training on palliative care including patient-centered communication skills for radiation oncology residents is lacking. This prompted the development of a serious illness communication curriculum designed for radiation oncology residents. <h3>Methods</h3> Curriculum development followed Kern's Six-step approach. A national survey of radiation oncology residency program directors outlined the lack of communication training and served as a general needs assessment. We performed an institution-specific targeted needs assessment with a cross-sectional survey and semi-structured interviews that reaffirmed a convincing need at the residency program level for a practice-based patient-centered communication skills training program. The objectives, educational strategies, implementation, and evaluation of the curriculum were then developed to target identified deficiencies in resident communication skills. <h3>Results</h3> Data from the targeted needs assessment showed that most residents felt only "somewhat prepared" (Likert 3/5) to discuss important topics such as prognosis (93%), reconciling the seriousness of one's illness (71%), and discontinuing life-sustaining treatments (64%). When asked how they might improve these skills some residents remarked, "practicing conversations," "observing others," and "learning best practices for these situations." A baseline radiation-specific simulated patient encounter was performed at the university's simulation-based learning center. Then, two virtual half-day teaching sessions led by expert faculty facilitators were held. These consisted of didactic learning and mentored resident practice with simulated patients and real time feedback. All teaching and practice were designed for radiation oncology residents. A post-course simulated patient encounter will be performed. Faculty trained in serious illness communication who did not participate in the course will then review the simulated patient encounters and complete a blinded standardized assessment to compare pre- and post-course measurable communication skills. <h3>Discussion</h3> We developed a practice-based patient-centered communication skills curriculum for radiation oncology residents. We expect this work in progress will show measurable improvement of these skills. We plan to integrate this curriculum on a regular, repeating basis for additional skill development and to facilitate durable learning. We hope this course can serve as an adaptable model that can be instituted among radiation oncology residency programs.

The Efficacy of Hospice Care for Terminally Ill Emergency Patients During the Coronavirus 2019 Pandemic

ObjectiveThis study aimed to explore the efficacy of hospice care for terminally ill emergency patients in the COVID-19 context.MethodsA total of 86 terminally ill emergency patients at the authors’ hospital from February 2020 to October 2020 were included in this study, they were randomly allocated into a control (n = 42) and an intervention (n = 44) group, respectively. The control group received routine nursing care, and the intervention group received hospice care.ResultsFollowing treatment, the survival time (as the primary outcome) in the intervention group was longer than in the control group (P < 0.05). Distress thermometer and psychological pain-related factor scores for the intervention group were lower than those of the control group (P < 0.001 for both). The comfort scores of all dimensions in the intervention group were higher than in the control group (P < 0.05). The scores for survival puzzle, symptom distress, independence, and mental well-being in all dimensions related to a sense of dignity were lower in the intervention than in the control group (P < 0.05 for all). The intervention group’s yield, avoidance, and total scores were lower than in the control group, whereas the face score was higher than in the control group (P < 0.05 for all).ConclusionIn the current COVID-19 context, the telehealth (psychological, physical, online remote support, critical illness communication, and death education) approach adopted by the Anning care team for terminally ill emergency patients and other aspects of peace care could help improve the physical and mental health of patients. Hospice care can minimise the physical and psychological pain of terminally ill patients in the emergency department and assist them in their final stage of life by providing a calming and comfortable environment.

Virtual Geritalk: Does Intensive Virtual Communication Skills Training Improve Use of Serious Illness Communication Skills?

Background: The COVID-19 pandemic presented a unique opportunity to adapt in-person communication skills training to a virtual format. Objective: Examine use of serious illness communication skills by learners after participating in an intensive virtual communication skills training. Design: Prospective cohort study. Setting/Subjects: Icahn School of Medicine at Mount Sinai, Clinical Fellows. Measurements: Family Meeting Communication Assessment Tool (FAMCAT) assessed fundamental and advanced communication skills. Results: As compared to a historical benchmark obtained after a prior in-person course, the virtual course showed equivalent or better use of communication skills across fundamental skills and advanced skills. Conclusions: Our findings suggest that a virtual communication skills training is associated with the use of serious illness communication skills in the clinical setting by learners.

Study protocol for Video Images about Decisions to Improve Ethical Outcomes with Palliative Care Educators (VIDEO-PCE): a pragmatic stepped wedge cluster randomised trial of older patients admitted to the hospital

IntroductionDespite the known benefit to patients and families, discussions about goals, values and preferences for medical care in advancing serious illness often do not occur. Many system and clinician factors,...

Assessing Family Caregiver Communication in Chronic Illness: Validation of the FCCT-CI.

Background: Chronic illness care demands attention to the unique needs of family caregivers who support care at home, yet few tools exist for family caregiver assessment in the social domain of practice. Objectives: The Family Caregiver Communication Tool (FCCT) assesses caregiver communication as part of the family system and was originally developed for cancer caregivers. The aim of this study was to develop and psychometrically-validate a version of the FCCT for Chronic Illness (FCCT-CI). Methods: We revised the FCCT, including the generation of new items, and psychometrically tested it in 303 family caregivers recruited through Amazon Prime Panels. Item reduction through exploratory factor analysis was conducted, internal consistency was assessed using Cronbach's alpha, and concurrent validity was conducted to demonstrate correlation of the new scale with previously validated instruments. Results: A principal axis analysis with promax rotation initially revealed a five-factor structure of the 27 items initially tested, but, after statistical and theoretical reduction and refinement, a 10 item FCCT-CI emerged. Cronbach's alpha ranged from .74 to .86 for the FCCT-CI instrument. Concurrent validity was supported by bivariate correlation tests. Conclusions: The FCCT-CI is the first psychometrically tested scale designed to assess caregiver communication with chronically ill patients, family members, and palliative care providers about caregiving. The FCCT-CI scale includes but is not limited to cancer caregiving and palliative care contexts and has good reliability and validity. Palliative care providers can use this tool to assess, design, and test interventions to support family caregivers.

Racial/ethnic disparities in serious illness communication for patients with cancer.

6540 Background: Racial/ethnic disparities in serious illness communication exist between patients with cancer and their oncologists. Our prior work has shown that goals of care discussions are three minutes shorter with racial/ethnic minority patients. In this study, we sought to compare oncologist's use of serious illness communication skills, patient participatory behavior, and overall communication quality during encounters with patients with advanced cancer of different self-reported races/ethnicities. Methods: We analyzed baseline recordings from a two-arm multisite randomized controlled trial to test a coaching model of communication skills training for solid tumor oncologists and their newly diagnosed advanced cancer patients. We audio recorded post-imaging patient-oncologist encounters for patients receiving systemic cancer treatment and coded transcripts for oncologist's use of serious illness communication skills (coded as count/encounter): open-ended questions, reflections, empathic responses to patient empathic opportunities, empathic statements, “sorry” statements, and elicitation of questions. We also assessed global codes of oncologist communication (assessed on 5-point Likert scales): flow, concerns addressed, attention, warmth, and respect. Finally, we coded patient participatory behavior (coded as count/encounter): asking questions and assertive responses. We compared the skills and behaviors by race/ethnicity of the patient using the non-parametric Kruskal-Wallis test. Results: We included the 56 (38%) recordings with oncologists who did not receive the intervention. The patients in these encounters were 25 (45%) female; 32 (57%) over the age of 65; 23 (41%) White Non-Hispanic, 20 (36%) Black Non-Hispanic, and 11 (20%) Hispanic. Overall, oncologists responded empathically to patients’ emotions only 19% of the time. Oncologists used fewer reflective statements with Black Non-Hispanic patients (mean 0.3 statements/encounter) as compared to White Non-Hispanic patients (1.1) and Hispanic patients (1.1), p = 0.02. Furthermore, coders rated oncologists as being less likely to address concerns of Black Non-Hispanic patients (mean Likert scale 3.1) as compared to White Non-Hispanic (3.8) and Hispanic (3.4) patients, p = 0.04. Finally, coders rated oncologists as having less warmth with Black Non-Hispanic patients (mean Likert scale 2.9) as compared to White Non-Hispanic (3.8) and Hispanic (3.3) patients, p = 0.04. Conclusions: In this diverse sample of patients with advanced cancer, oncologists used fewer reflective statements, were less attentive to concerns, and expressed less warmth with Black Non-Hispanic patients. Interventions are needed to overcome these striking racial/ethnic disparities in serious illness communication for patients with cancer.

Long-term effect of machine learning–triggered behavioral nudges on serious illness communication and end-of-life outcomes among patients with cancer: A randomized clinical trial.

109 Background: Early serious illness conversations (SICs) between oncology clinicians and patients are associated with improved mood, quality of life, and quality of end-of-life (EOL) care. Yet, most patients with cancer die without a documented SIC. We report on pre-specified 40-week SIC and EOL outcomes from a stepped-wedge randomized clinical trial (NCT03984773) testing the impact of clinician-directed behavioral nudges to prompt SICs among patients with cancer at high risk of mortality based on a machine learning algorithm. Methods: Our sample consisted of patients with cancer receiving care at one of 9 tertiary or community-based medical oncology clinics between June 2019 and April 2020. We identified high-risk patients using a prospectively validated electronic health record machine learning algorithm to predict 6-month mortality. The intervention consisted of: (1) Weekly emails comparing individual oncologists’ SIC rate relative to peers; (2) Weekly lists of forthcoming encounters with high-risk patients; and (3) Opt-out text messages to prompt SICs before high-risk patient encounters. Clinics were randomized in stepped-wedge fashion to receive the intervention in 4-week intervals through week 16, when all clinics received the intervention. Patients were followed through week 40. The primary outcome was SIC rates for all and high-risk patients. EOL outcomes among decedents were based on ASCO/NQF guidelines and included death in the hospital, intensive care unit admission within 30 days of death, receipt of systemic therapy within 14 days of death, hospice enrollment prior to death, and hospice length of stay. Intention-to-treat analyses were adjusted for clinic and wedge fixed effects and clustered at the oncologist-level. Results: The sample consisted of 20,506 patients and 41,021 encounters. 1,324 (6.5%) patients died by the end of follow-up. Among high-risk patients, the unadjusted SIC rate was 3.4% (59/1754) in the control period and 13.5% (510/3765) in the intervention period and remained &gt;12% throughout follow-up. In adjusted analyses, the intervention was associated with an increase in SICs (adjusted odds ratio 2.09, 95% CI 1.53-2.87, p&lt;0.001) and a decrease in systemic therapy at the end of life, relative to control (6.8% [72/1066]) vs 9.3% [24/258], adjusted odds ratio 0.27, 95% CI 0.12-0.63, p=0.002). There were no differences between control and intervention patients in hospice enrollment or length of stay, inpatient death, or EOL ICU utilization. Conclusions: In this randomized trial, a machine learning-based behavioral intervention led to a sustained increase in serious illness communication and reduction in EOL systemic therapy among outpatients with cancer. Machine learning and behavioral nudges can lead to long-lasting improvements in cancer care delivery. Clinical trial information: NCT03984773.

Delphi-endorsed Communication Skills Clinicians Need to Care for Hospitalized Incapacitated Patients.

BackgroundThe National Academy of Medicine recently identified improving clinicians’ serious illness communication skills as a necessary step in improving patient and family outcomes near the end of life, but there is not an accepted set of core communication skills for engaging with surrogate decision makers.ObjectiveTo determine the core serious illness communication skills clinicians should acquire to care for incapacitated, hospitalized patients with acute, life-threatening illness, including patients with Alzheimer’s disease and related dementias.MethodsFrom January 2019 to July 2020, we conducted a modified Delphi study with a panel of 79 experts in the field of serious illness communication. We developed a preliminary list of candidate communication skills through a structured literature review. We presented the candidate skills to the panelists in the context of three prototypical serious illness conversations. Over three rounds, panelists first augmented the list of candidate skills, then voted on the skills. The final set included skills deemed “very important” or “essential” by 70% of panelists. For external validation, we engaged 11 practicing clinicians and 7 community stakeholders for their perspectives on the expert-endorsed list of skills.ResultsThe panelists’ ratings indicate the importance of a diverse set of communication skills related to providing clear information exchange as well as emotional and psychological support to surrogates. The final set included 33 skills, 12 of which were endorsed for all three prototypical serious illness conversations. Practicing clinicians and community stakeholders supported the expert-endorsed framework with only minor additions.ConclusionWe generated a stakeholder-endorsed list of skills that can inform the content of communication skills training programs for clinicians who care for incapacitated patients in the inpatient setting. The skills go beyond those required to provide traditional cognitive decision support and suggest the need for a paradigm shift in curricular content for communication training.

Context Matters: Caregiver Engagement in Serious Illness Communication in the Long-Term Acute Care Hospital Setting (GP757)

Context Matters: Caregiver Engagement in Serious Illness Communication in the Long-Term Acute Care Hospital Setting (GP757)

“She Always Knew I Would Call”: The Role of Family Liaisons in Serious Illness Communications During the COVID-19 Pandemic (GP719)

Outcomes1. Recognize at least 3 ways in which continuity of care is important in serious illness communication in end-of-life care for patients and families2. Describe the role of the family liaison in supporting medical teams and patients’ families around end-of-life care communicationImportanceDue to visitor restrictions across hospitals during the COVID-19 pandemic, many families of critically ill patients could not be physically present with loved ones who were near the end of life (EOL). Clinicians also struggled with relying on telecommunication to deliver prognosis and offer support to grieving families. In an effort to optimize care teams, non–palliative care clinicians became family liaisons to provide phone or video updates to families of patients in the intensive care unit (ICU).Objective(s)To understand the role of family liaisons in end-of-life communication during the COVID-19 pandemic.Method(s)We conducted semistructured audio interviews with 23 clinicians (with additional interviews under way), 7 of whom were redeployed family liaisons, who worked with ICU patients at two U.S. academic hospitals that experienced surges in COVID-19 admissions. Transcripts were analyzed via thematic analysis.ResultsWhen patients’ families could not visit in person and were not able to grasp the seriousness of the patients’ rapidly deteriorating conditions, ICU clinicians experienced heightened distress and worried about providing care discordant with patients’ EOL wishes. Additionally, staff shortage and frequent team changes made it difficult for clinicians to provide timely and consistent updates via phone or video. Family liaisons, mostly recruited into the role due to the circumstances of COVID-19, reported that they served as a figure of continuity for families and medical teams and found meaning in their role by establishing trust and rapport with families, providing daily updates, and preparing families for goals-of-care conversations despite language or cultural differences. One ICU clinician reported that liaisons “took the burden and worry away” for teams and families.Conclusion(s)Continuity of care is essential in serious illness communication and may be provided by non–palliative care clinicians to help mitigate challenges during EOL care.ImpactOur findings highlight the need for institutional resources to help support the family liaison role.

Relationships and Resources That Support Pediatric Serious Illness Care and Communication: A Qualitative Study Among Children with Complex Chronic Conditions and Their Families (GP720)

Relationships and Resources That Support Pediatric Serious Illness Care and Communication: A Qualitative Study Among Children with Complex Chronic Conditions and Their Families (GP720)

Development of a measure of clinicians' self-efficacy for medical communication (SEMC).

Studies of clinician-patient communication have used varied, ad hoc measures for communication efficacy. We developed and validated the Self-Efficacy for Medical Communication (SEMC) scale as a standard, quantitative measure of clinician-reported skills in communicating difficult news. Using evidence-based scale development guidelines, we created two 16-item forms of the SEMC, one assessing communication with patients and one assessing communication with families. Clinicians providing oncological care in four organisations were invited to participate and provided consent. Participant demographics, responses to the SEMC items and responses to convergent and discriminant measures (those expected to relate strongly and weakly to the SEMC) were collected online. We performed analyses to determine the convergent and discriminant validity of the SEMC as well as its reliability and factor structure. Overall, 221 oncology clinicians (including physicians, residents, fellows, medical students, nurses, nurse practitioners and physician assistants) participated. The patient and family forms both demonstrated high internal consistency reliability (alpha=0.94 and 0.96, respectively) and were strongly correlated with one another (r=0.95, p<0.001). Exploratory factor analysis demonstrated that the SEMC measures a unitary construct (eigenvalue=9.0), and its higher mean correlation with convergent (r=0.46) than discriminant (r=0.22) measures further supported its validity. Our findings support the SEMC's validity and reliability as a measure of clinician-rated communication skills regarding conducting difficult conversations with patients and families. It provides a useful standard tool for future research in oncology provider-patient serious illness communication.

Serious Illness Communication in Cancer Care in Africa: A Scoping Review of Empirical Research

PURPOSE Serious illness communication (SIC) in cancer care describes conversations between clinicians, patients, and families about prognosis and treatment decisions. Cultural context influences SIC. Researchers have studied SIC across diverse settings in Africa. We aimed to describe and synthesize the heterogeneous body of research on SIC practices, preferences, and needs in Africa to identify research and training priorities. METHODS Our search strategy identified studies that focused on SIC within cancer or palliative care in Africa. Following PRISMA guidelines, a systematic literature search was performed using PubMed, Embase, Web of Science, CINAHL, African Index Medicus, and PsycINFO, yielding 1811 unique titles. After sequential review of abstracts, full text, and cited references, 42 articles met inclusion criteria. Quantitative and qualitative data describing study characteristics, aims, methods, and findings were abstracted and analyzed using descriptive statistics and thematic analysis. Critical appraisal was performed using the Mixed Methods Appraisal Tool. RESULTS The 42 included articles were published from 1997-2021, half since 2017, representing 16 countries and all African Union regions: West (33%), East (29%), South (21%), North (12%), and Central (5%). Most study designs were qualitative (45%) or quantitative surveys (50%). Study participants included patients (35%), family caregivers (18%), doctors (18%), nurses (12%), and/or other (11%). Study aims focused on disclosure of diagnosis (27%) or prognosis (20%), breaking bad news (15%), general patient-clinician communication (12%), truth-telling (8%), shared decision-making (7%), information needs/preferences (5%), and/or advance care planning (5%). Despite diverse contexts, common themes emerged. Study authors frequently recommended communication skills training. Critical appraisal demonstrated high quality of studies overall. CONCLUSION Research on SIC in Africa has increased in recent years. Most studies have focused on information delivery by clinicians; fewer on eliciting information from patients (eg, shared decision-making, advanced care planning). Significant opportunities exist for further study and for communication skills training.

Clinical Pearls

About 4 million cases of pediatric/neonatal sepsis occur globally each year, resulting in significant morbidity and mortality. The World Health Organization has prioritized innovative research in sepsis management. Monitoring the inadequate oxygen delivery (IDo2) index as a predictor of adverse events is an emerging area of interest that has primarily been used in pediatric cardiac surgery but not with children with sepsis.Roy and colleagues evaluated the relationship between IDo2 dose (mean IDo2 index during a specified time interval) and major adverse events (MAEs) in children admitted to the pediatric intensive care unit (PICU) with sepsis or septic shock. They found Children with MAEs had significantly higher IDo2 doses over multiple time intervals than did children without MAEs.Significant positive correlations between the IDo2 dose for 0 to 12 hours from admission and day 2 vasoactive-inotropic scores, organ dysfunction scores, PICU length of stay, and days of invasive ventilation.Although more studies are needed, findings suggest monitoring of the IDo2 dose can facilitate early recognition of children at highest risk of having MAEs and poor outcomes.See Article, pp 220-228Change-of-shift hand-off, also called shift report, is a complex social interaction considered a central part of patient safety by The Joint Commission. Structured formats improve information transfer in handoffs on medical-surgical units, but data on the perspectives of critical care nurses are limited.Rhudy and colleagues conducted focus groups with nurses from 4 types of adult intensive care units to understand their perceptions of the structure and organization of shift handoff. They identified 3 themes: Although further study is needed at other health care organizations, the findings validate a systematic approach to shift report that is flexible in accommodating specific populations of patients.See Article, pp 181-188Visitor restrictions during the COVID-19 pandemic dramatically changed end-of-life care, causing moral and psychological distress to both clinicians and families. Use of telecommunication technologies increased to support patient-family communication and care; however, little research has addressed providers’ experience with these technologies.Elma and colleagues interviewed clinicians on their experience using videoconferencing when caring for dying patients early in the pandemic. They found both benefits and limitations: Clinicians were positive about the value of virtual visits but felt the loss of physical family presence. Recommendations include improved access and advanced training for video-conferencing technology.See Article, pp 240-248Adult intensive care patients often require a surrogate decision maker when they cannot make decisions regarding their own care, yet clinician-family communication about treatment decisions in intensive care units can be limited. The US National Academy of Medicine has made improving clinicians’ serious illness communication skills a national priority. Although research shows training programs can improve these skills, there is currently no program that can be readily scaled to train thousands of clinicians.Gautier and colleagues developed and user tested a web- and videoconference-based training platform and found that This web-based program was developed with key stakeholder input and has the potential for scalability. The authors state that they will next evaluate the program for effects on improving nurse communication and family support skills.See Article, pp 189-201

“Shoot from the Hip”: What Patients with Cancer Want from Communication About Serious Illness During COVID-19 (S526)

Outcomes1. Describe what patients with cancer and caregivers value in communication about serious illness2. Examine strategies that model these valuesOriginal Research BackgroundWhen asked to share recommendations for providers and health systems to foster high-quality care during COVID-19, patients with cancer and their caregivers recommended providers to “communicate proactively and effectively” about serious illness.Research ObjectiveIn this secondary analysis of participant responses, we aimed to identify patient and caregiver perspectives on what it means to “communicate proactively and effectively” about serious illness.MethodsContent analysis of communication-related output from 15 semistructured interviews of diverse patients with cancer and caregivers of patients with serious illness.ResultsTheme 1: Transparency: Clinicians share the medical rationale for recommendations: “If what's explained to me is that my chance of recovery … is minimal, and I'm just going to increase my suffering, well, then that feels like a chance for acceptance.”Theme 2: Proactivity: Clinicians facilitate conversations about care preferences in advance: “Right now, you guys have this incredible opportunity to have these conversations. To enable—you know, oncologists to have these conversations with their patients while they're as an outpatient, before they get COVID?”Theme 3: Coordination: Clinicians integrate with the interdisciplinary palliative care team to communicate serious news: “I would ask that [what] be done a little bit better is the integration of the social worker with the doctor, especially in the palliative and hospice care. We know that not every doctor has got a good bedside manner… it's hard to tell someone you're going to die.”Theme 4: Respect for autonomy: Patients and caregivers feel empowered by clinicians to make informed decisions: “You're still in control of your decision-making, given the parameters, even though you're not in control of the parameters.”ConclusionPatients with serious illness and caregivers of patients with serious illness value transparent, proactive, and coordinated communication that respects their autonomy.Implications for Research, Policy, or PracticeEfforts to make serious illness communication more patient-centered during COVID-19 will target these areas that align with established patient-centered communication theories.

Toward a basic science of communication in serious illness

High-quality communication can mitigate suffering during serious illness. Innovations in theory and technology present the opportunity to advance serious illness communication research, moving beyond inquiry that links broad communication constructs to health outcomes toward operationalizing and understanding the impact of discrete communication functions on human experience. Given the high stakes of communication during serious illness, we see a critical need to develop a basic science approach to serious illness communication research. Such an approach seeks to link “what actually happens during a conversation” – the lexical and non-lexical communication content elements, as well as contextual factors – with the emotional and cognitive experiences of patients, caregivers, and clinicians. This paper defines and justifies a basic science approach to serious illness communication research and outlines investigative and methodological opportunities in this area. A systematic understanding of the building blocks of serious illness communication can help identify evidence-informed communication strategies that promote positive patient outcomes, shape more targeted communication skills training for clinicians, and lead to more tailored and meaningful serious illness care.