End of life physician-patient communication

INDIANAPOLIS – Although a growing body of research supports a link between effective communication and patient, family and physician satisfaction, doctors, including oncologists and other specialists who frequently care for terminal patients, do not routinely receive training in end-of-life conversations during medical school, residency training, or after they start to practice medicine.

A study published in June issue of the Journal of Psychosocial Oncology measured changes in physician's attitudes and knowledge after training in end-of-life communication using an innovative educational approach entitled "The Four Habits of Highly Successful Clinicians." The researchers found that participation in a program that fosters communication skills can have a positive and lasting effect on the physician's delivery of end-of-life care.

"We found that doctors are actually eager to improve their skills in end-of-life communication but don't often have the opportunity to do so. With a framework that makes sense to them, their confidence and competence increases," said study senior author Richard M. Frankel, Ph.D., professor of medicine at the Indiana University School of Medicine and a Regenstrief Institute research scientist.

"Anecdotally we learned from family members that they appreciated it greatly when compassionate end-of-life counsel was given to their loved ones," said Dr. Frankel.

The study investigators designed and evaluated a program to give practicing clinicians a core set of communication skills to discuss such issues as value and timing of palliative care, advance care plans, clinician grief, and managing anger in family members. The role of culture in communication with patients and family members was also highlighted. Program content was adapted for end-of-life communication from the Four Habits Model of Highly Effective Clinicians.

This physician-patient communication model was co-developed a decade ago by Dr. Frankel, a medical sociologist who focuses on doctor-patient communication. More than 10,000 physicians nationwide have been trained using this approach which has been shown to have a positive long- term effect on both physician and patient satisfaction. Succinctly put, the Four Habits are:

1. Invest in the beginning.
2. Elicit the patient's perspective.
3. Demonstrate empathy.
4. Invest in the end.

Results of the end-of-life communication training showed major changes in the oncologists studied. Sixty-five percent said they would be expressing condolences more than half the time in the future. Historically, a mere 3 percent said they planned to do so. The study found significantly increased professional satisfaction among the participants in dealing with end-of-life care three months after training.

The study concludes," Few clinicians will go through their careers without having a conversation with a patient or family member about advance care planning, terminal illness, death or grief. …the clinicians we studied were eager to learn more and improve. Skill-based courses in end-of-life communication meet a deeply felt need in clinicians and have the potential to make a lasting and positive difference in the quality of care given to patients and family members dealing with end of life concerns. We owe it to our patients to ensure that this final chapter is enacted with the greatest skill and compassion possible."

"Future research should examine the relationship between changes in knowledge and attitude and how these changes actually translate into clinical practice," said Dr. Frankel, who is also a research scientist at the Center for Implementing Evidence Based Practice at the Roudebush VA Medical Center in Indianapolis.

In addition to Dr. Frankel, authors of the study are Cecilia Runkle, Ph.D. of Group Health Permanente, Elizabeth Wu, M.A. and Edward C. Wang, M.D. of Southern California Permanente Medical Group, Inc.; Geoffrey H. Gordon, M.D. of Oregon Health and Science University. The study was funded by Kaiser Permanente.