Abstract
BACKGROUND
Early provider–patient communication about future care is critical for patients with heart failure (HF); however, advance care planning (ACP) discussions are often avoided or occur too late to usefully inform care over the course of the disease.
OBJECTIVE
To identify opportunities for physicians to engage in ACP discussions and to characterize physicians’ responses to these opportunities.
DESIGN
Qualitative study of audio-recorded outpatient clinic visits.
PARTICIPANTS
Fifty-two patients ≥ 65 years recently hospitalized for HF with one or more post-discharge follow-up outpatient visits, and their physicians (n = 44), at two Veterans Affairs Medical Centers.
APPROACH
Using content analysis methods, we analyzed and coded transcripts of outpatient follow-up visits for 1) patient statements pertaining to their future health or their future physical, psychosocial and spiritual/existential care needs, and 2) subsequent physician responses to patient statements, using an iterative consensus-based coding process.
RESULTS
In 13 of 71 consultations, patients expressed concerns, questions, and thoughts regarding their future care that gave providers opportunities to engage in an ACP discussion. The majority of these opportunities (84%) were missed by physicians. Instead, physicians responded by terminating the conversation, hedging their responses, denying the patient’s expressed emotion, or inadequately acknowledging the sentiment underlying the patient’s statement.
CONCLUSIONS
Physicians often missed the opportunity to engage in ACP despite openers patients provided that could have prompted such discussions. Communication training efforts should focus on helping physicians identify patient openers and providing a toolbox to encourage appropriate physician responses; in order to successfully leverage opportunities to engage in ACP discussions.
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REFERENCES
Goldstein NE, Lynn J. Trajectory of end-stage heart failure: the influence of technology and implications for policy change. Perspect Biol Med. 2006;49:10–8.
Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. BMJ. 2005;330:1007–11.
Gott M, Barnes S, Parker C, et al. Dying trajectories in heart failure. Palliat Med. 2007;21:95–9.
Caldwell PH, Arthur HM, Demers C. Preferences of patients with heart failure for prognosis communication. Can J Cardiol. 2007;23:791–6.
Harding R, Selman L, Beynon T, et al. Meeting the communication and information needs of chronic heart failure patients. J Pain Symptom Manage. 2008;36:149–56.
Boyd KJ, Murray SA, Kendall M, Worth A, Frederick Benton T, Clausen H. Living with advanced heart failure: a prospective, community based study of patients and their carers. Eur J Heart Fail. 2004;6:585–91.
Murray SA, Boyd K, Kendall M, Worth A, Benton TF, Clausen H. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community. BMJ. 2002;325:929.
Remme WJ, McMurray JJ, Rauch B, et al. Public awareness of heart failure in Europe: first results from SHAPE. Eur Heart J. 2005;26:2413–21.
Selman L, Harding R, Beynon T, et al. Improving end-of-life care for patients with chronic heart failure: "Let's hope it'll get better, when I know in my heart of hearts it won't". Heart. 2007;93:963–7.
Hickman SE, Hammes BJ, Moss AH, Tolle SW. Hope for the future: achieving the original intent of advance directives. Hastings Cent Rep 2005;Spec No:S26-30.
Goodlin SJ, Quill TE, Arnold RM. Communication and decision-making about prognosis in heart failure care. J Card Fail. 2008;14:106–13.
Tulsky JA. Beyond advance directives: importance of communication skills at the end of life. JAMA. 2005;294:359–65.
Lindenfeld J, Albert NM, Boehmer JP, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2010;16:e1–194.
Arnold M, Arvantis J, Droppo L, et al. End of Life Planning and Care for Heart Failure Patients. Summary for the Heart Failure End-of-Life Planning and Care Task Group. Ontario: Heart and Stroke Foundation of Ontario; 2010.
Davidson PM. Difficult conversations and chronic heart failure: do you talk the talk or walk the walk? Curr Opin Support Palliat Care. 2007;1:274–8.
Rodriguez KL, Appelt CJ, Switzer GE, Sonel AF, Arnold RM. "They diagnosed bad heart": a qualitative exploration of patients' knowledge about and experiences with heart failure. Heart Lung. 2008;37:257–65.
Walling A, Lorenz KA, Dy SM, et al. Evidence-based recommendations for information and care planning in cancer care. J Clin Oncol. 2008;26:3896–902.
Haidet P, Hamel MB, Davis RB, et al. Outcomes, preferences for resuscitation, and physician-patient communication among patients with metastatic colorectal cancer. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Am J Med. 1998;105:222–9.
Weiner JS, Cole SA. Three principles to improve clinician communication for advance care planning: overcoming emotional, cognitive, and skill barriers. J Palliat Med. 2004;7:817–29.
Kolarik RC, Arnold RM, Fischer GS, Tulsky JA. Objectives for advance care planning. J Palliat Med. 2002;5:697–704.
Detmar SB, Muller MJ, Wever LD, Schornagel JH, Aaronson NK. The patient-physician relationship. Patient-physician communication during outpatient palliative treatment visits: an observational study. JAMA. 2001;285:1351–7.
Bekelman DB, Nowels CT, Allen LA, Shakar S, Kutner JS, Matlock DD. Outpatient Palliative Care for Chronic Heart Failure. J Palliat Med: A Case Series; 2011.
Tung EE, North F. Advance care planning in the primary care setting: a comparison of attending staff and resident barriers. Am J Hosp Palliat Care. 2009;26:456–63.
Ramsaroop SD, Reid MC, Adelman RD. Completing an advance directive in the primary care setting: what do we need for success? J Am Geriatr Soc. 2007;55:277–83.
Curtis JR, Patrick DL, Caldwell ES, Collier AC. Why don't patients and physicians talk about end-of-life care? Barriers to communication for patients with acquired immunodeficiency syndrome and their primary care clinicians. Arch Intern Med. 2000;160:1690–6.
Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA. 1997;277:678–82.
Morse DS, Edwardsen EA, Gordon HS. Missed opportunities for interval empathy in lung cancer communication. Arch Intern Med. 2008;168:1853–8.
Lang F, Floyd MR, Beine KL. Clues to patients' explanations and concerns about their illnesses. A call for active listening. Arch Fam Med. 2000;9:222–7.
Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA. 2000;284:1021–7.
Baile WF, Glober GA, Lenzi R, Beale EA, Kudelka AP. Discussing disease progression and end-of-life decisions. Oncology (Williston Park) 1999;13:1021–31; discussion 1031–6, 1038.
Baile WF, Lenzi R, Kudelka AP, et al. Improving physician-patient communication in cancer care: outcome of a workshop for oncologists. J Cancer Educ. 1997;12:166–73.
Baile WF, Kudelka AP, Beale EA, et al. Communication skills training in oncology. Description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Cancer. 1999;86:887–97.
Back AL, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med. 2007;167:453–60.
Runkle C, Wu E, Wang EC, Gordon GH, Frankel R. Clinician confidence about conversations at the end of life is strengthened using the four habits approach. J Psychosoc Oncol. 2008;26:81–95.
Razavi D, Delvaux N. Communication skills and psychological training in oncology. Eur J Cancer. 1997;33(Suppl 6):S15–21.
Fischer GS, Arnold RM. Feasibility of a brief workshop on palliative care communication skills for medical interns. J Palliat Med. 2007;10:19–23.
Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial. Arch Intern Med. 1995;155:1877–84.
Alexander SC, Keitz SA, Sloane R, Tulsky JA. A controlled trial of a short course to improve residents' communication with patients at the end of life. Acad Med. 2006;81:1008–12.
Christakis NA, Iwashyna TJ. Attitude and self-reported practice regarding prognostication in a national sample of internists. Arch Intern Med. 1998;158:2389–95.
Schonfeld TL, Stevens EA, Lampman MM, Lyons WL. Assessing Challenges in End-of-Life Conversations With Elderly Patients With Multiple Morbidities. Am J Hosp Palliat Care 2011.
Pekmezaris R, Walia R, Nouryan C, et al. The impact of an end-of-life communication skills intervention on physicians-in-training. Gerontol Geriatr Educ. 2011;32:152–63.
Shannon SE, Long-Sutehall T, Coombs M. Conversations in end-of-life care: communication tools for critical care practitioners. Nurs Crit Care. 2011;16:124–30.
Reinke LF, Griffith RG, Wolpin S, Donesky-Cuenco D, Carrieri-Kohlman V, Nguyen HQ. Feasibility of a webinar for coaching patients with chronic obstructive pulmonary disease on end-of-life communication. Am J Hosp Palliat Care. 2011;28:147–52.
Szmuilowicz E, Szmuilowicz E, el-Jawahri A, Chiappetta L, Kamdar M, Block S. Improving residents' end-of-life communication skills with a short retreat: a randomized controlled trial. J Palliat Med. 2010;13:439–52.
Barclay S, Maher J. Having the difficult conversations about the end of life. BMJ. 2010;341:c4862.
The AM, Hak T, Koeter G, van Der Wal G. Collusion in doctor-patient communication about imminent death: an ethnographic study. BMJ. 2000;321:1376–81.
Quirt CF, Mackillop WJ, Ginsburg AD, et al. Do doctors know when their patients don't? A survey of doctor-patient communication in lung cancer. Lung Cancer. 1997;18:1–20.
Hoff L, Hermeren G. Information from physicians and retention of information by patients - obstacles to the awareness of patients of progressing disease when life is near the end. BMC Palliat Care. 2008;7:2.
Costello J. Truth telling and the dying patient: a conspiracy of silence? Int J Palliat Nurs. 2000;6:398–405.
Quill TE. Perspectives on care at the close of life. Initiating end-of-life discussions with seriously ill patients: addressing the "elephant in the room". JAMA. 2000;284:2502–7.
Christakis NA. Death Foretold: Prophecy and Prognosis in Medical Care. Chicago: University of Chicago Press; 2001.
Clayton JM, Butow PN, Arnold RM, Tattersall MH. Fostering coping and nurturing hope when discussing the future with terminally ill cancer patients and their caregivers. Cancer. 2005;103:1965–75.
Clayton JM, Hancock K, Parker S, et al. Sustaining hope when communicating with terminally ill patients and their families: a systematic review. Psychooncology. 2008;17:641–59.
Hancock K, Clayton JM, Parker SM, et al. Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review. Palliat Med. 2007;21:507–17.
Apatira L, Boyd EA, Malvar G, et al. Hope, truth, and preparing for death: perspectives of surrogate decision makers. Ann Intern Med. 2008;149:861–8.
Jessup M, Abraham WT, Casey DE, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119:1977–2016.
Funding Sources
This work was supported in part by #ECV-02-254 (PI: Gordon) from the United States Department of Veterans Affairs, Office of Research and Development, Health Services Research and Development Service. The views expressed in the article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Dr. Ahluwalia is supported by an Office of Academic Affiliations’ VA Associated health Postdoctoral Fellowship Program at the VA Greater Los Angeles HSR&D Center of Excellence
Prior Presentations
Presented as a paper at the 2011 Society of General Internal Medicine Annual Meeting, May 4th-May 7th 2010, Phoenix, AZ
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None disclosed.
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Ahluwalia, S.C., Levin, J.R., Lorenz, K.A. et al. Missed Opportunities for Advance Care Planning Communication During Outpatient Clinic Visits. J GEN INTERN MED 27, 445–451 (2012). https://doi.org/10.1007/s11606-011-1917-0
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DOI: https://doi.org/10.1007/s11606-011-1917-0