Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia.
School of Nursing, Midwifery and Health Systems, University College Dublin and Our Lady's Hospice and Care Services, Dublin, Ireland.
Cochrane Database Syst Rev. 2022 Jul 8;7(7):CD013116. doi: 10.1002/14651858.CD013116.pub2.
Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes.
To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL.
We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing.
This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life, we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes.
Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies.
Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials. Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication. Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations. Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life. Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear.
AUTHORS' CONCLUSIONS: Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.
在接近死亡时，关于生命终期（EoL）和生命终期护理的沟通对于提供高质量的护理至关重要。这种沟通通常很复杂，涉及到许多人（患者、家属、照顾者、卫生专业人员）。如何最好地与接近死亡的人进行沟通尚不清楚，但这是全球生命终期护理质量的一个重要问题。本综述填补了生命终期护理人际沟通（卫生专业人员与生命终期患者之间）的证据空白，重点是改善人际沟通和患者、家属和照顾者结局的干预措施。
评估旨在改善卫生保健专业人员与受生命终期影响的患者之间关于生命终期护理的口头人际沟通的干预措施的效果。
我们从建库起至 2018 年 7 月在 CENTRAL、MEDLINE、Embase、PsycINFO 和 CINAHL 中进行检索，无语言或日期限制。我们联系了纳入研究的作者和专家，并检索了参考文献列表以确定相关论文。我们检索了灰色文献来源、会议论文集和临床试验注册处，并于 2019 年 9 月对潜在相关研究进行了重新分类或正在进行的分类。2021 年 6 月再次运行数据库检索，并列出了潜在相关研究作为待分类或正在进行。
本综述评估了随机和准随机试验中干预措施的效果，这些干预措施旨在增强患者（预计在 12 个月内死亡）、其家属和照顾者以及参与其护理的卫生保健专业人员之间关于生命终期护理的人际沟通。来自任何年龄、任何地点或任何护理环境（如急性灾难性损伤、慢性疾病）的患者，以及所有参与其护理的卫生保健专业人员均符合条件。只要干预措施包括患者和家属或照顾者与卫生专业人员之间的人际互动（一种或多种），则所有沟通干预措施都符合条件。干预措施可以是简单的或复杂的，具有一个或多个沟通目标（例如，告知、技能、参与、支持）。关注的结果包括患者、家属和照顾者、卫生专业人员和卫生系统的效果，包括不良（非预期）效果。为确保本综述的重点仍然是生命终期最后 12 个月的人际沟通，我们排除了仅关注特定决策（共享或其他）以及此类决策所涉及的工具的研究。我们还排除了以报告特定决策的采用或完成作为主要结果的预先护理计划（ACP）的研究。最后，我们排除了仅报告患者结局作为主要结局的卫生专业人员沟通技能培训的研究。
采用标准的 Cochrane 方法，包括双重审查员对研究的选择、数据提取和纳入研究的质量评估。
共纳入了 8 项试验。所有研究均比较了干预措施与常规护理的效果。证据的确定性为低或极低。所有结局均因本综述的目的而降级为间接性，且许多结局因不精确性和/或不一致性而降级。方法学局限性通常不会共同降低确定性。综述结果概述如下。知识和理解（四项研究，低确定性证据；一项研究无可用数据）：改善沟通的干预措施（例如，问题提示清单，伴或不伴患者和医生培训）可能对疾病和预后的了解、信息需求和偏好几乎没有或没有影响，尽管研究规模较小，且试验中使用的措施各不相同。评估沟通（六项研究测量了几个结构（沟通质量、以患者为中心、参与偏好、医患关系、咨询满意度），大多数为低确定性证据）：在各个结构中，改善生命终期沟通的干预措施可能没有或仅有最小的效果，并且对干预措施（例如患者特定的反馈表对沟通质量的影响）的效果存在不确定性。生命终期或生命终期护理的讨论（六项研究测量了选定的结局，低或极低确定性证据）：家庭会议干预可能会增加重症监护病房（ICU）环境中生命终期讨论的持续时间，而使用结构化严重疾病对话指南可能会导致更早地讨论生命终期和生命终期护理（每项研究评估一次）。我们不确定这些干预措施是否会影响咨询中的讨论和问题提出，也不确定这些干预措施是否会对咨询中的沟通内容产生影响。不良结局或非预期后果（有限证据）：目前尚无足够的证据来确定与生命终期和生命终期护理相关的沟通干预措施（例如问题提示清单、家庭会议、结构化讨论）是否存在不良结局。三项研究报告了患者和/或照顾者的焦虑，但被认为是混杂的。没有报告其他不良后果或期望结果恶化。患者/照顾者的生活质量（四项研究，低确定性证据；两项研究无可用数据）：改善沟通的干预措施可能对生活质量几乎没有或没有影响。卫生保健专业人员的结局（三项研究，低确定性证据；两项研究无可用数据）：改善沟通的干预措施可能对卫生保健专业人员的结局（咨询期间沟通满意度）几乎没有或没有影响；其他结局（知识、沟通准备）尚不清楚。健康系统的影响：生命终期沟通干预措施（例如结构化生命终期对话）可能对照顾者或临床医生对生命终期护理质量的评分（满意度、症状管理、舒适度评估、护理质量）（三项研究，低确定性证据）或患者自我报告的护理和疾病状况、或满足的护理目标数量（一项研究，低确定性证据）几乎没有或没有影响。沟通干预措施（例如单独的问题提示清单或伴护士主导的沟通技能培训）可能略微增加平均咨询时间（两项研究），但其他卫生服务的影响（例如住院）尚不清楚。
本综述的研究结果对实践来说尚无定论。未来的研究可能会通过以下方式做出重要贡献：针对尚未在试验中研究的人群，寻求填补研究空白；以及开发更有针对性的结局测量指标，以更好地评估沟通对涉及生命终期沟通事件的各类人员的影响。混合方法和/或定性研究可能会对更好地理解不同利益相关方之间复杂的相互作用，并为更有效的干预措施和适当的结局测量指标的开发提供有益的信息。未来在这一领域的研究应将充分考虑受生命终期沟通和护理影响的各类人群作为一个关键的基本原则，共同设计这些干预措施和结局。
