6.3 Communication between professionals

Communication between health-care professionals is a core element of palliative care and is increasingly recognized as critical to health-care quality (National Healthcare Quality Report, 2011). The growing complexity of health-care delivery systems worldwide has led to a stronger emphasis on interprofessional communication, resulting in changes in health professional school curricula (McDonough and Bennett, 2006), institution accreditation requirements (Joint Commission Resources, 2009), and standards of interprofessional education (Interprofessional Education Collaborative Expert Panel, 2011). The importance of interprofessional collaboration was underscored in 2010 when the World Health Organization published its Framework for Action on Interprofessional Education and Collaborative Practice, emphasizing the need for more integrated and collaborative models of health-care training and delivery.

The focus on interprofessional communication comes, in part, as the result of the growing evidence about the practical consequences of communication successes and failures between health-care providers. The data show that failures in communication may lead to inferior palliative care, including medication errors, delays in treatment, wrong-site surgeries, higher patient mortality rates, longer hospital stays, and worse pain control and functional status (Mills et al., 2008; Martin et al., 2010). Poor communication may also lead to negative consequences for health-care professionals, including higher nursing turnover, negative feedback, and demoralization of colleagues (Health Professions Regulatory Network, 2008). Conversely, successful communication leads to better outcomes for patients and health-care teams including improved understanding by clinicians of patient care goals, improved team morale, higher staff retention, positive feedback from colleagues, and increased productivity (Health Professions Regulatory Network, 2008; Chang et al., 2009).

Palliative care clinicians are often in the position to facilitate communication among various members of the health-care team caring for a patient with a serious illness. First, a palliative care clinician’s initial assessment includes an evaluation of the patient’s overall clinical status and the roles of and relationships with the providers involved. Second, palliative care clinicians are often consulted for complex patients with difficult to manage symptoms and emotional suffering, leading to team distress, interpersonal conflict, ethical dilemmas, and lack of clarity about the plan of care. Third, most palliative care clinicians have had some communication skills training, and while their focus of care is patients and their families, many of the same communication techniques are effective with colleagues. Fourth, palliative care clinicians are accustomed to working in interdisciplinary teams (IDTs), where open, respectful communication is the expectation. As a result of these factors, palliative care clinicians can play a key role in pulling together the various providers and ensuring that their points of view are heard, misunderstandings are focu minimized, and a comprehensive plan of care is created that reflects input from all.

Many clinicians believe that the ability to communicate well is innate, that is, that people are either born to be good communicators or they are not. Evidence, however, shows that communication skills are both teachable and learnable (Back et al., 2007; Krimshtein et al., 2011). This is especially encouraging since health-care professionals’ communication skills do not improve reliably with experience alone (Wilkinson et al., 2008; Back et al., 2009a). Health-care providers that participate in communication skills training manifest changes in their behaviour that enhance communication (Reeves et al., 2008, Reeves, 2009), increased confidence as communicators (Back et al., 2007), improved assessment of interprofessional communication (Zwarenstein et al., 2007), and have increased patient satisfaction rates (Back et al., 2007). What’s more, communication skills training has been shown to have an impact on participants’ skill level even 5 years afterward (Roter and Hall, 2006). While the majority of interventions shown to improve communication in the health-care setting have been geared towards communication with patients, there is growing interest in designing interventions to improve interprofessional communication, too (Norgaard et al., 2012).

The guiding principles of good communication are familiar to many palliative care clinicians and are explored in more depth in Chapter 6.1. We summarize three key points here that are particularly important when considering interprofessional communication.

While palliative care clinicians communicate with other professionals in a wide variety of ways, we have chosen to consider two major categories as prototypes: communication within palliative care IDTs and communication between palliative care consultants and other providers.

Given the complex symptoms, psychosocial issues, and important choices that arise for patients and families facing life-limiting illness, skilful communication among members of the palliative care IDT is essential (Blacker and Deveau 2010). Good communication is a result of—and contributes to—important team attributes. The first attribute that facilitates team communication is having mutual goals and a process for evaluating team function in pursuit of those goals (Dahlin, 2010). When a palliative care team creates shared objectives, usually aimed at the relief of suffering, clinicians become more collaborative and work towards group aspirations rather than individual goals (McPherson et al., 2001). These goals are re-evaluated regularly since they often shift in response to new initiatives, challenging cases, and evolving staff competencies (Lencioni, 2002). Additionally, members of a team that communicates well have a clear understanding of individual responsibilities and roles. Each member of the team should be able to articulate the specific skill and expertise he or she brings to patients and the team (Orchard et al., 2005) and how it differs from that of other team providers. When these areas of knowledge and skill are communicated and respected, the group can function with more cohesion and greater utilization of one another’s skill sets (Hall, 2005). What’s more, if collaboration is carried out effectively, the clinician’s team identity trumps the clinician’s discipline identity (e.g. nursing, social work, pharmacy, etc.) and team outcomes supersede those of the individual (Lencioni, 2002). Well-communicating teams also have standards for communication among providers, including conflict negotiation (Lencioni, 2002). Interprofessional relationships are based on respectful communication, trust in one another’s motives, and commitment to accountability when discord arises (Interprofessional Education Collaborative Expert Panel, 2011). A high-functioning palliative care team recognizes the importance of good communication in attaining these three attributes and actively work towards cultivating a culture that supports it.

Even teams that acknowledge the importance of communication face many types of barriers that compromise it. First, there are practical and organizational issues such as staffing, geography, and caseloads. Since palliative care is a young and rapidly evolving field clinical teams are often in flux, with staffing models changing according to each institution’s demand for palliative care services and the resources allocated to team development (Billings, 2008). Palliative care teams can have any number of part-time or full-time clinicians of different disciplines rotating on and off service, leading to significant communication challenges and variable team cohesion. Moreover, palliative care can be delivered to patients with a wide variety of underlying conditions, leading to geographic spread even within a single institution and creating another obstacle to good communication. Lastly, in rapidly growing programmes caseloads can exceed staffing, leaving little time for the team to ensure that lines of communication are maintained. Teams that have stressful caseloads can abandon interdisciplinary work (where providers work together) for multidisciplinary work (where providers ‘divide and conquer’) as they struggle to meet the clinical demands. The result is poorer communication and integration of each provider’s skill sets and more working in parallel (Hall, 2005).

Second, there are barriers related to information value, hierarchy, and provider insight. In teams that emphasize biomedical information, non-medical providers can feel diminished (Wittenberg-Lyles, 2005). For example, if a social worker has to struggle to make his or her viewpoint heard, even when social or emotional distress is central to the patient’s needs, the result can be feelings of disempowerment for the clinician and an incomplete plan of care for the patient. Also, the standard medical hierarchy may lead to barriers in interprofessional communication by causing team members to feel uncomfortable raising concerns (Irvine et al., 2002). For example a floor nurse may have concerns about the safety of a patient’s discharge plan but feel unable to voice her worry to the physician who seems sure the patient is ready to go home. Lastly, clinicians can lack of insight about their own communication style and effectiveness. Physicians, in particular, tend to overestimate the efficacy of their communication with other team members (Mills et al., 2008; Chang et al., 2010).

Other hurdles to interdisciplinary communication relate to professional education and identity. Traditionally, skills are taught in ‘professional silos’ that can foster ‘power, competition, and hierarchy not teamwork and collaboration’ (Angelini, 2011, p. 175). This can result in limited understanding of or compassion for one another’s professional perspectives, priorities, and education (Leipzig et al., 2002). For example, a nurse may view social workers more as ‘friendly visitors’ than as clinicians who work from a solid clinical or theoretical grounding. In addition to misunderstandings about one another’s skill sets, palliative care IDT members can struggle with overlapping skills. IDT members share both ‘ingroup membership (the IDT) and outgroup membership (occupational group)’ (Wittenberg-Lyles et al., 2009, pp. 38–39) and clinicians can become protective of their disciplines and specific skill sets, leading to turf wars and interpersonal conflicts (Larson, 2003). For example, a palliative care nurse practitioner who enjoys exploring the psychosocial aspects of his patients’ care might worry that the social worker’s expertise will relegate him to medical management only.

Given the barriers just described, palliative care IDTs must take a purposeful approach to maximize team communication and function. One strategy receiving increasing attention is the use of structured communication tools (Byres et al., 2009; Denver Health, 2012). For example, structured team rounds have been shown to encourage meaningful contributions from all providers involved in patient care (O’Leary et al., 2010) and to increase team satisfaction and interprofessional teamwork (Maeyama et al., 2003). Not surprisingly, team members’ satisfaction increases based on the number of team members involved in the care meeting (Maeyama, 2003). Another example of structured communication is the model developed by Michael Leonard in 2002 called SBAR (Situation–Background–Assessment–Recommendation) (Institute for Health Care Improvement, n.d.). In this model, a clinician is encouraged to provide four categories of information when communicating a concern. The first is to describe the situation—the patient’s name, location, and cause for concern: ‘I am calling about Mrs X in room 14 who is having new episodes of apnoea.’ The second is to give a one-line summary of the background: ‘She is a 45-year-old woman with end-stage lung cancer who has required increasing doses of morphine in the last 48 hours.’ The third is to provide an assessment of what is occurring: ‘I believe that the change in her breathing indicates that she is close to death.’ The fourth is to offer a recommendation based on that assessment: ‘I think we should contact her husband to let him know that time might be short.’ A standardized method like this creates a mutual language and process for conveying information no matter who is calling, the nature of the concern, or the level of urgency.

A second strategy to enhance IDT communication is to have designated forums for discussion and feedback. Difficult patient cases should be debriefed either in real time or soon after to help the team grieve, air misgivings, provide support, and assess team process (Salas et al., 2005; Salas et al., 2008). Any member of the team should be able to initiate this for a patient and have the team respond, with time and support from leadership. An example is to hold ‘escalating patient care meetings’ where the team convenes at the first signs of a difficult patient case to map out a plan, raise concerns, and involve appropriate clinicians. Additionally, team members should have opportunities to provide critical feedback to one another and their leaders by using 360-degree reviews or feedback tools (Lockyer, 2003; Massagli and Carline, 2007). Feedback must be separated from compensation or performance evaluations so that it remains constructive and not punitive (Lencioni, 2002). No matter the method, teams should have mechanisms for providing feedback to one another both in times of high stress and in times of relative calm (Salas et al., 2005; Salas et al., 2008).

A third strategy to maximize IDT communication is taken from the study of high-reliability organizations (HROs) such as air-traffic control systems, nuclear power plants, and aircraft carriers. HROs deliberately create an organizational structure that flattens hierarchy by seeking input from front-line members and acknowledging expertise regardless of rank (O’Leary et al., 2012). In this manner each team member’s contribution is sought and valued, leading to empowerment for every team member to participate and voice suggestions and concerns (Hempel et al.2012). If we imagine applying these principles to a palliative care IDT, we can consider a case where a palliative care patient dies suddenly in the hospital and in the ensuing confusion the patient’s wife is not informed until she comes in to visit the patient. An HRO approach would include soliciting the perspective of all those involved, including the floor nurse, the administrative staff, the physician, the social worker, and so on. Protocols for notifying family members after the death of a loved one would then be studied and revised based on the input from all team members and communicated clearly back to all. With this approach the tendency to blame particular individuals, especially those in a lower position of power, is minimized, and team trust and communication is enhanced.

A fourth, closely related strategy to enhance IDT communication is to cultivate an open, no-fault culture in addressing medical errors (O’Daniel and Rosenstein, 2008). This requires a shift away from regarding medical errors as individuals’ mistakes and instead viewing them as a reflection of systems problems (Berwick and Leape, 1999; Institute of Medicine 1999; Institute of Medicine Committee on Quality of Healthcare in America, 2001). A particular danger arises when organizations focus on correcting mistakes by initiating checklists and safety systems but don’t recognize the more insidious problem that occurs when errors are identified through these mechanisms and people are afraid to speak up (Maxfield et al., 2005). In order to minimize this dynamic, organizations must tap into personal motivation and agency, that is, the belief that it is important to speak up and that one has the ability to do so. This is best achieved by interventions such as providing examples of non-threatening language to use when discussing mistakes; setting the expectation that each person is accountable for his or her own behaviour as well as that of colleagues; and encouraging providers to share their experiences of speaking up and empowering others to do the same. The effectiveness of these measures rests on the approach of team leaders, who must create an environment of ‘psychological safety that fosters open reporting, active questioning, and frequent sharing’ (Edmondson 2004, pp. ii8–ii9).

In this section about IDT communication, a number of themes emerge as important in maximizing good IDT communication and function. Table 6.3.1 integrates and expands on many of these points.

As with communication between members of the palliative care IDT, skilled communication is crucial between palliative care providers and other professionals. First, as noted in the introduction, palliative care clinicians are often consulted for difficult patient cases with complex medical, psychosocial, ethical, and emotional issues. Moreover, since palliative care addresses all of the biopsychosocial and spiritual domains of a patient’s care, clinicians collaborate with a wide range of providers of different disciplines across many settings. Furthermore, and perhaps most important, there is huge variability from country to country in access to palliative care services, ranging from no hospice or palliative care presence in some countries to one provider per 158 million people in Pakistan to one provider per 43 000 per people in the UK (Wright et al., 2008). Even in a single country palliative care programmes can vary widely from institution to institution depending on the history, level of development, and make-up of the programme (Goldsmith et al., 2008). Palliative care clinicians therefore meet varying levels of understanding and acceptance from other clinicians, and must often identify and overcome misperceptions even while trying to provide patient care.

Palliative care consultation rests on the same core principles as consultation by other specialists, including the fundamental importance of good communication. Consultants must remember that a basic principle of consultation etiquette is that the referring clinician is the consultant’s primary customer, and not the patient (Goldman et al., 1983). A consultant’s recommendations are conveyed to the referring clinician and the consultant does not have control over which—if any—recommendations will be followed (Meier and Beresford, 2007). Studies of physician compliance rates with consultants’ recommendations, however, highlight the importance of good communication with referring clinicians, with communication skills comprising ten of the 11 proven factors that increase compliance (the exception being the severity of the illness) (Cohn, 2003):

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Response within 24 hours (Pupa et al., 1986)

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5 or fewer recommendations (Sears and Charlson, 1983)

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Identification of critical recommendations (versus routine ones) (Pupa et al., 1986)

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Focus on central issues (Ballard et al., 1986)

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Specific, relevant recommendations (Horwitz et al., 1983)

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Definitive language (Klein et al., 1983)

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Specificity in drug dosage, route, frequency, duration (Horwitz et al., 1983)

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Frequent follow up including progress notes (Mackenzie et al., 1981)

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Direct verbal contact (Pupa et al., 1986)

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Therapeutic (versus diagnostic) recommendations (Ballard et al., 1986)

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Severity of illness (Sears and Charlson, 1983).

(Reproduced with permission from

Cohn SL, and Macpherson DS, Overview of the principles of medical consultation and perioperative medicine, in UpToDate, Basow, DS (ed), UpToDate, Waltham, MA, USA, Copyright © 2012 UpToDate, Inc. For more information visit <http://www.uptodate.com>)

Conversely, studies have also shown that if consultants do not follow these guidelines they will be more likely to receive poor feedback and fewer referrals (Goldman et al., 1983).

While all specialist consultation requires effective communication, it can be argued that palliative care consultation carries particular complexity and requires even greater attention to communication. First, providers in other specialties are sometimes uncertain about what palliative care is and which patients might benefit from palliative care consultation (Shipman et al., 2008). Some referring clinicians worry that there is a ‘palliative care agenda’ to stop aggressive treatments or to encourage patients to sign on to hospice. One survey of 131 clinicians, for example, found there was widespread concern that palliative care consultants would prematurely discuss end-of-life issues, which led to significant barriers to consultation requests (Rodrigues et al., 2007). Other referring clinicians delay referral to palliative care due to worry that it would alarm patients and families (Smith et al., 2012). Yet other referring clinicians find the name ‘palliative care’ problematic and would more readily refer patients if the consultation were called ‘supportive care’ (Ferrell, 2005). In each case, the interaction between palliative care providers and referring clinicians requires thoughtful clarification from the beginning in order to identify concerns or misperceptions before proceeding with the consult.

Second, palliative care consultation usually happens at a time of high emotion, in the context of disease progression leading to considerable symptom burden, psychosocial distress, or a turning point in disease course requiring clarification of the goals of care. Clinicians caring for patients with advanced illness often experience strong emotions themselves, including helplessness, frustration, guilt, and grief (Meier et al., 2001). Palliative care consultants must be able to manage the emotions evoked by the situation, and then communicate clearly in the midst of the turbulence in order to facilitate team health and effectiveness and arrive at the best plan of care (Loscalzo, 2008).

Third, unlike consultants whose specialties are defined by organ system (e.g. cardiology) or disease (e.g. oncology), palliative care addresses the whole patient, including physical, emotional, social, and spiritual aspects. The role of consultant, where the focus of evaluation is limited by the scope of the request, can therefore seem restricting and sometimes lead to internal conflict for the consultant (Meier and Beresford, 2007). Examples include seeing a patient to help with advance care planning who has significant physical symptoms not part of the original consult request; seeing a patient who asks direct questions about topics expressly forbidden by the referrer to discuss; seeing a patient who confides goals or worries not known by the referrer; or seeing a patient whose management the consultant strongly disagrees with (Meier and Beresford, 2007). These situations can be particularly challenging for palliative care clinicians whose aim is to relieve total suffering for patients who may define their needs differently from the referring clinician.

While there is no data supporting the use of a particular strategy in palliative care consultation, we draw from the evidence of medical consultation generally, on the opinions of experts in the field, and on our own clinical experience to recommend an approach that uses five core themes.

As outlined in the chapter, interprofessional communication is crucial in palliative care, both within palliative care IDTs and between palliative care clinicians and others. Strategies to improve interprofessional communication in palliative care have been named throughout the chapter, but what are the next steps?

Efforts to improve interprofessional communication in health care are happening at many levels. One is the increasing emphasis on integrated care pathways (ICPs), defined as ‘multidisciplinary tool[s] to improve the quality and efficacy of evidence based care and communication tool between professionals to manage and standardize the outcome of coordinated care’ (Vanhaecht et al., 2006, p. 28). ICPs should if possible be evidence based and act as a guide on how to diagnose, treat, and follow-up the patients and the families. ICPs can also act as standardized communication tools showing promise in improving both clinical outcomes and communication between providers (Mahmoud et al., 2008). Another effort is the convening of expert consensus panels to set standards for interprofessional communication in specific disciplines, fields, or locations, which then can be used by clinicians, administrators, and educators designing clinical or educational programmes (Interprofessional Education Collaborative Expert Panel, 2011). A third effort is the increasing attention from regulatory bodies to tie measures of interprofessional communication to accreditation of clinical and educational institutions (Joint Commission Resources, 2009). A fourth is the development of government health-care policies emphasizing the importance of interprofessional communication and providing guidelines and structures (including funding) for its implementation (The Enhancing Interdisciplinary Collaboration in Primary Health Care Initiative, Nolte, J., 2006). A fifth is continued research to expand the evidence base on interprofessional communication, including outcomes for individuals, programmes, and institutions (Manser, 2009; Martin et al., 2010), as well as efficacy studies for interventions designed to improve it (Baker et al., 2008). A sixth and perhaps most notable effort, however, is the increasing focus on interprofessional education. Clinicians in training (Carpenter, 2009) as well as practising providers (McPherson et al., 2001) are participating in innovative interdisciplinavry educational initiatives, which have been variably studied but have demonstrated efficacy in improving collaborative practice and clinical outcomes (Reeves et al., 2008; Reeves 2009).

Palliative care can clearly benefit from the growing attention on interprofessional communication worldwide and the resulting development of these communication protocols, policies, and curricula. In fact, palliative care as a field is positioned to help lead the way, since clinicians are often experts in both communication and interdisciplinary practice. The task now is to be sure the field keeps current with the evolving scholarship on interprofessional communication and continues to contribute to and apply the emerging wisdom for the benefit of terminally ill patients and the providers who care for them.