Factors Identified That Support, Impede Improvement in Serious Illness Conversations
Key findings
- This qualitative study involved interviews with 30 professionals in five healthcare systems that adopted the Serious Illness Care Program to characterize aspects of "clinical culture" that support or impede improvement in serious illness conversations
- Culture-related inhibitors include beliefs that conversations are about dying or withdrawing care, attitudes that serious illness communication is only the physician's job, discomfort with managing emotions, and lack of standard team workflows
- A change in clinical culture that supports serious illness conversations is to shift the emphasis from "end-of-life planning" to knowing and honoring what matters most to patients, which can reveal benefits to patient care and clinician meaning at work
- Other supportive changes are to empower advanced practice clinicians, nurses, and social workers to take expanded roles; conduct conversations earlier in the patient's disease course; and develop reliable procedures
- Beyond attention to organizational factors, enhancing clinical culture may improve the success of implementing the Serious Illness Care Program
In 2015, researchers at Harvard Medical School first described the Serious Illness Care Program (SICP), a multicomponent intervention. It includes a structured Serious Illness Conversation Guide, clinician communication skills training, and system changes, including processes for identifying patients, reminders in the workflow, and a template for documenting such conversations in the electronic health record.
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Prior research on implementing the SICP, published in BMJ Supportive & Palliative Care, addressed organizational factors and implementation strategies that encourage clinicians to have serious illness conversations.
Now, Joanna Paladino, MD, a physician–investigator in the Center for Aging and Serious Illness at Massachusetts General Hospital, Suzanne E. Mitchell, MD, of UMass Memorial Health, and colleagues have explored how clinical culture—attitudes, beliefs, and norms of health professionals—influences improvement in serious illness communication. They report in BMC Palliative Care.
Methods
The researchers undertook a qualitative study at five U.S. academic medical centers implementing the SICP as educational and quality improvement initiatives. Implementation is occurring across specialties, such as oncology, primary care, geriatrics, palliative care, and hospital medicine.
Between February 2020 and April 2021, Dr. Paladino conducted semi-structured 60-minute interviews with 30 participants: 13 physicians and one physician assistant who serve on teams overseeing institutional SICP implementation, 11 frontline clinician champions of the SICP, and five specialist physicians who are developing SICP processes.
The interviews focused on successes and challenges encountered while implementing the SICP, including but not limited to individual and interpersonal factors.
Results
Analysis of the transcripts revealed four culture-related domains that influence improvement in serious illness communication:
- Clinical paradigms
- Interprofessional empowerment
- Perceived conversation impact
- Practice norms
These are detailed in a table in the article.
Inhibitive Aspects of Clinical Culture
Some of the barriers to SICP implementation were:
- Discomfort and stigma—Interviewees said many clinicians across specialties outside palliative care associate serious illness conversations with discussions about end-of-life planning or transitions, including life-sustaining treatment preferences, hospice care, or limiting curative care.
- Lack of interprofessional empowerment—The analysis also revealed the importance of shifting from individual to team ownership of serious illness conversations. Attitudes that the conversations are the "physician's job," ambiguity about roles, and unprofessional behaviors by physicians in some instances keep some physician assistants, nurses, and social workers from feeling safe to initiate the conversations. The association of serious illness communication with end-of-life transitions or sharing poor prognoses adds to these concerns.
- Emotional costs—At a time when clinicians are constantly being asked to do more with less, discomfort with managing patients' and their own emotions can serve as barriers to practice change.
Supportive Aspects of Clinical Culture
Other comments revealed:
- The SICP can shift clinician mindset and practices toward a more positive and person-centered view of serious illness. Serious illness conversations are a way of knowing and honoring what matters to patients, supporting patients emotionally, and strengthening the therapeutic alliance.
- The person-centeredness of serious illness conversations enables some clinicians to strengthen connections with patients and provide more personalized care, and it can affirm their decision to work in healthcare.
The Effort Continues
Enhancing clinical culture may improve the success of implementing the SICP. Strategies may include shifting clinical paradigms about serious illness communication, empowering non-physicians, revealing benefits to patient care and clinician meaning, and promoting individual and team responsibility for earlier conversations with patients about their values and goals.
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