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Training needed for improved communication regarding serious illness in primary care

Lack of knowledge, discomfort with prognostication, and failures in coordination and documentation are some of the barriers challenging PCPs and primary care institutions in improving communication with patients regarding serious illnesses, according to a review published in JAMA Internal Medicine.

The authors of the review further concluded that ensuring conversations about patients’ goals and values occur at the appropriate time will require improved training, validation and dissemination of patient selection tools, systems for conducting and revisiting discussions, accessible documentation, and incentives for measurement, feedback and continuous improvement.

“The Institute of Medicine and the American College of Physicians’ High Value Care Task Force recently recommended systematic improvements in the quality and quantity of clinician-led discussions about goals, values and care preferences with patients with serious and life-threatening illnesses,” Joshua R. Lakin, MD, of the department of psychosocial oncology and palliative care at the Dana Farber Cancer Institute, in Boston, and colleagues wrote. “… Improving the quality and quantity of conversations about goals of care during serious illness holds potential to fulfill the construct of the quadruple aim of optimizing health system performance though improving patient experience and reducing costs, increasing population health, and improving the work life of clinicians. However, the role of the primary care team in these conversations is not well defined.”

To review the evidence base regarding communication with patients with serious illnesses in primary care, the researchers conducted a MEDLINE search, via PubMed, on Jan. 19. They identified 911 articles, later choosing 126 to be included in the review, with selected titles added from bibliography searches.

Of the 126 selected articles, 77 directly addressed primary care, 26 addressed specific patient populations and 23 addressed general topics.

According to the researchers, the literature review revealed two major topic areas — the role of primary care in communication about serious illness and clinician barriers and system failures that interfere with effective communication. The researchers noted the apparent ambiguity in the literature regarding whether PCPs or specialists are responsible for starting conversations, the benefits of PCPs and specialists conducting conversations, and the quantity and quality of such discussions. Clinician barriers to improved communication included lack of knowledge, skills and attitudes, as well as discomfort with making predictions and lack of clarity about when conversations about serious illness should begin. System barriers included failures in coordination, documentation, feedback and quality improvement.

“The role for primary care clinicians in this area is dynamic and remains incompletely defined,” Lakin and colleagues wrote. “Although fragmented and specialty-centric care may create barriers to conducting timely and effective conversations about serious illness, the longitudinal relationship of primary care clinicians with their patients places primary care teams in an ideal position to plan and lead conversations about serious illness, given proper training and support.” – by Jason Laday

Disclosure: The researchers report no relevant financial disclosures.