The Closing Composition: End-of-Life Communication Strategies

Background: Globally, palliative care at end-of-life (EOL) is indicated for over 19 million adults (Connor & Bermedo, 2014). Palliative and EOL care encompasses physical, psychosocial, and spiritual changes which necessitate ongoing intervention and evaluation (Coyle, 2015). Both the World Health Organization (WHO, 2016) and the International Association for Hospice and Palliative Care (IAHPC, 2016) identify the palliative care team’s interprofessional composition, of which nurses are an integral component. At the center of the interprofessional, palliative care team is the patient; who desires shared decision-making (Alston et al., 2012). Patients and families are best served when health care communication envelopes the elements of clinician expertise, patient and family goals and concerns, and medical evidence (IOM, 2015). Nurses have a unique and intimate role in the decision-making process by virtue of the amount of time they spend with the patient on a daily basis (Ferrell, Malloy, Mazanec, & Virani, 2016). A systematic review of the literature identified registered nurses in the roles of information broker, supporter, and advocate with patients and families engaged in EOL decision-making (Adams, Bailey, Anderson, & Docherty, 2011). These rich and meaningful roles hold communication as a central component—one which is best characterized by honesty and transparency (IOM, 2015) as well as an engagement that renders explicit the nature of bearing witness to personal suffering (Ferrell & Coyle, 2010). Dahlin and Wittenberg (2015) describe critical communication competencies of the registered nurse which echo the roles of information broker, supporter, and advocate reported by Adams and associates (2011). The imperative for nurse presence, practice expertise, and communication excellence is well established within the palliative and EOL nursing literature (Dahlin & Wittenberg, 2015; Wittenberg-Lyles, Goldsmith, Ferrell, & Ragan, 2013). However, absent in the literature are the strategies used by registered nurses when communicating with patients and families about EOL decision-making (Adams et al., 2011).

Purpose:  The purpose of this presentation is to share findings from a qualitative study with hospice/palliative care nurses regarding palliative and EOL communication strategies with patients and families. Our specific aim was to determine the key communication strategies employed by hospice/palliative nurses when engaging patients and families in advanced EOL decision–making.

Methods:  Using a phenomenological approach, this study describes hospice/palliative nurses’ experiences when engaging patients and families in EOL decision-making. A sample of 10 female hospice/palliative care nurses between the ages of 30-60 years of age participated in face-to-face interviews with both PI’s. Interviews lasted approximately 45-60 minutes. Interviews began with three lead-in questions, were audio recorded, and were transcribed verbatim by a qualified transcriptionist. Analysis of the transcripts began with the PI’s dwelling with the data followed by a shared process of iterative discovery of the overarching pattern and key themes. To illuminate the pattern and subsequent themes, the researchers employed the use of metaphors. Metaphor in qualitative research assists in the critical reexamination of a common experience through a different lens; expanding understanding and awareness (Carpenter, 2008).

Results:  The exemplars shared by these nurses were abundant with context and content. The EOL experience is not rehearsed; throughout the transcripts it was clear how, together, the patient, family, and the nurse must co-create the closing composition—which became the overarching pattern of the communication strategies described by these nurses. Essential to successful implementation of the closing composition is the understanding that these strategies are ever evolving and non-linear. The themes comprising the closing composition are: establishing context, acknowledgement through attentive listening, trust, wishes/goals of care, and honesty. Hope was interwoven throughout the closing composition and included knowing and accepting the patient and family’s journey, building trust through honesty, and identifying how they (patients and families) wish to write the final refrain.

Discussion: New nursing graduates in the United States (US) are expected to provide competent EOL care (American Association of Colleges of Nursing, 2016). They are also entering a healthcare environment caring for more patients with comorbidities, advancing age, and frailty. In the US and internationally (Connor & Bermedo, 2014), the educational environment should be the point of introduction for professional, therapeutic communication. This introduction must incorporate targeted content about palliative and EOL care communication and in on-going learning. Incorporating palliative and EOL case studies or simulation into pre-licensure student learning experiences has demonstrated student reports of enhanced confidence (Gillan, Parmenter, vander Riet, & Jeong, 2013) and the importance of presence when caring for patients and families at EOL (Fabro, Schaffer, & Scharton, 2014). However, the interview participants were quick to note that nothing in their pre-licensure education prepared them for the depth of skill required when communicating with patients and families at EOL. Interview participants acknowledged the positive influence of skilled health care professionals, i.e., physicians, nurses, chaplains, who role modeled several of the communication strategies described. Practicing nurses must be skilled in facilitating advance care planning conversations near EOL that reflect patient and family wishes and goals of care.

Conclusion: Based on descriptions offered by these registered nurses, we conclude that the EOL decision-making communication strategies could be considered universal, crossing cultures and settings. Additionally, conversations in which these communication strategies are used will provide a foundation for advance care planning which has the potential to impact both patient outcomes (Garrido, Balboni, Maciejewski, Bao, & Prigerson, 2015) and fiscal stewardship of healthcare resources (Bischoff, Sudore, Miao, Boscardin, & Smith, 2013).