Table 2 Supportive and inhibitive aspects of clinical culture of serious illness communication
From: Improving serious illness communication: a qualitative study of clinical culture
Domain | Inhibitive culture aspects | Supportive culture aspects |
|---|---|---|
Clinical paradigms • Knowledge & assumptions • Beliefs • Attitudes | • Association of serious illness communication with discussions about dying, hospice, or life-sustaining treatment decisions • Beliefs that serious illness conversations have a pre-ordained outcome of withdrawing or limiting curative care • Conflicted attitudes and discomfort toward communication | • Adoption of a definition of serious illness communication as knowing and honoring what matters to patients • Beliefs that the purpose of serious illness communication is to strengthen therapeutic relationships, provide emotional support, and enable partnership in all treatment decisions • Positive attitudes toward and comfort with eliciting patients’ values and goals |
Interprofessional empowerment • Confidence and self-efficacy • Psychological safety and trust • Role identity | • Reluctance and nervousness about conversations with patients because of uncertainty about what to say • Perceptions that serious illness communication is the physician’s job; lack of psychological safety for inter-professional clinicians • Feeling uncertain about role and scope of practice in serious illness communication | • Improved comfort and self-efficacy in initiating serious illness conversations with patients • Acceptance of inter-professional roles in serious illness communication; enhanced psychological safety and trust • Integration of serious illness communication into professional roles |
Perceived impact • Impact on patients • Impact on clinicians | • Concerns about taking away hope and increasing anxiety and/or sadness for patients • Feeling overwhelmed by serious illness communication due to discomfort with emotions and overburdened environments | • Perception that earlier values and goals conversations lessen distress for patients • Feeling more effective in personalizing care, more meaning and fulfillment at work, and stronger relationships with patients |
Practice norms • Timing of conversations • Focus and content of conversations • Reliability and accountability | • Reactive approach to communication that ‘avoids’ conversations until a crisis or poor prognosis at end of life • Predominantly medically oriented content of the conversations e.g. hospice, code status, life-sustaining treatment preferences • Lack of reliable team processes or unclear roles, ‘chaos’ and ‘kicking the can down the road’ effects | • Integrating earlier and longitudinal conversations into practice • Enhanced focus of conversations on patients’ values, goals, hopes, and worries (rather than treatments and procedures) • Shared responsibility and accountability that integrates communication into team processes and norms |