| Study design and sample | Descriptors of themes | Quality assessment | |||
|---|---|---|---|---|---|
| No. of studies | Design | Criteria | Rating | Overall | |
| Sub-theme 1: Uncertainty in prognosis | |||||
| 4 | 2 focus groups 2 survey | Two studies7,8 reported doctors and nursing staff in America and Canada who believe that uncertainty in diagnosis can act as a barrier to discussing prognosis in the end of life with people. One healthcare provider reported: “Often you know with 100% certainty that there's no hope…it's awkward, but I guess you can say that the chance is unlikely or less likely. However people often want you to be more specific, and that's hard because again you just don't know.” This theme was supported in the descriptive data collected in 2 surveys.42,90 Both of these surveys collected data from doctors on people who had recently died in hospital in the Netherlands and the USA. They enquired at what point the physicians were confident that the patient was in the last days of life, and when the prognosis was discussed with the patient. Both studies reported that the more confident the physicians were in the diagnosis the more likely they were to discuss prognosis with the patient and family members. | Limitations of evidence | Major limitations | LOW |
| Coherence of findings | Coherent | ||||
| Applicability of evidence | Applicable | ||||
| Theme saturation/sufficiency | Unclear | ||||
| Sub-theme 2: Information provision to patient | |||||
| 3 | 1 interview 1 focus groups | Information provision was reported in 2 American studies8,40 with populations including family members and nursing staff in ICUs as an important factor in communicating prognosis effectively. The following aspects of information provision to people were highlighted as potential barriers: Use of terminology “Physicians both use language that the families do not understand and do not recognise it.” Not ensuring understanding ”People don't want to look unintelligent so they don't always ask questions even though they don't understand the information being presented to them.” Accuracy in information rather than optimism ”We need hope, but we also need accurate information. We would rather have accurate information, rather than hope.” ”…the most difficult part of communication, from our (families) point of view is getting perspective.” “Prognosis are unrealistic and often portray ‘small victories’ instead of overall prognosis.” | Limitations of evidence | Minor limitations | LOW |
| Coherence of findings | Coherent | ||||
| Applicability of evidence | Applicable | ||||
| Theme saturation/sufficiency | Unclear | ||||
| Sub-theme 3: Information sharing between healthcare professionals | |||||
| 2 | 2 interview 2 focus groups | Two studies7,8 interviewed doctors and nursing staff in Canada and the USA. They reported that impaired information transfer between healthcare professionals could act as a barrier for effective communication of prognosis. Other professionals were felt to “(not) communicate optimally with each other or with other institutions regarding end of life discussion”. This lack of information transfer between the professions acts as a barrier to communication of prognosis, as they are unsure what other involved “specialists and consultants have said regarding prognosis”. This leads to “inconsistencies between team members in communicating prognosis to families”. This theme was linked with the difficulty in having multiple doctors involved in individual patient care. This was reported to act as a barrier to the communication of prognosis in 1 study40 interviewing family members of ICU patients. One family member reported: ”Ideally I would have loved to have 1 primary. One that does all the, you know…communicates.” In another American study interviewing nursing staff in ITU,8 the “different opinions about prognosis between care provider” was also reported to act as potential barrier to communication of prognosis. This was further reported by a relative in a UK study that interviewed bereaved carers and healthcare professionals49,50: ‘“You know, I had asked how long [until death] and [the doctor] said “how long is a piece of string”. I mean, fair enough, but [other healthcare professionals] kept saying: “she is not ready to die.”’ | Limitations of evidence | Minor limitations | LOW |
| Coherence of findings | Coherent | ||||
| Applicability of evidence | Applicable | ||||
| Theme saturation/sufficiency | Unclear | ||||
| Sub-theme 4: Communication skills | |||||
| 2 | 1 interview 1 focus group | Two American studies interviewing nursing staff and family members of people on ITU both commented on communication skills as important in facilitating effective communication of prognosis.8,40 Family members reported that it was far easier to hear bad news when it was delivered in “a sensitive, caring, compassionate manner”, often drawing on the issue of rapport to convey this. One patient reports: ”I…I think the medical is only 1 part of the equation. The quality of life, the human spirit… and being treated humanely, is so critically important and I think its lacking in the, in the education”. Nursing staff on ITU reported that ”poor bedside manner by surgeons” acted as a barrier in communicating prognosis. | Limitations of evidence | Minor limitations | LOW |
| Coherence of findings | Coherent | ||||
| Applicability of evidence | Applicable | ||||
| Theme saturation/sufficiency | Unclear | ||||
| Sub theme 5: Discomfort with discussion | |||||
| 2 | 2 focus groups | Two studies7,40 interviewing doctors and nursing staff in Canada and America reported that discomfort with emotion involved acted as a barrier to end of life communication. “Some doctors have difficulty…we had 3 physicians recently who, no matter how hard we tried, they never would talk with the patients and family about this… they themselves had difficulty dealing with it… they couldn't come to grips with it”. | Limitations of evidence | Minor limitations | LOW |
| Coherence of findings | Coherent | ||||
| Applicability of evidence | Applicable | ||||
| Theme saturation/sufficiency | Unclear | ||||
| Sub-theme 6: Relationship to patient | |||||
| 2 | 1 interview 1 focus group | Two studies7,40 interviewed family members, doctors and nursing staff in America and Canada. They reported that the short term relationships they often have with people can act as a barrier in hospital settings to communicating prognosis. “It's not easy. Decisions for us are different than those made by long-term care physicians… Our usually short term relationship with patients can pose a barrier….My willingness is reflected by my not really knowing the patient on a long term basis.” | Limitations of evidence | Minor limitations | LOW |
| Coherence of findings | Coherent | ||||
| Applicability of evidence | Applicable | ||||
| Theme saturation/sufficiency | Unclear | ||||
| Sub-theme 7: Role ambiguity | |||||
| 2 | 1 interview 2 focus group | Three studies7,8,40 with populations of family members, doctors and nurses in America and Canada reported role ambiguity as a barrier to the communication of prognosis. They report that when it is unclear whose role it is to discuss prognosis it can sometimes result in no one communicating it. One healthcare provider commented: ”I think overall we need the development of clear definitions of roles… What the role of the physician, the role of the nurse?” Family members of people in ITU also commented on role ambiguity as a barrier to communication as there are often multiple teams involved and it is difficult to know who is responsible for the patient and who to ask questions to. | Limitations of evidence | Minor limitations | LOW |
| Coherence of findings | Coherent | ||||
| Applicability of evidence | Applicable | ||||
| Theme saturation/sufficiency | Unclear | ||||
| Sub-theme 8: Training and experience | |||||
| 3 | 1 interview 2 focus groups | Three studies7,8,40 with populations of family members, doctors and nurses reported healthcare professionals' lack of training and experience in communicating prognosis acted as a barrier to this happening. Some have commented that this is due to a lack of exposure in some specialities of communicating prognosis. One healthcare provided commented that: “No one teaches us how to do these things. There no course on this and quite frankly our role models for this are few…a lot of this is learned at the bedside. I think there is a role to be had for educating physicians in an approach.” One family member interviewed commented: ”I would like to see all staff have to go through more bedside manners” | Limitations of evidence | Minor limitations | LOW |
| Coherence of findings | Coherent | ||||
| Applicability of evidence | Applicable | ||||
| Theme saturation/sufficiency | Unclear | ||||
| Sub-theme 9: Scheduling difficulties | |||||
| 3 | 1 interview 2 focus groups | Three studies7,8,40 with populations of family members, doctors and nurses in America and Canada reported scheduling difficulties as a barrier in end of life communication.
| Limitations of evidence | Minor limitations | LOW |
| Coherence of findings | Coherent | ||||
| Applicability of evidence | Applicable | ||||
| Theme saturation/sufficiency | Unclear | ||||
From: 6, Communication
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