Advance Care Planning Among Patients with Heart Failure: A Review of Challenges and Approaches to Better Communication

Language

Central to this process is the use of empathic language to demonstrate support and understanding. An expression of empathy is also an appropriate way to acknowledge and share difficult emotions when it becomes hard to know where to take the conversation next. Quill and colleagues [74] suggest the following empathic responses to patients’ emotional expressions:

• I wish for that too
• It's unfortunate that things aren't different
• I am so sorry that this happened to you
• I understand how much you want that
• It must be very hard to accept the seriousness of this illness

Relatedly, the use of medical jargon in ACP conversations can increase the distance between patients and their providers, and may hinder patient understanding. Physicians may use technical language out of habit, or as an unconscious way to emotionally separate themselves from the task of delivering bad news. However, clear communication using layperson terms is the most effective approach to providing information necessary to patient-centered decision making. Explaining medical procedures in simple terms can improve understanding and help to build trust with the physician (eg, “We will perform an angioplasty – a procedure where a special tube with a balloon on the end of it is inserted into your artery to stretch it open. This will improve blood flow and relieve some of the symptoms you are currently experiencing”.)

Cultural Issues in Communication

There are various cultural issues to consider and address when conducting ACP discussions with heart failure patients and their families. Heart failure disproportionately affects certain racial and ethnic groups (eg, African Americans) [77–79], and effective management of heart failure depends on the provision of culturally sensitive information and facilitation of culturally informed self-care behaviors. There is evidence of cultural variation in preferences for information and role in decision-making. For example, most white and African-American patients prefer to be fully informed of their condition [80], whereas other cultures may focus on protecting the patient from difficult information in order to maintain hope [80–86]. Moreover, even in cultures where nondisclosure is preferred, patients may want to be told the truth in an indirect, euphemistic, or even nonverbal manner [80,87–89]. These complexities underscore the importance of taking a patient-centered approach to ACP communication, respecting individuality and autonomy while ultimately facilitating decision-making [90,91].

Are There Effective Training Programs for ACP Communication?

Effective communication skills are a critical component of ACP conversations between clinicians and their patients; however, most clinicians do not receive formal training in ACP communication and believe it to be a difficult task [92]. Strong evidence of the effectiveness of communication skills training has yet to be established, largely due to variation in the approach to training and the specification of relevant outcomes. For example, a systematic review of communication skills training courses found that some courses are effective at improving different types of communication skills related to providing support and gathering information, but these courses lacked effectiveness in improving patient satisfaction or provider burnout and distress [93]. Similarly, a range of approaches to teaching clinicians effective ACP communication skills early in their medical training have been identified [94], but considerable variation in quality preclude any conclusions from being drawn about their effectiveness.