Skills and Strategies for Crisis Communication in Seriously Ill Patients: A Qualitative Study.

Abstract

There are few tools to help physicians conduct serious illness conversations during a health crisis, where there is a high probability of imminent death. The Serious Illness Conversation Guide (SICG) offers physicians a framework to lead conversations with seriously ill patients in a stable setting and may be adaptable to crisis communication. To identify the communication skills and strategies used by expert clinicians in crisis situations and to determine if the SICG can be adapted for use in crisis situations. We performed semi-structured interviews of physicians with experience in crisis communication and analyzed the transcripts using thematic analysis. Based on our results, we developed a preliminary adaptation of the SICG for crisis communication. We interviewed general internists (n = 8), intensive care (n = 3), and emergency medicine physicians (n = 7) who worked at The Ottawa Hospital, a tertiary care hospital in Ottawa, Canada. Physicians described several challenges to conducting serious illness conversations in crisis, including time constraints, uncertainty in prognosis, limited access to the patient's medical history, lack of an established therapeutic relationship, and a potentially high symptom burden. They outlined strategies to support communication in these settings, such as rapidly establishing trust, being transparent about uncertainty and allowing space for emotional expression. While all physicians agreed the SICG was adaptable to crisis settings, they noted the need to modify some of the language to better reflect the high-acuity setting. Elements of crisis communication absent from the SICG included gathering information on the medical context and prior wishes, assessing capacity, establishing the substitute decision-maker, involving family, and understanding the patient's pre-hospital quality of life and illness experience. We identified key skills and strategies for crisis communication. The SICG is relevant and adaptable for crisis communication. Future studies should test the adapted guide amongst patients and their caregivers.