It can be incredibly distressing for a family dealing with a serious or life-threatening illness to receive mixed messages from the clinical team about their child’s prognosis or care plan. The roots of this miscommunication may begin way before they must make an important treatment decision. For instance, clinical team members may have different opinions about when it is time to offer palliative care to families.
“Clinical teams caring for these complex patients often struggle to communicate effectively with each other as well as with families when they reach those branch points,” said Jennifer Walter, MD, a pediatrician and assistant professor in the department of pediatrics and the department of medical ethics at The Children’s Hospital of Philadelphia. Her research focuses on the intricacies of clinical communication.
During goals of care conversations where the team shares upsetting news and attempts to understand what is most important to families, it is essential that entire team is able to communicate with empathy and clarity. Yet, many physicians have not developed this basic skill set, Dr. Walter said, and team members may not always be in unison about the range of options that are appropriate to present to families. The end results for parents are confusion and mistrust as they contemplate the transition to supportive care.
Dr. Walter received a Sojourns Scholar Leadership Award from the Cambia Health Foundation to investigate the effectiveness of an interprofessional communication training program designed to improve clinical teams’ collaboration in creating care plans and how they prepare to share them consistently with families. Her study participants will be members of the cardiac intensive care unit at CHOP, which relies on many specialties including cardiologists, intensive care doctors, nurses, nurse practitioners, social workers, child life specialists, and surgeons. This large team must work together to effectively support parents in making decisions about significant surgeries or other risky procedures.
“My research will focus on how the team communicates with one another about the central elements of a good care plan for a patient and how they respectfully engage the different members of the team with different levels of expertise,” Dr. Walter said. “And then, how do they demonstrate that true collaboration in their communication with the family? Does the family really experience that the team is on the same page? Or, if there are differences of opinion, are they conveyed to the family clearly with the pros and cons of the different options?”
First, Dr. Walter will observe cardiac intensive care unit team meetings and audio record how they communicate with each other and families during clinical care discussions. Next, she will create a simulated family meeting and audio record how the team engages with actors playing the role of parents.
During the intervention phase of the investigation, small groups will participate in team building workshops to help them identify sources of communication breakdowns. They will supplement their communication skills by learning to how to give bad news and to elicit the values of family members. The training is based on methods created by a nonprofit organization called VitalTalk that originally taught oncologists how to communicate better with their adult patients. After the intervention, the investigators will observe and audio record another set of actual and simulated encounters with families.
The study team will use a validated, objective system that looks for behaviors associated with interprofessional collaboration to code randomized audio files from the pairs of meetings. For example, the coders will note if one voice is dominating the entire conversation or if there are opportunities for multiple team members to contribute important information. The clinical team members also will complete surveys to get their feedback about the collaborative experience before and after the intervention to see if they perceive any improvement.
“The hope would be to demonstrate that the intervention changes the clinicians’ behaviors and perception of collaboration in both simulated encounters as well as in actual encounters,” Dr. Walter said. “The next steps for these projects would be to develop a study that also would engage families. The real outcome that we care about is whether families identify their teams as more consistent and supportive in making decisions that they struggle with.”
The National Palliative Care Research Center also recognized Dr. Walter’s research with a career development award. Her mentors for the project include Bob Arnold, MD, developer of the VitalTalk system; Chris Feudtner, MD, PhD, a well-established pediatric palliative care clinician and researcher at CHOP; and Victoria Miller, PhD, a psychologist and director of research for the Craig-Dalsimer Division of Adolescent Medicine at CHOP, who has deep expertise in quantitative and qualitative coding of observational studies.