Clinicians' accounts of communication with patients in end-of-life care contexts: A systematic review.

OBJECTIVE: Communication between patients and end-of-life care providers requires sensitivity given the context and complexity involved. This systematic review uses a narrative approach to synthesise clinicians' understandings of communication in end-of-life care. METHODS: A systematic, narrative synthesis approach was adopted given the heterogeneity across the 83 included studies. The review was registered prospectively on PROSPERO (ID: CRD42019125155). Medline was searched for all articles catalogued with the MeSH terms "palliative care," "terminal care" or "end-of-life care," and "communication". Articles were assessed for quality using a modified JQI-QARI tool. RESULTS: The findings highlight the centrality and complexity of communication in end-of-life care. The challenges identified by clinicians in relation to such communication include the development of skills necessary, complexity of interpersonal interactions, and ways in which organisational factors impact upon communication. Clinicians are also aware of the need to develop strategies for interdisciplinary teams to improve communication. CONCLUSION: Training needs for effective communication in end-of-life contexts are not currently being met. PRACTICE IMPLICATIONS: Clinicians need more training to address the lack of skills to overcome interactional difficulties. Attention is also needed to address issues in the organisational contexts in which such communication occurs.

Nurse practitioners in aged care: documentary analysis of successful project proposals.

Meeting the primary health care needs of an aging population is an increasing challenge for many Western nations. In Australia, the federal government introduced a program to develop, test, and evaluate nurse practitioner models in aged care settings. In this article, we present a documentary analysis of 32 project proposals awarded funding under the Nurse Practitioner-Aged Care Models of Practice Program. Successfully funded models were diverse and were operated by a range of organizations across Australia. We identified three key priorities as underlying the proposed models: "The right care," "in the right place," and "at the right time." In this article, we explore how these priorities were presented by different applicants in different ways. Through the presentation of their models, the program's applicants identified and proposed to address current gaps in health services. Applicants contrasted their proposed models with available services to create persuasive and competitive applications for funding.

The omni-relevance of surgery: how medical specialization shapes orthopedic surgeons' treatment recommendations.

This article examines treatment recommendations in orthopedic surgery consultations and shows how surgery is treated as "omni-relevant" within this activity, providing a context within which the broad range of treatment recommendations proposed by surgeons is offered. Using conversation analysis to analyse audiotaped encounters between orthopedic surgeons and patients, we highlight how surgeons treat surgery as having a special, privileged status relative to other treatment options by (1) invoking surgery (whether or not it is actually being recommended) and (2) presenting surgery as the "last best resort" (in relation to which other treatment options are calibrated, described and considered). This privileged status surfaces in the design and delivery of recommendations as a clear asymmetry: Recommendations for surgery are proposed early, in relatively simple and unmitigated form. In contrast, recommendations not for surgery tend to be delayed and involve significantly more interactional work in their delivery. Possible implications of these findings, including how surgeons' structuring of recommendations may shape patient expectations (whether for surgery or some alternative), and potentially influence the distribution of orthopedic surgery procedures arising from these consultations, are considered.

How surgeons design treatment recommendations in orthopaedic surgery.

This paper examines how orthopaedic surgeons skilfully design treatment recommendations to display awareness of what individual patients are anticipating or seeking, and suggests limits to those efforts. It adds leverage to our parallel work by demonstrating that even when surgeons incorporate considerations of recipient design to 'fit' recommendations to patients' displayed orientations, an asymmetry between recommendations for vs. not for surgery remains: recommendations for surgery are generally proposed early, in relatively simple and unmitigated form, and as stand-alone options. In contrast, recommendations not for surgery tend to be significantly more complex: they are likely to be delayed, conveyed indirectly, mitigated and justified, and include other possible treatment options. These findings suggest a tension between surgeons' efforts to design recommendations for specific recipients and an overarching institutional bias favoring surgery. Surgeons' efforts to anticipate and respond to resistance to recommendations demonstrate a similar pattern: the methods used to counter patient resistance, and the sequential placement of those efforts, depends on whether the recommendation is for surgery or another treatment option. This work contributes to an understanding of treatment recommendations generally by showing how patients are co-implicated in their accomplishment: because surgeons incorporate considerations of recipient design in response to information provided explicitly or tacitly by patients, patients influence the rendering of recommendations from the beginning.