title: Improving Communication About Serious Illness in Primary Care: A Review.
abstract: The Institute of Medicine recently called for systematic improvements in clinician-led conversations about goals, values, and care preferences for patients with serious and life-threatening illnesses. Studies suggest that these conversations are associated with improved outcomes for patients and their families, enhanced clinician satisfaction, and lower health care costs; however, the role of primary care clinicians in driving conversations about goals and priorities in serious illness is not well defined.
  
  
  
  To present a review of a structured search of the evidence base about communication in serious illness in primary care.
  
  
  
  MEDLINE was searched, via PubMed, on January 19, 2016, finding 911 articles; 126 articles were reviewed and selected titles were added from bibliography searches.
  
  
  
  Review of the literature informed 2 major topic areas: the role of primary care in communication about serious illness and clinician barriers and system failures that interfere with effective communication. Literature regarding the role that primary care plays in communication focused primarily on the ambiguity about whether primary care clinicians or specialists are responsible for initiating conversations, the benefits of primary care clinicians and specialists conducting conversations, and the quantity and quality of discussions. Timely and effective communication about serious illness in primary care is hampered by key clinician barriers, which include deficits in knowledge, skills, and attitudes; discomfort with prognostication; and lack of clarity about the appropriate timing and initiation of conversations. Finally, system failures in coordination, documentation, feedback, and quality improvement contribute to lack of conversations.
  
  
  
  Clinician and system barriers will challenge primary care clinicians and institutions to meet the needs of patients with serious illness. Ensuring that conversations about goals and values occur at the appropriate time for seriously ill patients will require improved training, validation, and dissemination of patient selection tools, systems for conducting and revisiting conversations, accessible documentation, and incentives for measurement, feedback, and continuous improvement.
authors.affiliation: Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts2Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts3Ariadne Labs, Brigham and Women's Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts4Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Joshua R
authors.initials: JR
authors.lastname: Lakin
authors.affiliation: Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts2Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts3Ariadne Labs, Brigham and Women's Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts4Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts5Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Susan D
authors.initials: SD
authors.lastname: Block
authors.affiliation: Ariadne Labs, Brigham and Women's Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts6Division of Palliative Care, Department of Medicine, Massachusetts General Hospital, Boston.
authors.forename: J Andrew
authors.initials: JA
authors.lastname: Billings
authors.affiliation: Ariadne Labs, Brigham and Women's Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
authors.forename: Luca A
authors.initials: LA
authors.lastname: Koritsanszky
authors.affiliation: Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Cunningham
authors.affiliation: Department of Care Coordination, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Lisa
authors.initials: L
authors.lastname: Wichmann
authors.affiliation: Department of Care Coordination, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Doreen
authors.initials: D
authors.lastname: Harvey
authors.affiliation: Department of Medical Management, Brigham and Women's Physicians Organization, Boston, Massachusetts.
authors.forename: Jan
authors.initials: J
authors.lastname: Lamey
authors.affiliation: Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts2Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts3Ariadne Labs, Brigham and Women's Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts4Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts9Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Rachelle E
authors.initials: RE
authors.lastname: Bernacki
mesh_terms: D001291:Attitude of Health Personnel; D002983:Clinical Competence; D003142:Communication; D016638:Critical Illness; D004282:Documentation; D005246:Feedback; D006801:Humans; D010817:Physician-Patient Relations; D058007:Physicians, Primary Care; D011320:Primary Health Care; D058996:Quality Improvement