Talking about communication: challenges and chances in medical communication from the patients’ and healthcare professionals’ perspective

Introduction: Poor communication between healthcare professionals (HCP) and patients can lead to
misunderstandings and adverse outcomes in different situations. This thesis focuses on improvements
in communication in different settings by studying perceived communication challenges of HCPs
including communication of sensitive topics during the clinical ward rounds, patients’ preferences for
participation in medical decision-making, and the role of communication and shared decision-making
regarding the preference for or against cardiopulmonary resuscitation within patients and HCPs.
Methods: The following methodological approaches were used: three ancillary analyses of a
randomised controlled multicentre trial conducted between 2017 and 2019 at three Swiss teaching
hospitals to assess HCPs perceptions, patients’ participation preferences and the impact of sensitive
topics discussions during clinical ward rounds; two observational, cross-sectional surveys to assess
resuscitation preferences and predictors influencing decision-making in the general Swiss population
as well as HCPs regularly involved in resuscitation.
Results: Systematic feedback of HCPs (measured by a VAS on preference from 0 to 100) concerning
their perception of ward rounds (n=891) revealed that ward rounds conducted at the bedside are
preferred by the nursing staff (69.20 ± 20.32 versus 65.32 ± 20.92, respectively; adjusted difference
4.35, 95% CI –1.79 to 10.51; p<0.001), while physicians prefer outside the room presentation of
patients during ward rounds (82.63 ± 13.87 versus 66.59 ± 21.82; adjusted difference –16.51, 95% CI
–20.29 to –12.72; p=0.002) due to perceived better discussion of sensitive topics, better time
management and less staff discomfort.
Sensitive topics are found in a large proportion of medical inpatients (51.6%, n=919) particularly
medical uncertainty (n=251) among others. Discussing sensitive topics during ward rounds was
associated with lower satisfaction with care (87.7 ±14.6 versus 90.2 ±12.1; adjusted difference -2.5,
95%CI -4.28 to -0.72; p=0.006). Importantly, disagreement between physicians and patients was
found to be a risk factor for low patient satisfaction.
Concerning the analysis on patients’ preference for participation in medical decision-making, most
patients (62.2%, n=761) prefer collaborative decisions together with their physician. An active
decision-making preference is associated with lower trust in the healthcare team (adjusted difference -
5.08, 95% CI -8.69 to -1.48 points; p=0.006) and lower overall satisfaction (adjusted difference -7.17,
95% CI -11.01 to -3.34 points; p<0.001).
Looking at resuscitation preferences in the general Swiss population (n=1044), the majority wishes to
be resuscitated in a hypothetical case vignette with a 10 minute down time (59.5%) and as a personal
preference (79.7%). Main predictors for do-not-resuscitate (DNR) preference were the personal
resuscitation preference (adjusted OR 2.44, 95%CI 1.67 to 3.55; p<0.001) and the overestimation of
survival with good neurological outcome after cardiac arrest (adjusted OR per decile 0.91, 95%CI 0.84
to 0.99; p=0.02).
Within HCPs, preference for DNR code status was found in 85% (n=1532) in the case vignette and
53.2% (n=932) when making a personal decision for their own preference. Main predictors for DNR
Code Status for the case vignette included personal preferences for their own DNR Code Status
(adjusted OR 2.97, 95% CI 2.25 to 3.92; p < 0.001) and lower estimated OHCA survival (adjusted OR
0.98, 95% CI 0.97 to 0.99; p=0.001). Importantly, correct estimation of survival was a key parameter
because underestimation of survival was positively and overestimation was negatively associated with
a DNR Code Status. Compared to the general population who overestimated survival probabilities,
HCP had more realistic cardiac arrest survival estimates.
Discussion: This thesis, which is based on several secondary analyses of randomised trials, as well
as observational data, highlights situations where communication is a crucial factor directly influencing
satisfaction and outcomes of patients. These results stress the importance of teaching HCPs on how
to communicate in clinical practice, particularly to address sensitive topics during ward rounds. Also,
considering the patient’s individual participation preferences during ward rounds is important and can
lead to a more personalized approach in decision-making. Moreover, regarding DNR, HCPs should
provide in-depth discussions with patients regarding resuscitation preferences to prevent
misconceptions.