The authors concluded that limited evidence suggested that successful interventions to improve communication between patients receiving end-of-life care and professionals should combine training, patient discussion, and education. The authors' broad conclusion is reflected in the evidence presented, but the unclear quality of the included studies means that its reliability is unclear.

To evaluate interventions to enhance communication between the patient and the professional, for patients receiving end-of-life care. Also, to explore the applicability of interventions developed for cancer, beyond cancer care.

Ten databases, including MEDLINE, EMBASE, CINAHL, PsycINFO, and The Cochrane Library, were searched for papers published in English, up to February or March 2010. Search terms were reported. There was no search for grey literature.

Eligible for inclusion were studies of communication interventions to enhance care planning for health care professionals, in the context of palliative care, end-of-life care, terminal care, or supportive care. Patients with any life-limiting condition could be included.

The included studies were conducted in the USA, the UK, or Australia. Just under half of the studies included patients with generic life-limiting illnesses; others focused on cancer, heart or renal failure or both, or respiratory disease. Other participants were health professionals, academics, carers of patients, and their family members. Various interventions were described, and the delivery settings included primary, acute, community, and palliative care. Various outcomes were measured relating to the improvement, timing, and nature of discussions about end-of-life care; there were no health care outcomes.

Two independent reviewers seem to have selected the studies based on their abstracts. Disagreements were resolved by discussion and consensus.

The authors did not report any formal quality assessment of the included studies.

The data were extracted from the included studies to provide a narrative on core themes. The authors did not state how many reviewers carried out the data extraction.

A thematic synthesis (involving a mixture of research designs) was presented.

Sixteen studies were included. There were seven controlled trials (range 27 to 9,105 patients); three uncontrolled studies (where reported, range 17 to 108 patients); and six qualitative studies (where reported, range six to 65 patients).

Three core themes emerged from the mixed-methods synthesis, as follows:

Education to enhance professional communication skills: There were four quantitative studies, and one qualitative study. Training courses and workshops showed some success in helping health professionals to change attitudes, and deliver information and respond to patients regarding end-of-life care. The qualitative study suggested the optimal context for end-of-life discussion was a caring, trusting, long-term relationship that provided the opportunity for open and repeated negotiations for patient information preferences.

Communication to improve patient understanding: There was one quantitative study, and two qualitative studies. The positive impact of specific tools to facilitate patient understanding of end-of-life issues was discussed (for example, a card game designed to enable patients to voice and share concerns, and an advance care planning tool designed to empower patient-professional communication, based on goals and values in relation to the illness).

Communication to facilitate care planning: There were five quantitative, and three qualitative studies. Interviews, with a trained facilitator, were associated with successful communication between the patient and professional for care planning, particularly for the expression of patient preferences. Educational workshops for patients, and information provided solely by the health professional, had mixed success in increasing discussions about care preferences and completion rates for advance directives. The qualitative studies indicated that patient-led end-of-life discussions, initiated after recurrence of disease, and over an elapsed time frame, were more likely to be acceptable to patients. Information leaflets alone were not sufficient, and discussions initiated by general community nurses were more likely to lead to patients dying in their preferred place of care, rather than elsewhere.

Limited evidence suggested that successful interventions to improve communication between patients receiving end-of-life care and professionals should combine training, patient discussion, and education.

The review question was clear, the inclusion criteria were specified, and the decision to include mixed study designs was explained and justified by the authors. Several relevant databases were searched, but restrictions on language and publication status may mean that relevant studies were overlooked. There was some attempt to minimise error and bias in selecting studies, but this was unclear for data extraction.

The absence of any quality assessment means that the reliability of the included studies, and their synthesis, is unclear. The study details were presented adequately. The results of the included studies were extracted on the basis that including a range of study designs would not restrict exploration, but qualitative and quantitative aspects were largely presented separately. There was some attempt to map out and explain from more than one standpoint (triangulate) the findings.

The authors' broad conclusion is reflected in the evidence presented, but the unclear quality of the included studies means that its reliability is unclear.

Practice: The authors did not state any implications for practice.

Research: The authors stated that research should explore the potential for cost savings and decreased resource use, resulting from interventions to enhance patient-professional communication, during end-of-life care.

Funded by the Bupa Foundation, UK.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.