Table 1 Characteristics of the included studies

Alexander, 2006 [17]

To evaluate the effect of a short course to improve residents’ communication skills in delivering bad news and eliciting patients’ preferences for EOL care

Quasi-experimental study with a non-equivalent control group pretest-posttest design

56 internal medicine residents in the US

1. Intervention group: two-day retreat with 16-h curriculum focusing on (1) symptom management, (2) communication skills and (3) patient experience by small-group discussion, audio-visual materials and role-play

2. Control group: no intervention

1. Audio-recorded encounters with standardised patients before and after the intervention, which was evaluated by Bad-News Conversations and Patient Preferences

1. The intervention group demonstrated statistically significant increases in their overall skill ratings in the delivery of bad news, with improvement in the specific areas of information giving and responding to emotional cues.

2. Although cumulative scores for discussions about patient preferences for treatment did not increase, the intervention group demonstrated enhanced specific skills in EOL decision-making.

Bristowe, 2014 [18]

To develop and pilot a REnal specific Advanced Communication Training programme to advance the communication skills of renal professionals to support people with ESKD to make informed choices about their future care

Pre-test post-test design

16 renal professionals (9 nurses/health-care assistants and 7 consultants) in the UK

One full-day session and two half-day follow-up sessions to address the needs identified in the focus group, with structured sessions around each theme by presentation, discussion and role-play

1. Confidence in communicating about EOL issues with patients (pre-training, immediately post training, at 3 months post training)

1. There was a non-significant increase in confidence in communicating about EOL issues, which was maintained at 3 months.

Detering, 2014 [19]

To develop and evaluate an interactive ACP educational programme for general practitioners and doctors-in-training

Pre-test post-test design

148 doctors from GP and hospital settings (majority the latter) in Australia

The education program on ACP using a DVD, an interactive patient e-simulation, a structured 2 h workshop and a training manual to assist with facilitation of the workshop

Three components assessed before and after the education program: (1) knowledge of ACP; (2) attitudes towards ACP; (3) confidence in discussing ACP

There were no significant differences observed in ACP knowledge following training, and most participants were supportive of patient autonomy and ACP. After training, there was a significant improvement in self-reported confidence in six of eight items.

Greenberg, 1993 [20]

To evaluate the effect of an educational module on third-year medical students

RCT

141 third-year medical student in the US

1. High intervention group: received all the materials given to the low-intervention group, participated in a two-hour seminar during the second week of the clerkship on AD and death and dying experiences, and a follow-up session two weeks later on AD discussion

2. Low intervention group: received two articles pertaining to the DPAHC, a one-page summary of important aspects of the DPAHC a reference bibliography

3. Control group: no intervention, received no material about the DPAHC

1. Knowledge about the DPAHC assessed with 22 true/false/not-sure questions

2. Perceived skill and comfort assessed with 14 questions using a five-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’

1. All three groups improved significantly in knowledge about the DPAHC at follow-up. The high-intervention group improved significantly more than the control. or low-intervention group

2. High-intervention group reported more improved perceived skills and comfort and experience with discussing the DPAHC and end-of-life issues.

Jo, 2015 [21]

To examine the effects of an educational program on shared decision-making on EOL care performance, moral sensitivity and attitude towards shared decision-making among Korean nurses

Quasi-experimental study with a non-equivalent control group pretest-posttest design

41 ICU nurses in Korea.

1. Intervention group: educational programme on shared decision-making for 60 min per session, twice a week for 4 weeks

2. Control group: spending the same time but reading the moral guidelines of the hospital

1. End-of-life care performance scale

2. The Moral Sensitivity Questionnaire

3. Attitude towards shared decision-making scale

1. There was no significant difference between two groups in EOL care performance, although the increase in the interventional group was higher than that of the group.

2. Experimental group showed significantly higher scores in moral sensitivity and attitude towards shared decision-making after the intervention than the control group.

Lum, 2018 [22]

To develop and evaluate an ACP educational session on value-based ACP process

Pre-test post-test design

127 third-year medical students in the US

75-min value-based ACP educational session containing group discussion and watching an online video

Surveys on assessment of participants’ personal experiences with ACP conversations

1. 65% reported prior ACP conversations. After the intervention, 73% reported plans to discuss ACP, 91% had thought about preferences for future medical care, and 39% had chosen a medical decision maker. 14% completed an AD, and 1% talked with their health-care provider.

2. One month later, there was no evidence that the session increased students’ actions regarding these same ACP action steps.

Murray, 2010 [23]

To evaluate the effect of a program to train clinicians to support patients making decisions about place of EOL care

RCT

88 practitioners (majority nurses) from 7 community-based organizations and 3 hospital-based institutions in Canada

1. Intervention group: received six-week education program to target identified barriers to providing decision support for place of EOL care and improve decision support knowledge and skills by online tutorial, skill-building workshop and educational outreach

2. Control group: no education programme

1. Decisional Support Analysis Tool (DSAT10)

2. 10-item multiple choice questionnaires assessing knowledge of decisional support

3. Length of interaction in minutes

4. 31-item Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health Decisions survey tool

1. Compared to the control group, the intervention group had significantly greater improvement in DSAT10.

2. The intervention group scored significantly higher on the knowledge test than the control group.

3. The mean call duration was longer in the intervention group than the control group after the intervention.

4. The tool was rated as acceptable and clinically useful.

Seal, 2007 [24]

To evaluate the effect of the Respecting Patient Choices Program (RPCP) on fostering patient advocacy, promoting quality EOL assurance and associated job satisfaction

Prospective non-randomised control trial using convenience sampling and quasi-experimental and semi-structured focus group methods

278 nurses working in an acute care public hospital in South Australia

1. Intervention group: received RPCP focusing on quality of ACP process

2. Control group: no RPCP

1. 5-point Likert scales questionnaire

2. Focus group

1. There were statistically significant improvements in (1) encouragement to ensure patients could make informed choices about their EOL treatment, (2) the ability to uphold these wishes in practice, and (3) job satisfaction from delivering appropriate EOL care by nurse after RPCP program.

2. Focus group participants shared that it used to be hard to advocate for patients, but now they could act legitimately and felt ethically comfortable about ensuring EOL care.

Smith, 2013 [25]

To assess the feasibility and impact of a novel resident curriculum in EOL education to improve resident comfort with communication at EOL

Pre-test post-test design

165 internal medicine residents in the US

Two one-hour lunch conference sessions on EOL communication with didactic slides and scripted role play, and six one-hour morning reports focusing on discussion of real-time cases

Electronic survey with 24 questions related to demographics, previous requests for palliative care consultation, number of family meetings led, comfort with topics related to EOL care, behaviour during family meetings to discuss EOL care, and measures of self-efficacy for communication

The curriculum impacted resident reports of comfort with specific topics in EOL care, including discussions of code status and comfort care. Small impact on resident reports of self-efficacy for communication was also shown.

Wilson, 2017 [26]

To improve staff and family satisfaction with EOL communication and to increase the level of knowledge and the confidence of providers in discussing EOL issues in ICU through the quality improvement project

Pre-test post-test design

21 critical care staff (12 registered nurses, 4 acute care nurse practitioners, 1 social worker, 2 palliative care team members, 1 member from the spiritual care team, and 1 care manager) in the US

The first intervention was an educational program dealing with EOL communication, which was completed along with introduction of the standardised family meeting tool. The second was implementation of the new meeting format with documentation of the meeting outcomes in a standardised chart form.

1. Questionnaire was developed to assess healthcare providers’ knowledge, comfort level and experience of family meetings.

2. Chart review was conducted to document the variations and lack of consistency of family meetings.

1. Improved rating in perception of level of adequate training was found. There was an improvement in level of comfort after education.

2. Chart review demonstrated improvement in all areas of the team meeting documentation, indicating potential improved communication with the family and between care providers throughout all shifts.