Table 2.

Supportive and inhibitive aspects of clinical culture of serious illness communication

Domain	Inhibitive culture aspects	Supportive culture aspects
Clinical paradigms • Knowledge & assumptions • Beliefs • Attitudes	• Association of serious illness communication with discussions about dying, hospice, or life-sustaining treatment decisions • Beliefs that serious illness conversations have a pre-ordained outcome of withdrawing or limiting curative care • Conflicted attitudes and discomfort toward communication	• Adoption of a definition of serious illness communication as knowing and honoring what matters to patients • Beliefs that the purpose of serious illness communication is to strengthen therapeutic relationships, provide emotional support, and enable partnership in all treatment decisions • Positive attitudes toward and comfort with eliciting patients’ values and goals
Interprofessional empowerment • Confidence and self-efficacy • Psychological safety and trust • Role identity	• Reluctance and nervousness about conversations with patients because of uncertainty about what to say • Perceptions that serious illness communication is the physician’s job; lack of psychological safety for inter-professional clinicians • Feeling uncertain about role and scope of practice in serious illness communication	• Improved comfort and self-efficacy in initiating serious illness conversations with patients • Acceptance of inter-professional roles in serious illness communication; enhanced psychological safety and trust • Integration of serious illness communication into professional roles
Perceived impact • Impact on patients • Impact on clinicians	• Concerns about taking away hope and increasing anxiety and/or sadness for patients • Feeling overwhelmed by serious illness communication due to discomfort with emotions and overburdened environments	• Perception that earlier values and goals conversations lessen distress for patients • Feeling more effective in personalizing care, more meaning and fulfillment at work, and stronger relationships with patients
Practice norms • Timing of conversations • Focus and content of conversations • Reliability and accountability	• Reactive approach to communication that ‘avoids’ conversations until a crisis or poor prognosis at end of life • Predominantly medically oriented content of the conversations e.g. hospice, code status, life-sustaining treatment preferences • Lack of reliable team processes or unclear roles, ‘chaos’ and ‘kicking the can down the road’ effects	• Integrating earlier and longitudinal conversations into practice • Enhanced focus of conversations on patients’ values, goals, hopes, and worries (rather than treatments and procedures) • Shared responsibility and accountability that integrates communication into team processes and norms