The second conversation: Improving training around end-of-life care conversations

Doctors often find it difficult to initiate conversations about end-of-life care. The 'second conversation', led by a junior doctor, gives patients, carers and family members the time and space to reflect on information they have received, whilst providing doctors in training with a valuable educational opportunity that builds their skills and confidence in handling end-of-life care discussions.  

What we are doing

Piloting the 'second conversation' model

Initial conversations broaching end-of-life care tend to be led by a senior member of the medical team – usually the consultant or specialist registrar. These conversations can include subjects such as:

  • withdrawing or withholding treatment
  • changing the focus to best supportive care
  • discussing preferences regarding future care and escalation plans.

When these conversations are challenging, they can have a profound and lasting effect on the patient and clinician involved. This can create a culture of fear about initiating such conversations in future, meaning patients may be denied the opportunity to talk about what’s important to them.

Best practice suggests that patients, families and carers should be offered a follow-up conversation after imparting significant news, in order to ensure they fully understand the implications and have a chance to ask questions. 

The 'second conversation' model, currently being piloted at three NHS trusts in London, proposes that the second conversation is led by a foundation trainee, affording them an on-the-job opportunity to build their skills and confidence in communicating end-of-life care issues early in their career. This kind of experiential learning, supported by built-in observation, reflection and feedback, serves as a useful educational tool in breaking the barriers around talking about end-of-life care.

Educational benefits for trainees

Junior doctors taking part in the pilot have praised the structure of the second conversation model, noting that they found themselves listening more actively during the first conversation and felt better prepared for conversations with patients and carers. The 'second conversation' has also been used by trainees as an opportunity to complete an assessment in the ePortfolio, such as a mini clinical evaluation exercise, case-based discussion or reflection.

Evaluating the pilot

Led by Guy's and St Thomas' NHS Foundation Trust (GSTT), the second conversation model is being tested using quality improvement methodology at GSTT, Whittington Health NHS Trust and the Royal Free London NHS Foundation Trust. The Cicely Saunders Institute, King's College London, is leading an independent research study exploring the experiences of those using the second conversation model, together with views of patients and carers where appropriate. 

Find out more

For more information about the second conversation model and pilot, and to find out how you can get involved, please contact the project lead, Kimberly St John, at secondconversation@gstt.nhs.uk

The RCP's year-long campaign, Our Future Health, explores some of the challenges facing patients and clinicians in today's NHS, including issues around end-of-life care.

Who's involved

Organisations

  • Department of Ageing and Health and POPS (proactive care of older people going to have surgery) service at St Thomas’ Hospital
  • Department for the Care of Older People at the Whittington Hospital
  • Department for Elderly Medicine at the Royal Free Hospital