280 Seminars in Oncology Nursing, Vol 30, No 4 (November), 2014: pp 280-286

PALLIATIVE

CARE COMMUNICATION

ELAINE WITTENBERG-LYLES, JOY GOLDSMITH, AND CHRISTINE SMALL PLATT

Elaine WitResearch an

Joy GoldsmitUniversity of

Platt, MBA: Dof Memphis,

Address co

PhD, Divisio

City of Hope,

Duarte, CA 9

� 2014 Els

0749-2081/30

http://dx.doi.

OBJECTIVES: To summarize the challenges of teaching, practicing, and

learning palliative care communication and offer resources for improving

skills and educating others.

DATA SOURCES: A theoretically grounded, evidence-based communication

curriculum called COMFORT (Communication, Orientation and

opportunity, Mindful presence, Family, Openings, Relating, and Team).

CONCLUSION: The COMFORT curriculum is available for free through a Web

site, a smartphone/iPad application, and online for continuing education units.

IMPLICATIONS FOR NURSING PRACTICE: The COMFORT curriculum provides

resources to support the expansion and inclusion of palliative care practice

not only in oncology, but also in a wide variety of disease contexts.

KEY WORDS: Palliative care, communication, communication education,

nurse communication

INTEGRATING palliative care into oncologyrequires sensitive communication aboutdiagnosis, discussing factors influencingtreatment decision-making (employment,

financial, familial), relaying and mediatingcommunication among family members, and psy-chosocial counseling about difficult topics. A seriesof randomized controlled trials have recentlydemonstrated the benefits of palliative care in pa-

tenberg-Lyles, PhD: Division of Nursing

d Education, City of Hope, Duarte, CA.

h, PhD: Department of Communication,

Memphis, Memphis, TN. Christine Small

epartment of Communication, University

Memphis, TN.

rrespondence to Elaine Wittenberg-Lyles,

n of Nursing Research and Education,

1500 E. Duarte Road, Pop Sci Bldg 173,

1010. e-mail: elyles@coh.org

evier Inc. All rights reserved.

04-$36.00/0.

org/10.1016/j.soncn.2014.08.010

tients with advanced cancer integrated into stan-dard oncology care.1 Language is critical tofacilitating access to services because mostAmericans do not understand the term palliative

care,2 making it necessary for providers to beskilled at defining and describing the scope of palli-ative services.3 Articulating goals of care is anessential element of these conversations, so thatthis information can be shared with the oncologyteam who works with the patient and family tochoose appropriate care plans.4

When appropriate words are used to describepalliative care, consumers respond positively andwant palliative care services.2 However, fewnurses are prepared for or feel adept at facilitatingdiscussions about palliative topics and most reportreceiving little to no education about palliativecare communication.5 Yet, as our population con-tinues to age and the number of individuals withlife-limiting illness increases, it is necessary forall clinicians to be able to approach patients andfamilies about the services and benefits of

PALLIATIVE CARE COMMUNICATION 281

palliative care. This article presents an overview ofthe challenges of teaching, practicing, andlearning palliative care communication, and offersresources, tools, and training programs forimproving individual skills and educating others.The experiences of a pediatric oncology nurse,Jeremy, are used to feature moments in the prac-ticing life of a nurse and the communicationtraining needs encountered. Jeremy’s experiencesdepict communication difficulties and demon-strate the application of specific resources in clin-ical education and practice.

THE CHALLENGES OF PALLIATIVE CARE

COMMUNICATION

For nurses, palliative care communication canbe challenging for two primary reasons. First,healthcare systems create complex communica-tion environments for patient access and deliveryof palliative care. A lack of knowledge about palli-ative care still exists for some providers,3 makingit necessary for palliative care clinicians to providesystem-level education about the specialty toestablish referral networks.6 This lack of under-standing is convoluted by the debate over thename palliative care, with oncologists reportingpalliative care as a distressing term that reduceshope for patients and families.7 Patient and pro-vider education is needed to help patients andfamilies understand palliative care and the scopeof services provided by palliative care teams.2

In addition to these system-level influences oncommunication, nurses also face challenges withpalliative care communication topics and complexclinical situations. Nurses report being uncomfort-able discussing prognosis, hospice, advanced careplanning, referring a patient to hospice, and tellinga patient that he/she will die from cancer.8-11 In anational study, 46% of oncology nurses describedthat they sometimes, often, or always avoidedtalking with patients because they were uncom-fortable giving bad news.10 Team communicationcan also be problematic because of a lack of clearlydefined responsibilities among team members,reliance on informal channels of communication,and conflict caused by social circumstances.12

COMMUNICATION AND CLINICAL EDUCATION

Less than 10 years ago, nurses only received oneor two lectures on palliative care as part of their

nursing program education.13 Today, advances incurricular development in undergraduate and grad-uate nursing programs remain negligible.14 Grad-uate student nurses have limited knowledge aboutpalliative care15 and there are few interprofessionallearning opportunities for undergraduate and grad-uatenursesandeven less throughcontinuingeduca-tion forums.12,16 Overall, there is a general need forfurther education about palliative care in graduateand undergraduate nursing programs.While symptom management is consistently re-

ported as a top content area for palliative care ed-ucation, instruction on communication and howto communicate with patients and families aboutdeath and dying is also a well-documentedneed.15,17 Nurses need and want more educationon communication.10 Nurse communicationtraining has yielded significant results in theassessment of immediate outcomes (confidence,knowledge); however, retention of confidenceand skills has not been successfully demon-strated.18 The interdisciplinary structure of thepalliative care team also requires nurses to haveexposure to interprofessional education todevelop leadership skills and gain clarity on thenursing role within a team-based approach tocare.12 Aside from the 1-hour module on commu-nication in the End-of-Life Nursing EducationConsortium, which is offered as a continuing edu-cation course and not required by all nurses, mostnurses learn communication skills from on-the-job training, preceptors, and colleagues.19 Howev-er, these skills may or may not be evidenced-basedcommunication strategies that ensure quality pa-tient and family care or effective team practice.

APPROACH TO COMMUNICATION

The majority of nurse communication traininghas been modeled after approaches taken in medi-cine. Training workshops have included adaptedversions of ONCO-Talk20 or EPEC21 which providetraditional sender-receiver models of communica-tion andprimarily depict and address the role of thephysician. These programs prioritize informationexchange and ensure receipt of messages.22 Incontrast, the nurse’s communication role is trans-actional in nature, which means that both nurseand patient/family simultaneously and recipro-cally design, deliver, and interpret messages andcreate meaning together.23 In this transactionalmodel of communication, information is not

FIGURE 1. Health communication: building professionalskills (iOS App).

282 E. WITTENBERG-LYLES, J. GOLDSMITH, AND C.S. PLATT

deposited and then assessed for receipt; rather, it iscreated through the interaction with an emphasison task communication (accomplishing therelaying of information) alongside relationalcommunication (conveying nonverbal communi-cation). This approach is predicated upon theaxiom that people communicate all the time,regardless ofwhether or not they intend to commu-nicate, and that every message (verbal ornonverbal) conveys both content (verbal message)and relationship (nonverbal communication).24

Based on this approach to communication, the au-thors created an innovative curriculum calledCOMFORT and a series of ancillary resources.These resources are identified and described here.

COMFORT COMMUNICATION CURRICULUM

The COMFORT communication curriculum is atheoretically grounded curriculum for teachingpalliative care communication.23,25,26 COMFORTis an acronym that stands for C-Communication,O-Orientation and opportunity, M-Mindful pres-ence, F-Family, O-Openings, R-Relating, andT-Team and is detailed in a volume on communica-tion in palliative nursing.23 Narrative communica-tion is introduced as a communication techniqueto draw out patient/family stories, use the informa-tion as a guide in care planning, and provideperson-centered messages in difficult communica-tion situations. The use of nonverbal communica-tion is also highlighted to emphasize relationalcommunication strategies. The curriculum is not alinear guide, an algorithm, a protocol, or a rubricfor sequential implementation by clinicians, butrather a set of holistic principles that are practicedconcurrently and reflectively during patient/familycare. This patient-centered approach emphasizesthe collaborative, reciprocal nature of clinician-patient-family interactions as participants relation-ally create andadapt to sharedmeaning.COMFORThas been shown to improve clinician self-efficacy,attitudes toward communication, and reducecommunication apprehension.27,28

A key goal in the development of the COMFORTcurriculum was to disseminate resources and ma-terials for teaching, practicing, and learning pallia-tive care communication. Specific projectsinclude establishing a Web site to house all curric-ular materials, an iOS smartphone/iPad applica-tion (app) with communication strategies (seeFig. 1), and expanding the curriculum availabilityto online continuing education platforms. These

resources are readily available without cost ormembership.

TEACHING PALLIATIVE CARE COMMUNICATION

‘‘Gloria, a nurse faculty member, was assigned

to teach a new course called Trends in Nursing inthe undergraduate nursing program at her col-

lege. Within the BSN curriculum, the course ex-

plores the legal and ethical relationships in

nursing, palliative and end of life care, the eco-nomics of dying, and interpersonal relationships

among healthcare professionals, families, and pa-

tients. Gloria’s own clinical practice in oncology

and palliative care was extensive. However, she

had never built a course on these topics and

was searching for teaching materials in one loca-

tion to support the course objectives. A senior

faculty member directed Gloria to a new Website, the Clinical Communication Collaborative

(www.clinicalcc.com). Here she found developed

modules, instruction manuals with a variety of

PALLIATIVE CARE COMMUNICATION 283

teaching resources, power points, and directly

related research articles. Gloria integrated theseresources along with competency topics for the

class. As the course unfolded, a second-career

nursing student, Jeremy, found himself parti-

cularly drawn to palliative care as an area of

clinical practice. He met many times with Gloria

as he began to identify the essential role of pallia-

tive care in the field of pediatric oncology which

he hoped to enter upon graduation.’’The acceptance of palliative care as a specialty

presents a new demand as well as an opportunityfor nurse educators. The challenge for many clin-ical educators in nursing is integrating palliativecare content along with content specific to seriousand life-threatening cancers.29 The majority ofpalliative care patients are referred from oncology,thus nurse educators are challenged to effectivelyjoin these two disciplines. With few resourcesavailable and the demand to disseminate contenthigh, Gloria and other nurse faculty in the USare still limited in the availability of resources.

To disseminate curriculum for faculty, the Clin-ical Communication Collaborative (CCC) Website was launched in October 2012. The CCC is aresource Web site that houses clinical communi-cation tools for healthcare professionals. Thegoal is to support clinicians and educators throughcommunication training, education, and researchin order to meet the changing demands of health-care systems and address patient/family needs inthe context of cancer and other serious illnesses.The National Consensus Project for Quality Pallia-tive Care guidelines articulate how vital palliativecare communication and delivery is to all aspectsof oncology care. The formation and distributionof a curriculum and ancillary resources featuringcommunication in the practice of palliative careenables the work of faculty training the next gen-eration of clinicians. Uniquely, CCC intentionallyplaces COMFORT at the center of the curriculum.Resources featuring the COMFORT communica-tion curriculum have been tested, peer-reviewed,and taught,28,30,31 and are available to educatorson the CCC Web site.

PRACTICING PALLIATIVE CARE COMMUNICATION

‘‘Jeremy graduated and has been working on a

pediatric oncology wing of a comprehensivecancer center. The Wu family from Lijiang China

arrived to pursue care for their child Anli. At age

7 she had been diagnosed with brain stem glioma

and Jeremy became Anli’s nurse. She declined

rapidly and within days of their arrival lost theability to walk. The family brought with them

traditional healing herbs essential to the beliefs

and practices for many Chinese citizens. The

smell was strong by Western standards. Almost

immediately, other patients and families noticed,

and nursing staff began to complain. Pressure

from two unit nurses forced the Wu family to

dispose of the precious blend of herbs. A day later,the family announced that they were planning to

leave the hospital because they were not allowed

to include essential components from their own

culture. Jeremy consulted an app on his smart-

phone and located the cultural differences tab

with suggested communication strategies, and

used the information when he asked the family,

‘‘Can you describe the power of the herbs youbrought with you so we can find a way to incor-

porate them into your care?’’

Culture, team communication, structures ofinstitutional practice, and interpersonal commu-nication across cultures are just some of the mov-ing parts in the Wu family’s distress. The Wu’sprofound need to include their own cultural andspiritual practices related to the use of healingherbs was lost to the institution, its clinicians,and patients and families also receiving care onthe same floor. Eliciting essential informationfrom a patient and most especially a family isimperative to ensuring the best comfort possible.Palliative care delivered in the context ofadvanced cancer demands attention to psychoso-cial and spiritual aspects of dying. Palliative carecommunication must engage patients (and fam-ilies) in shared decision-making and includehonesty, inquiry, repetition, and empathy.4

Jeremy’s attempt to build a bridge to theWu’s afterconflict had escalated represents a clear effort topreserve quality care for this family.Pediatric oncology presents unique and com-

plex demands for parents who are confrontedwith the demand of decision-making and its pro-found implications and burdens.32 Like the Wu’sneed to integrate their own cultural practices forspiritual support, nursing communication strate-gies meant to achieve palliative goals are vital toreducing family suffering. Advance care planningis also a neglected topic by nurses who lack expe-rience, education, and time to address this impor-tant communication task.33 Not unlike the Wu’s,barriers to culture, health literacy, and the lifeworld of the patient/family are destructive to the

284 E. WITTENBERG-LYLES, J. GOLDSMITH, AND C.S. PLATT

trust shared between a nurse and patient/family.Nurses need a range of resources to manage theongoing challenge of communicating respect andcompassion to alleviate the cross-cultural burdensin terminal illness.

Health CommunicationBuilding Professional Skills is a smartphone or

iPad app that presents free, easily accessedprompts to help nurses engage palliative carecommunication practices (Fig. 1). Built from theCOMFORT curriculum housed on the CCC Website, The ‘Communication Toolkit’ and ‘DifficultScenarios’ provide over 100 practical skills injust seconds—for nurses like Jeremy who need im-mediate access to support for challenging commu-nication situations (Table 1). The toolkit feature ofthe app identifies communication topics for spe-cific nurse needs, such as dealing with family care-givers, health literacy tools, and responding tohard questions. Likewise, a separate componentof the app addresses difficult scenarios and pro-vides instruction on what to observe, what toask, and how to respond based on the context.More than 700 healthcare professionals havedownloaded the app since its release in September2013, primarily within the United States as well asthe United Kingdom, Canada, and Australia.

LEARNING PALLIATIVE CARE COMMUNICATION

While a core tenet of palliative care is that it isinterdisciplinary, courses and other educationalprograms for team practice and communicationare rare,16 Jeremy needed resources to improve

TABLE 1.Health Communication: Building Professional Skills

(iOS App)

Download Find Free App from iTunes Store

Navigate Select communication challenges you are

facing

Identify communication tools to employ in your

context

View See short video support from CCC faculty

about challenges in clinical communication

Engage Communicate with patients, families, teams

using the support and practical suggestions

from the Health Communication App

Respond Share your feedback and suggestions with us

using our brief pop-up survey

his situation, but had limits on his time in lightof his full work schedule. Given that continuingeducation is valued among hospice and palliativecare nurses,17 and self-directed learning packageshave been successfully implemented,18 Web-based and online platforms for instruction maybe viable options for providing palliative carecommunication education. E-learning and work-place distance learning have been proffered asfeasible educational approaches to meet educa-tional needs in palliative care.14

To meet the growing demand for interprofes-sional education and resources, two versions ofthe COMFORT modules were created forcontinuing education and made available at nocost. Through CECentral, offered through Univer-sity of Kentucky Healthcare (www.cecentral.com/comfort), four COMFORT modules were madeavailable (communication, orientation and oppor-tunity, family, and team). Each module consists ofa video introduction, brief didactic overview ofcommunication concepts, analysis of recordedreal-time interactions among hospice team mem-bers, and debriefing of exemplary and missedcommunication strategies. COMFORT delivery inonline modules has been an effective onlinecurricular tool in teaching a variety of disciplinesspecific palliative care communication strate-gies.31 After a peer-review process facilitatedthrough the Association of American Medical Col-leges, the COMFORT curriculum was selected asan Interprofessional Education Collaborativeresource. The curriculum was revised and shapedfor interprofessional learners, and the MedEd por-tal Web site continues to provide COMFORTprint materials including teaching instructions(www.mededportal.org/publication/9298).

RESEARCH IMPLICATIONS AND FUTURE NEEDS

In addition to structural and health policychanges, increased training of palliative carenurses and oncologists will be critical to meetthe growing demand for high-quality palliativecare and to meet the vision set by the AmericanSociety of Clinical Oncology (ASCO) for full inte-gration of palliative care by 2020.1 Full integrationof palliative care will be highly dependent on thenurse’s ability to provide early and ongoing assess-ment of patient and family palliative care needs,requiring flexible and fluid communication thatincludes the ability to interpret medical jargon,

PALLIATIVE CARE COMMUNICATION 285

procedures, treatment, manage conflict betweenfamily members, and convey support in decision-making about oncology care. Multiple educationmodalities are needed to reach nurses across a va-riety of care settings and bridge geographic bar-riers and financial constraints present in themajority of healthcare systems today.

The teaching of palliative care communicationwill be important to easing student concerns,fears, and trepidation about palliative care con-texts–a necessary component of encouraging stu-dents to focus on a career, commitment, andunderstanding of palliative care. To accomplishthis, educators need curriculum that incorporatesbuilding communication skills into palliative carecoursework. The short- and long-term goals of theClinical Communication Collaborative are de-signed to lay the foundational communicationframework to support curriculum development.Retaining professional palliative care staff alsocontinues to be challenging, often leading tohigh staff turnover.2 Future work is needed todevelop curriculum that also addresses the self-care needs of palliative care staff to aid in reten-tion efforts.

The current practice of palliative care commu-nication requires staff to focus on barriers topatient-centered communication and serve in areactive rather than proactive role. As palliativecare programs become more established, futurework will need to focus on the delivery processof care and how these processes influence commu-nication with patients and families. Communica-tion barriers, such as the one Jeremyexperienced with the Wu family, often havemore to do with reactive decisions rather thanproactive decision-making. Implementing pro-cesses of care that incorporate patient/familycommunication to determine care concerns andneeds at the beginning of care will serve as bettermodels of palliative care and potentially defraycosts associated with communication conflicts.Patient and family education, a cornerstone ofpalliative care communication, should be devel-oped so that communication practices meet

health literacy needs and include various modesof delivery, such as print and video.Future research should assess the benefits and

impact of social media and technology-basedcommunication among staff/palliative care.2 TheClinical Communication Collaborative continuesto research, plan, and develop alternative chan-nels to advance knowledge about palliative carecommunication, facilitating interventions thatwill improve psychosocial care across healthcaredisciplines and systems. Communication solu-tions such as Health Communication: BuildingProfessional Skills allow easy and unlimited accessto theory-based support tools; however, researchis needed to determine if nurses will use thesetools and how they will impact care delivery.Finally, learning palliative care communication

requires interprofessional education as well asteam-building activities to sustain team-based ap-proaches to care. Small group and problem-basedlearning approaches that facilitate the develop-ment of team communication and teamwork needto be a focal point of curricular development.Evolved educational programs like COMFORT,although nontraditional, may offer one approachto fostering team-based palliative care. Nursingprograms have traditionally relied onnurse-faculty and there is a need to explore usinginterdisciplinary faculty to teach palliative carecommunication.12 To meet this challenge, COM-FORT facilitator guides need further developmentfor all levels of nurse instruction, including specificgraduate nursing programs and multidisciplineteams.Regardless of advances in training and educa-

tion, the connection between competency andpractice has yet to be resolved in clinical communi-cation research. Outcome assessment followingimmediate conclusion of a training program doesnot necessarily yield implementation intopractice.As noted, patient feedback regarding nursecommunication is missing in interventionresearch.34 In-service support tools and continuingeducation modalities must reflect integrated, real-world situations with pragmatic solutions.

REFERENCES

1. Smith T, Temin S, Alesi E, et al. American Society of Clin-

ical Oncology provisional clinical opinion: the integration of

palliative care into standard oncology care. J Clin Oncol

2012;30:880-887.

2. Fletcher DS, Panke JT. Improving value in healthcare:

opportunities and challenges for palliative care professionals

in the age of health reform. J Hosp Palliat Nurs

2012;14:452-461.

286 E. WITTENBERG-LYLES, J. GOLDSMITH, AND C.S. PLATT

3. Ritchie CS, Ceronsky L, Cot�e TR, et al. Palliative care pro-

grams: the challenges of growth. J Palliat Med 2010;13:1065-

1070.

4. Gaertner J, Weing€artner V, Wolf J, Voltz R. Early palliative

care for patients with advanced cancer: how to make it work?

Curr Opin Oncol 2013;25:342-352.

5. Krimshtein NS, Luhrs CA, Puntillo KA, et al. Training

nurses for interdisciplinary communication with families in

the intensive care unit: an intervention. J Palliat Med

2011;14:1325-1332.

6. Glare PA. Early implementation of palliative care can

improve patient outcomes. J Natl Compr Canc Netw

2013;11(suppl 1):S3-S9.

7. Fadul N, Elsayem A, Palmer JL, et al. Supportive versus

palliative care: what’s in a name?: a survey of medical oncolo-

gists and midlevel providers at a comprehensive cancer center.

Cancer 2009;115:2013-2021.

8. Boyd D, Merkh K, Rutledge DN, Randall V. Nurses’ percep-

tions and experiences with end-of-life communication and care.

Oncol Nurs Forum 2011;38:E229-E239.

9. Schulman-Green D, McCorkle R, Cherlin E, Johnson-

Hurzeler R, Bradley EH. Nurses’ communication of prognosis

and implications for hospice referral: a study of nurses caring

for terminally ill hospitalized patients. Am J Crit Care

2005;14:64-70.

10. Helft PR, Chamness A, Terry C, Uhrich M. Oncology

nurses’ attitudes toward prognosis-related communication: a

pilot mailed survey of oncology nursing society members. On-

col Nurs Forum 2011;38:468-474.

11. Zhou G, Stoltzfus JC, Houldin AD, Parks SM, Swan BA.

Knowledge, attitudes, and practice behaviors of oncology

advanced practice nurses regarding advanced care planning

for patients with cancer. Oncol Nurs Forum 2010;37:E400-

E410.

12. Klarare A, Hagelin CL, F€urst CJ, FossumB. Team interac-

tions in specialized palliative care teams: a qualitative study.

J Palliat Med 2013;16:1062-1069.

13. Dickinson GE. End-of-life and palliative care issues in

medical and nursing schools in the United States. Death Stud

2007;31:713-726.

14. Becker R. Embracing education in palliative care. Int J

Palliat Nurs 2005;11:404.

15. Shea J, Grossman S, Wallace M, Lange J. Assessment of

advanced practice palliative care nursing competencies in

nurse practitioner students: implications for the integration of

ELNEC curricular modules. J Nurs Educ 2010;49:183-189.

16. Supiano KP. Weaving interdisciplinary and discipline-

specific content into palliative care education: one successful

model for teaching end-of-life care. Omega (Westport)

2013;67:201-206.

17. White KR, Coyne P, White S. Are hospice and palliative

nurses adequately prepared for end-of-life care? J Hosp Palliat

Nurs 2012;14:133-140.

18. Pitman S. Evaluating a self-directed palliative care

learning package for rural aged care workers: a pilot study. Int

J Palliat Nurs 2013;19:290-294.

19. Mullan BA, Kothe EJ. Evaluating a nursing communica-

tion skills training course: the relationships between self-rated

ability, satisfaction, and actual performance. Nurse Educ Pract

2010;10:374-378.

20. Back AL, Arnold RM, Tulsky JA, Baile WF, Fryer-

Edwards KA. Teaching communication skills to medical

oncology fellows. J Clin Oncol 2003;21:2433-2436.

21. The EPEC Project. Funded by The Robert Wood Johnson

Foundation: Institute for Ethics at the AmericanMedical Associ-

ation; 1999. Available at: http://www.epec.net. (accessed Sep 23,

2014).

22. Wittenberg-Lyles EM, Goldsmith J, Sanchez-Reilly S,

Ragan SL. Communicating a terminal prognosis in a palliative

care setting: deficiencies in current communication training

protocols. Soc Sci Med 2008;66:2356-2365.

23. Wittenberg-Lyles E, Goldsmith J, Ferrell B, Ragan S.

Communication inpalliativenursing.NewYork,NY:Oxford;2012.

24. Watzlawick P, Beavin J, Jackson DD. Pragmatics of hu-

man communication: a study of interactional patterns, pathol-

ogies, and paradoxes. New York: W.W. Norton; 1967.

25. Ragan S, Wittenberg-Lyles EM, Goldsmith J, Sanchez-

Reilly S. Communication as comfort: multiple voices in pallia-

tive care. New York: Routledge; 2008.

26. Wittenberg-Lyles E, Goldsmith J, Ragan S, Sanchez-

Reilly S. Dying with comfort: family illness narratives and early

palliative care. Cresskill, NJ: Hampton Press; 2010.

27. Wittenberg-Lyles E, Goldsmith J, Ragan S. The COM-

FORT initiative: palliative nursing and the centrality of commu-

nication. J Hosp Palliat Nurs 2010;12:282-294.

28. Wittenberg Lyles E, Goldsmith J, Richardson B, Hallett J,

Clark R. The practical nurse: a case for COMFORT communica-

tion training. Am J Hosp Palliat Care 2013;30:162-166.

29. Grant M, Elk R, Ferrell B, Morrison S, vonGunten C. Cur-

rent status of palliative care–Clinical implementation, educa-

tion, and research. CA Cancer J Clin 2009;59:327-335.

30. Goldsmith J, Wittenberg-Lyles E. Comfort: Evaluating a

new communication curriculum with nurse leaders. J Prof

Nurs 2013;29:388-394.

31. Wittenberg-Lyles E, Goldsmith J, Ferrell B, Burchett M.

Assessment of an interprofessional online curriculum for pallia-

tive care communication training. J PalliatMed 2014;17:400-406.

32. Foster T, Lafond D, Reggion C, Hinds P. Pediatric pallia-

tive care in childhood cancer nursing: From diagnosis to cure

or end of life. Semin Oncol Nurs 2010;26:205-221.

33. Blackford J, Street AF. Facilitating advance care planning

in community palliative care: conversation starters across the

client journey. Int J Palliat Nurs 2013;19:132-139.

34. Raunkiaer M, TimmH. Interventions concerning compe-

tence building in community palliative care services–a litera-

ture review. Scand J Caring Sci 2013;27:804-819.