Palliative consultations improve outcomes of care, and earlier consultations may confer additional benefit.

Objective: It is not known how often physicians use metaphors and analogies, or whether they improve patients' perceptions of their physicians' ability to communicate effectively. Therefore, the objective of this study was to determine whether the use of metaphors and analogies in difficult conversations is associated with better patient ratings of their physicians' communication skills. Design: Cross-sectional observational study of audio-recorded conversations between patients and physicians. Setting: Three outpatient oncology practices. Patients: Ninety-four patients with advanced cancer and 52 physicians. Intervention: None. Main outcome measures: Conversations were reviewed and coded for the presence of metaphors and analogies. Patients also completed a 6-item rating of their physician's ability to communicate. Results: In a sample of 101 conversations, coders identified 193 metaphors and 75 analogies. Metaphors appeared in approximately twice as many conversations as analogies did (65=101, 64% versus 31=101, 31%; sign test p < 0.001). Conversations also contained more metaphors than analogies (mean 1.6, range 0-11 versus mean 0.6, range 0-5; sign rank test p < 0.001). Physicians who used more metaphors elicited better patient ratings of communication (r ¼ 0.27; p ¼ 0.006), as did physicians who used more analogies (Spearman r ¼ 0.34; p < 0.001). Conclusions: The use of metaphors and analogies may enhance physicians' ability to communicate.

The FATE survey offers an important source of quality data that can be used to improve the end-of-life care of all veterans, regardless of the type of care they receive or their site of death.

To identify aspects of end-of-life care in the U.S. Department of Veterans Affairs (VA) health care system that are not assessed by existing survey instruments and to identify issues that may be unique to veterans, telephone interviews using open-ended questions were conducted with family members of veterans who had received care from a VA facility in the last month of life. Responses were compared to validated end-of-life care assessment instruments in common use. The study took place in four VA medical centers and one family member per patient was invited to participate, selected from medical records using predefined eligibility criteria. These family members were asked to describe positive and negative aspects of the care the veteran received in the last month of life. Interview questions elicited perceptions of care both at VA sites and at non-VA sites. Family reports were coded and compared with items in five existing prospective and retrospective instruments that assess the quality of care that patients receive near the end of life. Interviews were completed with 66 family members and revealed 384 codes describing both positive and negative aspects of care during the last month of life. Almost half of these codes were not represented in any of the five reference instruments (n=174; 45%). These codes, some of which are unique to the veteran population, were grouped into eight categories: information about VA benefits (n=36; 55%), inpatient care (n=36; 55%), access to care (n=33; 50%), transitions in care (n=32; 48%), care that the veteran received at the time of death (n=31; 47%), home care (n=26; 40%), health care facilities (n=12; 18%), and mistakes and complications (n=18; 27%). Although most of the reference instruments assessed some aspect of these categories, they did not fully capture the experiences described by our respondents. These data suggest that many aspects of veterans' end-of-life care that are important to their families are not assessed by existing survey instruments. VA efforts to evaluate end-of-life care for veterans should not only measure common aspects of care (e.g., pain management), but also examine performance in areas that are more specific to the veteran population.

This qualitative research article explores barriers experienced by a group of African American and Latinx adults who sought to enroll and stay enrolled in a publicly funded literacy class and how these barriers were related to policy. Barriers included (a) an inadequate number and type of available classes, (b) a lack of community awareness of classes, and (c) institutional procedures that determined class eligibility. Barriers were created as practitioners attempted to comply with government accountability policy and funding requirements. These findings provoke questions about whether accountability policies promote inequitable access to public adult literacy services for racially minoritized adults.