Program increases clinician-patient communication, shifts focus to ‘what matters most’
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Despite recommendations in clinical guidelines, a high proportion of patients with advanced cancer do not have appropriate conversations with health care providers about prognosis, treatment options and end-of-life preferences.
Only about 30% of patients who do engage in these discussions — known as serious illness conversations — have them with their primary oncologist.
Researchers at Dartmouth Cancer Center implemented a quality improvement project designed to increase the occurrence and documentation of serious illness conversations in the institution’s sarcoma and head and neck cancer clinics.
Their findings — published in JCO Oncology Practice — showed nearly three-quarters of eligible patients participated in these discussions after the intervention, compared with 0% at baseline. Most conversations occurred between patients and oncologists (57%), followed by specialty palliative care clinicians (30%) and advanced practice registered nurses (14%).
Healio spoke with two of the investigators — Garrett T. Wasp, MD, MPH, assistant professor of medicine at Geisel School of Medicine at Dartmouth and medical oncologist at Dartmouth Cancer Center, and Amelia M. Cullinan, MD, director of outpatient palliative care services and co-director of the serious illness care program at Dartmouth Hitchcock Medical Center — about the rationale for the initiative, the success it demonstrated, how they intend to expand the effort at Dartmouth and how other institutions can adopt a similar approach.
Healio: Can you describe your motivation for starting this project?
Wasp: Oncology practice guidelines indicate we should have serious illness conversations early on — and for all patients with advanced cancer. In my own practice, I feel having these conversations helps the clinical team, as well as the patient and his or her family better understand what is most important and clarify what is medically achievable. From the cancer center perspective, we needed a systematic approach to conduct and document these interactions so we could ensure all patients who needed these important conversations have them.
Healio: What does a “serious illness conversation” comprise?
Cullinan: The Serious Illness Conversation guide, developed by Ariadne Labs at Brigham and Women’s Hospital/Harvard T.H. Chan School of Public Health, is a patient-, family- and clinician-tested tool that can be downloaded at no cost at www.ariadnelabs.org/wp-content/uploads/2017/05/SI-CG-2017-04-21_FINAL.pdf. The guide provides language and structure to navigate sensitive conversations. The guided conversation allows clinicians to elicit the patients’ own understanding of their illness and desired prognostic information, and then share tailored information with them. The conversation then draws out patients’ values and goals.
Healio: Why is it important that serious illness conversations occur early in treatment for people with advanced cancer?
Wasp: Oncology practice guidelines emphasize early conversations for two main reasons. First, unexpected events can happen at any time during the illness course, so it is best to understand preferences in advance of those changes. Second, patients have the most options earlier in the illness course, so mapping out patient values early provides the best chance to ensure that care is goal-concordant.
Healio: Can you briefly describe the results of your project?
Wasp: Our study describes the first part of an ongoing, sequential, cancer center-wide initiative to educate oncology teams about having serious illness conversations, and to make these conversations normal procedure for all seriously ill patients. In the clinics we targeted, the multidisciplinary and embedded family care partner approach we followed increased our documentation of these important conversations from 0% to 70% of eligible patients. We did this work at the start of the COVID-19 pandemic, and the disruption provided both opportunities and challenges. Telehealth allowed us to do standalone conversations with patients and their families uncoupled from chemotherapy visits, which allowed for a better focus on what matters most to them. However, workforce disruptions made it harder to incorporate other members of the care team — such as social workers and nurse navigators — directly into the conversations.
Healio: Did the results meet your expectations?
Wasp: Yes, but there is definitely more work to be done. All parties involved feel proud of the uptake and documentation of these conversations. Nevertheless, the final rates of documentation were around 70% of patients and, according to guidelines, they ideally should be 100%. The experience of integrating a family care partner was positive for our group, and more work needs to be done to evaluate spreading this approach to other clinics. We are currently doing that work.
Healio: What type of instruction did clinicians receive at the start of the program?
Cullinan: The centerpiece of this model of care is the Serious Illness Conversation Guide — which we teach clinicians in a 3-hour, interactive, skills-based workshop — and then offer in-person coaching when clinicians are integrating their first serious illness conversations with their patients. Most clinicians either declined coaching or used coaching one to two times before becoming independent.
Healio: Why is it important to document these conversations?
Wasp: The benefits of the documentation are more theoretical rather than directly linked to an outcome that makes a patient’s life better. Potential benefits include sharing the patient’s values of medical treatment to a wider audience of clinicians. Patients receive medical care across various settings (eg, inpatient, outpatient, etc.) and all parties involved want to have the most up-to-date understanding of what matters most to patients and their understanding of what is medically achievable. I believe these conversations are more flexible and clinically useful than traditional advanced directives, and the documentation aspect still has the same downsides as advanced directives.
Healio: What is the role of caregivers or family members in these conversations?
Wasp: We train clinicians and develop workflows to help maximize the opportunity for family and caregivers to join the conversation. However, we first ask the patient his or her own preference for family or caregiver involvement. Often the patient's preference drives family/caregiver participation.
Healio: How would you suggest other institutions implement a similar program?
Wasp: The Serious Illness Conversation Guide developed by Ariadne Labs is a nice tool for supporting clinicians through the conversation. In terms of health system support, the following likely are helpful: communication skills training; a standardized way to document and access these conversations via the electronic medical record; and implementation support as the clinical teams work through integrating new processes into routine care.
Healio: What are your next steps?
Wasp: We already have spread the intervention to other clinics in the cancer center and are analyzing the outcomes of that work. We will present a poster at ASCO Quality Care Symposium in October that will highlight those results. In the future, we intend to expand the program to different specialty groups beyond medical oncology.
Healio: Is there anything else you feel is important to emphasize?
Wasp: Standalone telehealth visits to conduct these conversations during the COVID-19 pandemic felt like a good strategy for many patients to involve other family members in these conversations and create a “space” for this communication, aside from the routine clinical work of safely giving cancer treatments that tend to crowd out other activities during the clinic visit.
For more information:
Amelia M. Cullinan, MD, can be reached at Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756; email: amelia.m.cullinan@hitchcock.org.
Garrett T. Wasp, MD, MPH, can be reached at Norris Cotton Cancer Center at Dartmouth-Hitchcock, 1 Medical Center Drive, Lebanon, NH 03756; email: garrett.t.wasp@hitchcock.org.
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