Communication gaps among clinicians may limit conversations about prognosis, hospice
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Clinicians in acute or post-acute care settings may delay or avoid serious illness conversations with patients whose cancer prognoses are worsening out of deference to the patient’s oncologist, according to study findings.
Researchers conducted 37 semi-structured interviews with physicians and leaders in hospital medicine, oncology, palliative care, home health care and hospice. Investigators coded and analyzed the interviews using thematic content analysis.
Evaluation of the responses yielded insights into how care silos, lack of clear clinical roles and other factors may affect communication between oncologists and other clinicians.
“The landscape of cancer care has dramatically changed in terms of new treatments, and clinicians with expertise in acute and post-acute care are hesitant to recommend hospice because they don’t know whether the oncologist may want to offer some cutting-edge clinical trial or new drug,” Sarguni Singh, MD, associate professor in the division of hospital medicine at University of Colorado Anschutz Medical Campus and University of Colorado Cancer Center member, told Healio. “These clinicians don’t feel empowered to have a differing opinion than the oncologist, when many times they might be the person with more experience assessing prognosis in a nursing home setting.”
Healio spoke with Singh about the rationale for the study, the key findings and how this potential care gap might be addressed.
Healio: Prior to your study, how much evidence existed about this topic?
Singh: There wasn’t a whole lot that I had seen in the literature about how dynamics between non-oncology and oncology clinicians may influence serious illness communication and hospice recommendations. A lot of the literature focuses on advance care planning initiatives, how to talk to people about end-of-life care, and the integration of palliative care with oncology care. There wasn’t much about how acute and post-acute care clinicians viewed their roles in leading or having these discussions compared with oncologists.
Healio: What motivated you to conduct this study?
Singh: Like most things in research, this came directly from my clinical experience. I work as an oncology hospitalist, so I care for older adults with cancer in the hospital setting. I discharge them to nursing homes, and I see the ways in which many clinicians with different expertise are deferring conversations about hospice enrollment to oncologists. It’s challenging and problematic because, oftentimes, oncologists aren’t available and haven’t seen their patients in a while. It ends up being that the people who are actually caring for these patients and see that they are getting worse don’t feel confident broaching the topic of hospice because they don’t want to step on the toes of the oncologist. Sometimes, the thinking is that the oncologist might have another line of treatment that they or the patient wants to pursue.
Healio: How did you conduct the study?
Singh: We had previously studied the perspectives of clinicians working in nursing homes. For this study we interviewed people who worked in different settings — hospitalists, palliative care specialists, and those who work in home health care and hospice settings. We also interviewed oncologists to get their perspectives.
The questions were initially set in the context of studying a palliative care intervention called ALIGN, which is intended to provide more support to patients with cancer going into nursing homes. We wanted to know how to make ALIGN more helpful to nursing staff, patients and everyone involved. In the answers to those questions, it really came through that there was an interesting dynamic between oncologists and non-oncologist clinicians.
Healio: What did you find?
Singh: The study yielded four main findings. First, people are very concerned that discharging an older adult with cancer to a skilled nursing facility can be a sign of worsening prognosis. There is a lot of concern that when we send people to these facilities, they’re not actually going to do better.
Second, the care silos that happen when you send a patient to a nursing home for subacute rehabilitation limit conversations about prognosis or recommendations for hospice during a time when patients are getting sicker and may be changing their preferences for care. These communication barriers may limit the delivery of goal-concordant care.
Third, clinicians noted that levels of distress among caregivers significantly escalates during the period of transition from a hospital to a nursing home and then from the nursing home back to the community. Caregivers are observing their loved ones get sicker and have more limited functional status. Finally, clinicians in acute, post-acute care, and in the community who are not trained in oncology are the ones taking care of these patients, but they don’t feel empowered to lead conversations about changing goals of care or hospice. There is a confusion about who is supposed to lead these types of conversations and the default pathway right now is to defer to the oncologist.
Healio: Why do you think non-oncologist clinicians feel this way?
Singh: There are many factors at play. I think clinicians in acute and post-acute care respect the oncologist’s knowledge base about available treatment options and their opinion on prognosis. This, in a way, sets the stage for non-oncology clinicians wanting “permission” to recommend hospice to a patient from the patient’s oncologist. In addition to the feeling of respect for the oncologist-patient relationship, it’s also about what patients and family members want, and many of them do look to their oncologists to make those decisions. The patient might say, “I want to talk to my oncologist about this.” Clinicians might be hesitant to step into that dynamic. Clinicians in acute and post-acute care may under recognize their own skill set in prognosis estimation.
Healio: What feedback did you get from the oncologists you interviewed?
Singh: I was surprised by what the oncologists said. The oncologists in this study acknowledged that they struggle with those conversations and that they do want the ability to weigh in, but they don’t necessarily view themselves as the only people in charge of having that conversation with the patient.
Healio: What are the potential effects of this gap in care?
Singh: We know that the 3-month window after an older adult with cancer is discharged to a skilled nursing facility can be comprised of complex medical decision making and changing preferences of care. Lack of appropriate serious illness communication during this time can result in unwanted hospitalizations and unwanted, aggressive care at the end of life. This care is often not patient-centered care. It also often is highly distressing for patients and their families, and also is costly to the health system.
Healio: What are some strategies to improve this situation?
Singh: We need to better understand how oncologists and non-oncologists relate to each other in terms of serious illness communication. There are many new technologies being developed to share electronic health records between health systems. However, if certain clinician groups don’t feel empowered to lead serious illness conversations when patients in their care are getting sicker than having the relevant information may not change the pattern of care. We need to understand the perspectives of each clinician and how they work together to better serve patients during this end-of-life trajectory.
Reference:
For more information:
Sarguni Singh, MD, can be reached at sarguni.singh@cuanshutz.edu.
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