Adopting Clinician Training to Prompt Comprehensive End-of-Life Conversations

A series of communication-focused interventions resulted in more, earlier, better, and more accessible conversations about patients’ values, goals, and preferences when faced with life-limiting cancer, according to a single-center study.

The interventions, initiated at Dana-Farber Cancer Institute and two satellite clinics, included clinical tools, clinician training, and system-wide changes. For example, the Serious Illness Conversation Guide (SICG) was designed to address situations in which clinicians were unsure of what to say during serious illness discussions. The SICG gave clinicians psychologically informed language to assess a patient’s understanding of their illness and patient information preferences.

“Our study shows that this institution-wide intervention, which trained and supported oncology clinicians in improving their conversation practices and integrating those conversations into routine outpatient practice, resulted in broad access to more, earlier, and better serious illness conversations for patients with advanced cancer as well as more accessible documentation of these conversations in the EMR [electronic medical record],” wrote Joanna Paladino, MD, of Dana-Farber Cancer Institute and Brigham and Women’s Hospital in Boston.

The study randomly assigned 91 participating clinicians to either the intervention arm or a control arm of usual care. All clinicians identified patients for use of the surprise question: “Would you be surprised if this patient died in the next year?” Patients who responded “no” were also included in the study (n = 278). Seventy-six of the 91 physicians had at least 1 patient who died during the study period, and these physicians were included in the analysis.

Results of the primary endpoint analysis, published in JAMA Internal Medicine, showed that the Serious Illness Conversation Program (SICP) interventions had little effect on patient outcomes of goal-concordant care and peacefulness for decedents. However, there were significant reductions in moderate-to-severe anxiety and depression symptoms.

These results, published in JAMA Oncology, detailed secondary outcomes: documentation of at least one serious illness conversation before death, timing of the initial conversation, quality of the conversation, and accessibility in EMRs.

“The SICP resulted in nearly universal access to such conversations, with 96% of intervention patients having at least 1 documented conversation before death,” the researchers wrote.

Almost 20% more patients in the intervention arm compared with the control arm had a serious illness conversation documented in their EMR (96% vs 79%; P = .005), and this documentation was significantly more accessible (P < .001). These conversations occurred a median of 2.4 months earlier for patients in the intervention arm (143 vs 71 days; P < .001).

Documentation of these discussions was more comprehensive and patient-centered for patients assigned to the intervention. Details included a greater focus on values of goals (89% vs 44%; P < .001), prognosis or illness understanding (91% vs 48%; P < .001), and life-sustaining treatment preferences (63% vs 32%; P = .004).

“The significant increase in conversations in the intervention arm suggests that successfully integrating these conversations into a typical oncology practice is feasible,” the researchers wrote. “A structured conversation guide and matching EMR documentation tool, reminder process, and clinician training and coaching appear to have addressed known barriers to serious illness communication, including clinicians’ lack of communication training, time constraints, and cumbersome (or absent) systems for having and documenting conversations.”

Commenting on the results, Ronald Epstein, MD, of the University of Rochester School of Medicine and Dentistry, told Cancer Network that this secondary analysis demonstrated that a multicomponent systems intervention can improve frequency, timing, and quality of discussions about advance directives, but he noted that the main findings of the study interject a word of caution.

“Her study and others’ show that physicians’ assessments of their communication with patients do not correlate well with shared understanding of prognosis, quality of life, the therapeutic alliance, and goal-concordant care at the end of life,” Epstein said. “Interventions such as Paladino’s should be adopted but must be supplemented with additional systems changes, patient activation, and clinician communication training to achieve the goals of compassionate and effective end-of-life care.”

In an editorial published with the article, Belinda E. Kiely, MBBS, PhD, FRACP, of the National Health and Medical Research Council Clinical Trials Centre at the University of Sydney in Australia, and Martin R. Stockler, MBBS, MSc, FRACP, of Chris O’Brien Lifehouse in Camperdown, Australia, suggested several ways that these results should influence clinical practice.

“Oncologists should initiate conversations about serious illness with patients who have a significant risk of dying in the foreseeable future. Not because this will necessarily improve outcomes, but because patients want, require, and deserve to know what is coming,” they wrote. “These conversations should go beyond ceilings of care to include values, priorities, and preferences. The conversations should be documented, accessible, and flagged in the EMR to increase the accessibility to others involved in the patient’s care.”