Nursing-Led Palliative Cancer Care May Improve Advanced Care Planning

Investigators reported that nursing-led palliative care may sufficiently improve advanced care planning uptake, defined as an end-of-life conversation with an oncologist or completion of advanced directive, in patients with advanced cancer, according to findings from a secondary analysis of the CONNECT study (NCT02712229).

“[It’s important] to really think about the holistic patient and family, their experience, and how the very art and science of nursing can help them during this time," according to an expert from the University of Pittsburgh.

The study included a total of 672 patients. Of these, 378 did not report an end-of-life conversation at baseline and completed a 3-month assessment. In total, 45.1% of patients in the intervention arm (n = 182) and 14.8% in the standard of care arm (n = 196) had an end-of-life conversation at 3 months (unadjusted odds ratio [OR], 4.72; P <.001).

These findings were consistent following adjustment, with investigators reporting that significantly more patients in the CONNECT arm were likely to report having an end-of-life conversation with their oncologist compared with the control group (adjusted OR, 5.28; P <.001).

“[The study] showed that advanced care planning could be enhanced by having nurses talk about this. This is part of [including] nurses in holistic cancer care, and not just relegating them to be the people who give the chemotherapy or take the vital signs,” according to study author Margaret Rosenzweig, PhD, CRNP-C, AOCNP, FAAN. “[It’s important] to really think about the holistic patient and family, their experience, and how the very art and science of nursing can help them during this time.”

Rosenzweig is the distinguished service professor of nursing and a professor of medicine at the Hillman Cancer Center Acute & Tertiary Care, University of Pittsburgh.

Investigators indicated that 216 patients did not report an advanced directive at baseline and completed the 3-month assessment. In this population, 43.2% and 18.1% of patients in the CONNECT and control arms, respectively, reported having an advanced directive by the 3-month assessment (unadjusted OR, 3.45; P <.001). The findings were consistent following adjustment (adjusted OR, 3.68; P <.001).

“If we [could, we should avoid] making this a conversation for the very end of life or when cancer becomes very advanced and dire, but instead part of a discussion of having advanced stage cancer,” Rosenzweig explained. “These days, there are so many different treatments, and it is certainly not an automatic death sentence to have an advanced stage cancer. But even more important for patients to think about, if there would be an emergency or a gradual progression towards death, who is going to be helping to make these decisions if the patient is incapable? Does the person who is your proxy decision maker know what you would like and what your preferences are in the context of this illness?”

Investigators compiled the secondary analysis using data from the CONNECT study, which assessed the use of palliative care compared with standard care in community cancer centers. Patients enrolled on the trial between July 2016 and October 2019 across 17 community clinics within the Hillman Cancer Center network in Pennsylvania.

Patients could enroll on the study if they had been diagnosed with an advanced solid tumor, their oncologist affirmed that they would not be surprised if the patient passed away within the next year, and had an ECOG performance status of 0 to 2. Randomization was done by clinical site instead of by the patient, thus creating a cluster randomization meant to reduce the potential of unintentional crossover.

The CONNECT intervention consisted of putting oncology infusion room nurses through an immersive 3-day training session headed by palliative care experts. The training covered several key skills:

• addressing symptom needs,
• engaging patients and caregivers in advanced care planning,
• providing emotional support for patients and caregivers,
• and communicating and coordinating the right care for patients.

Patients in the CONNECT arm had monthly meetings at minimum with a CONNECT-trained nurse for 3 months; this took place following or immediately preceding oncology appointments. Nurses constructed care plans with patients that took factors such as goals of care and symptoms into consideration.

Those in the standard of care arm underwent standard oncology treatment provided by an oncologist and an in-clinic nurse. This included any specialty supportive or palliative care services that their oncologist deemed necessary. Moreover, advanced care planning was based on recommendation from the patients’ clinical team. However, there was no additional support to encourage advanced care planning in this cohort.

“The idea of training the infusion room nurses was ideal, but very difficult to implement. There were multiple reasons why that did not become really sustainable,” Rosenzweig said. “[Considering] the provider shortages, it became even less realistic to think that this could happen. The great majority of nurses who participated felt like it really enhanced their career and that they learned skills they can always provide to their patients. Probably the reason that we didn't see huge differences in the quality of life and symptom measures was because the time nurses had to spend with the patients probably just wasn't long enough. It's all in the context of this busy infusion room, and they were really struggling with all their other responsibilities.

All patients received a full assessment at enrollment and at 3 months. A total of 2 validated questions were included in the advanced care planning engagement survey:

1. Have you and any of your healthcare providers at the cancer center discussed any particular wishes you have about the care you would want to receive if you were dying?
2. Have you completed a living will or advance directive?

Among those who did not report having a prior end-of-life conversation at baseline, the median patient age was 69.1 years, and most patients were White (95.2%). Moreover, most patients ranked religion as being very important (61.1%); had a high school diploma or GED (42.3%); were married (58.7%); and stated that they could just manage to get by (35.2%) or had enough income to get by with a little extra (37.6%).

The most common disease types were lung (34.9%), gastrointestinal (19.6%), breast/gynecologic (18.8%), and genitourinary (12.2%) cancer. Additionally, most patients had an ECOG performance status of 1 (58.7%), and the mean symptom burden score per Edmonton Symptom Assessment System criteria was 23.9.

Reference

Cohen MG, Althouse AD, Arnold RM, et al. Primary palliative care improves uptake of advance care planning among patients with advanced cancers. J Nat Can Cen Net. 2023;21(4):383-390 doi:10.6004/jnccn.2023.7002