Evaluating an Intervention to Improve Communication Between Oncology Clinicians and Patients With Life-Limiting Cancer

Abstract

IMPORTANCE Earlier clinician-patient conversations about patients' values, goals, and preferences in serious illness (ie, serious illness conversations) are associated with better outcomes but occur inconsistently in cancer care. OBJECTIVE To evaluate the efficacy of a communication quality-improvement intervention in improving the occurrence, timing, quality, and accessibility of documented serious illness conversations between oncology clinicians and patients with advanced cancer. DESIGN, SETTING, PARTICIPANTS This cluster randomized clinical trial in outpatient oncology was conducted at the Dana-Farber Cancer Institute and included physicians, advanced-practice clinicians, and patients with cancer who were at high risk of death. MAIN OUTCOMES AND MEASURES The primary outcomes (goal-concordant care and peacefulness at the end of life) are published elsewhere. Secondary outcomes are reported herein, including (1) documentation of at least 1 serious illness conversation before death, (2) timing of the initial conversation before death, (3) quality of conversations, and (4) their accessibility in the electronic medical record (EMR). RESULTS We enrolled 91 clinicians (48 intervention, 43 control) and 278 patients (134 intervention, 144 control). Of enrolled patients, 58% died during the study (n=161); mean age was 62.3 years (95% CI, 58.9-65.6 years); 55% were women (n=88). These patients were cared for by 76 of the 91 enrolled clinicians (37 intervention, 39 control); years in practice, 11.5 (95% CI, 9.2-13.8); 57% female (n=43). Medical record review after patients' death demonstrated that a significantly higher proportion of intervention patients had a documented discussion compared with controls (96% vs 79%, P = .005) and intervention conversations occurred a median of 2.4 months earlier (median, 143 days vs 71 days, P < .001). Conversation documentation for intervention patients was significantly more comprehensive and patient centered, with a greater focus on values or 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). Documentation about end-of-life care planning did not differ between arms (80% intervention vs 68% control, P = .08). Significantly more intervention patients had documentation that was accessible in the EMR (61% vs 11%, P < .001). CONCLUSIONS AND RELEVANCE This communication quality-improvement intervention resulted in more, earlier, better, and more accessible serious illness conversations documented in the EMR. To our knowledge, this is the first such study to demonstrate improvement in all 4 of these outcomes.

Quality Measurement of Serious Illness Communication: Recommendations for Health Systems Based on Findings from a Symposium of National Experts

“…However, they are actionable, feasible, and face valid. 47,48 Symposium participants value goal-concordant care as an outcome both relevant to and dependent on SIC. This construct is among the most challenging to measure 49,50 and some feel that it cannot be feasibly measured for any purpose.…”

Training Clinicians in Serious Illness Communication Using a Structured Guide: Evaluation of a Training Program in Three Health Systems

“…The clinician training, tested in two research trials, 45,46 teaches clinicians to have conversations about patients' values, goals, and prognosis using a scalable tool, the Serious Illness Conversation Guide (''Guide''). 8 The training involves interactive methods, including reflection, demonstration and debriefing, cognitive maps, and skills practice with feedback.…”

Communicating with patients and families about difficult matters: A rapid review in the context of the COVID-19 pandemic

“…66,67 Prominent contemporary approaches include the SPIKES protocol, 68 VitalTalk, 69 and the Serious Illness Conversation Guide (SICG). 70 The recommendations made in Box 1 have important similarities and differences to these resources. For instance, recommendations to elicit the patient's perspective (SPIKES), assess perception of illness (VitalTalk), and assess illness understanding (SICG) are consistent with the second recommendation listed in Box 1.…”