Room for Improvement in End-of-Life Communication

Roxanne Nelson

March 27, 2013

HOLLYWOOD, Florida — Cancer patients with advanced or incurable disease are dealing with the emotional impact of a life-limiting illness, and treatment decisions are complex; to communicate with them, clinicians require a distinct set of skills.

The current approach is failing, according to Anthony Back, MD, professor in the oncology division and adjunct associate professor of medical history and ethics at the University of Washington School of Medicine in Seattle.

Dr. Anthony Back

"We need to figure out how to talk to patients and to match their values with the treatment decisions they have to make," Dr. Back said during a presentation here at the National Comprehensive Cancer Network 18th Annual Conference. "It is a multipronged approach."

Many patients with incurable cancer perceive their prognosis inaccurately. "When you ask patients how they are doing, the response is often a mixture of what they're hoping will happen to them and what the doctor has told them," he explained.

Dr. Back noted that evidence-based communication skill training for physicians is limited. "We have to figure out a way, in training programs, move skill training into the world and for it to be effective," he said.

He added that "we all struggle with system infrastructure that fails to capture, display progress, or prompt clinicians about end-of-life care planning."

"I know that there is a tremendous amount of work going on around the country," Dr. Back continued, "but it is not at the point where we can depend on it as a clinical system."

Paradigm Shifts

There are 2 main paradigm shifts that must occur to improve communication about end-of-life care, Dr. Back explained.

The first is for clinicians to move away from the idea that patients are "resistant," and to play an active role. He notes that he often hears clinicians say that the patient isn't ready; instead, clinicians should be thinking, "What can I do differently to change the flavor of this conversation?"

This requires skills, a training system, and a community that is going to disseminate what is really working. "I see little pockets of excellence around the country, but I'm not sure we have a way of moving that into the big frame of what happens," he said.

The second paradigm applies to all members of the team. They need to change their attitude from "I don't have time" to "I'll do my share as part of the team," he noted.

This requires communication skills that are deployed across the care system or care team, a learning system, and positive reinforcement for outcomes that patients and families value.

Toolbox of Skills

Dr. Back emphasized that clinicians do not need to become therapists or invest huge amounts of time. However, they do need "to change the texture of what happens in their day-to-day practice."

He provided a "toolbox of communication skills" to help guide these changes.

First, show the map of best care. He encourages clinicians to think about what they want to accomplish before entering the room. It should be limited to 2 points; more than that can overwhelm the patient.

Second, lay out the options right away, and keep it simple. "Remember that working memory holds just a few items and that your patient is under stress," he noted.

Third, weigh the pros and cons. This can be done with double framing, which will increase the patient's understanding, and "is a way to minimize our biases," he said. For example, tell the patient that "with this option, 30 of 100 patients have their cancer shrink for a few months" or "70 of 100 patients have their cancer grow or just stay about the same."

Fourth, offer a prognosis. Listen for the patient's language and then use it. If the patient is interested, statistics can be provided, Dr. Back explained. In addition, 'best case' and 'worst case' information can be provided.

Fifth, pace yourself; realize it's not going to happen in 1 visit. Presenting information can trigger a lot of worry in the patient. "Be ready for the emotion that is going to come out," he said. In addition, "when starting to make decisions, start with decisions that are going to be easier."

Sixth, reinforce the positive. Pointing out the positive things that patients and families are doing is constructive and can be powerful.

Finally, make a recommendation, which is what patients often want to hear from their physician. This "can help accelerate" a patient's thinking, he said. "Clinicians often give all of these data to patients and expect them to put it together. I think this is a place for you to lead by example." Instead of saying, "this is what we have to do," tell them, "this is how I think we can move forward in a way that honors the kind of life you've lived," Dr. Back said.

National Comprehensive Cancer Network (NCCN) 18th Annual Conference.