Reminders May Trigger Advance Care Conversations Earlier

Larry Hand

October 28, 2014

A simple trigger reminder to oncologists at key times during the course of care of a seriously ill cancer patient may prompt earlier discussions regarding advance care planning (ACP) for the end-of-life phase, according to preliminary research presented at the inaugural Palliative Care in Oncology Symposium, held in Boston, Massachusetts, October 24-25.

Joanna Paladino, MD, a palliative care clinician at Dana-Farber Cancer Institute, Boston, and colleagues presented partial results of an ongoing cluster-randomized clinical trial that they are running.

In this study, clinicians identify patients at high risk for death within a year, then undergo 2.5 hours of training on the use of a guide to serious illness conversations. The guide has seven open-ended questions regarding a patient's understanding of his or her illness and prognosis, fears, goals, and what trade-offs a patient is willing to make in terms of care and living. It also has guidance on how to communicate with family members.

So far, 88 oncology clinicians have screened 15,576 patients and have identified 1743 who were at high risk for death within a year. To date, 332 patients have been enrolled, with 104 patients and 40 clinicians in the intervention arm. One requirement is that patients have "a therapeutic relationship" with their main clinician, which means they would have had at least four visits prior to enrollment, Dr Paladino told Medscape Medical News in an interview.

The researchers presented data on 124 subsequent triggered visits after enrollment. The first trigger consists of an email prompt, usually from Dr Paladino, for the clinician to initiate a conversation on ACP. Of those visits, 62% resulted in completed conversations, with 79% of the conversations occurring after the first trigger and 92% after a second trigger. A subsequent trigger could consist of placing a note on the clinician's face sheet or computer.

For the 62 triggered visits that did not result in ACP conversations, clinicians gave varying reasons as to why, with 26% citing not enough time, and 20% citing clinician attitudes toward impact and timing. However, 46% cited patient-specific issues, such as patient anxiety or depression.

we often move from treatment to treatment, because that's what's very comfortable for us. Dr Joanna Paladino

"The main point is that having a trigger in the selection of patients draws attention of the oncology team to the fact that patients may benefit from a conversation about their values, priorities, and prognosis," Dr Paladino said. "Our system has created a default in which there are missed opportunities in conversations, and part of that is related to the fact that we often move from treatment to treatment, because that's what's very comfortable for us. That's the language clinicians are taught."

"Creating a pause for a patient who has a serious illness and a prognosis of a year or less will allow us to reframe the conversation and bring the patient's priorities and values into the center of the discussion," she added.

Rachelle E. Bernacki, MD, coauthor and director of quality initiatives for psychosocial oncology and palliative care at Dana-Farber, added, "I think the takeaway is that, if we remind people and give them a simple nudge, so to speak, that people will do this. It's appealing to the physician's core sense of what they do in their practice. Talking about a person's life goals and mission is one of the most important things we can do."

An expert not involved in this study agrees. Vicki Jackson, MD, PhD, chief of palliative care at Massachusetts General Hospital in Boston, said: "These are critically important conversations. We actually have to have permission to identify those opportunities and when to do it, and I think a trigger is a really useful way."

Dr Jackson told Medscape Medical News: "We also have to train clinicians to be able to communicate appropriately, and the next step in all of this research is going to be seeing, once we've triggered it, what's the quality of conversation and then what is the effect of that conversation on outcomes and healthcare utilization."

"The key piece for us is beginning to understand the population," she said. "When we understand the population, who is at high risk of serious illness and death, then we can help through conversation and support the patients and their families throughout the course of their illness."

The researchers disclosed no relevant financial relationships.

Palliative Care in Oncology Symposium: Abstract 84. Presented October 24, 2014.


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