September 02, 2022
5 minute read
Despite clinical guideline recommendations, a high proportion of patients with advanced cancer do not have appropriate conversations with health care providers about prognosis, treatment options, and end-of-life preferences.
Only about 30% of patients who participate in these discussions — called Critical Illness Conversations — have them with their primary oncologist.
Dartmouth Cancer Center researchers implemented a quality improvement project designed to increase the frequency and documentation of critical illness conversations in the facility’s sarcoma and head and neck cancer clinics .
Their findings — published in JCO Oncology Practice — showed that almost three-quarters of eligible patients participated in these discussions after the intervention, compared to 0% at baseline. Most conversations were between patients and oncologists (57%), followed by palliative care clinicians (30%) and advanced practice registered nurses (14%).
Garrett T. Wasp
Healio spoke to two of the investigators – Garrett T. Wasp, MD, MPH, assistant professor of medicine at Geisel School of Medicine at Dartmouth and medical oncologist at Dartmouth Cancer Center, and Amelia M. Cullinan, MD, Director of Outpatient Palliative Care Services and Co-Director of the Critical Illness Care Program at Dartmouth Hitchcock Medical Center – on why the initiative exists, the success it has demonstrated, how they plan to expand the effort at Dartmouth and how other institutions can take a similar approach.
Helio: Can you write your motivation to start this project?
Wasp: Oncology practice guidelines say we should have conversations about serious illness early on — and for all patients with advanced cancer. In my own practice, I find that these conversations help the clinical team, as well as the patient and family, better understand what is most important and clarify what is medically feasible. From the perspective of the cancer center, we needed a systematic approach to conducting and documenting these interactions to ensure that all patients who needed these important conversations had them.
Healio: What? do one “serious illness conversation” to understand?
Cullinan: The Serious Illness Conversation Guide, developed by Ariadne Labs at Brigham and Women’s Hospital/Harvard TH Chan School of Public Health, is a patient, family, and clinician-tested tool that can be downloaded for free at www.ariadnelabs.org/wp-content/uploads/2017/05/SI-CG-2017-04-21_FINAL.pdf. The guide provides language and structure for navigating sensitive conversations. Guided conversation allows clinicians to elicit patients’ own understanding of their disease and desired prognostic information, and then share personalized information with them. The conversation then elicits the values and goals of the patients.
Healio: Why is it important that critical illness conversations happen early in treatment? for people with advanced cancer?
Wasp: Oncology practice guidelines emphasize early conversations for two main reasons. First, unexpected events can occur at any time during the course of the disease, so it is best to understand preferences before these changes. Second, patients have the most options earlier in the disease course, so mapping patient values early offers the best chance of ensuring care is on target.
Healio: Can you briefly describe the results of your project?
Wasp: Our study describes the first part of an ongoing, sequential, cancer center-wide initiative to educate oncology teams about critical illness conversations and make such conversations a normal procedure for all patients. seriously ill. In the clinics we targeted, the multidisciplinary and integrated family care partner approach we followed increased our documentation of these important conversations from 0% to 70% of eligible patients. We did this work at the start of the COVID-19 pandemic, and the disruption provided both opportunities and challenges. Telehealth has allowed us to have self-contained conversations with patients and their families, unrelated to chemotherapy visits, allowing us to better focus on what matters most to them. However, workforce disruptions have made it harder to bring other members of the care team — such as social workers and nurse navigators — directly into the conversations.
Healio: Were the results there? your expectations?
Wasp: Yes, but there is definitely more work to be done. All parties involved are proud of the adoption and documentation of these conversations. Nevertheless, the final documentation rates were around 70% of patients and, according to the guidelines, they should ideally be 100%. The experience of integrating a family care partner has been positive for our group, and there is still work to be done to evaluate the spread of this approach to other clinics. We are currently doing this work.
Healio: What type of instruction did clinicians receive in start of the program?
Cullinan: The centerpiece of this model of care is the Critical Illness Conversation Guide – which we teach clinicians in a 3-hour interactive skills-based workshop – and then provide in-person coaching as clinicians integrate their first conversations about critical illnesses with their patients. Most clinicians either declined coaching or used coaching once or twice before becoming independent.
Healio: Whis it important to document these conversations?
Wasp: The benefits of documentation are more theoretical than directly related to an outcome that improves a patient’s life. Potential benefits include sharing the values of patient medical treatment with a wider audience of clinicians. Patients receive medical care in a variety of settings (eg, inpatient, outpatient, etc.) and all parties involved want to have the most up-to-date understanding of what matters most to patients and their understanding of what is medically feasible. I believe these conversations are more flexible and clinically useful than traditional advance directives, and the documentation aspect still has the same drawbacks as advance directives.
Healio: What is the role of caregivers Where family members in these conversations?
Wasp: We train clinicians and develop workflows to help maximize the opportunity for family and caregivers to join the conversation. However, we first ask the patient about their own preference for family or caregiver involvement. Often, patient preference determines family/caregiver involvement.
Healio: What would you suggest other institutions are implementing a similar program?
Wasp: The Critical Illness Conversation Guide developed by Ariadne Labs is a great tool to support clinicians through the conversation. In terms of health system support, the following are likely to be useful: training in communication skills; a standardized way to document and access these conversations via the electronic medical record; and implementation support as clinical teams work to integrate new processes into routine care.
Healio: What are your next steps?
Wasp: We have already extended the intervention to other clinics in the cancer center and are analyzing the results of this work. We will present a poster at the ASCO Quality Care Symposium in October that will highlight these results. In the future, we intend to expand the program to different specialty groups beyond medical oncology.
Healio: Is there anything else you feel is important to emphasize?
Wasp: Self-directed telehealth visits to lead these conversations during the COVID-19 pandemic seemed like a good strategy for many patients to engage other family members in these conversations and create a “space” for this communication, outside of the routine clinical work of safely administering cancer treatments that tend to crowd out other activities during the clinic visit.
For more information:
Amelia M. Cullinan, MD, can be contacted at Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756; email: [email protected]
Garrett T. Wasp, MD, MPH, can be contacted at Norris Cotton Cancer Center in Dartmouth-Hitchcock, 1 Medical Center Drive, Lebanon, NH 03756; email: [email protected]