Communication Differences between Oncologists and Palliative Care Clinicians: A Qualitative Analysis of Early, Integrated Palliative Care in Patients with Advanced Cancer

Abstract

Background: Growing evidence demonstrates the benefits of early, integrated palliative care (PC) for patients with advanced cancer and their caregivers. Yet, data are lacking on the communication patterns within this model of care. Objective: The goals of this study were to describe the content of patient-clinician discussions among patients receiving PC and to compare differences in discussion content between oncologists and PC clinicians. Design: We conducted a qualitative observational analysis. Setting/Subjects: We included patients with incurable lung and esophageal cancer enrolled in a randomized trial of early, integrated PC versus usual oncology care. We analyzed 68 audio-recorded clinic visits (34 oncologist visits; 34 PC clinician visits) immediately after patients' (N = 19) first and second cancer progressions. We examined themes of clinician communication, comparing the content and frequency of discussions between oncologists and PC clinicians. Results: Although both oncology and PC clinicians discussed symptom management, medical understanding, and treatment decision making with patients at nearly all postprogression visits, PC clinicians tended to assess patient understanding of the treatment process and prognosis more often than oncologists. PC clinicians addressed patient coping, caregiver experiences and needs, and advance care planning more frequently than oncologists. Conclusion: PC clinicians play a distinct, complementary role to oncologists in providing care for patients with advanced cancer and their caregivers. PC clinicians tend to assess and elaborate on patient understanding of prognosis and treatment and emphasize effective coping, caregiver needs, and advance care planning. These results illuminate the communication elements by which early, integrated PC may improve patient and caregiver outcomes.

Advance care planning for patients with cancer in palliative care: A scoping review from a professional perspective

“…Substitute decision‐maker is a trusted individual named by the patient (Zhou et al, 2010). Different names were used, like power of attorney for health care (Hu et al, 2010; Obel et al, 2014; Zhou et al, 2010), healthcare proxy (Thomas et al, 2019; Zhou et al, 2010) or healthcare surrogate (Bickel et al, 2016).…”

“…Orders regarding life‐sustaining treatment— in other words, restrictions placed on the care provided (Hirvonen et al, 2018)—included orders regarding medical treatment (Ermers et al, 2019). They were advance directives (Bickel et al, 2016; Bires et al, 2018; Hu et al, 2010; Obel et al, 2014; Zhou et al, 2010), Physician Orders for Life‐Sustaining Treatment (POLST) (Zhou et al, 2010) and code status orders (Bickel et al, 2016; Obel et al, 2014; Thomas et al, 2019). They determine the type of emergent treatment a patient would or would not receive if their breathing or heart were to stop, such as decision on resuscitation (Bickel et al, 2016; Ermers et al, 2019; Hirvonen et al, 2018; Obel et al, 2014; Seymour et al, 2010; Tokito et al, 2015).…”

“…Alleviation of suffering contained issues related to alleviation of suffering, such as preferences for palliative care (Zhou et al, 2010), documenting encounter for palliative care with ICD‐10 code Z51.5 (palliative care) (Hirvonen et al, 2018), euthanasia, palliative sedation (Ermers et al, 2019) and hospice care (Ermers et al, 2019; Thomas et al, 2019; Zhou et al, 2010).…”

“…Preferred place of death references were home (Boyd et al, 2010; Thomas et al, 2019) and nursing care home (Seymour et al, 2010) and were connected with impending death (Ermers et al, 2019).…”

“…In practice, this meant when patients were discharged from hospital care once oncology treatment had ended (Boyd et al, 2010) and had only a couple of months to live (Bires et al, 2018; Ermers et al, 2019), or only with late‐stage patients, particularly those with deadly or quickly progressing cancers nearing end of life (Bires et al, 2018). However, Thomas et al (2019) found a low frequency of ACP on outpatient visits after first and second cancer progressions, although according to Hirvonen et al (2018), both DNR and living wills should be in order in the case of late palliative or end‐of‐life stage cancer.…”