Effects of a Communication Intervention Randomized Controlled Trial to Enable Goals-of-Care Discussions

Abstract

PURPOSE: Patients with advanced cancer often have a poor understanding of cancer incurability, which correlates with more aggressive treatment near the end of life (EOL). We sought to determine whether training oncologists to elicit patient values for goals-of-care (GoC) discussions will increase and improve these discussions. We explored its impact on use of aggressive care at EOL. METHODS: We enrolled and used block randomization to assign 92% of solid tumor oncologists to 2-hour communication skills training and four coaching sessions. We surveyed 265 patient with newly diagnosed advanced cancer with < 2-year life expectancy at baseline and 6 months. We assessed prevalence and quality of GoC communication, change in communication skills, and use of aggressive care in the last month of life. RESULTS: Intervention (INT) oncologists’ (n = 11) skill to elicit patient values increased (27%-55%), while usual care (UC) oncologists’ (n = 11) skill did not (9%-0%; P = .01). Forty-eight percent (n = 74) INT v 51% (n = 56) UC patients reported a GoC discussion ( P = .61). There was no difference in the prevalence or quality of GoC communication between groups (global odds ratio, 0.84; 95% CI, 0.57 to 1.23). Within 6 months, there was no difference in deaths (18 INT v 16 UC; P = .51), mean hospitalizations (0.47 INT v 0.42 UC; P = .63), intensive care unit admissions (5% INT v 9% UC; P = .65), or chemotherapy (26% INT v 16% UC; P = .39). CONCLUSION: Use of a coaching model focused on teaching oncologists to elicit patient values improved that skill but did not increase prevalence or quality of GoC discussions among patients with advanced cancer. There was no impact on high care utilization at EOL.

Addressing palliative care and end-of-life issues in patients with advanced cancer: a systematic review of communication interventions for physicians not specialised in palliative care

“…Across the 24 included publications, 22 different interventions were evaluated. Two interventions were evaluated in two publications each 47–50. Two times, an adapted version in form of one submodule or one workshop of an intervention reported in another publication was investigated 51 52…”

“…Half of them are from North America (n=12), followed by Europe (n=6), Asia (n=5) and Australia (n=1). Thirteen publications reported randomised controlled trials (RCTs) 47–50 54–62. The remaining 11 papers reported uncontrolled intervention studies with at least two measurement time points (pre and post) 51–53 63–70.…”

“…However, the majority (n=20 articles) reported sample sizes of less than 70 participating physicians. In the majority of the publications (n=14), the target group were oncologists (medical, surgical and radiation oncologists) 49 50 53–56 59 61 64 66–70. In eight publications, the study participants were multi-specialty physicians working in oncology (oncologists and organ-specific physicians)47 48 51 52 57 60 62 65 and two exclusively targeted physicians other than oncologists 58 63.…”

“…The interventions were conducted in very different settings. While four interventions were carried out only virtual,58 61 63 67 a majority (n=18) was carried out at least partly in person47–57 59 60 62 64–66 68–70 (table 2; detailed description in online supplemental material S4). The length ranged from short and individual computer-assisted trainings or videos58 61 63 67 to multiple hour51–53 or multiple day workshops 56 64 68.…”

“…The length ranged from short and individual computer-assisted trainings or videos58 61 63 67 to multiple hour51–53 or multiple day workshops 56 64 68. Some interventions (n=6) consisted of basic group sessions plus follow-up appointments such as individual coaching sessions, consolidation workshops, video conferences or phone calls 47–50 54 55 57 59. Half of the reported interventions (n=10) lasted more than 1 day or consisted of several hours spread over a longer period of time, that is, weeks or months 47 48 54 56 57 60 64–66 68 70.…”