One study found that opportunities for discussions about end-of-life care (EOL) for cancer patients are often missed by oncologists. These results were published in JAMA network open.
“Because oncologists often see patients through disease trajectories – building long-term relationships and relationships – they have unique opportunities to engage in early and ongoing conversations around goals of care,” wrote the authors of the study.
Opportunities to address end-of-life care
The objective of this study was to identify successful and missed opportunities for end-of-life care discussions between oncologists and ambulatory patients with advanced cancer. These topics include advance care planning, palliative and palliative care, discontinuation of treatment, and post-death wishes.
Investigators analyzed audio recordings of outpatient visits from 2010 to 2014 that were performed for the Studying Communication in Oncologist-Patient Encounters randomized clinical trial. A total of 141 patients were recruited from two university medical centers. The majority of the patient cohort was Caucasian (87.2%) and 38.3% were female. The patients had stage IV malignancies and their visits with medical, gynecologic and radiation oncologists were evaluated. Of 39 oncologists, 19.5% were female and 82.9% were Caucasian. The average age of patients and oncologists was 56.3 years.
The full sample included 423 visits. EOL discussions have been defined as any passing mention or substantial discussion of EOL topics. A random sample of 31 patients (93 visits) was analyzed to determine missed opportunities.
The authors defined a missed opportunity as “a lack of exploration by the practitioner of the patient’s values, goals or preferences in response to a patient statement regarding cancer progression, death or disease experience,” despite an openness in the conversation where such a discussion would have been appropriate, if not necessary.
Five percent of visits include EOL chats
Twenty-one visits (5%) included discussions about advanced patient care, treatment discontinuation, palliative care, or post-death wishes. Seventeen patient-oncologist dyads (12%) had at least one discussion about end-of-life care, and three dyads had more than one meeting with a discussion about end-of-life. The 17 dyads with an EOL discussion included 13 oncologists (33%).
In the subgroup analysis of missed opportunities, 5% of visits included end-of-life discussions and 38% of missed opportunities. Evaluation of multiple visits with missed appointments revealed that 61% of patient-oncologist dyads missed opportunities to discuss these topics, including 14 of 22 oncologists (64%).
Twenty-three oncologists in the full sample had either a missed opportunity or an end-of-life discussion, and 17.4% had both. The authors noted three themes of deviation from these topics by oncologists, which led to missed opportunities to explore patient goals, including: inadequate response to patient concerns about disease progression or death ; using an upbeat talk about the future to address patient concerns; or expressing concerns about stopping treatment.
According to the authors, three themes were identified regarding the ways in which oncologists have successfully seized opportunities to relate to discussions about end-of-life care: re-evaluation of treatment in response to patient expressions of concern; honor patients as experts on their personal goals; and supervise the re-evaluation of treatment with the help of anticipatory advice.
“Successful EOL conversations included anticipatory advice on trade-offs between quality of life and symptom burden; these topics may be less uncomfortable for oncologists to discuss and may be useful strategies for starting these conversations, ”the study authors wrote. “Additionally, the oncologists who engaged in these conversations responded to patients’ emotional concerns with understanding and empathy. “
In conclusion, the authors wrote: “Given that decades of work has aimed at improving communication among oncologists on end-of-life topics, it is of concern that these opportunities for discussion are still largely overlooked. In addition, missed opportunities to discuss advance care planning, palliative care, palliative care, treatment discontinuation and post-death wishes allow aggressive, cumbersome and expensive end-of-life treatment to occur. continue unchecked. Future efforts must overcome obstacles, such as oncologists’ fear of upsetting patients and discomfort during end-of-life discussions, and the challenges inherent in providing a time-sensitive prognosis, in tandem with the need. respond to patients’ emotions and express empathy.