Despite Skills Training, Goals of Care Discussions Are Still Not Always Happening
Kristie L. Kahl
Goals of care discussions between patients and their oncologists are very important. However, the prevalence of and satisfaction with these discussions are somewhat lagging, according to study results presented at the 2018 American Society of Clinical Oncology (ASCO) Annual Meeting.
These discussions should include information about the cancer itself, as well as treatment options, side effects, prognosis, and most importantly, the patient’s values.
“It is really important for patients to understand goals of care discussions because that is the way they will be able to make informed decisions about subsequent treatment that can affect key parts of their lives,” Nina A Bickell, M.D., MPH, from the Department of Population Health Science and Policy at the Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai in New York City, said in an interview with CURE.
Therefore, Bickell and colleagues set out to determine if communication skills coaching had an impact on the prevalence and satisfaction with goals of care discussions among patients with advanced cancers.
Twenty-two oncologists from four academic, community, municipal and rural hospitals were recruited and randomized with their patients to receive communication skills training (54 percent) or usual care.
Before intervention, oncologists were surveyed about their perspectives on, comfort in and training in regards to conducting goals of care discussions. Oncologists were later coached on how to improve their communication skills, which included brief VitalTalk-based communication skills and four coaching sessions with patients. VitalTalk is a nonprofit that focuses on improving communication skills for doctors who are treating patients with serious illness.
After their three-month post-imaging visit, which the researchers considered a potential decision point, 265 patients were surveyed. In addition, the researchers assessed audiotape recordings to evaluate the Goals of Care discussions during these visits.
Patients in the intervention arm were 63 years old on average, and the majority were white (53 percent). Thirty-five patients (13 percent) died within six months of the baseline surveys. Intervention oncologists reported having 17.3 years in practice, and 72.7 percent had training in goals of care discussions.
Intervention oncologists’ skills appeared to improve with coaching compared with the control arm, however, there was no effect on patient reports on goals of care discussions. For example, 47.7 percent of patients in the intervention arm reported to have had a goals of care discussion with their oncologist compared with 50.9 percent in the control arm.
“Training did improve their communication skills, so the training was effective and that is really important. The challenge was that it didn’t really make a difference between the trial arms in how often the conversation was happening or how well it was being done,” Bickell said.
In addition, only 50 percent of intervention oncologists asked patients “about the things in life that are important given your cancer diagnosis,” and only 19 percent discussed prognosis. The majority of patients with a less than two-year life expectancy believed the goal of their treatment was to cure their cancer and only one-third of patients knew it was unlikely their cancer would be cured.
In addition, older patients were less likely to have goals of care discussions.
However, the audiotapes showed a little more promise compared with the patient surveys. “What we found was that, in fact, the intervention physicians were twice as likely to have a goals of care discussion based on the audiotapes compared with the control physicians,” Bickell explained. “Which was a somewhat different finding from what we found in the patients’ survey.”
Of note, regardless of trial arm, patients who reported having higher self-efficacy were more likely to have these discussions with their oncologists. In addition, the majority of patients who talked about having a balance between life-prolonging treatments, side effects and quality of life reported that they felt more knowledgeable of what to expect with their diagnosis.
“I think one of the things that can be done is coaching patients as to how they can (interact with their doctor to ask them questions),” Bickell said.
“The bottom line is that these skills are teachable. What our data showed is that we can improve the skills, now we just have to work on getting that to take hold,” she added. “The take home for patients should be that this is an important conversation and it is one that they should really be asking their doctors about, and their doctors should be open to having these conversations.”