Top 10 Tips Palliative Care Clinicians Should Know About Messaging for the Public

When speaking to public audiences, palliative care advocates often reach for personal experiences of great meaning and significance in their own lives, and often distill those experiences to a key message. However, this approach may not be the most effective way to engage a public audience whose closest experience with palliative care is based on social media or third-hand stories. Research demonstrates that the lay public often starts with inaccurate assumptions about palliative care, including that it is only for people at end of life. These misunderstandings can lead people with serious illness to decline palliative care services that are backed by evidence and demonstrate real benefit. This phenomenon of "declines based on inaccurate assumptions" is widely seen in clinical practice and palliative care demonstration projects. Public messaging is an evidence-based approach to engage more effectively with the public when doing outreach for palliative care. The 10 tips provided are based on a multiyear and multiorganizational project focused on improving the messaging of palliative care for the public. As palliative care services are increasingly expanded and integrated into health systems, public messaging can provide a new approach for building partnerships with the public by offering messages that consistently meet their needs based on their current perceptions. Incorporating public-informed messaging strategies could enable palliative care clinicians and advocates to address the lay public with greater confidence and clarity about how palliative care can serve them, their families, and their communities.

Development, Feasibility, and Acceptability of an Oncologist Group Peer Support Program From ASCO's Clinician Well-Being Task Force

PURPOSE

The COVID-19 pandemic has had deleterious effects on oncologist professional and personal well-being, the optimal delivery of quality cancer care, and the future cancer care workforce, with many departing the field. Hence, the identification of evidence-based approaches to sustain oncologists is essential to promote well-being.

MATERIALS AND METHODS

We developed a brief, oncologist-centered, virtual group peer support program and tested its feasibility, acceptability, and preliminary impact on well-being. Trained facilitators provided support to peers on the basis of burnout research in oncology with available resources to enhance oncologist resilience. Peers completed pre- and postsurvey assessment of well-being and satisfaction.

RESULTS

From April to May 2022, 11 of 15 (73%) oncologists participated in its entirety: mean age 51.1 years (range, 33-70), 55% female, 81.8% Ca, 82% medical oncologists, 63.6% trained ≥15 years, average 30.3 patients/wk (range, 5-60), and 90.9% employed in hospital/health system practice. There was a statistically significant difference in pre- and postintervention well-being (7.0 ± 3.6 v 8.2 ± 3.0, P = .03) with high satisfaction with postgroup experience (9.1 ± 2.5). These quantitative improvements were affirmed by qualitative feedback. These themes included (1) an enhanced understanding of burnout in oncology, (2) shared experience in practice of oncology, and (3) fostering connections with diverse colleagues. Future recommendations proposed included (1) restructuring group format and (2) tailoring groups according to practice setting (academic v community).

CONCLUSION

Preliminary results suggest that a brief, innovative oncologist-tailored group peer support program is feasible, acceptable, and beneficial for enhancing well-being dimensions including burnout, engagement, and satisfaction. Additional study is required to refine program components (optimal timing, format) to support oncologist well-being, now during the pandemic and well into recovery.

What Patients and Caregivers Experience When They Receive Palliative Care: A Study Eliciting Metaphors That Could Shape Public Messaging

Many patients who could benefit from Palliative Care do not receive services because of lack of awareness or misconceptions. This high level of public unfamiliarity combined with inaccurate beliefs equating Palliative Care with dying calls for public messaging designed to increase public familiarity and correct misconceptions. A barrier to widespread public messaging, however, is the scarcity of messages developed with empirical research in public perceptions of the lived experience of receiving palliative care. In this report, we describe qualitative research aimed at identifying the "deep metaphors" associated with palliative care, to provide an empirical foundation for further creative work. We interviewed 8 patients receiving palliative care and 8 caregivers using a qualitative method, Zaltman Metaphor Elicitation Technique, that is specially designed to reveal unconscious metaphors and socially shared associations that participants held about experiencing palliative care. Study participants likened the onset of serious illness as a massive disruption resulting in stunning losses with far-reaching consequences. What serious illness "took away" from them was a sense of certainty about where their lives were going, and these participants described experiencing (1) shame and embarrassment about what was happening to them; (2) a sense that no one was listening to them; (3) feeling lost and uncertain about what to do, feeling stuck; and (4) losing parts of their identity to illness. What they felt in need of, to counter what had been taken away, was (1) validation for what they were going through; (2) agency to determine their own quality of life and have input into their care; (3) guidance to access a network of resources; and (4) regeneration of their self-worth, resulting in a new version of their identity. This research provides guidance for message developers on frames, language, and visuals for future campaigns designed to create public interest in palliative care.

Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients

CONTEXT

Outcomes after cardiopulmonary resuscitation (CPR) remain poor. We have spent 10 years investigating an "informed assent" (IA) approach to discussing CPR with chronically ill patients/families. IA is a discussion framework whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals, thus removing the burden of decision-making from the patient/family, while they retain an opportunity to disagree.

OBJECTIVES

Determine the acceptability and efficacy of IA discussions about CPR with older chronically ill patients/families.

METHODS

This multi-site research occurred in three stages. Stage I determined acceptability of the intervention through focus groups of patients with advanced COPD or malignancy, family members, and physicians. Stage II was an ambulatory pilot randomized controlled trial (RCT) of the IA discussion. Stage III is an ongoing phase 2 RCT of IA versus attention control in in patients with advanced chronic illness.

RESULTS

Our qualitative work found the IA approach was acceptable to most patients, families, and physicians. The pilot RCT demonstrated feasibility and showed an increase in participants in the intervention group changing from "full code" to "do not resuscitate" within two weeks after the intervention. However, Stages I and II found that IA is best suited to inpatients. Our phase 2 RCT in older hospitalized seriously ill patients is ongoing; results are pending.

CONCLUSIONS

IA is a feasible and reasonable approach to CPR discussions in selected patient populations.

Top Ten Tips Palliative Care Clinicians Should Know About Psychedelic-Assisted Therapy in the Context of Serious Illness

Psychedelic-assisted therapy (PAT) is a burgeoning treatment with growing interest across a variety of settings and disciplines. Empirical evidence supports PAT as a novel therapeutic approach that provides safe and effective treatment for people suffering from a variety of diagnoses, including treatment-resistant depression, substance use disorder, and post-traumatic stress disorder. Within the palliative care (PC) field, one-time PAT dosing may lead to sustained reductions in anxiety, depression, and demoralization-symptoms that diminish the quality of life in both seriously ill patients and those at end of life. Despite a well-noted psychedelic renaissance in scholarship and a renewed public interest in the utilization of these medicines, serious illness-specific content to guide PAT applications in hospice and PC clinical settings has been limited. This article offers 10 evidence-informed tips for PC clinicians synthesized through consultation with interdisciplinary and international leading experts in the field with aims to: (1) familiarize PC clinicians and teams with PAT; (2) identify the unique challenges pertaining to this intervention given the current legalities and logistical barriers; (3) discuss therapeutic competencies and considerations for current and future PAT use in PC; and (4) highlight critical approaches to optimize the safety and potential benefits of PAT among patients with serious illness and their caregivers.

Early palliative/supportive care in acute myeloid leukaemia allows low aggression end-of-life interventions: observational outpatient study

OBJECTIVES

Early palliative supportive care has been associated with many advantages in patients with advanced cancer. However, this model is underutilised in patients with haematological malignancies. We investigated the presence and described the frequency of quality indicators for palliative care and end-of-life care in a cohort of patients with acute myeloid leukaemia receiving early palliative supportive care.

METHODS

This is an observational, retrospective study based on 215 patients consecutively enrolled at a haematology early palliative supportive care clinic in Modena, Italy. Comprehensive hospital chart reviews were performed to abstract the presence of well-established quality indicators for palliative care and for aggressiveness of care near the end of life.

RESULTS

131 patients received a full early palliative supportive care intervention. All patients had at least one and 67 (51%) patients had four or more quality indicators for palliative care. Only 2.7% of them received chemotherapy in the last 14 days of life. None underwent intubation or cardiopulmonary resuscitation and was admitted to intensive care unit during the last month of life. Only 4% had either multiple hospitalisations or two or more emergency department access. Approximately half of them died at home or in a hospice. More than 40% did not receive transfusions within 7 days of death. The remaining 84 patients, considered late referrals to palliative care, demonstrated sensibly lower frequencies of the same indicators.

CONCLUSIONS

Patients with acute myeloid leukaemia receiving early palliative supportive care demonstrated high frequency of quality indicators for palliative care and low rates of treatment aggressiveness at the end of life.

Use of Messaging Principles to Design a Facebook Ad Promoting Public Engagement in Serious Illness Care for National Healthcare Decisions Day

Public hesitation to engage in advance care planning, consultation with palliative care, and admission to hospice is a significant barrier to improving patient outcomes. In previous study, we derived five empirically supported messaging principles, and in this project we used these messaging principles to design, place, and analyze a 60-second video for the Oregon Coalition for Living Well with Serious Illness. The video was scripted to emphasize a single message that had emerged from the empirical research: that "you should have a say in your care." We deliberately did not use the term "advance care planning" because our prior focus groups showed that most consumers did not use this term. The marketing plan for the resulting video on Facebook included a paid sponsorship of the full-length video through a Facebook boosted post, and three 10-second ads featuring key lines from the video that tested different elaborations of the central message. Facebook Analytics indicated that the 60-second video was viewed 67,650 times in the week it was promoted. The three 10-second ads, which showed selected moments from the full-length video, were viewed a total of 253,087 times. Of the three 10-second ads, the one emphasizing "What matters to me is being near my family" (65% of clicks) strongly outperformed "I don't want to go out on a machine" and "I've heard so many medical horror stories" (35% for both messages combined) as messages that persuaded viewers to click through the ad to the website. Use of the messaging principles to guide the design and marketing of this Facebook ad shows that (1) the public is interested in serious illness care, (2) that targeted social media can be used to reach a defined public audience, and that (3) this public messaging strategy can be implemented at relatively low cost.

Occupational and Personal Consequences of the COVID-19 Pandemic on US Oncologist Burnout and Well-Being: A Study From the ASCO Clinician Well-Being Task Force

INTRODUCTION

The COVID-19 pandemic is an unprecedented global crisis profoundly affecting oncology care delivery.

PURPOSE

This study will describe the occupational and personal consequences of the COVID-19 pandemic on oncologist well-being and patient care.

MATERIALS AND METHODS

Four virtual focus groups were conducted with US ASCO member oncologists (September-November 2020). Inquiry and subsequent discussions centered on self-reported accounts of professional and personal COVID-19 experiences affecting well-being, and oncologist recommendations for well-being interventions that the cancer organization and professional societies (ASCO) might implement were explored. Qualitative interviews were analyzed using Framework Analysis.

RESULTS

Twenty-five oncologists were interviewed: median age 44 years (range: 35-69 years), 52% female, 52% racial or ethnic minority, 76% medical oncologists, 64% married, and an average of 51.5 patients seen per week (range: 20-120). Five thematic consequences emerged: (1) impact of pre-COVID-19 burnout, (2) occupational or professional limitations and adaptations, (3) personal implications, (4) concern for the future of cancer care and the workforce, and (5) recommendations for physician well-being interventions. Underlying oncologist burnout exacerbated stressors associated with disruptions in care, education, research, financial practice health, and telemedicine. Many feared delays in cancer screening, diagnosis, and treatment. Oncologists noted personal and familial stressors related to COVID-19 exposure fears and loss of social support. Many participants strongly considered working part-time or taking early retirement. Yet, opportunities arose to facilitate personal growth and rise above pandemic adversity, fostering greater resilience. Recommendations for organizational well-being interventions included psychologic or peer support resources, flexible time-off, and ASCO and state oncology societies involvement to develop care guidelines, well-being resources, and mental health advocacy.

CONCLUSION

Our study suggests that the COVID-19 pandemic has adversely affected oncologist burnout, fulfillment, practice health, cancer care, and workforce. It illuminates where professional organizations could play a significant role in oncologist well-being.

Creating a Blueprint of Well-Being in Oncology: An Approach for Addressing Burnout From ASCO's Clinician Well-Being Taskforce

Optimizing the well-being of the oncology clinician has never been more important. Well-being is a critical priority for the cancer organization because burnout adversely impacts the quality of care, patient satisfaction, the workforce, and overall practice success. To date, 45% of U.S. ASCO member medical oncologists report experiencing burnout symptoms of emotional exhaustion and depersonalization. As the COVID-19 pandemic remains widespread with periods of outbreaks, recovery, and response with substantial personal and professional consequences for the clinician, it is imperative that the oncologist, team, and organization gain direct access to resources addressing burnout. In response, the Clinician Well-Being Task Force was created to improve the quality, safety, and value of cancer care by enhancing oncology clinician well-being and practice sustainability. Well-being is an integrative concept that characterizes quality of life and encompasses an individual's work- and personal health-related environmental, organizational, and psychosocial factors. These resources can be useful for the cancer organization to develop a well-being blueprint: a detailed start plan with recognized strategies and interventions targeting all oncology stakeholders to support a culture of community in oncology.

Public Messaging for Serious Illness Care in the Age of Coronavirus Disease: Cutting through Misconceptions, Mixed Feelings, and Distrust

A year ago, we began a project designed to align public messages from 10 organizations involved in advance care planning (ACP), palliative care (PC), and hospice to increase public engagement. By public messaging, we are referring to a well-established evidence-driven method of disseminating information at scale that enables the public to take action to protect their health. Our project plan was upended by the coronavirus disease 2019 (COVID-19) pandemic-but we used the opportunity to conduct focus groups during the pandemic that, compared with focus groups conducted before the pandemic, provide an important portrait of public perceptions of serious illness care that can be used to design for greater public engagement. Our findings can be summarized in three observations. First, misunderstanding of ACP, PC, and hospice is wide ranging and deep. Second, COVID-19 evokes its own brand of confusion and ambivalence that is distinct from other serious illnesses. And third, distrust of the health care system has become the new normal. Despite these findings, our focus group participants strongly endorsed five messaging principles (1) talk up the benefits, (2) present choices for every step, (3) use stories that are positive and aspirational, (4) invite dialogue-more than once, and (5) invoke a new team-of people who matter, clinicians, medical institutions, and community organizations who are ready to help. After listening to 100-word stories describing real patient experiences with ACP, PC, and hospice, our focus group participants expressed interest and appreciation. But to improve public engagement broadly, we need to explain our work to the general public in a way that makes them want to know more.

Impact of a Novel Goals-of-Care Communication Skills Coaching Intervention for Practicing Oncologists

Background: Oncologists routinely have opportunities for goals-of-care (GoC) discussions with patients. GoC discussions increase the likelihood that patients receive care consistent with their values. However, oncologists often feel ill-equipped to discuss end-of-life care. Objective: To assess the impact of a communication training and coaching intervention (INT) for oncologists during GoC discussions. Design: We randomized oncologists to usual care (UC) or a communication skills training INT, which consisted of an interactive training session and four joint visits with communication coaches. Setting/Subjects: Solid tumor oncologists seeing advanced cancer patients at four hospitals in New York and Connecticut. Measurements: Three blinded coders evaluated recorded encounters before and after INT using a validated tool to assess skill attainment. Results: Oncologists (n = 22) were 32% female and averaged 46 years of age. In baseline visits, INT oncologists (n = 11) and UC oncologists (n = 11) had no difference in the number of mean skills employed out of 8 GoC skills (INT 3.5, UC 2.4; p = 0.18). Post-INT, INT oncologists were significantly more likely to elicit patient values (55% vs. 0%; p = 0.01). There was no significant difference in overall mean skills employed (INT 3.4, UC 2.2; p = 0.14). Assessing for understanding, offering "I wish" statements, and providing prognosis were the least utilized skills among all oncologists. Conclusion: Our real-time communication skills coaching INT resulted in a significant increase in oncologists' ability to elicit patient values during GoC discussions, suggesting that skill acquisition can occur in the face of less intensive training. Future studies can highlight gaps leading to the lack of differences in utilization of other skills.

Crisis Symptom Management and Patient Communication Protocols Are Important Tools for All Clinicians Responding to COVID-19

Symptom management and skilled communication with patients and families are essential clinical services in the midst of the coronavirus disease 2019 pandemic. Although palliative care specialists have training in these skills, many frontline clinicians from other specialties do not. It is imperative that all clinicians responding to the coronavirus disease 2019 crisis have access to clinical tools to support symptom management and difficult patient and family communication.

Public Perceptions of Advance Care Planning, Palliative Care, and Hospice: A Scoping Review

Background: Although access to advance care planning (ACP), palliative care, and hospice has increased, public attitudes may still be barriers to their optimal use. Purpose: To synthesize empirical research from disparate sources that describes public perceptions of ACP, palliative care, and hospice in ways that could inform public messaging. Data Sources: Searches of PubMed and other databases were made from January 2011 to January 2020. Study Selection: Studies reporting survey or interview data with the public that asked specifically about awareness and attitudes toward ACP, palliative care, or hospice were included. Data Extraction and Synthesis: Two reviewers independently screened citations, read full texts, and performed data abstraction. Twelve studies met inclusion criteria and included >9800 participants. For ACP, 80% to 90% of participants reported awareness, and a similar proportion considered it important, but only 10% to 41% reported having named a proxy or completed a written document. For palliative care, 66% to 71% of participants reported no awareness of palliative care, and those who reported awareness often conflated it with end-of-life care. However, after being prompted with a tested definition, 95% rated palliative care favorably. For hospice, 86% of participants reported awareness and 70% to 91% rated it favorably, although 37% held significant misconceptions. Limitations: A limited number of studies met inclusion criteria, and some were published in nonpeer reviewed sources. The studies reflect public perceptions pre-COVID-19. Conclusion: Consumer perceptions of ACP, palliative care, and hospice each have a distinct profile of awareness, perceptions of importance, and reports of action taking, and these profiles represent three different challenges for public messaging.

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

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.

A Call to Action: Ethics Committee Roundtable Recommendations for Addressing Burnout and Moral Distress in Oncology

Oncologist well-being is critical to initiating and maintaining the physician-patient relationship, yet many oncologists suffer from symptoms of burnout. Burnout has been linked to poor physical and mental health, as well as increased medical errors, patient dissatisfaction, and workforce attrition. In this Call to Action article, we discuss causes of and interventions for burnout and moral distress in oncology, highlight existing interventions, and provide recommendations for addressing burnout and improving well-being at the individual and organizational levels to deliver ethical, quality cancer care.

Patient-Clinician Communication Issues in Palliative Care for Patients With Advanced Cancer

The delivery of palliative care to patients with advanced cancer and their families, whether done by oncology clinicians or palliative care clinicians, requires patient-centered communication. Excellent communication can introduce patients and families to palliative care in a nonthreatening way, build patient trust, enable symptom control, strengthen coping, and guide decision making. This review covers deficiencies in the current state of communication, patient preferences for communication about palliative care topics, best practices for communication, and the roles of education and system intervention. Communication is a two-way, relational process that is influenced by context, culture, words, and gestures, and it is one of the most important ways that clinicians influence the quality of medical care that patients and their families receive.

Effect of a Patient and Clinician Communication-Priming Intervention on Patient-Reported Goals-of-Care Discussions Between Patients With Serious Illness and Clinicians: A Randomized Clinical Trial

Importance

Clinician communication about goals of care is associated with improved patient outcomes and reduced intensity of end-of-life care, but it is unclear whether interventions can improve this communication.

Objective

To evaluate the efficacy of a patient-specific preconversation communication-priming intervention (Jumpstart-Tips) targeting both patients and clinicians and designed to increase goals-of-care conversations compared with usual care.

Design, Setting, and Participants

Multicenter cluster-randomized trial in outpatient clinics with physicians or nurse practitioners and patients with serious illness. The study was conducted between 2012 and 2016.

Interventions

Clinicians were randomized to the bilateral, preconversation, communication-priming intervention (n = 65) or usual care (n = 67), with 249 patients assigned to the intervention and 288 to usual care.

Main Outcomes and Measures

The primary outcome was patient-reported occurrence of a goals-of-care conversation during a target outpatient visit. Secondary outcomes included clinician documentation of a goals-of-care conversation in the medical record and patient-reported quality of communication (Quality of Communication questionnaire [QOC]; 4-indicator latent construct) at 2 weeks, as well as patient assessments of goal-concordant care at 3 months and patient-reported symptoms of depression (8-item Patient Health Questionnaire; PHQ-8) and anxiety (7-item Generalized Anxiety Disorder survey; GAD-7) at 3 and 6 months. Analyses were clustered by clinician and adjusted for confounders.

Results

We enrolled 132 of 485 potentially eligible clinicians (27% participation; 71 women [53.8%]; mean [SD] age, 47.1 [9.6] years) and 537 of 917 eligible patients (59% participation; 256 women [47.7%]; mean [SD] age, 73.4 [12.7] years). The intervention was associated with a significant increase in a goals-of-care discussion at the target visit (74% vs 31%; P < .001) and increased medical record documentation (62% vs 17%; P < .001), as well as increased patient-rated quality of communication (4.6 vs 2.1; P = .01). Patient-assessed goal-concordant care did not increase significantly overall (70% vs 57%; P = .08) but did increase for patients with stable goals between 3-month follow-up and last prior assessment (73% vs 57%; P = .03). Symptoms of depression or anxiety were not different between groups at 3 or 6 months.

Conclusions and Relevance

This intervention increased the occurrence, documentation, and quality of goals-of-care communication during routine outpatient visits and increased goal-concordant care at 3 months among patients with stable goals, with no change in symptoms of anxiety or depression. Understanding the effect on subsequent health care delivery will require additional study.

Trial Registration

ClinicalTrials.gov identifier: NCT01933789.

A National Strategy For Palliative Care

In 2014 the World Health Organization called for palliative care to be integrated as an essential element of the health care continuum. Yet in 2017 US palliative care services are found largely in hospitals, and hospice care, which is delivered primarily in the home, is limited to people who are dying soon. The majority of Americans with a serious illness are not dying; are living at home, in assisted living facilities, or in nursing homes; and have limited access to palliative care. Most health care providers lack knowledge about and skills in pain and symptom management, communication, and care coordination, and both the public and health professionals are only vaguely aware of the benefits of palliative care and how and when to access it. The lack of policy supports for palliative care contributes to preventable suffering and low-value care. In this article we outline the need for a national palliative care strategy to ensure reliable access to high-quality palliative care for Americans with serious medical illnesses. We review approaches employed by other countries, list the participants needed to develop and implement an actionable strategy, and identify analogous US national health initiatives to inform a process for implementing the strategy.

Effects of Early Integrated Palliative Care on Caregivers of Patients with Lung and Gastrointestinal Cancer: A Randomized Clinical Trial

BACKGROUND

The family and friends (caregivers) of patients with advanced cancer often experience tremendous distress. Although early integrated palliative care (PC) has been shown to improve patient-reported quality of life (QOL) and mood, its effects on caregivers' outcomes is currently unknown.

MATERIALS AND METHODS

We conducted a randomized trial of early PC integrated with oncology care versus oncology care alone for patients who were newly diagnosed with incurable lung and noncolorectal gastrointestinal cancers and their caregivers. The early PC intervention focused on addressing the needs of both patients and their caregivers. Eligible caregivers were family or friends who would likely accompany patients to clinic visits. The intervention entailed at least monthly patient visits with PC from the time of diagnosis. Caregivers were encouraged, but not required, to attend the palliative care visits. We used the Hospital Anxiety and Depression Scale (HADS) and Medical Health Outcomes Survey Short-Form to assess caregiver mood and QOL.

RESULTS

Two hundred seventy-five caregivers (intervention n = 137; control n = 138) of the 350 patients participated. The intervention led to improvement in caregivers' total distress (HADS-total adjusted mean difference = -1.45, 95% confidence interval [CI] -2.76 to -0.15, p = .029), depression subscale (HADS-depression adjusted mean difference = -0.71, 95% CI -1.38 to -0.05, p = .036), but not anxiety subscale or QOL at week 12. There were no differences in caregivers' outcomes at week 24. A terminal decline analysis showed significant intervention effects on caregivers' total distress (HADS-total), with effects on both the anxiety and depression subscales at 3 and 6 months before patient death.

CONCLUSION

Early involvement of PC for patients with newly diagnosed lung and gastrointestinal cancers leads to improvement in caregivers' psychological symptoms. This work demonstrates that the benefits of early, integrated PC models in oncology care extend beyond patient outcomes and positively impact the experience of caregivers.

IMPLICATIONS FOR PRACTICE

Early involvement of palliative care for patients with newly diagnosed lung and gastrointestinal cancers leads to improvement in caregivers' psychological symptoms. The findings of this trial demonstrate that the benefits of the early, integrated palliative care model in oncology care extend beyond patient outcomes and positively impact the experience of caregivers. These findings contribute novel data to the growing evidence base supporting the benefits of integrating palliative care earlier in the course of disease for patients with advanced cancer and their caregivers.

REMAP: A Framework for Goals of Care Conversations

Conversations regarding goals of care with patients who have advanced cancer still occur too late, and oncologists say they lack the training to have these conversations effectively. Experts recommend a number of strategies when having these discussions, including discussing prognosis, responding to patient emotion, exploring values, and often making a recommendation for medical treatments that fit those values. To help learners, from residents to attending oncologists, learn these complex conversational skills, we have developed a framework with a mnemonic, REMAP: Reframe, Expect emotion, Map out patient goals, Align with goals, and Propose a plan. In the reframe step, the oncologist provides a big picture “headline” that lets the patient know things are in a different place. This is followed by actively attending to the patient’s emotional response (expect emotion). Then, to map the patient’s goals, the oncologist asks open-ended questions that are designed to help the patient think about the values that should guide his or her treatment. The oncologist then aligns with those values by explicitly reflecting them back to the patient. If the patient gives permission, the oncologist will then use those values to propose a medical plan that matches patient values. The processes underlying REMAP encourage oncologists and other clinicians to seek to understand and remain flexible, adapting their recommendations to what they hear from the patient, with ongoing revision based on the shared decision-making process. This will lead to patient-centered decisions that promote better end-of-life care.

Disseminating effective clinician communication techniques: Engaging clinicians to want to learn how to engage patients

Patient-clinician communication that promotes patient engagement enhances health care quality. Yet, disseminating effective communication interventions to practicing clinicians remains challenging. Current methods do not have large and sustainable effects. In this paper, we argue that both top-down approaches (mandated by institutions) should be coupled with bottom-up approaches that address clinician motivation, confidence, and barriers. We need to engage clinicians in the same way we ask them to engage patients - strategically and with empathy. We discuss potentially innovative strategies to integrate top-down and bottom-up approaches in ways that fit clinicians' busy schedules and can inform policy.

Effects of Early Integrated Palliative Care in Patients With Lung and GI Cancer: A Randomized Clinical Trial

Purpose We evaluated the impact of early integrated palliative care (PC) in patients with newly diagnosed lung and GI cancer. Patients and Methods We randomly assigned patients with newly diagnosed incurable lung or noncolorectal GI cancer to receive either early integrated PC and oncology care (n = 175) or usual care (n = 175) between May 2011 and July 2015. Patients who were assigned to the intervention met with a PC clinician at least once per month until death, whereas those who received usual care consulted a PC clinician upon request. The primary end point was change in quality of life (QOL) from baseline to week 12, per scoring by the Functional Assessment of Cancer Therapy-General scale. Secondary end points included change in QOL from baseline to week 24, change in depression per the Patient Health Questionnaire-9, and differences in end-of-life communication. Results Intervention patients ( v usual care) reported greater improvement in QOL from baseline to week 24 (1.59 v -3.40; P = .010) but not week 12 (0.39 v -1.13; P = .339). Intervention patients also reported lower depression at week 24, controlling for baseline scores (adjusted mean difference, -1.17; 95% CI, -2.33 to -0.01; P = .048). Intervention effects varied by cancer type, such that intervention patients with lung cancer reported improvements in QOL and depression at 12 and 24 weeks, whereas usual care patients with lung cancer reported deterioration. Patients with GI cancers in both study groups reported improvements in QOL and mood by week 12. Intervention patients versus usual care patients were more likely to discuss their wishes with their oncologist if they were dying (30.2% v 14.5%; P = .004). Conclusion For patients with newly diagnosed incurable cancers, early integrated PC improved QOL and other salient outcomes, with differential effects by cancer type. Early integrated PC may be most effective if targeted to the specific needs of each patient population.

Effect of a Patient-Centered Communication Intervention on Oncologist-Patient Communication, Quality of Life, and Health Care Utilization in Advanced Cancer: The VOICE Randomized Clinical Trial

Importance

Observational studies demonstrate links between patient-centered communication, quality of life (QOL), and aggressive treatments in advanced cancer, yet few randomized clinical trials (RCTs) of communication interventions have been reported.

Objective

To determine whether a combined intervention involving oncologists, patients with advanced cancer, and caregivers would promote patient-centered communication, and to estimate intervention effects on shared understanding, patient-physician relationships, QOL, and aggressive treatments in the last 30 days of life.

Design, Setting, and Participants

Cluster RCT at community- and hospital-based cancer clinics in Western New York and Northern California; 38 medical oncologists (mean age 44.6 years; 11 (29%) female) and 265 community-dwelling adult patients with advanced nonhematologic cancer participated (mean age, 64.4 years, 146 [55.0%] female, 235 [89%] white; enrolled August 2012 to June 2014; followed for 3 years); 194 patients had participating caregivers.

Interventions

Oncologists received individualized communication training using standardized patient instructors while patients received question prompt lists and individualized communication coaching to identify issues to address during an upcoming oncologist visit. Both interventions focused on engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information. Control participants received no training.

Main Outcomes and Measures

The prespecified primary outcome was a composite measure of patient-centered communication coded from audio recordings of the first oncologist visit following patient coaching (intervention group) or enrollment (control). Secondary outcomes included the patient-physician relationship, shared understanding of prognosis, QOL, and aggressive treatments and hospice use in the last 30 days of life.

Results

Data from 38 oncologists (19 randomized to intervention) and 265 patients (130 intervention) were analyzed. In fully adjusted models, the intervention resulted in clinically and statistically significant improvements in the primary physician-patient communication end point (adjusted intervention effect, 0.34; 95% CI, 0.06-0.62; P = .02). Differences in secondary outcomes were not statistically significant.

Conclusions and Relevance

A combined intervention that included oncologist communication training and coaching for patients with advanced cancer was effective in improving patient-centered communication but did not affect secondary outcomes.

Trial Registration

clinicaltrials.gov Identifier: NCT01485627.

Addressing Burnout in Oncology: Why Cancer Care Clinicians Are At Risk, What Individuals Can Do, and How Organizations Can Respond

Despite their benevolent care of others, today, more than ever, the cancer care professional who experiences overwhelming feelings of exhaustion, cynicism, and inefficacy is in grave jeopardy of developing burnout. Clinicians are repeatedly physically and emotionally exposed to exceedingly long hours in direct care with seriously ill patients/families, limited autonomy over daily responsibilities, endless electronic documentation, and a shifting medical landscape. The physical and emotional well-being of the cancer care clinician is critical to the impact on quality care, patient satisfaction, and overall success of their organizations. The prevention of burnout as well as targeting established burnout need to be proactively addressed at the individual level and organizational level. In fact, confronting burnout and promoting wellness are the shared responsibility of both oncology clinicians and their organizations. From an individual perspective, oncology clinicians must be empowered to play a crucial role in enhancing their own wellness by identification of burnout symptoms in both themselves and their colleagues, learning resilience strategies (e.g., mindful self-compassion), and cultivating positive relationships with fellow clinician colleagues. At the organizational level, leadership must recognize the importance of oncology clinician well-being; engage leaders and physicians in collaborative action planning, improve overall practice environment, and provide institutional wellness resources to physicians. These effective individual and organizational interventions are crucial for the prevention and improvement of overall clinician wellness and must be widely and systematically integrated into oncology care.

Self-Assessment Scores Improve After Simulation-Based Palliative Care Communication Skill Workshops

BACKGROUND

We conducted a randomized trial of a simulation-based multisession workshop to improve palliative care communication skills (Codetalk). Standardized patient assessments demonstrated improved communication skills for trainees receiving the intervention; however, patient and family assessments failed to demonstrate improvement. This article reports findings from trainees' self-assessments.

AIM

To examine whether Codetalk resulted in improved self-assessed communication competence by trainees.

DESIGN

Trainees were recruited from the University of Washington and the Medical University of South Carolina. Internal medicine residents, medicine subspecialty fellows, nurse practitioner students, or community-based advanced practice nurses were randomized to Codetalk, a simulation-based workshop, or usual education. The outcome measure was self-assessed competence discussing palliative care needs with patients and was assessed at the start and end of the academic year. We used robust linear regression models to predict self-assessed competency, both as a latent construct and as individual indicators, including randomization status and baseline self-assessed competency.

RESULTS

We randomized 472 trainees to the intervention (n = 232) or usual education (n = 240). The intervention was associated with an improvement in trainee's overall self-assessment of competence in communication skills ( P < .001). The intervention was also associated with an improvement in trainee self-assessments of 3 of the 4 skill-specific indicators-expressing empathy, discussing spiritual issues, and eliciting goals of care.

CONCLUSION

Simulation-based communication training was associated with improved self-assessed competency in overall and specific communication skills in this randomized trial. Further research is needed to fully understand the importance and limitations of self-assessed competence in relation to other outcomes of improved communication skill.

Building Resilience for Palliative Care Clinicians: An Approach to Burnout Prevention Based on Individual Skills and Workplace Factors

For palliative care (PC) clinicians, the work of caring for patients with serious illness can put their own well-being at risk. What they often do not learn in training, because of the relative paucity of evidence-based programs, are practical ways to mitigate this risk. Because a new study indicates that burnout in PC clinicians is increasing, we sought to design an acceptable, scalable, and testable intervention tailored to the needs of PC clinicians. In this article, we describe our paradigm for approaching clinician resilience, our conceptual model, and curriculum for a workplace resilience intervention for hospital-based PC teams. Our paradigm for approaching resilience is based on upstream, early intervention. Our conceptual model posits that clinician well-being is influenced by personal resources and work demands. Our curriculum for increasing clinician resilience is based on training in eight resilience skills that are useful for common challenges faced by clinicians. To address workplace issues, our intervention also includes material for the team leader and a clinician perception survey of work demands and workplace engagement factors. The intervention will focus on individual skill building and will be evaluated with measures of resilience, coping, and affect. For PC clinicians, resilience skills are likely as important as communication skills and symptom management as foundations of expertise. Future work to strengthen clinician resilience will likely need to address system issues more directly.

The challenge of measuring intra-individual change in fatigue during cancer treatment

PURPOSE

To evaluate how well three different patient-reported outcomes (PROs) measure individual change.

METHODS

Two hundred and fourteen patients (from two sites) initiating first or new chemotherapy for any stage of breast or gastrointestinal cancer participated. The 13-item FACIT Fatigue scale, a 7-item PROMIS^® Fatigue Short Form (PROMIS 7a), and the PROMIS^® Fatigue computer adaptive test (CAT) were administered monthly online for 6 months. Reliability of measured change was defined, under a population mixed effects model, as the ratio of estimated systematic variance in rate of change to the estimated total variance of measured individual differences in rate of change. Precision of individual measured change, the standard error of measurement of change, was given by the square root of the rate-of-change sampling variance. Linear and quadratic models were examined up to 3 and up to 6 months.

RESULTS

A linear model for measured change showed the following by 6 and 3 months, respectively: PROMIS CAT (0.363 and 0.342); PROMIS SF (0.408 and 0.533); FACIT (0.459 and 0.473). Quadratic models offered no noteworthy improvement over linear models. Both reliability and precision results demonstrate the need to improve the measurement of intra-individual change.

CONCLUSIONS

These results illustrate the challenge of reliably measuring individual change in fatigue with a level of confidence required for intervention. Optimizing clinically useful measurement of intra-individual differences over time continues to pose a challenge for PROs.

A Procedural Approach to Teaching Residents To Conduct Intensive Care Unit Family Conferences

RATIONALE

Family conferences are an essential component of high-quality ICU care and an important skill for physicians. For residents, intensive care unit (ICU) rotations represent an opportunity to learn to conduct family conferences, and residents are already familiar with an approach for learning ICU procedures with steps of increasing responsibility organized as a module.

OBJECTIVES

To determine the acceptability and feasibility of a procedure-training module for teaching family conferences.

METHODS

We conducted a feasibility pilot study of a family conference training module with residents during a one-month ICU rotation over a three-month period. The module had five components: (1) two-minute instructional video; (2) faculty observation of two family conferences; (3) standardized observation and formative evaluation; (4) online resident procedure log; and (5) family conference note template to document the conference in the medical record. We evaluated acceptability with an anonymous survey.

RESULTS

Twenty-seven residents rotated through the ICU during the pilot with 11 completing only one observed conference (41%) and 4 completing two or three observed conferences (15%). The most common reasons for not having conducted observed and evaluated conferences included competing work demands and conferences occurring at night. The survey response rate was 44% (12/27). Of respondents, 92% gave the module a rating of good, very good, or excellent and 92% stated they would recommend the module to others.

CONCLUSIONS

This five-component module for teaching family conferences was rated as acceptable by most respondents, but significant barriers to successful implementation must be addressed before this is likely to be an effective teaching method.

Physicians' and Nurse Practitioners' Level of Pessimism About End-of-Life Care During Training: Does It Change Over Time?

CONTEXT

An enhanced understanding of trainee attitudes about end-of-life care is needed to inform interventions to improve clinician communication about dying and death.

OBJECTIVES

To examine changes in trainee pessimism about end-of-life care over the course of one academic year and to explore predictors of pessimism among residents, fellows, and nurse practitioners.

METHODS

We used baseline and follow-up surveys completed by trainees during a randomized controlled trial of an intervention to improve clinician communication skills. Surveys addressed trainee feelings about end-of-life care. Latent variable modeling was used to identify indicators of trainee pessimism, and this pessimism construct was used to assess temporal changes in trainee attitudes about end-of-life care. We also examined predictors of trainee pessimism at baseline and follow-up. Data were available for 383 trainees from two training programs.

RESULTS

There was a significant decrease in pessimism between baseline and follow-up assessments. Age had a significant inverse effect on baseline pessimism, with older trainees being less pessimistic. There was a direct association of race/ethnicity on pessimism at follow-up, with greater pessimism among minority trainees (P = 0.028). The model suggests that between baseline and follow-up, pessimism among younger white non-Hispanic trainees decreased, whereas pessimism among younger trainees in racial/ethnic minorities increased over the same period.

CONCLUSION

Overall, trainee pessimism about end-of-life care decreases over time. Pessimism about end-of-life care among minority trainees may reflect the influence of culture on clinician attitudes about communication with seriously ill patients. Further research is needed to understand the evolution of trainee attitudes about end-of-life care during clinical training.

"Why are we doing this?": clinician helplessness in the face of suffering

BACKGROUND

When the brutality of illness outstrips the powers of medical technology, part of the fallout lands squarely on front-line clinicians. In our experience, this kind of helplessness has cognitive, emotional, and somatic components.

OBJECTIVES

Could we approach our own experiences of helplessness differently? Here we draw on social psychology and neuroscience to define a new approach.

METHODS

First, we show how clinicians can reframe helplessness as a self-barometer indicating their level of engagement with a patient. Second, we discuss how to shift deliberately from hyper- or hypo-engagement toward a constructive zone of clinical work, using an approach summarized as "RENEW": recognizing, embracing, nourishing, embodying, and weaving--to enable clinicians from all professional disciplines to sustain their service to patients and families.

The power of words: discussing decision making and prognosis

One of the most important skills in medicine is communication. It lies at the heart of the doctor-patient relationship, and is particularly important when one has been diagnosed with a potentially life-threatening condition. Words are powerful and too often can be interpreted in ways not intended. In our session at the 2013 ASCO Annual Meeting, we discuss the communication of cancer and ways we might want to consider discussions regarding treatment options and prognosis. We recognize that all patients are different and that approaches should be individualized, to reflect each person's needs (what they want to know) while respecting their limits (how much they want to know). We discuss the concept of shared decision making, and how it can be used when there is uncertainty in what treatments may (or may not) accomplish. Finally, we discuss the skills that constitute a toolkit for communication, which we hope can be tailored to meet the variable needs of those we are caring for and by doing so, can be of help to clinicians in their own practices. In the era of personalized medicine, treatments may become more complex, and more options may be available. We hope to encourage providers to welcome patients as active participants in their care by sharing information, requesting their input, and by engaging them in important processes such as advance care planning-to ensure their needs and wishes are respected in the present and for whatever may come in the future.