Actual and Missed Opportunities for End-of-Life Care Discussions With Oncology Patients

• Authors: Kristin E Knutzen, Emory University; Olivia A Sacks, Boston Medical Center; Olivia C Brody-Bizar, Dartmouth College, Hanover; Genevra F Murray, Boston Medical Center; Raina H Jain, Dartmouth College, Hanover; Lindsay A Holdcroft, Dartmouth College, Hanover; Shama S Alam, Pharmaceutical Product Development, Evidera; Matthew A Liu, University of California, San Diego; Kathryn I Pollak, Duke University; James A Tulsky, Dana-Farber Cancer Institute; Amber E Barnato, Geisel School of Medicine at Dartmouth
• Journal Title: JAMA Network Open
• Volume: Volume 4, Number 6
• Publisher: JAMA Network | 2021-06-10
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1001/jamanetworkopen.2021.13193
• Subjects: Health Sciences, Oncology; Health Sciences, Medicine and Surgery
• Keywords: Oncology Patients

Abstract

Importance Early discussion of end-of-life (EOL) care preferences improves clinical outcomes and goal-concordant care. However, most EOL discussions occur approximately 1 month before death, despite most patients desiring information earlier. Objective To describe successful navigation and missed opportunities for EOL discussions (eg, advance care planning, palliative care, discontinuation of disease-directed treatment, hospice care, and after-death wishes) between oncologists and outpatients with advanced cancer. Design, Setting, and Participants This study is a secondary qualitative analysis of outpatient visits audio-recorded between November 2010 and September 2014 for the Studying Communication in Oncologist-Patient Encounters randomized clinical trial. The study was conducted at 2 US academic medical centers. Participants included medical, gynecological, and radiation oncologists and patients with stage IV malignant neoplasm, whom oncologists characterized as being ones whom they “…would not be surprised if they were admitted to an intensive care unit or died within one year.” Data were analyzed between January 2018 and August 2020. Exposures The parent study randomized participants to oncologist- and patient-directed interventions to facilitate discussion of emotions. Encounters were sampled across preintervention and postintervention periods and all 4 treatment conditions. Main Outcomes and Measures Secondary qualitative analysis was done of patient-oncologist dyads with 3 consecutive visits for EOL discussions, and a random sample of 7 to 8 dyads from 4 trial groups was analyzed for missed opportunities. Results The full sample included 141 patients (54 women [38.3%]) and 39 oncologists (8 women [19.5%]) (mean [SD] age for both patients and oncologists, 56.3 [10.0] years). Of 423 encounters, only 21 (5%) included EOL discussions. Oncologists reevaluated treatment options in response to patients’ concerns, honored patients as experts on their goals, or used anticipatory guidance to frame treatment reevaluation. In the random sample of 31 dyads and 93 encounters, 35 (38%) included at least 1 missed opportunity. Oncologists responded inadequately to patient concerns over disease progression or dying, used optimistic future talk to address patient concerns, or expressed concern over treatment discontinuation. Only 4 of 23 oncologists (17.4%) had both an EOL discussion and a missed opportunity. Conclusions and Relevance Opportunities for EOL discussions were rarely realized, whereas missed opportunities were more common, a trend that mirrored oncologists’ treatment style. There remains a need to address oncologists’ sensitivity to EOL discussions, to avoid unnecessary EOL treatment.