Serious Illness Conversation Guide Can Help Clinicians Communicate with Critically Ill Patients

MedicalResearch.com Interview with:
Joanna Paladino, MD
Director of Implementation, Serious Illness Care Program | Ariadne Labs
Brigham and Women’s Hospital | Harvard T.H. Chan School of Public Health
Palliative Care | Dana-Farber Cancer Institute
Instructor | Harvard Medical School and

Dr. Rachelle Bernacki MD MS
Director of Quality Initiatives
Psychosocial Oncology and Palliative Care
Senior Physician, Assistant Professor of Medicine
Harvard Medical School

Dr. Paladino’s responses:

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Paladino: People living with serious illness face many difficult decisions over the course of their medical care. These decisions, and the care patients receive, should be guided by what matters most to patients, including their personal values, priorities, and wishes. These conversations don’t often happen in clinical practice or do so very late in the course of illness, leaving patients exposed to getting care they don’t want.

Doctors and nurses want to have these important discussions, but there are real challenges, including insufficient training and uncertainties about when and how to start the conversation. We designed an intervention with clinical tools, clinician training, and systems-changes to address these challenges. When tested in a randomized clinical trial in oncology, we found that the intervention led to more, earlier, and better conversations between oncology clinicians and their patients with life-limiting cancer. These findings demonstrate that it is possible to ensure reliable, timely, and patient-centered serious illness conversations in an outpatient oncology practice.

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Paladino:  A simple tool with gentle, relatable language- the Serious Illness Conversation Guide- can help clinicians have a better conversation with patients, earlier in their illness course, about their values, goals and preferences. If you are interested in improving conversations in your setting, or perhaps on a broader level, consider visiting our Community of Practice website, https://portal.ariadnelabs.org, where materials are available free of charge.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Paladino: Studying which ingredients of communication interventions drive the biggest improvements in conversations is really important, so we can figure out how to reach more clinicians and more patients. We also need to measure the impact of conversations on patient and family experience of care, outcomes that matter to patients with serious illness and are feasible to measure, as well as clinician experience, satisfaction, and meaning in work. 

MedicalResearch.com: Is there anything else you would like to add?

Dr. Paladino: With tools, training, and support, we were able to see these conversations happen significantly earlier in the patient’s illness course, about 5 months before death in the intervention group compared to about 2.5 months in the control group. This finding is important because earlier conversations can give patients, families, and their clinicians more time to plan and prepare. Questions such as – What are your most important goals? What are your biggest fears and worries about the future with your health? What abilities are so critical to your life that you can’t imagine living without them? – get to the heart of what matters most to patients and can help clinicians and patients navigate these conversations together.

No disclosures 

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Rachelle Bernacki’s responses: :

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Bernacki : The final year of life with serious illness can be filled with emotional distress and uncertainty about treatment options. People with serious illness have goals besides just living longer, including being with family and being at home. Experts agree that seriously ill patients benefit from meaningful conversations with their doctors and nurses when those conversations focus on patient goals and values. We wanted to understand if it is possible to fill in the gaps we see: Few patients having the conversation; few clinicians feeling prepared to have these conversations; systems often unprepared as well. The Serious Illness Care Program is designed to comprehensively address gaps with tools, training, and system-changes The study demonstrated that the program led to more, better, and earlier conversations between clinicians and patients and reduced patient anxiety and depression. The intervention did not demonstrate whether the conversations resulted in care that aligned with patient goals or greater peacefulness at the end of life. The intervention did not impact survival rates.

 

MedicalResearch.com: What should readers take away from your report?

Dr. Bernacki : Having better conversations with your patients with serious Illness is possible with training and using a structured framework, the Serious Illness Conversation Guide. If you are interested in improving conversations in your setting or perhaps on a broader level, consider visiting our Community of Practice website, https://portal.ariadnelabs.org, where our materials are available free of charge.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

 

Dr. Bernacki : Better measures and assessment of whether patients are attaining the type of care they want (goal-concordant care) are needed. Furthermore, I would measure these outcomes across the entire course of serious illness, because how patients are living with serious illness is just as important as measurement at the end of life.

MedicalResearch.com: Is there anything else you would like to add? Any disclosures?

 

Dr. Bernacki : Once you start a conversation, more conversations follow, and I believe those conversations likely reduce anxiety for patient. Talking about the future and what to expect makes it less frightening for patients. If you can provide anticipatory guidance for seriously ill patients and families, we can allay some of the burden.

No disclosures

Citation:

Paladino J, Bernacki R, Neville BA, et al. Evaluating an Intervention to Improve Communication Between Oncology Clinicians and Patients With Life-Limiting CancerA Cluster Randomized Clinical Trial of the Serious Illness Care ProgramJAMA Oncol. Published online March 14, 2019. doi:10.1001/jamaoncol.2019.0292

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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