Earlier, More Thorough Conversations Eases Distress in Advanced-Stage Patients

Nurses and other healthcare providers can mitigate emotional distress and improve quality of life in patients with cancer by having earlier and more thorough conversations about their care, according to a recent study conducted at the Dana-Farber Cancer Institute.

The study of the Adriadne Labs Serious Illness Care Program, which was published in JAMA Internal Medicine and JAMA Oncology, found that when oncology clinicians have more, earlier, and better conversations with patients who have advanced-stage disease, the patients reported less emotional suffering. The conversations were geared toward the wishes of the patients — with 90% discussing their goals and values – which happened about 2.4 months earlier than they usually would have, placing them almost 5 months before the patients’ death.

As a result of these conversations, the proportion of patients who had moderate to severe anxiety or depression was cut in half, with anxiety improvements sustaining for at least 24 weeks.

“Patients want their providers to broach these conversations. When they do, it’s like approaching the elephant in the room,” said Barbara Reville, DNP, ANP-BC, ACHPN, nurse director of adult palliative care at Brigham and Women’s Hospital and the Dana-Farber Cancer Institute and fellowship director of the Harvard Palliative Care Nurse Practitioner Fellowship, in an interview with Oncology Nursing News.

For oncology nurses and other providers who may be apprehensive to approach these kinds of talks with their patients, palliative care experts developed the Serious Illness Conversation Guide, which offered advice on how to talk with patients regarding their prognosis, disease, values and personal goals, fears and sources of strengths, critical abilities that matter to their quality of life, and what they may be willing to go through to extend their survival.

“Unfortunately, we do know quite a bit about how often these conversations are happening. Usually less than a third of patients are having conversations like this, and they often have them late,” said Rachelle Bernacki, MD, MS, associate director of the Serious Illness Care Program and director or quality initiatives and senior physician of adult palliative care at the Dana-Farber Cancer Institute said in an interview with Oncology Nursing News.

“What we really wanted to do was to teach [clinicians] to document things like ‘[the patient] is willing to go through,” she added.

Reville and Bernacki both agreed that conversations around prognosis are often the most difficult to have. Thanks to feedback from nurses, functional prognostic markers were added to the Serious Illness Conversation Guide. So now practitioners do not always need to discuss prognosis in terms of time left to live, but instead can say things like, “you will need some therapy before being able to be independent again.”

Clinicians who participated in the guide received a 2.5-hour communication training with palliative care experts, as well as supportive coaching. Ninety-one doctors, nurse practitioners, and physician assistants tested the program, which was used on 139 patients, whose outcomes were compared to 139 patients who received usual care.

There was no difference between the two groups when it came to goal-concordant care and peacefulness for patients who died. However, the researchers noted that this may be because there were fewer patient deaths than expected, and the sample size may have been too small to draw any conclusions.

Thanks to programs like these, as well as organizations such as the End-of-Life Nursing Education Consortium, oncology nurses are realizing their role in having these difficult, but important conversations with their patients.

“It’s changing, but we’ve got a way to go,” Reville said. “I think projects like these are really helpful.”

The Serious Illness Conversation Guide program has since expanded to more than 20 partner sites across the nation.

“We were really happy to show that it is feasible to train people how to have more, better, and earlier conversations,” Bernacki said.