How to Introduce End-of-Life Discussions

End-of-life conversations should be introduced months, or even years, before a patient with cancer nears their death, explained Tony C. Campbell, MD, MSCI, associate professor of medicine at the University of Wisconsin.

During the 2019 National Comprehensive Cancer Network (NCCN) Annual Conference, he discussed ways that healthcare providers can begin this process.

“A fundamental key point to think about when talking about transitioning to end-of-life care is that it begins far before someone is at the very end of their life,” Campbell said in an interview with Oncology Live, a sister publication of Oncology Nursing News.

One of the first steps that clinicians can take is to help their patient develop prognostic awareness. For patients with advanced-stage disease, this means that they are aware that their disease is incurable. To do this, Campbell asks his patients a simple question, usually after they receive the results of a test or a scan: Do you want to talk about what that means? More often than not, patients respond with yes, Campbell said.

Clinicians should introduce the idea that the cancer is incurable early on, according to Campbell, and then again at point of progression when discussing next treatment options. “Handy times to [have that talk] are at times of progression when you’re switching treatment, and also at times when you have a test result,” Campbell said. “Interestingly, you can do it when you have good news or bad news.”

When there is good news, a clinician can say something like this: “I have great news from your CAT scans. This treatment is going to help you live longer. I’m not sure exactly how much longer, but it will help. It’s still ultimately a disease that will become resistant to this treatment.”

That strategy could work for the patient’s family and caregivers, or practitioners may need to take on a new approach.

“In terms of patients’ families and caregivers, I think it’s important to attending to individuals as individuals, recognizing that a single patient or caregiver might be in different places,” Campbell said. “So paying attention to where the different members of that patients’ family and caregiver support network are with their own coping and prognostic awareness is probably the best strategy.”

The NCCN established a set of guidelines to help lead oncologists, nurses, and other members of the care team in having these kinds of discussions. They, too, emphasize the importance of introducing the conversation long before the patient reaches end of life, as well as the importance of hospice and/or palliative care, and symptom management—this can help mitigate anxiety and depression, and may even help patients live longer, according to Campbell.

Ultimately, it comes down to a multidisciplinary approach.

“Quality care is based upon not only just what medications are used, but also the care and concern that [clinicians] show for patients and families,” Campbell said. “Communication strategies can really augment that demonstration of care and concern.”