Oncology Infusion Nurses Propel Advanced Care Planning Conversations in Cancer Care

A nurse-led primary palliative care intervention led to an increase in end-of-life discussions and the completion of advance directives among patients with advanced cancer, according to a study published in the Journal of the National Comprehensive Cancer Network.¹

The findings are based on a secondary analysis of patients who were randomly assigned to monthly conversations with trained nursing staff or standard care. Among those who did not have an end-of-life conversation (EOLC) at baseline, 45.1% had an ELOC at data cutoff of 3 months postintervention (n = 182) compared with 14.8% of patients in the control arm (n = 196; adjusted odds ratio [OR], 5.28; 95% CI, 3.10-8.97; P < .001). Among patients who did not complete an advance directive (AD) at baseline, 43.2% of patients in the intervention arm (n = 111) vs 18.1% of patients in the control group (n = 105), completed an AD during the study time frame (OR, 3.68; 95% CI, 1.89-7.16; P < .001). The unadjusted OR for this comparison was 3.45 (P < .001).¹

“Our findings show that a nurse-led primary palliative care intervention improves advance care planning uptake, assessed as an EOLC with one’s oncologist or completion of an advance directive, among patients with advanced cancer,” Michael Cohen, MD, a gynecologic oncologist at the University of Pittsburgh School of Medicine, and co-investigators, wrote in the study. “Nurse-led primary palliative care is a promising approach to improve advance care planning among patients with advanced cancer, particularly for those without access to specialty palliative care.”

According to investigators, patients often struggle to understand or engage in the complex medial decision-making that is necessary during end-of-life care. Advance care planning seeks to make that process easier.

Advance care planning is defined as a “process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care.”² Studies have suggested that advanced care planning offers a significant benefit to patients—it has been shown to increase a patient’s likelihood of dying in a preferred location, superior hope at the end of life, less anxiety surrounding death for patients, and decreased decisional anxiety for caregivers.^3-6 Despite this, advance care planning often occurs late or not at all.

Palliative care specialists often initiate conversations and are experts in helping patients navigate advance care planning. However, access to palliative specialists can be limited, especially across large health care networks.¹

The CONNECT study (NCT02712229) sought to address this limitation by training oncology nurses to lead primary palliative care across the community cancer center clinics.¹ The study was carried out across 17 community clinics in the Hillman Cancer Center network. The trial enrolled patients between July 2016 an October 2019.

As part of the CONNECT intervention, oncology infusion nurses attended an immersive 3-day training hosted by palliative care experts. There were 4 key competencies highlighted in this training: (1) addressing symptom needs; (2) engaging patients and caregivers in advance care planning; (3) providing emotional support to patients and caregivers; and (4) communicating and coordinating appropriate care. Following the training, nurses met with their patient at least monthly over the course of 3 months, during which time they built shared care plans with their patients, ensuring that symptom burden and goals of care were established and discussed.

One of the key objectives of the first CONNECT visit was to determine whether the patient had a surrogate decision-maker. In further visits, questions expanded to different goals of care such as “What is important to you if you were to get sicker?” Nurses brought their findings to the oncologist who used the information to address the patients’ needs.

Of note, although nurses were able to discuss advance directives and review them with the patients, they were not able to sign legal documents.

In comparison, standard of care comprised standard oncology treatment by oncologists and in-clinic nurses. Any specialty supportive or palliative care services were done at the discretion of the oncologists. ACP was at the discretion of the patient’s clinical team and no additional support was provided to encourage ACP in the standard-of-care group.

A total of 672 patients were enrolled in the CONNECT study, they were evenly assigned 1:1 to both arms (n = 336, respectively). In the CONNECT intervention arm, 65 patients had received an EOLC prior to the initiation, whereas 271 had not. In addition, 89 patients died or withdrew during the 3-month assessment, leaving 182 patients to complete the 3-month assessment, and a total of 82 patients who had EOLC at 3 months (4.1%).¹

In the standard care arm, 67 patients had undergone prior EOLC, and 269 had not. Seventy-three patients died or withdrew, with 196 completing the 3-month assessment. Twenty-nine completed EOLC at 3 months follow-up (14.8%).

“Based on the intervention providing palliative care led by oncology nurses, our findings represent a promising approach for meeting an unmet need across community oncology centers and a novel way to address the current NCCN Clinical Practice Guidelines in Oncology for Palliative Care recommending that advance care planning is facilitated for all patients with advanced malignancies,” study authors concluded.

References

1. Cohen MG, Althouse AD, Arnold RM, et al. Primary palliative care improves uptake of advance care planning among patients with advanced cancers. J Natl Compr Canc Netw. 2023;21(4):383-390. doi:10.6004/jnccn.2023.7002
2. Sudore RL, Lum HD, You JJ, et al. Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel. J Pain Symptom Manage. 2017;53(5):821-832. doi:10.1016/j.jpainsymman.2016.12.331
3. Orlovic M, Callender T, Riley J, Darzi A, Droney J. Impact of advance care planning on dying in hospital: evidence from urgent care records. PLoS One. 2020;15(12):e0242914. doi:10.1371/journal.pone.0242914
4. Cohen MG, Althouse AD, Arnold RM, et al. Hope and advance care planning in advanced cancer: is there a relationship? Cancer. 2022;128(6):1339-1345. doi:10.1002/cncr.34034
5. Brown AJ, Shen MJ, Ramondetta LM, Bodurka DC, Giuntoli 2nd RL, Diaz-Montes T. Does death anxiety affect end-of-life care discussions? Int J Gynecol Cancer. 2014;24(8):1521-1526. doi:10.1097/IGC.0000000000000250
6. Chiarchiaro J, Buddadhumaruk P, Arnold RM, White DB. Prior advance care planning is associated with less decisional conflict among surrogates for critically ill patients. Ann Am Thorac Soc. 2015;12(10):1528-1533. doi:10.1513/AnnalsATS.201504-253OC