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Saturday, June 4, 2016

Who Leads End-of-Life Discussions Matters, Study Reports

By Catlin Nalley

CHICAGO--In 2016 Medicare began reimbursing clinicians for engaging in all end-of-life discussions. Research has shown that what is said is important, but does it matter who does the talking?

Researchers at Weill Cornell Medicine conducted a longitudinal study to determine the importance of whom on the care team engages in these discussions with patients, according to Simon Mentis Cohen, research assistant at the Center for Research on End-of-Life Care at Weill Cornell Medicine.

This study takes a closer look at whether advanced cancer patients' illness understanding varies depending on whether they discussed their re-staging scan results with an oncologist versus another care team member. Initial findings, reported at the 2016 ASCO Annual Meeting, support that which member of the care team leads the end-of-life discussion does make a difference (Abstract 6545).

Study Methodology

"Coping with Cancer II" recruited patients at seven comprehensive cancer centers across the country between 2010 and 2015. Eligible participants included patients who had advanced cancer associated with a life expectancy of 6 months or less.

"We interviewed patients before and after they discussed the results of their most recent re-staging scan with their oncology provider," explained Cohen. "This was designed in order to evaluate end-of-life communications between patients and their oncology providers and the effects of such discussions."

"Patients reported whether they discussed their re-staging scan results with an oncologist or another care team member and whether or not they discussed an end-of-life topic during the re-staging scan discussion," he continued. "Patients also reported before and after their re-staging scan discussion whether or not they thought their cancer was late- or end-stage."

Patients who had discussions with multiple providers were excluded from the study. Multiple logistic regression analysis was used to estimate the effect of discussing re-staging scan results with an oncologist versus another care team member on patients' post-scan illness understanding, adjusting for scan results communicated, pre-scan illness understanding and clinic site, according to researchers.

Study Results

Advanced cancer patients who discussed their re-staging scan results with an oncologist versus an oncology fellow or nurse practitioner were three times more likely to recognize that their disease was late- or end-stage, according to Cohen.

A sub analysis of only patients who reported discussing an end-of-life topic (i.e. prognosis, curability, life-expectancy, or end-of-life goals of care) was conducted. In this group, patients who met with an oncologist versus an oncology fellow or nurse practitioner were 4.5 times more likely to recognize that their disease was late- or end-stage.

ohen reported that the focus on what patients recalled of discussions during their re-staging scans could be a potential limitation of this analysis.

"We consider what patients hear to be crucial, but others may consider what oncology providers report was discussed to be a more reliable report," he explained. "The oncology provider reports will be examined in a future study."

Continued Research

The "Coping with Cancer II" study marks the first step in understanding this facet of end-of-life discussions. According to Cohen, the next step will be to take a closer look at the reasons why oncologists were more effective than oncology fellows and nurse practitioners at promoting accurate illness understanding.

"For example, were oncologists more effective at engaging in these discussions because of their position as the authority figure on the cancer care team, because the language they used during the conversations was more comprehensible, or for another reason," Cohen noted. "In the future we will examine audio recordings that we have collected of these re-staging scan discussions in order to shed light on this question."

 Practice Implications

This study has the potential to impact end-of-life discussions across the continuum of care.

"Our findings demonstrate the importance of oncologists engaging in re-staging scan discussions and end-of-life discussions with advanced cancer patients in order to promote accurate patient illness understanding," said Cohen. "Advanced cancer patients' illness understanding is linked to preferences for life-extending therapy versus comfort care and predicts chemotherapy use and hospice enrollment."

"The better patients understand the reality of their condition, the more prepared they will be to make informed end-of-life care choices that are consistent with their values," he concluded.

Catlin Nalley is an associate editor.