Having meaningful conversations with patients diagnosed with advanced forms of cancer and their families is about their disease is an important, but often difficult, part of providing advanced care.  Patients need to partner with their care team to make future treatment decisions that reflect their own values and align with what matters most.

These ‘Serious illness conversations’, which should include clinicians sharing information on prognosis and treatment options, and patients and their loved ones sharing their values and preferences can elicit strong emotions for patients, family and clinicians. Especially if this involves acknowledging bad outcomes or dying.

Despite professional guidelines recommending early serious illness conversations for all patients with advanced cancer, many times these conversations occur, unfortunately, late or not at all.

As the first part of a larger initiative across Dartmouth Cancer Center, a broad team of clinician-researchers, clinical partners, data scientists and even a patient partner have implemented a quality improvement project that was able to increase the occurrence and documentation of these important conversations in two disease-specific medical oncology clinics. Over the 18-month study period, the teams increased their baseline documentation rate from 0% to 70%, or 43 of 63 eligible patients.

Results of the project were published in JCO Oncology Practice, an American Society of Clinical Oncology (ASCO) journal.

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Evidence-based training
“We partnered with our colleagues in Palliative Care, who provided an evidence-based training program to increase our knowledge, skills and comfort in leading serious illness conversations,” says lead author Garrett T. Wasp, MD, a medical oncologist in Dartmouth Cancer Center’s Head & Neck Cancer Program.

The group identified four drivers for their success: standardized work, an engaged interdisciplinary team, engaged patients and families, and system-level support. With the help of Dartmouth Health’s technology team, clinicians succeeded in documenting serious illness conversations in a standardized, one-page format that was easily accessible in the electronic medical record. The work also inspired creation of clinician-facing tools that allow for automated tracking and reporting of serious illness conversations.

The Serious Illness Conversation Model of Care is one intervention in the Promise Partnership Learning Health System: a joint venture between Dartmouth Cancer Center, The Dartmouth Institute for Health Policy & Clinical Practice and Dartmouth Health.

Co-author and palliative care physician Amelia M. Cullinan, MD, joined by a team of skilled communication coaches, has spread the intervention to three additional clinical oncology groups, with two more onboarding in summer of 2022.

“These partnerships have led to insights into strategies that both individuals and health systems can use to enhance communication and decision-making for all serious illnesses, not just cancer,” Wasp said.

“More effective patient–clinician communication will lead to better adherence to professional guidelines and should produce care that is more patient-centered,” Wasp concluded.

The authors of the study are planning additional publications and presentations at a future national society meetings which are expected to including using patient-reported outcomes to help better access the impact.

[1] Wasp GT, Cullinan AM, Anton CP, Williams A, Perry JJ, Holthoff MM, Buus-Frank ME. Interdisciplinary Approach and Patient/Family Partners to Improve Serious Illness Conversations in Outpatient Oncology. JCO Oncol Pract. 2022 Jul 20:OP2200086. doi: 10.1200/OP.22.00086. Epub ahead of print. PMID: 35858156.

Featured image: Medical oncologist Garrett T. Wasp, MD, (left) and director of outpatient palliative care, Amelia M. Cullinan, MD, (right) are part of the team actively improving the implementation of structured Serious Illness Conversations between patients with advanced cancer and their providers. Photo courtesy: Mark Washburn/Dartmouth Cancer Center. Used with permission.

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