Coaching, Question Prompts Improved End-of-Life Discussions

Use of communication coaching that included a question prompt list (QPL)-or structured lists of questions given to patients prior to consultations-helped patients with advanced cancer and their caregivers to bring up topics of concern during oncology office visits, according to the results of a study published in the Journal of Clinical Oncology.

“In a context in which patients are known to have misconceptions about their illness and prognosis, we found that patients with advanced cancer who participated in a combined QPL and coaching intervention identified key topics of interest relevant to the status of their disease, including prognosis, and that they brought up topics relevant to disease status and prognosis more often than control-group patients did,” wrote Rachel A. Rodenbach, MD, of the University of Pittsburgh Medical Center Montefiore Hospital, and colleagues. “In this sense, our intervention appears to have been effective in giving a voice to patients and their caregivers during office visits with their oncologists.”

Rodenbach and colleagues had previously reported results of a trial that combined training of oncologists with use of a QPL for outpatients with advanced cancer and showed that the intervention improved communication between patient and physicians.

With this secondary analysis, the researchers looked into how the intervention affected the number and nature of topics brought up during the oncology office visit. The trial included 170 patients with advanced nonhematologic cancers taken from 24 participating oncology practices. Oncologists were assigned to either individualized communication training or no intervention, and patients were assigned to a pre-visit coaching session with a QPL (n = 84) or no intervention (n = 86).

More than 70% of patients who received the intervention brought up QPL-related topics during the office visit compared with only 32.6% of control patients (P < .001). These topics included expectations/prognosis, current cancer state, goals of treatment, cancer treatment, symptom management, and preferences/concerns about end-of-life care. Patients given the coaching session were three times more likely to ask about their prognosis compared with controls (16.7% vs 5.8%; P = .03).

“Although this finding represents an important advance in the promotion of discussions that have an effect on future treatment decisions, prognosis discussions remain infrequent,” the researchers noted. “Most patients continue to have much more optimistic prognosis estimates and more unrealistic treatment expectations than their oncologists, and our intervention had no effect on these discrepancies.”

During coaching sessions, 262 topics of interest were identified and 60.3% were QPL-related, including 12.7% that addressed prognosis. According to the researchers, almost all items from the QPL booklet were brought up by at least one patient.

“Taken together, the link observed in this study between patient intentions (as revealed by topics prioritized through use of a QPL and coaching) and actions (as demonstrated through what was brought up during their subsequent office visit) suggests a possible mechanism whereby the intervention was effective,” the researchers wrote. “The finding that most topics of interest were brought up by patients and caregivers (rather than clinicians), coupled with the finding that oncologists nearly always responded to topics raised by patients regardless of whether they received training, suggests that discussion of topics important to patients was more a result of the patient/caregiver targeted component of the intervention than of oncologist communication training.”