New study identifies approach for improving end-of-life conversations for people with cancer

New research in the April 2023 issue of the Journal of the National Comprehensive Cancer Network finds that specially trained oncology infusion room nurses can improve advance care planning (ACP) for patients with advanced cancer. In this study, oncology nurses underwent an immersive, three-day training session on palliative care.

As compared to patients who received standard care, those who participated in this targeted and specialized intervention had a dramatically increased rate of creating advance directives and taking part in conversation about end-of-life issues.

Of the people included who had not previously had an end-of-life conversation, 45.1% of patients who engaged with these trained nurses within this program subsequently engaged in conversations about end-of-life care within three months, compared to just 14.8% who underwent standard care. The numbers were similar (43.2% and 18.1%, respectively) for those who completed an advance directive, also known as a living will.

"I was surprised to see that this approach to primary palliative care increased uptake of advance care planning so significantly, particularly because the oncology nurses told us that this was one of the hardest things we asked them to do. Clearly, they rose to the challenge and were able to have a major impact on rates of ACP," said Yael Schenker, MD, MAS, FAAHPM, director of the Palliative Research Center and professor in the Division of General Internal Medicine, University of Pittsburgh and UPMC.

"Advance care planning is a process designed to help people have a voice in their medical care. For people with serious illness like advanced cancer, this kind of communication can allay anxiety, help patients and families to feel more supported in decision making, and help to ensure that people receive the kind of care that aligns with their preferences."

The randomized trial involved 672 patients across 17 community clinics in Western Pennsylvania from July 2016 through October 2019. All enrolled patients had advanced solid tumor malignancies and an indication from their doctor that end-of-life would not be surprising within a year. The patients completed a survey on ACP at the time of enrollment, and again three months later. 378 did not initially report having had an end-of-life conversation and 216 lacked an advance directive at the time of enrollment.

The palliative care training for the nurses focused on four key areas:

1. Addressing symptom need
2. Engaging patients and caregivers in ACP
3. Providing emotional support to patients and caregivers
4. Communicating and coordinating appropriate care

"Advance care planning is an important component of care for patients with advanced cancers," continued Dr. Schenker. "Empowering and training nurses to develop shared care plans with patients and communicate this with oncologists represents a unique and effective way to improve advance care planning in this population. Leadership support and protected time are needed to ensure that nurses are able to accomplish non-treatment-related activities like advance care planning."

"Advance care planning is critical to providing high-quality care to patients with cancer and is highlighted in the NCCN Guidelines for Palliative Care," commented Anne M. Walling, MD, Ph.D., FAAHPM, Associate Professor of Medicine; Director of Palliative Care Research; Department of Medicine, UCLA and Member of the UCLA Jonsson Comprehensive Cancer Center, who was not involved in this research.

Dr. Walling—who was recently named Chair of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Panel for Palliative Care—continued, "These study results provide evidence to support oncology nurses playing a key role in this important care process."