Chicago, IL—As palliative care assumes a larger role in clinical practice, talking with patients about their goals of care, especially early in the disease course, is more important than ever. In fact, according to Anthony L. Back, MD, Co-Director, Cambia Palliative Care Center of Excellence, University of Washington, Seattle, having conversations about end-of-life and supportive care is one of the critical competencies that every oncologist and cancer care clinician needs to take into consideration.
“The question is no longer why we should learn this; it’s how we should put this into practice,” said Dr Back. “It’s clear that upgrading communication skills will have a high return on investment.”
As Dr Back reported at the 2017 ASCO annual meeting practice management sessions, recent research has demonstrated a huge disconnect between what physicians think is important and what they’re actually doing when it comes to communicating with their patients.
End-of-Life Conversations
A large study from the University of Washington showed that, when rating their own skills related to the goals of care and end-of-life conversations, physicians often perceive their level of training to be insufficient.
“Not many physicians had formal training in this capacity when they were fellows, and it shows in their conversations,” said Dr Back.
In the largest observational study ever conducted of oncologists talking to patients with metastatic disease, published in 2015 in the Annals of Internal Medicine, skills critical to overcoming barriers were seldom utilized. Of 450 audio-recorded conversations, oncologists made empathic statements in only 11% of their conversations.
“These results show that our ability to notice emotion and use it as a tool to help us move through the conversation isn’t well established,” Dr Back observed.
The good news, however, is that recognizing and responding to emotion is a skill that can be learned, and according to Dr Back, can change physician behavior.
“Physicians who have had evidence-based training use more empathy, ask more questions to understand, and explore more values,” he said. “When you get to the critical conversation, knowing and being able to talk about values with a patient is probably the most critical thing you can do.”
In other words, communication skills training is a worthwhile investment. In a randomized trial in the United Kingdom, improvements in oncologists’ communication skills persisted 12 months after participating in a training program.1 Physicians who start to use these skills receive a lot of positive feedback, which reinforces the behavior, Dr Back explained. Even more interesting, he added, recent data have shown that an increase in physician skills leads to more patient trust. In a separate randomized trial of oncologists, those trained in clinical empathy used more empathy, and their patients had higher trust.2
“If you’re talking about goals of care or changing direction for a patient in a tough place, building trust is probably the single most important thing you can do,” said Dr Back.
REMAP
To help oncologists have these conversations more effectively, especially when changing course late in the trajectory of illness, Dr Back and colleagues developed a framework with the mnemonic REMAP, which stands for the following strategies:
- Reframe the situation
In the reframe step, the oncologist provides a big picture “headline” that lets the patient know things are in a different place. “Explain that you’re in a different place in the trajectory and that more anticancer treatment would do more harm than good,” said Dr Back. - Expect emotion and acknowledge
Oncologists, and especially fellows, feel like their job is to not upset the patient; however, in this situation, a lot of emotion means that your patient is hearing what is actually happening, said Dr Back. It’s important to respond to the emotion here, not to dampen it down. - Map out the important value
To map the patient’s goals, the oncologist asks open-ended questions that are designed to help the patient think about the values that should guide his or her treatment. Anchor values to the current moment, and start to think about the future if that’s possible, Dr Back advised. - Align those values with the patient and family
The oncologist then aligns with those values by explicitly reflecting them back to the patient. Affirming your patient’s values explicitly shows you listened, said Dr Back. - Plan treatments to uphold values
Finally, if the patient gives permission, the oncologist will then use those values to propose a medical plan that matches patient values. “Talk from positive frame first, so the patient knows the plan,” said Dr Back. “After the plan, discuss what you’ll withhold.”
“This process encourages oncologists to seek to understand and remain flexible, adapting their recommendations to what they hear from the patient,” he concluded. “This will lead to patient-centered decisions that promote better end-of-life care.”
References
1. Fallowfield L, Jenkins V, Farewell V, Solis-Trapala I. Enduring impact of communication skills training: results of a 12-month follow-up. Br J Cancer. 2003;89:1445-1449.
2. Tulsky JA, Arnold RM, Alexander SC, et al. Enhancing communication between oncologists and patients with a computer-based training program: a randomized trial. Ann Intern Med. 2011;155:593-601.