What was the research about?
In advance care planning, people make decisions about their preferences for medical care they would want to receive if they become unable to speak for themselves. For example, a person might decide ahead of time that they would be willing to use a feeding tube. People may also name someone to make medical decisions for them if needed.
In this study, the research team made a video on advance care planning. The team wanted to learn if the video changed discussions between patients and their surgeons before major cancer surgery. The study compared the effects of the video on advance care planning with a general video about the hospital where patients were having surgery.
What were the results?
Patients who saw the video on advance care planning didn’t talk with their surgeon about advance care planning more than patients who didn’t see the video. Also, those who saw the video on advance care planning were more likely to say that it was helpful than patients who saw the general video about the hospital.
Who was in the study?
The study included 92 patients. All patients were undergoing major surgery to treat cancer. The most common type of cancer among the patients was pancreatic cancer (32 percent). Among all patients in the study, 85 percent were white and 11 percent were African American. The average age of patients was 60, and 63 percent of patients were women.
What did the research team do?
The research team assigned patients by chance to watch either the video on advance care planning or the general video. Patients watched their assigned video when they joined the study.
The video on advance care planning featured patients, caregivers, and doctors. It included information on
- The surgery and what to expect on the day of surgery
- Why advance care planning is important
- Naming a person to make decisions when a patient can’t speak for themselves
The general video described the hospital and its surgery program. But it didn’t talk about advance care planning.
After patients watched the assigned video, the team recorded the discussions between patients and surgeons. The team listened to see if patients talked about advance care planning with their surgeons. The team also listened to see if patients named someone to make health decisions for them.
Patients filled out surveys four times: before watching the video, before surgery, and then one week and one month after surgery. The surveys asked if the patient had named someone who could make decisions for them if needed and if the patient found the video to be helpful.
When designing the video and during the study, the research team worked with patients, caregivers, doctors, nurses, and experts in advance care planning.
What were the limits of the study?
All surgeons in the study saw the video on advance care planning. As a result, the surgeons may have changed how they talked with all patients in the study.
Future research could look at other ways to encourage patients and surgeons to discuss advance care planning.
How can people use the results?
Even though the video didn’t affect what patients and surgeons talked about, patients still found the video to be helpful. Hospitals may consider using similar videos when discussing advance care planning with patients.
To evaluate whether an advance care planning (ACP) video developed for patients and families having aggressive surgical treatment for cancer improved patient centeredness and ACP content in the preoperative discussion with the surgeon compared with a control video
|Design||Randomized controlled trial|
|Population||92 patients undergoing major cancer surgery|
Primary: patient centeredness of patient-surgeon conversation during presurgical consent visit, ACP content in the patient-surgeon conversation during presurgical consent visit
Secondary: patient hospital anxiety and depression scale score, patient goals of care, patient and surgeon satisfaction, helpfulness of video, medical decision maker designation
|Timeframe||Cross-sectional assessment of primary outcomes|
This randomized controlled trial compared the effectiveness of an ACP video with a control video for patients undergoing major surgery for cancer at a single hospital. The ACP video featured patients, caregivers, and clinicians and included information about the surgery and what patients could expect on the day of surgery. It described the importance of ACP, identifying a medical decision maker, discussing preferences with that decision maker, and communicating those preferences to the surgical team before surgery. The control video, previously developed by the hospital’s marketing team, included information on the history of the Johns Hopkins Hospital surgery program, including scientific developments and ongoing innovations in patient safety.
The study included 92 patients undergoing major cancer surgery with one of nine cancer surgeons at Johns Hopkins Hospital. The patients’ surgeries were serious enough that the surgeons scheduled the patients for admission to the surgical intensive care unit immediately following surgery. The most common type of cancer among the patients was pancreatic (32%). Of the patients, 63% were women, 85% were white, and 11% were African American. The average age of patients was 60.
Following randomization, 45 patients viewed the intervention video and 47 viewed the control video. Patients viewed their assigned video at the beginning of the study, before their surgery.
To assess patient centeredness and ACP content in the patient’s presurgery conversations with their doctors, researchers analyzed audio recordings of the presurgical visits. Researchers operationalized patient centeredness as the ratio of social or emotional talk to biomedical information shared in the visit. The team operationalized ACP content by counting the number of times patients and surgeons discussed ACP during the conversation. To assess secondary outcomes, researchers administered patient surveys at enrollment, at the patient’s presurgical consent visit, and at the one-week and one-month postsurgical visits.
Patients and families, providers, and ACP experts worked with researchers during the development of the ACP video and throughout the design and conduct of the study.
Researchers found no differences in the patient centeredness or ACP content of the audio recordings of the presurgical consent visit between patients who viewed the ACP video and those who viewed the control video. At baseline, 80% of patients who saw the ACP video and 77% of patients who viewed the control video had already designated a medical decision maker. Further, 23% of the conversations of patients who viewed the ACP video and 10% of the conversations of patients who viewed the control video addressed other ACP content.
Patients who viewed the ACP video rated it as more helpful than patients in the control group rated the control video (p=0.007). The groups did not differ in reports of hospital anxiety and depression, goals of care, patient and surgeon satisfaction, or designation of a proxy medical decision maker.
The nine surgeons participating in the study had viewed the intervention video prior to the study, which may have affected their conversations with patients about ACP regardless of whether patients viewed the ACP or control video. Although 92 patients participated in the study, researchers were only able to record 61 presurgical consent visits to assess patient centeredness. Results may have been different if researchers had analyzed all conversations.
Conclusions and Relevance
Although patients found the ACP video to be helpful, it did not change the patient centeredness or ACP content in the patient-surgeon discussions.
Future Research Needs
Future research might examine how to facilitate patient-centered conversations about ACP between doctors and patients having major surgery for cancer.
Final Research Report
View this project's final research report.
More to Explore...
Using Video to Help Patients Facing Major Surgery
Rebecca Aslakson speaks about how this project will assist patients discuss and make important decisions before entering the operating room.
Results of This Project
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Stories and Videos
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also confirms that the research has followed PCORI’s Methodology Standards. During peer review, experts who were not members of the research team read a draft report of the research. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. Reviewers do not have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve how the research team analyzed its results or reported its conclusions. Learn more about PCORI’s peer-review process here.
In response to peer review, the PI made changes including
- Adding information to the report about the intervention video. The researchers added a table that describes the time spent on different concepts in the video.
- Describing a conceptual rationale for why the video intervention would be more effective than verbal communication for advanced care planning.
- Addressing some potential reasons why the video intervention did not show a significant effect on changing the patient-physician conversation to one more focused on psychosocial or emotional issues. In their response to reviewers, the researchers indicated that when they spoke to participating surgeons after the study, they learned that most doctors had a “‘hard-wired’ script” they followed for these discussions, with little opportunity for patients to change the conversation to one more focused on psychosocial or emotional issues.
- Responding to reviewers’ concerns about the study’s measure of communication outcomes by providing empirical evidence that the outcomes and the way they were measured were appropriate. The researchers went on to say that they would study the interactions between patients and doctors in a more qualitative manner to better assess communication quality.
- Clarifying in the report the reasons why the researchers determined that integration of the preoperative video was successful. Although the study found no significant effect on communication and advanced care planning outcomes, the researchers noted that, given past evidence that surgeons are reticent to engage in pre-operative advanced care planning, just integrating the video into pre-operative routines was an important outcome.
Conflict of Interest Disclosures
Study Registration Information
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