Results Summary
What was the research about?
Patients with serious illness and their doctors may talk about goals of care, or GOC, discussions that include
- What matters most to the patient
- What the patient wants to accomplish with treatment
- How long the patient might live
GOC talks can be hard for patients and doctors. Without GOC talks, patients with late-stage cancer might not understand their treatment options or understand that treatment won’t cure them. But doctors don’t always have training to bring up these topics.
In this study, the research team provided extra training to doctors who treat patients with cancer about how to have GOC talks with patients. The team compared newly diagnosed patients who saw these doctors with patients whose doctors didn’t have the extra training. Then the team looked at whether patients reported having a GOC talk and how well that talk went.
What were the results?
Patients whose doctors had extra training didn’t report a difference in the number or quality of GOC talks compared with patients whose doctors who didn’t have the extra training. Whether or not their doctors had extra training in GOC talks, patients were equally likely to
- Say they had a GOC talk
- Say their doctors did the best job the patient could imagine in the GOC talk
- Say that the care they got in the six months after the GOC talk matched their preferences
- Go to the emergency room or hospital, stay in an intensive care unit, or receive chemotherapy in the last month of life
Doctors who had extra training improved their communication skills compared with the start of the study. Doctors who didn’t have the extra training didn’t improve their communication skills.
Who was in the study?
The study included 265 patients who were newly diagnosed with advanced cancer and had a life expectancy of less than two years. Of these, 51 percent were white, 29 percent were black, and 20 percent were Asian or another race; 19 percent were Hispanic. The average age was 64, and 60 percent were men.
What did the research team do?
The research team recruited 22 cancer doctors at four hospitals. All doctors attended a one-hour class about why talking about GOC with patients is important. The team then chose 11 doctors by chance to receive extra training on how to have GOC talks with patients.
The research team recruited 265 patients of the doctors taking part in the study. Patients filled out a survey about
- Whether they talked with their doctors about the GOC topics
- How well the doctors had done talking about GOC topics
Six months later, patients or caregivers completed a survey about whether the care patients received matched their preferences. To assess doctors’ communication skills, the research team recorded each doctor having a GOC talk with a patient before and again after training. The team looked at health records of patients who died to see how often in the last month of their life they
- Went to the emergency room or hospital
- Stayed in an intensive care unit
- Received chemotherapy
Patients with cancer, caregivers, and doctors gave input during the study.
What were the limits of the study?
The extra training doctors got was only part of a larger program on how to talk with patients about sensitive topics. Results may have been different if doctors had received more training.
Future research could explore other ways to help doctors and patients talk about GOC.
How can people use the results?
Cancer centers can use results of this study when considering ways to improve GOC conversations between doctors and patients.
Professional Abstract
Objective
To test the effectiveness of communication skills training for oncologists versus usual care on improving the number and quality of goals of care (GOC) conversations with patients newly diagnosed with advanced cancer
Study Design
| Design Elements | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 22 oncologists in 4 hospitals; 265 patients undergoing primary treatment for newly diagnosed solid tumor cancer with less than 2-year life expectancy |
| Interventions/ Comparators |
|
| Outcomes |
Primary: GOC conversation, patient’s perception of quality of GOC conversation Secondary: change in oncologist’s communication skills, aggressiveness of care and healthcare utilization at end of life, care alignment with patient goals |
| Timeframe | Six-month follow-up for primary outcomes |
This randomized controlled trial examined how often patients newly diagnosed with advanced solid tumor cancer said they had a GOC conversation and how they rated that conversation’s quality. GOC conversations include discussion of patients’ prognosis, treatment preferences, and life priorities. The study compared patients who received usual care with those who received care from an oncologist who had completed communication skills training.
All 22 oncologists in the four-hospital study attended grand rounds on the importance, timing, and content of GOC conversations. Researchers then randomized 11 of these oncologists to also complete two hours of training based on OncoTalk. The OncoTalk program trained clinicians to discuss patients’ values and attend to emotions. This training was followed by four visits with newly diagnosed patients with cancer accompanied by an OncoTalk-trained palliative care specialist who provided coaching.
Researchers recruited 265 patients newly diagnosed with advanced cancer who had an office visit scheduled to discuss imaging results and disease progression with oncologists in each group. Of these patients, 51% were white, 29% were black, and 20% were Asian or another race; 19% were Hispanic. The average age was 64, and 60% were male.
Following the visit, patients completed a survey about whether they perceived that a GOC conversation had occurred during the visit. Patients completed a second survey six months later to determine whether they received care consistent with their preferences. For patients who died, caregivers completed the survey, and researchers measured healthcare utilization and aggressiveness of care in the four weeks before death, including emergency department (ED) visits, hospitalizations, intensive care unit (ICU) admissions, or use of chemotherapy. To assess oncologists’ communication skills, researchers audiotaped each oncologist having a GOC conversation with a patient before and again after their training and then reviewed recordings using a validated checklist.
Patients with cancer, caregivers, and doctors gave input on the intervention, surveys, and study outcomes.
Results
Patients in each group were equally likely to
- Report having GOC conversations
- Say their doctors did the best imaginable job talking with them about goals
- Say their care was aligned with their preferences
- Have ED visits, hospitalizations, ICU admissions, or chemotherapy in the last month of life
Physicians who had OncoTalk training showed improved communication skills compared with the start of the study (p=0.02). Physicians who did not have additional training had no significant change.
Limitations
The one-time training covered only a portion of content in the full OncoTalk curriculum; results may have been different if oncologists had undergone further reinforcement of skills.
Conclusions and Relevance
Compared with usual training, a communication skills training intervention for oncologists did not improve patients’ perceptions that GOC conversations took place, how patients rated those conversations, or change intensity of care at the end of life.
Future Research Needs
Future research could focus on other ways to increase the number and quality of GOC conversations between oncologists and patients.
Final Research Report
View this project's final research report.
Journal Citations
Results of This Project
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot 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 descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers expressed concern that the goals of care GOC discussion appeared to be framed as a single event. The researchers responded that they were certainly aware that GOC discussions are not and should not be a single event. However, because the intervention had to be somewhat scripted and reliably implemented, they identified a suggested time for beginning these discussions. In interviews with oncologists, the researchers identified the visit to review imaging results after the first round of chemotherapy as an opportune time for a GOC discussion. While the researchers aimed to provide skills for improving ongoing conversations, the study needed a specific and measurable delivery method.
- The reviewers wondered if the study lacked power especially given that fewer patients participated than planned. The researchers had proposed to follow 280 patients, but only followed 265. The researchers explained that this change reduced the study’s power only slightly, still providing more than 80 percent power to detect a difference in the prevalence and quality of GOC discussions.
- The reviewers expressed concern that the primary outcome measure was a composite measure without previous psychometric testing. Thus, the validity and reliability of the measure could not be confirmed, and the items that went into the composite could be considered very different constructs: prevalence and quality. The researchers explained that most of questions making up the composite measure were taken from other validated instruments based on the questions’ coverage of specific focus areas (i.e., patient values, treatment preferences, and global assessment of communication quality). But in response to reviewer comments, the researchers said they refocused the primary outcome on value, which was the intended target of the intervention. The researchers dropped the components about treatment preferences and prognosis. Results of the revised analyses still showed no significant difference between the intervention and usual care groups.