How Oncology Fellows Discuss Transitions in Goals of Care: A Snapshot of Approaches Used Prior to Training

Abstract

Introduction: The moment when a physician raises the possibility of discontinuing palliative chemotherapy at the end of life is a critical moment in the illness, and a difficult conversation. Expert recommendations cite the importance of giving bad news in these situations but there is limited research addressing how physicians should discuss transitions in goals of care from disease-modifying therapy to end-of-life care. While existing research includes survey data and observational studies of oncologist outpatient visits with patient who have advanced cancer, there are no studies that characterize actual physician communication behaviors when the physician tried to initiate a transitions conversation with a patient who has advanced cancer. Method: In this study, we examined the communication approaches used by oncology fellows discussing transitions with a standardized patient using audiorecordings collected prior to an intensive communication skills workshop. In this preworkshop encounter, each oncology fellow had the task of discussing a transition in goals of care with a patient who was experiencing cancer progression despite treatment with existing evidence-based therapies. We used qualitative methodology to characterize the approaches used by oncology fellows in 20 of these pre-workshop conversations. Results: We identified two themes in the approaches that fellows used: (1) the limitations of biomedical disease-modifying treatments and (2) the possibility of a new direction for medical care when disease-modifying treatments have been exhausted. Conclusion: We found that for each theme, fellows tended to emphasize a logical frame or an experiential frame. Understanding these frames could be useful in designing future communication skills training interventions.