New Clinical Guideline Urges Early Hospice Discussion for Advanced Cancer Patients

The American Society of Clinical Oncology (ASCO) has issued a consensus guideline for patient-clinician communication in cancer care, with a focus on clear and empathic conversations with patients and their families throughout the illness course, from diagnosis to consideration of end-of-life care.

Cancer clinicians are advised to ensure patient understanding of prognosis and treatment options, establish clear care goals based on patient values and priorities, and initiate discussion of hospice early in the course of terminal cancer (within a month of diagnosis of advanced disease), according to the guideline, which was published in the Journal of Clinical Oncology.

“Clinicians face a monumentally difficult task: to guide patients on what may be the scariest and most unpleasant journey of their lives. We need to preserve their hope while at the same time giving them accurate information,” says Timothy Gilligan, MD, lead author and co-chair of the ASCO expert panel that developed the guideline. “Helping oncology clinicians improve their communication skills ultimately helps patients, and that is what is most important.”

Clinical Oncology Communication Topics

The authors say effective communication skills enhance the well-being of clinicians, patients and their families. “When providers understand who their patients are, what they want from their life and their cancer treatment, and how they make decisions, patients are empowered,” they write.

ASCO convened a multidisciplinary panel of experts in fields such as medical oncology, hospice and palliative medicine, psychiatry, nursing, communication skills and health disparities to develop best-practice recommendations based on a systematic review of the medical literature 2006– 2016 and formalized through a consensus process.

The panel identified best practices and formulated recommendations for nine key topic areas in clinical oncology communication:

1. Application across the care continuum
2. Goals of care and prognosis
3. Treatment options
4. End-of-life care
5. Family involvement
6. Language and literacy barriers
7. Cost of care
8. Healthcare disparities
9. Clinician training

The nine recommendations address specific aspects of each topic along with suggested strategies for their implementation in the clinical setting.

Three Suggested Communication Strategies

Prognosis and Goals of Care

Tailor diagnostic and prognostic information to the patient’s needs, providing hope and reassurance while not misleading the patient. Triggers for discussions of prognosis and goals of care include initial diagnosis, relapse or disease progression, change in patient goals or treatment approach, and patient/family request.

• Assure the patient that as their clinician, you will do everything you can to ensure the best possible outcome. “I will do everything I can to support you.”
• Express solidarity. “I wish I had better news.”
• Avoid minimizing bad news or changing the subject. Pause. Wait for the patient’s response, then respond empathically and encourage questions.

Treatment Options

Discuss all treatment options—including clinical trials and palliative/hospice care— in a way that facilitates understanding, promotes autonomy and preserves patient hope.

• Determine whether the patient’s values and preferences have changed since the last conversation.
• Frame the treatment options in the context of these goals and priorities.
• Focus on what can be done; acknowledge uncertainty.
• Reinforce that the patient will not be abandoned. “I will continue to take care of you, whatever happens.”

End-of-Life Care

Initiate discussion of end-of-life care preferences early in the course of incurable cancer and revisit the topic periodically. Identify and suggest local resources to provide “robust support” to patients and their loved ones transitioning to care near life’s end.

• Introduce hospice by aligning the patient’s goals and needs with the treatments and services that hospice care provides. “I understand that you don’t want to spend any more time in the hospital, but you are scared about pain control at home. There is a program called hospice that can help you stay at home and manage your pain and other symptoms.”
• Published protocols such as SPIKES, PREPARED, and the Serious Illness Conversation may be helpful in guiding end-of-life conversations.
• Triggers for revisiting this conversation include illness progression, functional decline, increased high-intensity healthcare utilization and consideration of high-risk or high-burden interventions.

The guideline has also been published in the Journal of Oncology Practice and is available on the ASCO website at asco.org/supportive-care-guidelines.

Source: “Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline,” Journal of Clinical Oncology; November 1, 2017; 35(31):3618- 3632. Gilligan T, Coyle N, Baile WF, et al; Cleveland Clinic, Cleveland, OH; Memorial Sloan Kettering Cancer Center, New York City; The University of Texas MD Anderson Cancer Center, Houston.