Early discussion of patients’ values by oncology nurses.

Abstract

3 Background: Optimal advance care planning allows patients to articulate their values as an affirmation of personhood and a touchstone for medical decision-making. Ideally, it occurs when patients are well enough to express themselves thoughtfully, with opportunities for iteration as the clinical situation unfolds. We piloted a novel program of systematic, oncology nurse-led values discussions with patients soon after diagnosis, testing feasibility, and acceptability in high-volume clinics in a dedicated cancer center. Methods: Within an institutional initiative integrating primary and specialist palliative care from diagnosis for all cancer patients regardless of stage or prognosis, specialists trained oncology nurses (90 minutes) to use specific questions ( re living well, hopes, fears, sources of strength, abilities essential for acceptable quality of life) and an empathic communication framework to discuss health-related values with newly-diagnosed patients over two consecutive clinic visits. Nurses summarized discussions on a template for patient verification, oncologist review, and EMR documentation. Documentation was re-reviewed with the patient quarterly (sooner on patient or clinician request). Feasibility and acceptability were evaluated in three clinics for patients with hematologic or gastrointestinal (GI) cancers. Results: Oncology nurses conducted a total of 83 discussions (part 1=38, part 2=29, template review=16) with 15 and 23 newly-diagnosed hematologic and GI cancer patients, respectively. No patient declined participation. Discussions averaged 8 minutes; summaries were reviewed in 4 minutes, and all were verified by patients. Clinic workflow and volume (about 20 patients/clinic day) were maintained. Of 12 patients, all reported feeling comfortable with the process, 92% considered it helpful, 92% would recommend it to others. In structured interviews, patients, families, and clinicians strongly endorsed this process. Conclusions: Early, nurse-led discussions of patient values are feasible and acceptable in high-volume outpatient oncology clinics. Next steps include optimization of EMR accessibility, scalability, and evaluation of impact on other patient-focused and utilization outcomes.