Oncologists’ experiences with goals of care conversations.

Abstract

50 Background: ASCO guidelines suggest that patients with advanced cancer should have goals of care (GoC) conversations with their oncologists, yet only 37% report having them, often at the end of life. Describing oncologists’ experiences with GoC conversations is a crucial first step in tailoring communication training interventions. Methods: We conducted semi-structured interviews with oncologists at academic, community, municipal, and rural hospitals (n = 4) in New York and Connecticut. We analyzed data using interpretive description. Three coders developed a code key, independently and then jointly coded transcripts, and identified themes. Results: Oncologists (n = 21) were 67% male, averaged 46 years old (range 34-68) and 20 years (range 8-42) in practice, and 59% reported training in GoC. Sixty-nine percent were White, 23% Asian, and 8% Hispanic. Within oncologist narratives we identified generalizable facilitators and detractors to their practice of GoC conversations. Facilitator experiences included formal training in GoC discussions, a practice culture that supported GoC conversations (i.e. presence of specialty level palliative care), interactions with patients who they perceived to have realistic expectations, and good strategies for self-care and coping. One oncologist stated, “I can't cry or die with every patient because then I won't make it through the day.” Detractors included patient failure to understand cancer severity or treatment goals, younger patient age, and being the oncologist sought for second opinion. Oncologists described active patient participation, respect for patient beliefs and values, and achieving agreement on a care plan as elements of successful GoC discussions. An oncologist summarized, “People who are in the healthcare field think that goals of care are an immutable statement, but it’s not.... the way you can make an effective goals of care discussion, is to relate to their reality.” Conclusions: Multiple considerations impact oncologists’ experiences with GoC conversations. Tailoring communication interventions to address these concerns may increase rates of earlier and ongoing GoC conversations. Clinical trial information: NCT02374255.