A randomized controlled trial of a skills training for oncologists and a communication aid for patients to stimulate shared decision making about palliative systemic treatment (CHOICE): study protocol

Educating for supported decision making and shared decision making: a scoping review of educational design and outcomes for education and training interventions

PURPOSE

To characterise existing knowledge about the design and learning outcomes of education and training programs for supported or shared decision making.

MATERIALS AND METHODS

A scoping review was performed to identify academic and grey literature, published between January 2006 and February 2022, that reported on the design and/or learning outcomes of supported or shared decision making education or training programs. Eligible literature was mapped across domains of educational design and Kirkpatrick's hierarchy of learning effectiveness, and then qualitatively synthesised using cross-case analysis.

RESULTS

A total of 33 articles were identified (n = 7 for supported decision making and n = 26 for shared decision making) that provided education or training to supporters of persons with mental illness or substance use disorders (n = 14), dementia or neurocognitive disorders (n = 6), cognitive disability (n = 5), mixed populations (n = 1), and those receiving end-of-life care (n = 7). In their design, most programs sought specific changes in practice (behaviour) via experiential learning. Reported educational outcomes also focused on supporter behaviour, with limited evidence for how changes in learner attitudes, skills, or knowledge might be contributing to changes in supporter behaviour.

CONCLUSIONS

Future education and training would benefit from a closer engagement with theories of teaching and learning, particularly those oriented towards co-design.

Potential Adverse Outcomes of Shared Decision Making about Palliative Cancer Treatment: A Secondary Analysis of a Randomized Trial

BACKGROUND

While shared decision making (SDM) is advocated for ethical reasons and beneficial outcomes, SDM might also negatively affect patients with incurable cancer. The current study explored whether SDM, and an oncologist training in SDM, are associated with adverse outcomes (i.e., patient anxiety, tension, helplessness/hopelessness, decisional uncertainty, and reduced fighting spirit).

DESIGN

A secondary analysis of a randomized clinical trial investigating the effects of SDM interventions in the context of advanced cancer. The relations between observed SDM (OPTION12), specific SDM elements (4SDM), oncologist SDM training, and adverse outcomes were analyzed. We modeled adverse outcomes as a multivariate phenomenon, followed by univariate regressions if significant.

RESULTS

In total, 194 patients consulted by 31 oncologists were included. In a multivariate analysis, observed SDM and adverse outcomes were significantly related. More specifically, more observed SDM in the consultation was related to patients reporting more tension (P = 0.002) and more decisional uncertainty (P = 0.004) at 1 wk after the consultation. The SDM element "informing about the options" was especially found to be related to adverse outcomes, specifically to more helplessness/hopelessness (P = 0.002) and more tension (P = 0.016) at 1 wk after the consultation. Whether the patient consulted an oncologist who had received SDM training or not was not significantly related to adverse outcomes. No relations with long-term adverse outcomes were found.

CONCLUSIONS

It is important for oncologists to realize that for some patients, SDM may temporarily be associated with negative emotions. Further research is needed to untangle which, when, and how adverse outcomes might occur and whether and how burden may be minimized for patients.

HIGHLIGHTS

Observed shared decision making was related to more tension and uncertainty postconsultation in advanced cancer patientsHowever, training oncologists in SDM did not affect adverse outcomes.Further research is needed to untangle which, when, and how adverse outcomes might occur and how burden may be minimized.

Shared Decision Making in Health Care Visits for CKD: Patients' Decisional Role Preferences and Experiences

RATIONALE & OBJECTIVE

Research on shared decision making (SDM) in chronic kidney disease (CKD) has focused almost exclusively on the modality of kidney replacement treatment. We explored what other CKD decisions are recognized by patients, what their preferences and experiences are regarding these decisions, and how decisions are made during their interactions with medical care professionals.

STUDY DESIGN

Cross-sectional study.

SETTING & PARTICIPANTS

Patients with CKD receiving (outpatient) care in 1 of 2 Dutch hospitals.

EXPOSURE

Patients' preferred decisional roles for treatment decisions were measured using the Control Preferences Scale survey administered after a health care visit with medical professionals.

OUTCOME

Number of decisions for which patients experienced a decisional role that did or did not match their preferred role. Observed levels of SDM and motivational interviewing in audio recordings of health care visits, measured using the 4-step SDM instrument (4SDM) and Motivational Interviewing Treatment Integrity coding tools.

ANALYTICAL APPROACH

The results were characterized using descriptive statistics, including differences in scores between the patients' experienced and preferred decisional roles.

RESULTS

According to the survey (n=122) patients with CKD frequently reported decisions regarding planning (112 of 122), medication changes (82 of 122), or lifestyle changes (59 of 122). Of the 357 reported decisions in total, patients preferred that clinicians mostly (125 of 357) or fully (101 of 357) make the decisions. For 116 decisions, they preferred a shared decisional role. For 151 of 357 decisions, the patients' preferences did not match their experiences. Decisions were experienced as "less shared/patient-directed" (76 of 357) or "more shared/patient-directed" (75 of 357) than preferred. Observed SDM in 118 coded decisions was low (median4; range, 0 - 22). Motivational interviewing techniques were rarely used.

LIMITATIONS

Potential recall and selection bias, and limited generalizability.

CONCLUSIONS

We identified multiple discrepancies between preferred, experienced, and observed SDM in health care visits for CKD. Although patients varied in their preferred decisional role, a considerable number of patients expressed a preference for shared decision making for many decisions. However, SDM behavior during the health care visits was observed infrequently.

PLAIN-LANGUAGE SUMMARY

Shared decision making (SDM) may be a valuable approach for common chronic kidney disease (CKD) decisions, but our knowledge is limited. We collected patient surveys after health care visits for CKD. Patients most frequently experienced decisions regarding planning, medication, and lifestyle. Three decisional roles were preferred by comparable numbers of patients: let the clinician alone decide, let the clinician decide for the most part, or "equally share" the decision. Patients' experiences of who made the decision did not always match their preferences. In audio recordings of the health care visits, we observed low levels of SDM behavior. These findings suggest that the preference for "sharing decisions" is often unmet for a large number of patients.

Effect of a prediction tool and communication skills training on communication of treatment outcomes: a multicenter stepped wedge clinical trial (the SOURCE trial)

Background

For cancer patients to effectively engage in decision making, they require comprehensive and understandable information regarding treatment options and their associated outcomes. We developed an online prediction tool and supporting communication skills training to assist healthcare providers (HCPs) in this complex task. This study aims to assess the impact of this combined intervention (prediction tool and training) on the communication practices of HCPs when discussing treatment options.

Methods

We conducted a multicenter intervention trial using a pragmatic stepped wedge design (NCT04232735). Standardized Patient Assessments (simulated consultations) using cases of esophageal and gastric cancer patients, were performed before and after the combined intervention (March 2020 to July 2022). Audio recordings were analyzed using an observational coding scale, rating all utterances of treatment outcome information on the primary outcome-precision of provided outcome information-and on secondary outcomes-such as: personalization, tailoring and use of visualizations. Pre vs. post measurements were compared in order to assess the effect of the intervention.

Findings

31 HCPs of 11 different centers in the Netherlands participated. The tool and training significantly affected the precision of the overall communicated treatment outcome information (p = 0.001, median difference 6.93, IQR (-0.32 to 12.44)). In the curative setting, survival information was significantly more precise after the intervention (p = 0.029). In the palliative setting, information about side effects was more precise (p < 0.001).

Interpretation

A prediction tool and communication skills training for HCPs improves the precision of treatment information on outcomes in simulated consultations. The next step is to examine the effect of such interventions on communication in clinical practice and on patient-reported outcomes.

Funding

Financial support for this study was provided entirely by a grant from the Dutch Cancer Society (UVA 2014-7000).

Shared decision making with Oncologists and Palliative care specialists (SOP) model help advanced pancreatic cancer patients reaching goal concordant care: A prospective cohort study

BACKGROUND

Pancreatic cancer is often diagnosed at a late stage with a poor prognosis due to insidious symptoms and lack of evidence-based screening in general population. Palliative care's acceptance in Asian cultures is hindered by misconceptions and ineffective communication about management that improve quality of life other than cancer directed treatment. Our study aimed to determine the effect of the Shared decision-making with Oncologists and Palliative care specialists (SOP) model developed from the traditional shared decision-making (SDM) model on the palliative care acceptance rate and medical resource utilization.

METHODS

This is a prospective cohort study implementing the SOP model at the National Taiwan University Hospital from January 2018 to December 2019 for patients with advanced pancreatic cancer. Medical resource utilization was defined and recorded as the rate of hospitalization, emergency room (ER), and intensive care unit admissions. We compared the results between two groups: patients who received the SOP model in 2019 and patients who did not receive it in 2018.

RESULTS

137 patients with advanced pancreatic cancer were included in our study. The result showed that the acceptance rate of palliative care significantly increased from 50% to 78.69% after the SOP model (p = 0.01). The hospitalization rate did not show a significant difference between 2018 (93.42%, 95% CI: 0.88-0.99) and 2019 (93.44%, 95% CI: 0.87-1.00). 83.61% (95% CI: 0.74-0.93) of our patients in 2019 had at least one ER visit; the rate was 81.5% (95% CI: 0.73-0.91) in 2018 (p = 0.28). The percentage of patients admitted to the ICU increased from 3.95% in 2018 to 8.2% (95% CI: -0.05-0.08) in 2019 (95% CI: 0.11-0.15) (p = 0.00). The hospitalization and ER visit showed no statistically difference between 2 years.

CONCLUSIONS

The modified SOP model markedly augmented palliative care's acceptance of patients with advanced pancreatic cancer. Adoption of the SOP model would provide these patients a more proactive and systematic approach to deliver needed healthcare.

Effect of Clinician-Expressed Empathy in Advanced Cancer on Different Ethnic Groups: Results from an Experimental Video-Vignette Study

Background: In advanced cancer, clinician-expressed empathy can improve patients' psychological outcomes. It remains unknown whether all patients benefit equally from empathy. Objective: To explore whether the effect of clinician-expressed empathy on patients' psychological outcomes is moderated by patient ethnicity. Methods: Using an experimental video-vignette design, 160 participants watched a consultation-video with/without added empathy. Using regression analysis, the moderating effect of ethnicity (non-Western- vs. Dutch/Western-immigration background) on the relationship between empathy and psychological outcomes was assessed. Results: The main effect of empathy on satisfaction (p = 0.001), trust (p = 0.002), and self-efficacy (p < 0.001) was moderated by ethnicity (satisfaction, p = 0.050; trust, p = 0.066; self-efficacy, p = 0.075). No main effect of empathy nor moderation by ethnicity was found for anxiety (state anxiety: p = 0.284, p = 0.319; current anxiety: p = 0.357, p = 0.949). No main effects of ethnicity (satisfaction, p = 0.942; trust, p = 0.724; self-efficacy, p = 0.244; state anxiety, p = 0.812; current anxiety p = 0.523) were found. Conclusion: In advanced cancer, non-Western patients might benefit most from empathy. Dutch Trial Registration Number: NTR NL8992.

Status quo of advanced cancer patients participating in shared decision-making in China: a mixed study

PURPOSE

Patients with advanced cancer are usually willing to participate in shared decision-making (SDM), but in clinical practice, patient participation is easily ignored. This study aimed to analyze the current SDM status of advanced cancer patients and related factors.

METHODS

In quantitative research, we administered a cross-sectional survey to 513 advanced cancer patients in 16 tertiary hospitals in China. A sociodemographic information questionnaire, the Control Preference Scale (CPS), and Perceived-Involvement in Care Scale (PICS) were used to analyze current SDM status and influencing factors. Our qualitative research was based on the Ottawa Decision Support Framework (ODSF), and 17 advanced cancer patients were interviewed to explore their perceptions of SDM.

RESULTS

Our quantitative results show that patients' actual and expected decision-making participation differed; statistically significant influencing factors were age, insurance, and whether patients were worried about the therapeutic effects. We also found that dynamic decision-making mode changes, disease information acquisition, decision-making participation obstacles, and family members' roles affected patients' SDM through qualitative interviews.

CONCLUSION

Advanced cancer patients' SDM in China is dominated by sharing and continuously fluctuates. Influenced by Chinese traditional culture, family members play an important role in SDM. In clinical work, we should pay attention to the dynamic changes in patients' participation in decision-making and the role of family members.

Effects of a communication training for oncologists on early addressing palliative and end-of-life care in advanced cancer care (PALLI-COM): a randomized, controlled trial

INTRODUCTION

In advanced cancer care, early communication about palliative care (PC) and end-of-life (EoL)-related issues is recommended, but is often impeded by physicians' communication insecurities. We investigated the effect of a newly developed compact communication skills training 'PALLI-COM' on oncologists' competencies to early address PC/EoL-related issues.

MATERIALS AND METHODS

We conducted a randomized, controlled trial (RCT) with an intervention group (IG; 2 × 90 min training) and a wait list control group (CG) at five sites. At two assessment points, participating oncologists led videotaped medical consultations with simulated patients (SPs) via a privacy compliant video conference platform. SPs were represented by trained actors. The taped conversations were rated for primary outcome (communication skills assessed by adapted COM-ON-checklist and COM-ON-coaching rating scales) by raters blinded for study group. Secondary outcomes included oncologists' self-reported communication skills (Self-Efficacy in Palliative Care Scale, Thanatophobia-Scale, Communication about End of Life Survey, study-specific items) as well as external rating of the SPs. Univariate analyses of covariance with baseline adjustment were used to analyze intervention effects.

RESULTS

A total of 141 oncologists [age: mean (standard deviation) = 32.7 (6.3) years, 60% female (n_IG = 73, n_CG = 68)] participated. Following intervention, the IG showed significantly more improvement in four out of five assessed communication skills: 'reacting to emotions and showing empathy', 'pointing out opportunities and giving hope', 'addressing the EoL' and 'explaining the concept of PC'. IG participants also improved more than CG participants in almost all secondary outcomes assessed by participants and SPs: oncologists' self-efficacy, attitudes towards caring for terminally ill patients, communication strategies and confidence in dealing with PC/EoL-related issues as well as communication quality from the SPs' perspective.

CONCLUSION

Findings indicate that the compact communication skills training PALLI-COM increases oncologists' competencies in early addressing PC/EoL-related issues from different perspectives. Implementation in routine oncology residency might improve advanced cancer care by strengthening these communication skills.

Attitudes Toward Striving for Quality and Length of Life Among Patients With Advanced Cancer and a Poor Prognosis

PURPOSE:

When deliberating palliative cancer treatment, insight into patients' attitudes toward striving for quality of life (QL) and length of life (LL) may facilitate goal-concordant care. We investigated the (1) attitudes of patients with advanced cancer toward striving for QL and/or LL and whether these change over time, and (2) characteristics associated with these attitudes (over time).

METHODS:

We performed a secondary analysis of a randomized controlled trial on improving shared decision making (SDM), without differentiation between intervention arms. Patients (n = 173) with advanced cancer, a median life expectancy of < 12 months without anticancer treatment, and a median survival benefit of < 6 months from systemic therapy were included in seven Dutch hospitals. We used audio-recorded consultations and surveys at baseline (T0), shortly after the consultation (T2), at 3 and 6 months (T3 and T4). Primary outcomes were patients' attitudes toward striving for QL and LL (Quality Quantity Questionnaire; T2, T3, and T4).

RESULTS:

Overall, patients' attitudes toward striving for QL became less positive over 6 months ( P < .01); attitudes toward striving for LL did not change on group level. Studying individual patients, 76% showed changes in their attitudes toward striving for QL and/or LL at some point during the study, which occurred in various directions. More helplessness/hopelessness ( P < .001), less fighting spirit ( P < .05), less state anxiety ( P < .001), and more observed SDM ( P < .05) related to more positive attitudes toward striving for QL. Lower education, less helplessness/hopelessness, more fighting spirit, and more state anxiety ( P < .001) related to more positive attitudes toward striving for LL.

CONCLUSION:

Oncologists may explore patients' attitudes toward striving for QL and LL repeatedly and address patients' coping style and emotions during SDM to facilitate goal-concordant care throughout the last phase of life.

Possible alleviation of symptoms and side effects through clinicians' nocebo information and empathy in an experimental video vignette study

To alleviate anti-cancer treatment burden in advanced breast cancer, patient-clinician communication strategies based on nocebo-effect mechanisms are promising. We assessed distinct/combined effects on psychological outcomes (e.g. anxiety; main outcome) and side-effect expectations of (1) nocebo information about the (non)pharmacological origin of side effects, and (2) clinician-expressed empathy through reassurance of continuing support. Furthermore, we explored whether information and empathy effects on side-effect expectations were mediated by decreased anxiety. In a two-by-two experimental video-vignette design, 160 cancer patients/survivors and healthy women watched one of four videos differing in level of nocebo information (±) and empathy (±). Regression and mediation analysis were used to determine effects of information/empathy and explore anxiety's mediating role. Anxiety was not influenced by empathy or information (Stai-state: p = 0.295; p = 0.390, VAS p = 0.399; p = 0.823). Information improved (specific) side-effect coping expectations (p < 0.01). Empathy improved side-effect intensity expectations (p < 0.01 = specific; p < 0.05 = non-specific/partial) and specific side-effect probability expectations (p < 0.01), and increased satisfaction, trust, and self-efficacy (p < 0.001). No mediating effects were found of anxiety on expectations. Mainly empathy, but also nocebo information improved psychological outcomes and-mainly specific-side-effect expectations. Exploring the power of these communication elements in clinical practice is essential to diminish the anti-cancer treatment burden in advanced breast cancer.

A randomized controlled trial assessing behavioral, cognitive, emotional and physiological changes resulting from a communication skills training in physicians caring for cancer patients

OBJECTIVE

This randomized study assesses behavioral, cognitive, emotional and physiological changes resulting from a communication skills training (CST) for physicians caring for cancer patients.

METHODS

Medical specialists (N = 90) were randomly assigned in groups to complete a manualized 30-h CST or to a waiting list. Assessments included behavioral (communication skills), cognitive (self-efficacy, sense of mastery), emotional (perceived stress) and physiological (heart rate) measures. Assessments were made at baseline (both groups), after CST program (training group), and four months after (waiting list group). All assessments were conducted before, during, and after a complex communication task with an advanced-stage cancer simulated patient (SP).

RESULTS

Trained physicians had higher levels of communication skills (from RR=1.32; p = .003 to RR=41.33; p < .001), self-efficacy (F=9.3; p = .003), sense of mastery (F=167.9; p < .001) and heart rate during the SP encounter (from F=7.4; p = .008 to F=4; p = .050) and same levels of perceived stress (F=3.1; p = .080).

CONCLUSION

A learner-centered, skills-focused and practice-oriented manualized 30-h CST induced multilevel changes indicating physician engagement in a learning process.

PRACTICE IMPLICATIONS

Trainers should consider the CST multilevel benefits (behavioral, cognitive, emotional and physiological) before, during and after a complex communication simulated task as an innovative way to assess the efficacy of a communication skills learning process.

Prognostic disclosure in oncology - current communication models: a scoping review

BACKGROUND

Prognostic disclosure is essential to informed decision making in oncology, yet many oncologists are unsure how to successfully facilitate this discussion. This scoping review determines what prognostic communication models exist, compares and contrasts these models, and explores the supporting evidence.

METHOD

A protocol was created for this study using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols extension for Scoping Reviews. Comprehensive literature searches of electronic databases MEDLINE, EMBASE, PsycINFO and Cochrane CENTRAL were executed to identify relevant publications between 1971 and 2020.

RESULTS

In total, 1532 articles were identified, of which 78 met inclusion criteria and contained 5 communication models. Three of these have been validated in randomised controlled trials (the Serious Illness Conversation Guide, the Four Habits Model and the ADAPT acronym) and have demonstrated improved objective communication measures and patient reported outcomes. All three models emphasise the importance of exploring patients' illness understanding and treatment preferences, communicating prognosis and responding to emotion.

CONCLUSION

Communicating prognostic estimates is a core competency skill in advanced cancer care. This scoping review highlights available communication models and identifies areas in need of further assessment. Such areas include how to maintain learnt communication skills for lifelong practice, how to assess patient and caregiver understanding during and after these conversations, and how to best scale these protocols at the institutional and national levels.

Informing Patients With Esophagogastric Cancer About Treatment Outcomes by Using a Web-Based Tool and Training: Development and Evaluation Study

Background

Due to the increasing use of shared decision-making, patients with esophagogastric cancer play an increasingly important role in the decision-making process. To be able to make well-informed decisions, patients need to be adequately informed about treatment options and their outcomes, namely survival, side effects or complications, and health-related quality of life. Web-based tools and training programs can aid physicians in this complex task. However, to date, none of these instruments are available for use in informing patients with esophagogastric cancer about treatment outcomes.

Objective

This study aims to develop and evaluate the feasibility of using a web-based prediction tool and supporting communication skills training to improve how physicians inform patients with esophagogastric cancer about treatment outcomes. By improving the provision of treatment outcome information, we aim to stimulate the use of information that is evidence-based, precise, and personalized to patient and tumor characteristics and is communicated in a way that is tailored to individual information needs.

Methods

We designed a web-based, physician-assisted prediction tool—Source—to be used during consultations by using an iterative, user-centered approach. The accompanying communication skills training was developed based on specific learning objectives, literature, and expert opinions. The Source tool was tested in several rounds—a face-to-face focus group with 6 patients and survivors, semistructured interviews with 5 patients, think-aloud sessions with 3 medical oncologists, and interviews with 6 field experts. In a final pilot study, the Source tool and training were tested as a combined intervention by 5 medical oncology fellows and 3 esophagogastric outpatients.

Results

The Source tool contains personalized prediction models and data from meta-analyses regarding survival, treatment side effects and complications, and health-related quality of life. The treatment outcomes were visualized in a patient-friendly manner by using pictographs and bar and line graphs. The communication skills training consisted of blended learning for clinicians comprising e-learning and 2 face-to-face sessions. Adjustments to improve both training and the Source tool were made according to feedback from all testing rounds.

Conclusions

The Source tool and training could play an important role in informing patients with esophagogastric cancer about treatment outcomes in an evidence-based, precise, personalized, and tailored manner. The preliminary evaluation results are promising and provide valuable input for the further development and testing of both elements. However, the remaining uncertainty about treatment outcomes in patients and established habits in doctors, in addition to the varying trust in the prediction models, might influence the effectiveness of the tool and training in daily practice. We are currently conducting a multicenter clinical trial to investigate the impact that the combined tool and training have on the provision of information in the context of treatment decision-making.

Roleplay as an Educational Strategy in Palliative Care: A Systematic Integrative Review

INTRODUCTION

Simulation activities, such as roleplay, have become established in undergraduate and graduate education in several subjects of healthcare. The objective of this study was to synthesize the evidence available in the literature on the use of roleplay as an educational strategy in palliative care.

METHODS

Using the method proposed by Whittemore and Knafl, this integrative systematic review was carried out based on the following guiding question: "What is the available evidence in the literature on the use of roleplay as an educational strategy in the teaching of palliative care?" The databases used for the selection of articles were the following: Web of Science, Scopus, Cochrane Library, PubMed, CINAHL, EMBASE, and LILACS. There were no limitations regarding the year of publication or language.

RESULTS

The articles (n = 34) were grouped into 3 categories, according to the purpose of roleplay use: 1) Use of roleplay as an educational strategy to teach communication in palliative care; 2) Use of roleplay as an educational strategy to teach the communication of bad news, and 3) Use of roleplay as an educational strategy to teach end-of-life care.

CONCLUSION

Roleplay has been employed in the teaching of palliative care in order to develop skills related to communication and to the provision of end-of-life care. These educational activities have mainly been directed to healthcare students and professionals. Future investigations should further evaluate the efficacy of this teaching strategy, based on studies with more robust designs that allow the establishment of cause-and-effect relationships.

The power of clinician-expressed empathy to increase information recall in advanced breast cancer care: an observational study in clinical care, exploring the mediating role of anxiety

OBJECTIVE

Experimental studies have found that clinician-expressed empathy improves patients' information recall in (advanced) cancer consultations. It remains unclear, however, whether these results are generalizable to clinical care and, if so, what the underlying mechanism is. We aimed to i) determine the relationship between clinician-expressed empathy and patients' information recall in clinical advanced breast cancer consultations; and ii) test whether the relationship between clinician-expressed empathy and recall is mediated by a decrease in patients' anxiety.

METHODS

Forty-one consultations between oncologists and female patients with advanced breast cancer were audio recorded. Patients' post-consultation information recall and pre- and post-consultation anxiety (0-100) were assessed. Recall was scored according to a self-created questionnaire. Clinician-expressed empathy (0-100) was assessed by observers. Structural Equation Modelling was used for all analyses.

RESULTS

Participants remembered 61% of the information discussed. Clinician-expressed empathy significantly increased patients' total information recall (p = .041) and recall of treatment aims/positive effects (p = .028). The mediating role of anxiety could not be established.

CONCLUSION

Although the underlying mechanism remains unclear, clinicians have a powerful tool to improve seriously ill breast cancer patients' recall of information: empathy.

PRACTICE IMPLICATIONS

These insights should encourage clinicians to express empathy; practical communication training might prove helpful.

How does physicians' decisional conflict influence their ability to address treatment outcomes in a decision-making encounter with an advanced-stage cancer simulated patient? A descriptive study

OBJECTIVES

This descriptive study assesses how physicians' decisional conflict influences their ability to address treatment outcomes (TOs) in a decision-making encounter with an advanced-stage cancer simulated patient (SP).

METHODS

Physicians (N = 138) performed a decision-making encounter with the SP trained to ask for TOs information. The physicians' decisional conflict regarding patients' cancer treatments in general was assessed with the General Decisional Conflict Scale (Gen-DCS). The physicians' decisional conflict regarding the SP's cancer treatments was assessed with the Specific Decisional Conflict Scale (Spe-DCS). Physicians' ability to address TOs during the encounter was assessed with an interaction analysis system: the Multi-Dimensional Analysis of Patient Outcome Predictions (MD.POP). Weekly time spent with cancer patients was assessed with a questionnaire.

RESULTS

Physicians' Spe-DCS (β = -.21 ; p = .014) and weekly time spent with cancer patients (β = .22 ; p = .008) predicted the number of TOs addressed during the encounter. Spe-DCS scores predicted nearly all MD.POP dimensions (r = -.18 ; p = .040 to r = -.30 to p < .001) whereas Gen-DCS scores predicted nearly none MD.POP dimensions.

CONCLUSION

Physicians' specific decisional conflict interferes with their ability to address TOs in a decision-making encounter with an advanced-stage cancer SP.

PRACTICE IMPLICATIONS

Physicians should be trained to address TOs according to patient preferences, despite their own decisional conflict.

The Effect of Using the Question Prompt List on Shared Decision Making, Self-Efficacy in Decision Making, and Preferences for Participation Among Women with Breast Cancer: A Study Protocol

Background: There is increasing awareness that patients with cancer desire information as well as strategies to support their capacity to actively participate in informed decision-making. This study will evaluate outcomes of using a question prompt list (QPL) on shared decision making (SDM), decision-making self-efficacy, and preferences for participation among Iranian women with breast cancer, who are referred to a Tehran Comprehensive Cancer Center. Methods: This research will utilize a randomized controlled trial. The research population is patients with breast cancer, who are referred to the Oncology Radiotherapy Unit, Imam Khomeini Hospital, Tehran following tumor resection. After completing baseline surveys (demographics and health survey, decision self-efficacy scale, and control preferences scale), participants will be randomized into either a control or a treatment group based on block design. The treatment group will receive routine care along with the QPL that provides information on decision-making relative to treatment options (chemotherapy, radiotherapy, or both treatments) following meeting their oncologist. They will be trained to use the QPL which they will use to ask questions about their treatment choices when meeting with their physician or through computer-mediated modalities such as WhatsApp or other social messengers. These patients will have the opportunity to think about the treatment options and will be referred for medical treatment following their decision. The control group will receive routine care (physician discussion and receipt of treatment information). Following decision-making regarding treatment, the questionnaires will be administered (9-item SDM questionnaire, decision self-efficacy scale, and control preferences scale). Data will be analyzed using SPSS 16. Discussion: The current study will provide experimental evidence for the preliminary efficacy or lack of an intervention that has the potential to improve shared decision-making outcomes, a better understanding of personal preferences related to decision-making and self-efficacy in medical decision-making for Iranian patients with breast cancer.

Patients' and Clinicians' Perceptions of Clinician-Expressed Empathy in Advanced Cancer Consultations and Associations with Patient Outcomes

Background: Empathy is a cornerstone of effective communication. However, clinicians' and patients' perceptions of clinician-expressed empathy might differ. The independent perceptions of patients and clinicians on clinician-expressed empathy in advanced cancer consultations and the associations of these perceptions with patient outcomes are unknown. Objective: We assessed (1) patients' and clinicians' independent perceptions of clinician-(self-)expressed empathy in advanced cancer consultations and (2) the associations between these perceptions and affective patient outcomes. Methods: This observational study included data from 41 consultations in the advanced breast cancer setting. Postconsultation, patients' and clinicians' perceptions of clinician-expressed empathy were assessed, as well as patients' (1) pre-post anxiety, (2) post-anxiety, (3) emotional well-being, and (4) satisfaction. Multilevel regression analyses were run to draw conclusions. Results: Patients perceived higher levels of empathy than clinicians, without a significant relationship between the two (mean [M] = 85.47, standard deviation [SD] = 14.00 vs. M = 61.88, SD = 15.30, 0-100 scale; β = 0.14, p < 0.138, 95% confidence interval [CI] = -0.04 to 0.32). Higher patient-perceived empathy was associated with decreased anxiety [(1) β = -0.67, p = 0.039, 95% CI = -1.30 to -0.03; (2) β = -0.15, p = 0.042, 95% CI = -0.30 to -0.01], higher satisfaction (β = 0.05, p < 0.001, 95% CI = 0.03 to 0.08), and lower emotional distress (β = -0.32, p < 0.001, 95% CI = -0.48 to -0.16). There were no associations with clinicians' perceptions [(1) β = -0.34, p = 0.307, 95% CI = -1.00 to 0.31; (2) β = -0.02, p = 0.824, 95% CI = -0.17 to 0.14; (3) β < 0.01, p = 0.918, 95% CI = -0.03 to 0.02; (4) β = 0.08, p = 0.335, 95% CI = -0.08 to 0.25]. Conclusions: Patients' and clinicians' empathy perceptions differed. In improving patient outcomes, the focus should be on patients' perceptions of clinician-expressed empathy. Future research could focus on ways to elicit patients' perceptions of empathy with the higher aim of improving patient outcomes.

Effects of a Communication Intervention Randomized Controlled Trial to Enable Goals-of-Care Discussions

PURPOSE

Patients with advanced cancer often have a poor understanding of cancer incurability, which correlates with more aggressive treatment near the end of life (EOL). We sought to determine whether training oncologists to elicit patient values for goals-of-care (GoC) discussions will increase and improve these discussions. We explored its impact on use of aggressive care at EOL.

METHODS

We enrolled and used block randomization to assign 92% of solid tumor oncologists to 2-hour communication skills training and four coaching sessions. We surveyed 265 patient with newly diagnosed advanced cancer with < 2-year life expectancy at baseline and 6 months. We assessed prevalence and quality of GoC communication, change in communication skills, and use of aggressive care in the last month of life.

RESULTS

Intervention (INT) oncologists' (n = 11) skill to elicit patient values increased (27%-55%), while usual care (UC) oncologists' (n = 11) skill did not (9%-0%; P = .01). Forty-eight percent (n = 74) INT v 51% (n = 56) UC patients reported a GoC discussion (P = .61). There was no difference in the prevalence or quality of GoC communication between groups (global odds ratio, 0.84; 95% CI, 0.57 to 1.23). Within 6 months, there was no difference in deaths (18 INT v 16 UC; P = .51), mean hospitalizations (0.47 INT v 0.42 UC; P = .63), intensive care unit admissions (5% INT v 9% UC; P = .65), or chemotherapy (26% INT v 16% UC; P = .39).

CONCLUSION

Use of a coaching model focused on teaching oncologists to elicit patient values improved that skill but did not increase prevalence or quality of GoC discussions among patients with advanced cancer. There was no impact on high care utilization at EOL.

Development of a contemporary evidence-based practice workshop for health professionals with a focus on pre-appraised evidence and shared decision-making: a before-after pilot study

Shared decision-making (SDM) has emerged as a key skill to assist clinicians in applying evidence-based practice (EBP). We aimed to develop and pilot a new approach to teaching EBP, which focuses on teaching knowledge and skills about SDM and pre-appraised evidence. We designed a half-day workshop, informed by an international consensus on EBP core competencies and invited practicing clinicians to participate. Skills in SDM and communicating evidence were assessed by audio-recording consultations between clinicians and standardised patients (immediately pre-workshop and post-workshop). These were rated by two independent assessors using the OPTION (Observing Patient Involvement, 0 to 100 points) and ACEPP (Assessing Communication about Evidence and Patient Preferences, 0 to 5 points) tools. Participants also completed a feedback questionnaire (9 Likert scale and four open-ended questions). Fourteen clinicians participated. Skills in SDM and communicating research evidence improved from pre-workshop to post-workshop (mean increase in OPTION score=5.5, 95% CI 1.0 to 9.9; increase in ACEPP score=0.5, 95% CI 0.02 to 1.06). Participant feedback was positive, with most indicating 'agree' or 'strongly agree' to the questions. A contemporary approach to teaching clinicians EBP, with a focus on SDM and pre-appraised evidence, was feasible, perceived as useful, and showed modest improvements in skills. Results should be interpreted cautiously because of the small study size and pre-post design.

Realizing better doctor-patient dialogue about choices in palliative care and early phase clinical trial participation: towards an online value clarification tool (OnVaCT)

BACKGROUND

Patients with advanced cancer for whom standard systemic treatment is no longer available may be offered participation in early phase clinical trials. In the decision making process, both medical-technical information and patient values and preferences are important. Since patients report decisional conflict after deciding on participation in these trials, improving the decision making process is essential. We aim to develop and evaluate an Online Value Clarification Tool (OnVaCT) to assist patients in clarifying their values around this end-of-life decision. This improved sharing of values is hypothesized to support medical oncologists in tailoring their information to individual patients' needs and, consequently, to support patients in taking decisions in line with their values and reduce decisional conflict.

METHODS

In the first part, patients' values and preferences and medical oncologists' views hereupon will be explored in interviews and focus groups to build a first prototype OnVaCT using digital communication (serious gaming). Next, we will test feasibility during think aloud sessions, to deliver a ready-to-implement OnVaCT. In the second part, the OnVaCT, with accompanied training module, will be evaluated in a pre-test (12-18 months before implementation) post-test (12-18 months after implementation) study in three major Dutch cancer centres. We will include 276 patients (> 18 years) with advanced cancer for whom standard systemic therapy is no longer available, and who are referred for participation in early phase clinical trials. The first consultation will be recorded to analyse patient-physician communication regarding the discussion of patients' values and the decision making process. Three weeks afterwards, decisional conflict will be measured.

DISCUSSION

This project aims to support the discussion of patient values when considering participation in early phase clinical trials. By including patients before their first appointment with the medical oncologist and recording that consultation, we are able to link decisional conflict to the decision making process, e.g. the communication during consultation. The study faces challenges such as timely including patients within the short period between referral and first consultation. Furthermore, with new treatments being developed rapidly, molecular stratification may affect the patient populations included in the pre-test and post-test periods.

TRIAL REGISTRATION

Netherlands Trial Registry number: NTR7551 (prospective; July 17, 2018).

Effect of a Skills Training for Oncologists and a Patient Communication Aid on Shared Decision Making About Palliative Systemic Treatment: A Randomized Clinical Trial

BACKGROUND

Palliative systematic treatment offers uncertain and often limited benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). This trial examined the independent and combined effect of an oncologist training and a patient communication aid on SDM.

METHODS

In this multicenter randomized controlled trial with four parallel arms (2016-2018), oncologists (n = 31) were randomized to receive SDM communication skills training or not. The training consisted of a reader, two group sessions, a booster session, and a consultation room tool (10 hours). Patients (n = 194) with advanced cancer were randomized to receive a patient communication aid or not. The aid consisted of education on SDM, a question prompt list, and a value clarification exercise. The primary outcome was observed SDM as rated by blinded observers from audio-recorded consultations. Secondary outcomes included patient-reported SDM, patient and oncologist satisfaction, patients' decisional conflict, patient quality of life 3 months after consultation, consultation duration, and the decision made.

RESULTS

The oncologist training had a large positive effect on observed SDM (Cohen's d = 1.12) and on patient-reported SDM (d = 0.73). The patient communication aid did not improve SDM. The combination of interventions did not add to the effect of training oncologists only. The interventions affected neither patient nor oncologist satisfaction with the consultation nor patients' decisional conflict, quality of life, consultation duration, or the decision made.

CONCLUSION

Training medical oncologists in SDM about palliative systemic treatment improves both observed and patient-reported SDM. A patient communication aid does not. The incorporation of skills training in (continuing) educational programs for medical oncologists is likely to stimulate the widely advocated uptake of shared decision making in clinical practice.

TRIAL REGISTRATION

Netherlands Trial Registry NTR 5489.

IMPLICATIONS FOR PRACTICE

Treatment for advanced cancer offers uncertain and often small benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). SDM is increasingly advocated for ethical reasons and for its beneficial effect on patient outcomes. Few initiatives to stimulate SDM are evaluated in robust designs. This randomized controlled trial shows that training medical oncologists improves both observed and patient-reported SDM in clinical encounters (n = 194). A preconsultation communication aid for patients did not add to the effect of training oncologists. SDM training effectively changes oncologists' practice and should be implemented in (continuing) educational programs.

Availability and effectiveness of decision aids for supporting shared decision making in patients with advanced colorectal and lung cancer: Results from a systematic review

Introduction

Shared decision making is not always commonplace in advanced colorectal or lung cancer care. Decision aids (DAs) might be helpful. This review aimed (a) to provide an overview of DAs for patients with advanced colorectal or lung cancer and assess their availability; and (b) to assess their effectiveness if possible.

Methods

A systematic literature search (PubMed/EMBASE/PsycINFO/CINAHL) and Internet and expert searches were carried out to identify relevant DAs. Data from the DAs included were extracted and the quality of studies, evidence (Grading of Recommendations Assessment, Development and Evaluation) and effectiveness (International Patient Decision Aid Standards) of DAs were determined.

Results

Ten of the 12 DAs included (four colorectal cancer, four lung cancer and four generic) are still available. Most (9/12) were applicable throughout the disease pathway and usable for all decisions, or to the decision for supportive care with/without anti‐cancer therapy. Seven studies tested effectiveness. Effects on patient outcomes varied, but were generally weakly positive (e.g., DAs improved patient satisfaction) with low evidence. Study quality was fair to good.

Conclusion

There is a lack of readily available DAs that have been demonstrated to be effective in advanced colorectal or lung cancer. Rigorous testing of the effects of currently available and future DAs, to improve patient outcomes, is urgently needed.

Promoting shared decision making in advanced cancer: Development and piloting of a patient communication aid

OBJECTIVE

To learn how to configure a patient communication aid (PCA) to facilitate shared decision-making (SDM) about treatment for advanced cancer.

METHODS

The PCA consists of education about SDM, a question prompt list, and values clarification methods. Study 1. A first version was presented to 13 patients, 8 relatives and 14 bereaved relatives in interviews. Study 2. A second version was used by 18 patients in a pilot study. Patients and oncologists were interviewed, patients were surveyed, and consultations were audio-recorded.

RESULTS

Respondents reported that the aid facilitated patient control over information, raised choice awareness and promoted elaboration. Risks were identified, most importantly that the aid might upset patients. Also, some respondents reported that the PCA did not, or would not support decision making because they felt sufficiently competent, did not perceive a role for themselves, or did not perceive that the decision required elaboration.

CONCLUSIONS

Opinions on the usefulness of the PCA varied. It was challenging to raise awareness about the presence of a choice, and to find a balance between comprehensive information and sensitivity.

PRACTICE IMPLICATIONS

A future study should demonstrate whether the PCA can improve SDM, and whether this effect is stronger when oncologists receive training.

Effects of Shared Decision Making on Distress and Health Care Utilization Among Patients With Lung Cancer: A Systematic Review

CONTEXT

Lung cancer is associated with significant distress, poor quality of life, and a median prognosis of less than one year. Benefits of shared decision making (SDM) have been described for multiple diseases, either by the use of decisions aids or as part of supportive care interventions.

OBJECTIVES

The objective of this study was to summarize the effects of interventions facilitating SDM on distress and health care utilization among patients with lung cancer.

METHODS

We performed a systematic literature search in the CINAHL, Cochrane, EMBASE, MEDLINE, and PsychINFO databases. Studies were eligible when conducted in a population of patients with lung cancer, evaluated the effects of an intervention that facilitated SDM, and measured distress and/or health care utilization as outcomes.

RESULTS

A total of 12 studies, detailed in 13 publications, were included: nine randomized trials and three retrospective cohort studies. All studies reported on a supportive care intervention facilitating SDM as part of their intervention. Eight studies described effects on distress, and eight studies measured effects on health care utilization. No effect was found in studies measuring generic distress. Positive effects, in favor of the intervention groups, were observed in studies using anxiety-specific measures (n = 1) or depression-specific measures (n = 3). Evidence for reductions in health care utilization was found in five studies.

CONCLUSION

Although not supported by all studies, our findings suggest that facilitating SDM in the context of lung cancer may lead to improved emotional outcomes and less aggressive therapies. Future studies, explicitly studying the effects of SDM by using decision aids, are needed to better elucidate potential benefits.

Communication skills training for healthcare professionals working with people who have cancer

BACKGROUND

This is the third update of a review that was originally published in the Cochrane Library in 2002, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress, which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective.

OBJECTIVES

To assess whether communication skills training is effective in changing behaviour of HCPs working in cancer care and in improving HCP well-being, patient health status and satisfaction.

SEARCH METHODS

For this update, we searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid, Embase via Ovid, PsycInfo and CINAHL up to May 2018. In addition, we searched the US National Library of Medicine Clinical Trial Registry and handsearched the reference lists of relevant articles and conference proceedings for additional studies.

SELECTION CRITERIA

The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In updated versions, we limited our criteria to RCTs evaluating CST compared with no CST or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real or simulated people with cancer or both, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects method. For continuous data, we used standardised mean differences (SMDs).

MAIN RESULTS

We included 17 RCTs conducted mainly in outpatient settings. Eleven trials compared CST with no CST intervention; three trials compared the effect of a follow-up CST intervention after initial CST training; two trials compared the effect of CST and patient coaching; and one trial compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists, residents, other doctors, nurses and a mixed team of HCPs. Overall, 1240 HCPs participated (612 doctors including 151 residents, 532 nurses, and 96 mixed HCPs).Ten trials contributed data to the meta-analyses. HCPs in the intervention groups were more likely to use open questions in the post-intervention interviews than the control group (SMD 0.25, 95% CI 0.02 to 0.48; P = 0.03, I² = 62%; 5 studies, 796 participant interviews; very low-certainty evidence); more likely to show empathy towards their patients (SMD 0.18, 95% CI 0.05 to 0.32; P = 0.008, I² = 0%; 6 studies, 844 participant interviews; moderate-certainty evidence), and less likely to give facts only (SMD -0.26, 95% CI -0.51 to -0.01; P = 0.05, I² = 68%; 5 studies, 780 participant interviews; low-certainty evidence). Evidence suggesting no difference between CST and no CST on eliciting patient concerns and providing appropriate information was of a moderate-certainty. There was no evidence of differences in the other HCP communication skills, including clarifying and/or summarising information, and negotiation. Doctors and nurses did not perform differently for any HCP outcomes.There were no differences between the groups with regard to HCP 'burnout' (low-certainty evidence) nor with regard to patient satisfaction or patient perception of the HCPs communication skills (very low-certainty evidence). Out of the 17 included RCTs 15 were considered to be at a low risk of overall bias.

AUTHORS' CONCLUSIONS

Various CST courses appear to be effective in improving HCP communication skills related to supportive skills and to help HCPs to be less likely to give facts only without individualising their responses to the patient's emotions or offering support. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', the mental or physical health and satisfaction of people with cancer.

Training for Medical Oncologists on Shared Decision-Making About Palliative Chemotherapy: A Randomized Controlled Trial

BACKGROUND

Systemic treatment for advanced cancer offers uncertain and sometimes limited benefit, while the burden can be high. This study examines the effect of shared decision-making (SDM) training for medical oncologists on observed SDM in standardized patient assessments.

MATERIALS AND METHODS

A randomized controlled trial comparing training with standard practice was conducted. Medical oncologists and oncologists-in-training (n = 31) participated in a video-recorded, standardized patient assessment at baseline (T0) and after 4 months (T1, after training). The training was based on a four-stage SDM model and consisted of a reader, two group sessions (3.5 hours each), a booster session (1.5 hours), and a consultation card. The primary outcome was observed SDM as assessed with the Observing Patient Involvement scale (OPTION12) coded by observers blinded for arm. Secondary outcomes were observed SDM per stage, communication skills, and oncologists' satisfaction with communication.

RESULTS

The training had a significant and large effect on observed SDM in the simulated consultations (Cohen's f = 0.62) and improved observed SDM behavior in all four SDM stages (f = 0.39-0.72). The training improved oncologists' information provision skills (f = 0.77), skills related to anticipating/responding to emotions (f = 0.42), and their satisfaction with the consultation (f = 0.53).

CONCLUSION

Training medical oncologists in SDM about palliative systemic treatment improves their performance in simulated consultations. The next step is to examine the effect of such training on SDM in clinical practice and on patient outcomes.

IMPLICATIONS FOR PRACTICE

Systemic treatment for advanced cancer offers uncertain and sometimes limited benefit, while the burden can be high. Hence, applying the premises of shared decision-making (SDM) is recommended. SDM is increasingly advocated based on the ethical imperative to provide patient-centered care and the increasing evidence for beneficial patient outcomes. Few studies examined the effectiveness of SDM training in robust designs. This randomized controlled trial demonstrated that SDM training (10 hours) improves oncologists' performance in consultations with standardized patients. The next step is to examine the effect of training on oncologists' performance and patient outcomes in clinical practice.