Primary Palliative Care Betters Access to Advanced Care Planning in Cancer

Yael Schenker, MD, MAS, FAAHPM

A 3-day immersive training program in palliative care for oncology nurses significantly improved advanced care planning (ACP) outcomes among patients with advanced cancer, according to findings from the Cluster Randomized Trial of a Primary Palliative Care Intervention (CONNECT) trial (NCT02712229).

According to data published in Journal of the National Comprehensive Cancer Network¹, the trial included 672 patients across 17 community clinics, all who had advanced solid tumor malignancies, an ECOG performance status of 0-2, and anticipated end-of-life conversations within a year.

In the intervention arm of the study, patients had regular meetings with a CONNECT-trained nurse over a 3-month period, typically before or following their otherwise scheduled oncology appointment. During these meetings, nurses shared care plans with patients, including an assessment of symptom burden and goals of care. At the first visit, nurses engaged in ACP with patients by assessing whether patients had a surrogate decision-maker, and further delved into ACP by assessing goals of care through questions during subsequent visits.

Compared with standard care, patients in the nurse-led program showed an increase in initiating end-of-life conversations and completing advance directives within 3 months. Of those who hadn't previously had end-of-life discussions, 45.1% had conversations with the trained nurses vs 14.8% in the standard care group. Additionally, 43.2% of patients in the nurse-led program completed advance directives compared with 18.1% in the standard care group.

These data highlight the potential of nurse-led palliative care interventions and show the importance of such training to improve ACP understanding among patients with advanced cancers. Overall, specialized care by trained nurses can help improve the quality of end-of-life decision-making for patients with cancer.

In an interview with Targeted OncologyTM, Yael Schenker, MD, MAS, FAAHPM, Palliative Research Center, section of palliative care and medical ethics, division of general internal medicine, University of Pittsburgh, discussed the importance of palliative care and advanced care planning for patients with advanced cancers.

Targeted Oncology: Can you discuss the importance of palliative care specialists?

We know that specialty palliative care is critically important for patients with advanced cancer. We know that it improves quality of life, we know that it decreases symptom burdens, we know that it helps people, and their families make treatment decisions, and it helps to make sure that people are receiving the kind of care that makes sense for them. We know that as palliative care specialists, palliative care is guideline recommended for all patients with advanced cancer, and it's a limited resource trying to fulfill an insatiable demand. We are always looking for new and innovative ways to deliver palliative care and to make best use of the specialty services we have available.

What is advanced care planning?

Advanced care planning is a process of engaging people and their families at any age or stage of serious illness in planning for future decisions about their treatment and about their care. It is also guideline recommended for patients with advanced cancer, so it is very important.

Can you discuss the methods and design of the analysis you were a part of regarding primary palliative care intervention for patients with cancer?

This is actually a secondary analysis of a large trial that we conducted. It was a trial of a primary palliative care intervention for patients with advanced cancer. We designed this study because we know that most patients with advanced cancer don't have access to palliative care specialists. We wanted to see with an intervention that involved training, oncology infusion room nurses to provide the basic components of palliative care and see whether we could improve some of the same outcomes. This analysis is one of the secondary outcomes of this study, which was looking at improvements in advance care planning.

It was a large trial that was conducted at 17 different community oncology practices without access to onsite specialty palliative care, and it involved enrolling 672 patients and their family caregivers. We randomized at the practice level practices either who had their infusion nurses trained and supported to provide primary palliative care or were randomized to the control group where patients received standard oncology care.

What were the main findings?

For this secondary analysis, we looked at 2 different outcomes related to advanced care planning. One was having a conversation with their oncologist about what was important near the end of life, and 2 was the completion of an advanced directive, which is a document that specifies your values, goals, and wishes for the kind of care you would want to receive near the end of life. We found that for patients who received the primary palliative care intervention, the oncology nurse led primary palliative care, there was a significant increase in rates of advanced directives and the frequency of conversations with oncologists increased approximately threefold in the intervention group.

For community oncologists, what are the key takeaways from the secondary analysis?

This study built on many studies over decades, showing that in usual care and usual practice at baseline, advanced care planning is not happening very often. The study confirmed that. I think we also found that oncology nurses and infusion nurses who are trained and supported to play this key role could have a major impact. I will say that it is hard to fit advanced care planning into standard oncology care. Practices are busy, oncologists are busy, and so this may be 1 way to do that, without taking time from patients' visits with their oncologist.

Are there any other ways that you believe we can fill this demand with delivering palliative care?

That's an important question and our group and our Palliative Research Center is looking for innovative models of palliative care delivery that leverage all the resources we have available. The primary palliative care and training the primary team to deliver palliative care is 1 approach. We're also thinking about ways to expand access to palliative care specialists through telemedicine, e-consults, telehealth, and there are a lot of things we need to be looking at, because we know palliative care doesn't exist at all the places it needs to exist, specialty palliative care, and that creates access barriers. It also creates equity issues, particularly for patients who are not in urban academic centers.

What are the ways you see this in influencing research moving forward?

I think the question of how we deliver high-quality palliative care to every patient with advanced cancer and every patient with palliative care needs [is key]. How do we right size our delivery models? How do we optimize use of available resources? Those are important questions for the field going forward. Specialty palliative care will always be a limited resource, and we have to figure out how to use that resource most effectively, most efficiently, and most equitably. Those are the important questions for the field going forward.

REFERENCE:

Cohen MG, Althouse AD, Arnold RM, et al. Primary palliative care improves uptake of advance care planning among patients with advanced cancers. J Natl Compr Canc Netw. 2023;21(4):383-390. doi:10.6004/jnccn.2023.7002