Serious illness conversations between doctors and patients with poor prognosis are not happening nearly as often as they should, according to oncologist and author Ranjana Srivastava. Writing in The Guardian, she highlights a new study that tested simple nudges to increase these critical discussions, which help understand patients' goals and appetite for toxic treatments.
The Challenge of Discussing Mortality
Patients often feel well but can deteriorate without warning, leaving families surprised. Holistic care for incurably ill patients must include conversations about mortality, but getting there is hard—sometimes patients aren't ready, and sometimes doctors aren't. In an era of abundant treatment options, there is always something else to offer desperate patients to keep hope alive.
Study Findings on Nudging Conversations
Researchers tested four approaches: mailing a letter to the patient encouraging thinking about these issues, emailing the oncologist before the appointment suggesting the patient may need such a conversation, both nudges, or none. They looked for evidence of a serious illness conversation in the dedicated advance care planning section of medical records and via an AI algorithm scanning the entire record.
In the advance care planning section, nudging the patient alone made no difference—just 10% had a documented conversation, the same as the control group. This rose to 16% with a clinician nudge and 17% with both nudges. When the entire medical record was scanned, results improved: 22% of controls and nudged patients had documented conversations, rising to 28% with clinician nudges and 32% with both nudges.
Key Takeaways
First, serious illness conversations are far too rare, costing patients and society enormously. When they do happen, they are often not properly documented, which matters when patients are met in emergencies by professionals lacking time to mine records. Second, telling patients to have these conversations with their oncologist doesn't work. The salient lesson is that reminding doctors to have them is useful, and reminding both doctors and patients simultaneously is even better.
Barriers and Solutions
Immediate barriers for clinicians include lack of communications training, time constraints, and burnout. Systemically, matching the right doctor with the right patient on the right day for a consequential conversation about death and dying remains challenging. However, with insight into why these conversations matter and how better communication saves healthcare dollars, and foresight to build systems fit for the future, change is possible and necessary.
As Srivastava reflects on her own patient encounter, she gently tells her patient that it's important to plan for a time when her health worsens, for everyone's sake. The patient responds with gratitude: "Thank you, I needed to hear that."
