In the ever-evolving facilitation of cancer care, the challenge ahead of hospitalists is daunting. It is important for them to master the art of talking about prognosis with patients. This has been a problem for generations. For example, physicians have a hard time addressing sensitive topics that directly impact cancer outcomes and treatment choices. A recent case report has brought new focus on this decades-long conundrum. Beyond that, it provides a meaningful blueprint for how oncologists, hospitalists and patients themselves should interact and engage in conversations.
Marina George, MD, reiterates the need for hospitalists to help patients address their goals of care. She argues that healthcare providers need to do a better job of even explicitly asking patients what they desire. Otherwise, they run the risk of inadvertently designing something that conflicts with those preferences. The recent discourse on this topic has been intensified by discussions among clinicians on social media platforms, notably sparked by a Reddit post concerning a patient with metastatic colon cancer.
Importance of Honest Discussions
Dr. Douglas Koo, oncology hospitalist from Mount Sinai, has a different but equally troubling concern. In reality, many oncologists are reluctant to have direct, honest discussions about prognosis. He explains that lots of families wait because they’re scared and they don’t want to give up hope. At the same time, he’s an outspoken advocate for aggressive treatment strategies. Koo has watched this dynamic play out again and again in clinical settings. As she observes, “Oncology hospitalists deal with this situation all day, every day. Often, it’s in the moment of hospitalization that the key opportunity comes, giving patients and families an opportunity to actually hear what they might — or might not — have been told previously.”
The usual practice for oncologists is to talk about prognosis in average or ranges of averages. This approach risks hiding atypical patient experiences, shocking families with the realities of their loved ones’ conditions when it is too late. In opposition, the case report calls on healthcare providers to set a consistent standard of prognostic information and deliver that information to families.
Dr. David J. Casarett, who published a noteworthy case report in 2006 about a patient with lung cancer, underscores the criticality of these conversations in enhancing patient care. His perspectives highlight the need for documenting conversations around prognosis deeply into the electronic health record (EHR). This practice helps ensure that every clinician who touches a patient’s care is completely aligned with their preferences and goals.
“If those conversations are clearly documented in the EHR, in a place where other clinicians can see them easily, it helps clinicians get on the same page.” – David J. Casarett, MD
Shifting the Conversation in Outpatient Settings
The nuances of prognostication conversations in the outpatient setting add another level of difficulty. According to Dr. Loh, patients often struggle with understanding their prognosis during these visits due to emotional stress and the overwhelming nature of information presented. He recommends having these discussions in outpatient environments. This environment not only reduces pressure felt by patients, but it includes additional support tailored to patients’ needs.
For George, it’s about determining what matters to a patient from the very beginning. Taking the time to do so can make a world of difference in their healthcare journey. By acknowledging these preferences, clinicians can better personalize treatments and medication regimens to fit patients’ unique needs, improving their overall quality of life.
“If the preference is known earlier, we would tailor treatments and tailor the healthcare journey in a way that would help the person experience life in a very different way.” – Marina George, MD
Here again, Dr. Casarett’s team has been remarkably successful in raising the conversation about end-of-life care among patients who are hospitalized. At baseline, less than 10% of patients had prognosis-congruent conversations documented within six months of the end of life. Now, that number has jumped to nearly 60%. Despite this progress, Casarett acknowledges that demonstrating tangible impacts on outcomes such as hospice utilization or readmission rates remains challenging.
Institutional Efforts to Improve Communication
Memorial Sloan Kettering Cancer Center knows just how important structured communication can be when it comes to talking about cancer prognosis. To provide better quality care for cancer patients, they decided to implement a specialized hospital medicine service. The institution has published a guide in the Journal of Hospital Medicine to assist healthcare providers in navigating these difficult discussions.
Dr. Koo underscored that clinicians across the board were eager to prove their unique and specialized role in providing hospital inpatient cancer care. That passion led to the development of some amazing new resources. He emphasized that as recently as a decade ago, everyone thought these people were best served by an oncologist. That perception has turned sharply upside down.
“We knew we were doing something special as hospitalists caring exclusively for patients with cancer.” – Douglas Koo, MD, MPH
Collaborative efforts between hospitalists and oncologists are critical. This collaboration between different medical professionals allows for a well-rounded plan of action specific to a patient’s individual needs. Hospitalists excel at coordinating care across multiple disciplines, including social work and case management, which is crucial for optimizing treatment pathways for cancer patients.
“Hospitalists are experts at hospital-based care processes, communication, and organizing care between a patient’s oncologist, consultants, social work, case management, and many others to improve the quality of care that these patients receive.” – Douglas Koo, MD, MPH
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