A Video Decision Aid Improves Informed Decision Making in Patients With Advanced Cancer Considering Palliative Radiation Therapy.

CONTEXT: Advanced cancer patients have unrecognized gaps in their understanding about palliative radiation therapy (PRT). OBJECTIVES: To build a video decision aid for hospitalized patients with advanced cancer referred for PRT and prospectively test its efficacy in reducing decisional uncertainty, improving knowledge, increasing treatment readiness and readiness for palliative care consultation, and its acceptability among patients. METHODS: Forty patients with advanced cancer hospitalized at Memorial Sloan Kettering Cancer Center watched a video decision aid about PRT and palliative care. Patients' conceptual and logistical knowledge of PRT, decisional uncertainty, treatment readiness, and readiness for palliative care consultation were assessed before and after watching the video with a six-item knowledge survey, the decisional uncertainty subscale of the Decisional Conflict Scale, and Likert instruments to assess readiness to accept radiation treatment and/or palliative care consultation, respectively. A postvideo survey assessed the video's acceptability among patients. RESULTS: After watching the video, decisional uncertainty was reduced (28.3 vs. 21.7; P = 0.02), knowledge of PRT improved (60.4 vs. 88.3; P < 0.001), and PRT readiness increased (2.0 vs. 1.3; P = 0.04). Readiness for palliative care consultation was unchanged (P = 0.58). Patients felt very comfortable (70%) watching the video and would highly recommend it (75%) to others. CONCLUSION: Among hospitalized patients with advanced cancer, a video decision aid reduced decisional uncertainty, improved knowledge of PRT, increased readiness for PRT, and was well received by patient viewers.

Giving Voice to Patient Values Throughout Cancer: A Novel Nurse-Led Intervention.

CONTEXT: Optimal advance care planning allows patients to articulate their values as a touchstone for medical decision making. Ideally, this occurs when patients are clinically stable, and with opportunities for iteration as the clinical situation unfolds. OBJECTIVES: Testing feasibility and acceptability in busy outpatient oncology clinics of a novel program of systematic, oncology nurse-led values discussions with all new cancer patients. METHODS: Within an institutional initiative integrating primary and specialist palliative care from diagnosis for all cancer patients, oncology nurses were trained to use specific questions and an empathic communication framework to discuss health-related values during outpatient clinic visits. Nurses summarized discussions on a template for patient verification, oncologist review, and electronic medical record documentation. Summaries were reviewed with the patient at least quarterly. Feasibility and acceptability were evaluated in three clinics for patients with hematologic or gastrointestinal malignancies. RESULTS: Oncology nurses conducted 177 total discussions with 67 newly diagnosed cancer patients (17 with hematologic and 50 with gastrointestinal malignancies) over two years. No patient declined participation. Discussions averaged eight minutes, and all patients verified values summaries. Clinic patient volume was maintained. Of 31 patients surveyed, 30 (97%) reported feeling comfortable with the process, considered it helpful, and would recommend it to others. Clinicians strongly endorsed the values discussion process. CONCLUSION: Nurse-led discussions of patient values soon after diagnosis are feasible and acceptable in busy oncology clinics. Further research will evaluate the impact of this novel approach on additional patient-oriented outcomes after broader dissemination of this initiative throughout our institution.

1-2-3 Project: A Quality Improvement Initiative to Normalize and Systematize Palliative Care for All Patients With Cancer in the Outpatient Clinic Setting.

BACKGROUND: Prior work to integrate early palliative care in oncology has focused on patients with advanced cancer and primarily on palliative care consultation. We developed this outpatient clinic initiative for newly diagnosed patients at any stage, emphasizing primary (nonspecialist) palliative care by oncology teams, with enhanced access to palliative care specialists. METHODS: We piloted the project in two medical oncology specialty clinics (for patients with myelodysplastic syndrome and GI cancer, respectively) to establish feasibility. On a visit-based schedule, patients systematically reported symptoms, information/decision-making preferences, and illness understanding. They also participated in discussions of their core values with their oncology nurse. Oncology teams were first responders to palliative care needs, whereas specialists were available for clinician support and direct patient consultation. RESULTS: All 58 eligible patients were enrolled. In both clinics, patient self-reports documented a heavy symptom burden. Information/decision-making preferences and illness understanding levels varied across patients. Patients prepared new advance directives. Oncology nurses documented discussions of core values. Requests for palliative care consultation decreased over time as oncology teams embraced their primary palliative care role with coaching from the specialists. Clinic workflow and patient volume were maintained. CONCLUSION: Our pilot experience suggests that in outpatient oncology clinics, a structured, scheduled, and systematic approach is feasible to deliver palliative care to newly diagnosed patients with cancer at any stage and throughout their illness trajectory. This novel approach identified important, actionable palliative care needs, relying primarily on oncology teams to respond to these needs, while enhancing access to palliative care specialist input. Expansion to additional clinics will allow evaluation of scalability and generalizability, along with measurement of a broader range of important outcomes.

Advances in radiation treatment of patients with breast cancer.

Breast cancer is the most commonly diagnosed cancer among women in the United States. Approximately half of all patients diagnosed with early-stage breast cancer receive conservative breast surgery followed by consolidative radiation treatment. A number of technologic advances have been made in radiation therapy planning and treatment that minimize early and late toxicities and may improve treatment outcomes. Among these are (a) the treatment of patients with large or pendulous breasts or cardiopulmonary disease in the prone position, (b) intensity-modulated radiation treatment, which delivers precise, highly conformal radiation dose distributions within the breast by using computerized inverse treatment planning and intensity-modulated radiation beams to produce the required dose distribution, and (c) brachytherapy, which is the placement of a radioactive source within the lumpectomy bed. These advances are gaining national recognition and are available at many institutions. Nurses play a vital role in educating patients; therefore, nurses must have the information they need to inform their patients about these advances. The information in this article will allow nurses to help patients understand the anticipated treatment and related side effects and make informed decisions.