Goals-of-Care Conversations in Gynecologic Oncology
Timely goals-of-care conversations are imperative for the delivery of high-quality cancer care for patients at high risk of death, according to research by Davidson and colleagues.1
The Consultant360 editors spoke with associate professor in gynecologic oncology at Duke University and the fellowship director, Brittany A. Davidson, MD, about navigating goals-of-care conversations in gynecologic oncology, including how to identify patients at high risk of death who might benefit from a timely goals-of-care conversation, how to have a goals-of-care conversation, and how the conversations impact clinical practice. Dr Davidson also discussed these topics during a session at The Society of Gynecologic Oncology (SGO) 2023 Annual Meeting on Women’s Cancer titled "Navigating High Stakes Conversations in Gynecologic Oncology: Goals of Care Conversations."
Consultant360: Please provide an overview of the session “Navigating High Stakes Conversations in Gynecologic Oncology: Goals-of-Care Conversations.”2
Brittany A. Davidson, MD: This was an educational forum at our annual SGO meeting that was really aimed for clinicians, both physicians, advanced practice providers on topics that we see all the time in clinical medicine and clinical GYN oncology, but are oftentimes rife with challenges. We know that delivering serious news to patients, there are a lot of barriers to doing that. And so the opportunity for this session was to offer the audience some skills that make these challenging conversations just a little bit easier and hopefully they'd be more willing to engage in them with their patients and their families.
C360: Please describe how the educational program around goals of care conversations at end-of-life was developed.
Dr Davidson: My colleagues and I who developed this are all vital talk facilitators. So we have gone through a series of education to be able to teach folks these communication skills. And so as such, we use several of their talking maps or paradigms that help walk folks through goals of care conversations. And for this particular session, we really wanted to focus on particularly end-of-life conversations. How does one transition from the treatment train, so to speak, so people who have been on anti-cancer treatment for potentially months or even years, how do we help facilitate the conversation to shift our goals or shift our focus to really focus more aggressively on quality of life, potentially using more palliative care or hospice options. And again, these are just challenging because there's a lot of emotion tied to it. Both on the physician side and the patient and their family, and so they can be really hard.
C360: How does one identify patients at high risk of death who might benefit from timely goals-of-care conversations?
Great question. So goals of care conversations for patients with cancer should really be happening early and often during the course of their cancer. So we should not be waiting until a patient is near death to have our first goals of care conversation. Because truly in medicine and especially in cancer care, our goal for treatment is goal concordant care. So basically matching the treatments we are recommending to the goals that the patient has. But there's no way you can do that if you've never actually sat down with a patient and asked them what their goals are. What are their hopes for the future, whether or not they were just recently diagnosed, or maybe they're sitting with a new diagnosis of recurrent uterine or cervical cancer and they're struggling to figure out how to move forward. Well, the only way we know how to move forward is to first figure out what's the end goal for the patient, what are they hoping for, and what do they want?
And then with that information, we can match our treatment recommendations to be in line with the patient's own goals and values. So these are not one-time conversations. We should be having these again early and often.
C360: How do these conversations impact clinical practice?
Dr Davidson: They're the foundation of our clinical practice, right? When I have these conversations with patients and what I tell other clinicians is that we are the experts in the medical side of things. We have the medical knowledge and medical expertise, but the patients are really the experts in their own lives lived and the perspective that they're bringing to the table. And so I really encourage people to think about this as a conversation between two experts. And at the end of it, the goal is to have a shared decision about how to move forward. And so truly, these are foundational in my mind. So they impact care explicitly, right? The care is based on these goals of care conversations.
C360: What are ways to get to this end goal?
Dr Davidson: Absolutely. So we have a talking map called Remap about how to walk through this. The first part of it is really sharing the serious news. And this is something that we as physicians are often not very good at, because we're about to share some really hard, potentially sad news, and we often try to beat around the bush because we don't want to be direct. We feel like that's too harsh or too unkind. But in reality, what we do is confuse the patient because we're not being direct and then the patient has no idea what information we've actually just shared. So one of the skills that we tried to teach at this session was how to deliver an effective headline to get the point across, because if the patient doesn't understand that we're at a different place now, potentially there are fewer effective or safe treatment options or maybe really no treatment options. You can't make a decision. The patient has to understand that bit of information. I think where this is novel for many people is that we like to jump right to plan. We like to fix things. That's why we went into medicine to help and to fix. But instead of jumping right to our treatment recommendation, there's a key pivotal step in the middle where we map out patients' values. We map out what's important to them and what does a good day look like? What do they hope for the future or maybe what are they really worried about? What are they hoping doesn't happen? So, it's really headline, expect emotions that the patients are going to give when we share hard news, map out values, and then offer a goal-concordant treatment recommendation.
C360: What is next for research on this topic?
That's a great question. There's abundant literature out there that demonstrates how important these goals of care conversations are. That's not novel. But we still struggle in how to implement them or have these conversations in that sort of early and often timeframe that is recommended by the American Society of Clinical Oncology. And so I think that's really, it's almost like an implementation science problem. How do we make this happen? We all know it should happen. There are lots of different constraints on our time clinic flow, potentially patient-level barriers to these conversations. So how do we overcome those hurdles? Because these conversations are so key for our patients with advanced or recurring cancers.
C360: Is there anything else you'd like to add?
Dr Davidson: One of the most important things is that communication skills for healthcare professionals are teachable skills. Just like we learned so many other skills in medicine, so can we learn communication skills? Yes, there are some people that are born with excellent communication skills and maybe starting off at a little bit more of an advanced stage. But that doesn't mean that folks who feel like they have poor communication skills or struggle during these conversations can't get better. There are so many avenues and resources out there to improve your communication skills. And there's just such an overwhelming amount of literature that enhancing our communication skills, not only helps our patients and their families, but also helps ourselves in terms of decreasing stress and anxiety about these challenging conversations and potentially even prevents burnout for providers who are having these conversations with frequency. So there's hope for everyone from a communication standpoint. We can all continue to learn these skills.
If you're interested for more resources about how to improve these communication skills or if you're a patient, write down questions. It's so important that you are able to engage in these conversations. And if you feel like your doctor's not willing to go there, ask them. These are conversations that need to happen, and you should absolutely want or should absolutely feel comfortable advocating for yourself to make them a reality.
References:
1. Davidson BA, Puechl AM, Watson CH, et al. Promoting timely goals of care conversations between gynecologic cancer patients at high-risk of death and their providers. Gynecol Oncol. 2022;164(2):288-294. doi:10.1016/j.ygyno.2021.12.009
2. Davidson BA. Navigating high stakes conversations in gynecologic oncology: goals of care conversations. Talk presented at: The Society of Gynecologic Oncology (SGO) 2023 Annual Meeting on Women’s Cancer. March 26, 2023. Accessed April 20, 2023. https://www.sgo.org/