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OtherOncology Briefs

Having hard conversations

Advance care planning, serious illness conversations, and goals of care discussions with oncology patients

Leah O’Shea and Anna N. Wilkinson
Canadian Family Physician February 2025; 71 (2) 117-120; DOI: https://doi.org/10.46747/cfp.7102117
Leah O’Shea
Palliative medicine physician at The Ottawa Hospital in Ontario and Assistant Professor at the University of Ottawa.
MD CCFP(PC)
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Anna N. Wilkinson
Associate Professor in the Department of Family Medicine at the University of Ottawa, a family physician with the Ottawa Academic Family Health Team, a general practitioner oncologist at The Ottawa Hospital Cancer Centre, Program Director of PGY-3 FP-Oncology, and Regional Cancer Primary Care Lead for Champlain Region.
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In Canada, cancer remains the leading cause of death, with 247,100 new cases and 88,100 deaths estimated in 2024.1 Individuals diagnosed with cancer face many challenges throughout their illness experience; complex decision making related to their treatment and end-of-life care are chief among these concerns. Given that many patients with cancer are at risk of developing impairments related to decision making as their disease progresses, frequent and robust communication with their loved ones and health care team regarding their health goals and preferences is vitally important.2

In its most general sense, advance care planning (ACP) involves the consideration and communication of a patient’s health care values and goals with their loved ones and health care professionals. Advance care planning has been defined as a “process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care.”3 The goal of ACP is to help ensure that medical care is congruent with an individual’s wishes during serious and chronic illness.3 There is ongoing debate surrounding the effectiveness of ACP conversations at accomplishing improved goal-concordant care, reduced subsequent health care use, and improved quality of life and end-of-life care; regardless, conversations about a patient’s values and goals, especially amid advanced illness, remain extremely important.4

Serious illness communication continuum

Traditionally, ACP has included discussions about concrete issues such as resuscitation and life support, identification of substitute decision makers, and completion of advance directives.5 More recently, the framework of ACP discussions has broadened to include concepts such as serious illness conversations (SICs) and goals of care (GOC). While sometimes used interchangeably in clinical practice, these 3 topics represent different conversations along a continuum (Figure 1; P. Munene, MD; teaching presentation to internal medicine residents, University of Ottawa, 2021). These conversations may be iterative and nonlinear as the clinical picture evolves.

Figure 1.
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Figure 1.

Serious illness communication continuum

Advance care planning can be considered the first step in a series of important conversations to initiate with patients who have advanced illness, particularly those with cancer. Advance care planning for a patient with cancer may include confirming the selection of a substitute decision maker, discussing any advance directives, and exploring the patient’s overall goals and values when it comes to their health. Many cancer patients have expressed wanting to have ACP conversations earlier in their disease trajectory and would prefer these conversations to occur with a trusted clinician, such as their family physician.6,7

Serious illness conversations are an emerging construct in which a trusted clinician explores the patient’s specific illness understanding (ie, the patient’s understanding of their specific oncologic diagnosis). During this conversation the clinician shares information about prognosis according to the patient’s preferences and elicits the patient’s goals, values, and priorities in an open-ended format. The SIC might also involve a medical recommendation about next steps when indicated.8 Clinicians can use an evidence-based tool, such as the Serious Illness Conversation Guide (Figure 2),9,10 to provide a structured approach to the SIC.

Figure 2.
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Figure 2.

Serious Illness Conversation Guide

Sharing a prognosis is often the most difficult part of an SIC, yet discussing this information is crucial. Most patients with cancer want to know their prognosis and having this information shared with them can lead to a reduction in anxiety and depression symptoms.11,12 Clinicians are often worried about being wrong when they prognosticate; however, most patients understand that clinicians cannot be perfectly accurate when discussing their prognosis.13 The purpose of discussing prognosis is to help patients begin a planning process, not to be right or wrong. Finally, some clinicians worry that patients might “die sooner” after receiving prognosis information, but this has not been supported in the literature.14 Clinicians should be aware that prognostication in the setting of novel treatments like immunotherapy in metastatic disease can be extremely challenging given variable response rates and unpredictable durations of response.15 Tips on sharing an expected prognosis with patients are presented in Box 1.

Box 1.

Tips for discussing prognosis

  • Be prepared to discuss prognosis before meeting with the patient. Review necessary medical details to help inform your conversation

  • Avoid giving an exact number of expected days, weeks, or months left to live

  • Consider using more general terms such as “days to weeks,” “weeks to months,” or “months to years”

  • Remind patients of uncertainty when discussing prognosis

The third step of the continuum, the GOC conversation, is specific to a particular treatment option (eg, venting gastrostomy placement in the setting of a bowel obstruction) and involves integration of the patient’s previously discussed values and goals into shared decision making.16 These conversations often occur when the specific treatment decision needs to be made. Goals-of-care conversations are much easier to initiate and conduct when patients have already had a general ACP discussion and a more specific SIC.

Advance care planning, SICs, and GOC discussions are often emotionally charged and can be difficult for both patients and clinicians. There are some general communication tips that can be followed to help improve the success of these interactions (Box 2).

Box 2.

Tips for good communication

  • Ensure you have a quiet space free of distractions

  • Give the patient the opportunity to invite a caregiver or loved one to the conversation

  • Encourage the patient to sit if desired. Sit with the patient

  • Review the medical details of the case

  • Use simple language and avoid medical jargon

  • Ask the patient to explain their understanding of the medical details of their case

  • Give opportunities for the patient to ask questions

  • Allow for moments of silence

  • Have a plan for future steps

Team approach

Serious illness communication for patients diagnosed with cancer is a sensitive topic and can be challenging for family physicians to integrate into their practice, given the many other competing priorities that need to be managed. As well, cancer patients often have many health care professionals involved in their circle of care, making it difficult to know whose responsibility it is to initiate and lead these conversations. It is clear, however, that patients achieve deeper prognostic awareness and illness understanding when serious illness communication with their health care team occurs over time, in different settings (eg, oncology, primary care, palliative care), and with different disciplines (eg, medicine, psychology, chaplaincy, social work).17 Therefore, it is beneficial for family physicians to engage in these conversations with their patients, even if they just touch on small pieces across the continuum over multiple visits. It is the summation of many conversations that help patients with advanced disease learn how to express what is most important to them and make fully informed decisions regarding their care.17

Conclusion

Patients diagnosed with cancer will face many challenges during their illness journey. Family physicians are trusted members of these patients’ health care teams and can play an important role in ACP, SICs, and GOC discussions. This article has highlighted the differences between these types of conversations and provides some communication suggestions to help make these conversations more successful.

Notes

Oncology Briefs was a quarterly series that provided evidence-based reviews of key oncology topics relevant to family practice and postgraduate education. The series covered topics ranging from screening, diagnosis, and treatment to survivorship care and more. The series was coordinated by Dr Anna N. Wilkinson of the Cancer Care MIG (Member Interest Group) at the College of Family Physicians of Canada; articles were reviewed by members of the Cancer Care MIG. This is the final article of the series.

Footnotes

  • Competing interests

    Dr Anna N. Wilkinson is a consultant for Thrive Health.

  • This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to https://www.cfp.ca and click on the Mainpro+ link.

  • La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro de février 2025 à la page e29.

  • Copyright © 2025 the College of Family Physicians of Canada

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Having hard conversations
Leah O’Shea, Anna N. Wilkinson
Canadian Family Physician Feb 2025, 71 (2) 117-120; DOI: 10.46747/cfp.7102117

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