Small, targeted reminders for both clinicians and patients to have serious illness conversations led to a significant increase in the number of conversations recorded, allowing for oncologists to better honor patients' goals and wishes for their cancer care, according to findings of a randomized controlled clinical trial published in JNCCN—Journal of the National Comprehensive Cancer Network.
“Past research has shown these conversations improve patient anxiety and quality of life and help them get care that matches their goals, especially near the end of life,” said one of the lead researchers, Christopher R. Manz, MD, MSHP, of Dana-Farber Cancer Institute. “Having the conversation with a provider they trust, and documenting it somewhere accessible, is what allows the rest of the team to honor the patients’ wishes, particularly if the patient is ill and unable to advocate for themself.”
Study Methods
Researchers conducted a four-arm randomized controlled trial at five disease-based oncology clinics at two sites of an academic cancer center between December 2022 and July 2024. Enrolled adult patients with cancer (n = 1,051) all had pathways data showing they were starting treatment associated with a poor prognosis and did not have serious illness conversations documented within 6 months in the Advance Care Planning module of their electronic health record.
The randomized study arms included:
- A nudge consisting of a mailed letter and questionnaire encouraging a serious illness conversation (n = 273)
- A clinician nudge comprising an email reminder prior to a clinic visit to prompt a serious illness conversation (n = 240)
- Both nudges (n = 277)
- No nudges (n = 261).
The primary study outcome was the proportion of patients who had serious illness conversations within 60 days of randomization compared with the control arm of no nudges and the compared with the combined nudge arm. Additionally, there was a prespecified alternate outcome measure of serious illness conversations identified in the free text of clinician notes using natural language processing.
Key Findings
The rates of serious illness conversations occurring within 60 days were 10.7% for the control arm, 16.7% for the clinician nudge arm, 10.6% for the patient nudge arm, and 17.3% for the combined nudge arm. The rates with natural language processing were 22.6%, 28.8%, 22.3%, and 32.5% for the four arms, respectively.
In the combined nudge arm, patients had significantly higher rates of serious illness conversations within the Advance Care Planning module of their electronic health record or in the free text of clinician notes, as identified by natural language processing, than patients in the control arm (P = .045 and P = .01, respectively). The clinician nudge and patient nudge groups did not have significantly higher serious illness conversation rates compared with the control group.
“The key is precision. Nudging clinicians at the right time for the right patient rather than blasting reminders for every patient is how we turn this into a helpful quality improvement initiative rather than a burdensome email. Burnout is real and alert fatigue undermines the goal of these nudges: when they feel like noise, they get ignored,” noted co-lead author Cody E. Cotner, MD, of Harvard Medical School. “When a patient is prepared to have these conversations through initial outreach and walks into the office already thinking about what matters most to them, the clinician has a more receptive partner across the desk, and the conversation is easier to start and goes deeper.”
Elise Carey, MD, a palliative care specialist at Mayo Clinic Comprehensive Cancer Center, and a Member of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Panel for Palliative Care, who was not involved with this research, noted: “What is especially striking is that the benefit was driven largely by the clinician nudge, suggesting that small, well-timed supports can help clinicians make space for these essential conversations even in a busy clinical practice. Overall, this study offers a realistic, scalable step toward bringing serious illness conversations into oncology care earlier and more reliably.”
DISCLOSURES: For full disclosures of the study authors, visit jnccn.org.
