Dartmouth Project Seeks to Determine Best Timing for Serious Illness Talks

New-Hampshire-based Dartmouth Cancer Center has launched a quality improvement project aimed at ensuring timely goals of care conversations. 

Through the project, the center seeks to design an interdisciplinary serious illness conversation care model.The Dartmouth Cancer Center, The Dartmouth Institute for Health Policy & Clinical Practice and Dartmouth Health are collaborating on the initiative through a joint venture.

The goal is to help educate clinicians on how to incorporate these conversations into their “normal workflow,” Dartmouth researchers told Hospice News in an email. Researchers included Dr. Garrett Wasp, medical oncologist in Dartmouth Cancer Center’s Head & Neck Cancer Program and assistant professor of medicine at Dartmouth’s Geisel School of Medicine, as well as Dr. Amelia Cullinan, palliative medicine provider at the Dartmouth Hitchcock Medical Center and Clinics and assistant professor of medicine at Geisel.

“The Serious Illness Care Model of Care was developed as a way of expanding primary palliative care skills to a wider clinician group,” Cullinan and Wasp told Hospice News. “Our colleagues in oncology were a natural place to start. We have plans to expand the SIC MOC to other medical specialties, like cardiology, nephrology, and pulmonary/critical care medicine. The SIC MOC teaches these specialist teams a systematic approach to eliciting and documenting seriously ill patients’ values and goals.”

A multidisciplinary team at the cancer center rolled out a standardized questionnaire-based screening system over the course of two-years to help clinicians determine the right timing for serious illness conversations.

Dartmouth researchers examined the initiative’s impacts in a recent study published in the JCO Oncology Practice, a journal of the American Society of Clinical Oncology. The study spanned an 18-month period in which multidisciplinary teams rose their baseline documentation of serious illness conversations (SICs) up to 70%, with these discussions taking place among 43 out of 63 eligible patients. An amount that surpassed the initial goal of raising the bar by 25%.

The project was birthed from the challenges, disruptions and opportunities that the pandemic brought to palliative and hospice care providers, according to Cullinan and Wasp. Telehealth allowed for serious illness care conversations to be “uncoupled” from patient care visits for cancer treatments, which allowed for a “better focus on what matters most to patients and their families,” they added.

The downsides, however, were that workforce disruptions made it harder to incorporate other members of the care team like social workers and nurse navigators directly into the conversation themselves, said Wasp and Cullinan.

The “centerpiece” in Dartmouth’s model hinges on a serious illness conversation guide developed by Ariadne Labs which provides language and structure to navigate sensitive conversations, they explained.

The education initiative included a three-hour interactive, skills-based workshop for clinicians to learn how to hold these conversations, as well as the opportunity for in-person coaching when first integrating them with their patients.

Most clinicians either declined coaching, or used coaching one to two times before becoming independent in having SICs with patients, said Wasp and Cullinan.

The model helped guide conversations that allowed clinicians to elicit the patients’ own understanding of their illness, desired prognostic information, and share that tailored information with them, according to Cullinan and Wasp. These conversations would then lead to patients sharing their values and goals for the time ahead in their illness trajectories, including the end of life.

“We train clinicians to expect and respond to emotion throughout the conversation, particularly when conversations take place later in the patients’ illness,” Cullinan and Wasp told Hospice News in an email. “While most patients are able to articulate their values clearly to their oncology teams, sometimes additional support is needed. Oncologists are welcome to refer patients who need additional support to our outpatient palliative care team for these conversations.”