Trial Summary

Study question and significance: Many older adults with advanced cancer do not discuss treatment preferences or goals of care with their clinicians. Lack of communication about patients’ preferences can lead to patients receiving care that does not match their values.

Design and setting: Stepped-wedge, cluster randomized trial testing the delivery of a video decision aid to patients together with goals-of-care communication skills training to oncology clinicians in 29 clinics in 3 healthcare systems in the South, Midwest, and Mid-Atlantic regions from April 1, 2020, to November 30, 2022. The study included 13,800 patients aged 65 years or older. Each clinic was randomly assigned to either the intervention or usual care at the beginning of the study. Due to the stepped-wedge design of the trial, all clinics were exposed to the intervention by the end of the study.

Intervention and methods: The intervention included an evidence-based, patient-facing video decision aid available in 25 languages. It also included a communication training program to improve clinicians’ skills in delivering serious news, responding to emotion, and eliciting patients’ goals. The primary outcome was documentation of advance care planning in the electronic health record, which could include documentation of a goals-of-care conversation, palliative care, hospice, or limitation of life-sustaining treatments.

Findings: The proportion of patients with documentation of advance care planning was greater with the ACP PEACE intervention than with usual care (adjusted rate difference, 6.8% [95% CI, 2.8%-10.8%]; P < .001). The difference was attributable to a greater proportion of patients in the intervention phase having a goals-of-care conversation. There were no significant differences between the intervention and usual care for the documentation of palliative care, hospice, or limitation of life-sustaining treatments.

Conclusions and relevance: A video decision aid for older patients with advanced cancer, coupled with communication skills training for clinicians, led to higher rates of documented advance care planning in oncology clinics. The innovative approach led to a clinically meaningful increase in documentation of advance care planning, a widely used metric that reflects high-quality, patient-centered care delivery.

NIH Project Information