A Values Proposition for Cancer Care

In marketing, a value proposition is a statement of a company’s distinctive benefit to customers, appealing to their decisional influences and addressing their unmet needs. In oncology, we contend that a values proposition reflects a clinician’s commitment to partner with patients to improve outcomes through individualized communication and shared decision-making centered on the patient’s values. Health-related values offer a person’s unique perspective on what is most important, gives meaning, and defines acceptable quality of life while facing cancer. They may be informed by a host of individual, familial, cultural, social, and religious factors. Values are closely tied to personhood, ie, each patient’s uniqueness and intrinsic worth. Respect for values and personhood can (1) help patients feel heard and understood and (2) enhance the patient-reported quality of clinicians’ communication—both measures of person-centered care endorsed by the National Quality Forum.¹

We contend that integrating health-related values is, in fact, precision oncology. Whereas cancer can threaten personhood and dignity, patients’ articulation of what they value is affirming, especially through ongoing mutual discussions with clinicians that foster a trusting therapeutic relationship. Honoring values humanizes this relationship, treating patients as they want rather than how clinicians may personally want—the Platinum Rule²—as compared to the proverbial Golden Rule: to treat others as one would choose for one-self. For instance, a patient may value trust with the care team and so we demonstrate unencumbered partnership and accompaniment every step of the way. Perhaps they value a future with minimal pain and suffering, giving us the opportunity to reassure the patient with a firm commitment to symptom management. An emphasis on patient values during care can profoundly and positively affect the lived experience of cancer.

Goals of care conversations (GOCCs) are a favored target of efforts to improve health communication, expected to engage the patient in clarifying particular needs and preferences and co-creating a personalized plan. Unfortunately, the term goals of care itself lacks clarity. In a review of almost 200 articles published within 1 year that used the term, less than 15% included an operant definition, and nearly 90% focused on outcomes rather than life priorities; the most common uses were to describe discussions of treatment intent and end of life (EOL).³

Ideally, GOCCs entail a mutual exchange between clinician and patient, allowing the patient to both know about the illness and be known as an individual.⁴ Patients are encouraged to convey their health-related values and personhood, while clinicians provide expertise and empathy, incorporating patient-reported information to individualize the care plan. This framework is also flexible and dynamic. It should not be restricted to EOL, which has attached stigma and fear, but rather begin at diagnosis, regardless of prognosis, and continue throughout the illness, with iteration and elaboration. As patients live on or approach death, those with advanced cancer increasingly depend on such communication to navigate widening treatment options and share in decision-making to enhance survival and quality of life in a balance that is personally appropriate. Throughout the course, patients’ values remain the polestar.

Amid ever-increasing prognostic uncertainty, patients’ values will remain the most relevant focus of discussion and person-centered decisions. They sustain the relationship between oncology team and patient. They are more encompassing, enduring, and enlightening than goals of care—recommended for discussion at a specific illness juncture—or EOL care preferences. Regardless of diagnosis, stage, or prognosis, and even in times of good health with no evidence of disease, values deserve, if not demand, discussion and documentation. The earlier this occurs, the more it is normalized as part of routine essential care, rather than dreaded as a signal of approaching death, and the more clinicians hone their skills for emotionally challenging conversations if and when the disease advances despite cancer therapy. Revisiting values over time can also embrace multiple concurrent or successive goals and evolving preferences.

As oncology teams struggle to keep up in high-volume clinics and hospital services, efficient communication with patients about their values as a systematic, consistent, documented practice becomes a critical challenge. A skillful clinician can usually elicit patient values in about 10 minutes, but in a clinic scheduling 20 or more patients each day, the entire time for a visit that must address myriad other issues might be only slightly longer. Thus, even when clinicians are fully committed and adequately prepared to discuss patient values, practical challenges often preclude it.

However, an obligation—the values proposition—remains to leverage the full interdisciplinary team, along with digital technology advances, toward person-centered solutions that are feasible and acceptable to all involved, optimally developed through a design-thinking process that prioritizes the patient and clinician needs while capturing efficiencies.^5,6 Moreover, prompted and open exploration of patient values (eg, what they hope for most and deem most critical to live acceptably well, whom they identify as most supportive) enhances efficiency for clinicians in crafting goal-concordant care plans. For example, knowing a patient values independence in walking and talking as nonnegotiable abilities may be consistent with a comfort-focused plan with goals to maximize functional independence if debility worsens. Thus, values serve as the basis for tailored GOCCs and co-identification of actionable steps. Although goals frequently emerge from values, values may be overlooked during focused GOCC.

Eliciting, documenting, and integrating patients’ values into clinical care need not be the exclusive province of clinicians. Oncology clinicians are primarily responsible to lead the practice of person-centered care for patients with cancer, including the fundamental work of discussing patient values. This patient-clinician dyad is usually the therapeutic relationship of greatest longevity and depth and the main locus for partnership and shared decision-making. However, lay personnel have been helpful in documenting patients’ goals and preferences with favorable effects on utilization, and it is possible they can help support the values process. In addition, palliative care specialists are specifically trained to address patient values and help align care accordingly. Through the electronic health record, values can be known by all team members, especially through use of a standardized template that is readily recognizable and displayed in a centralized location, and revisited at regular intervals or critical junctures such as hospitalization or intensive care unit admission.⁷ Although the electronic health record is often viewed as time-consuming and burdensome by those responsible for documentation, it can be used to their advantage with features such as automatic incorporation of patients’ values responses in oncologists’ documentation of visits; collaboration with informatics expert colleagues offers opportunities for optimization.

To be clear, quality care should not be driven solely by whatever the patient wants; values must be considered in the broader context of safety, evidence, and ethics. While focusing more holistically on values may not solve larger systems issues that complicate care provision, it can ground clinicians in a person-centered approach to practice. When health-related values discussions are routinely incorporated into clinical encounters, team members can reflect on the appropriateness of their treatment recommendations and tailor options accordingly. This crucial intervention will require more than just enthusiastic endorsement from patients and clinicians. For sustained, successful implementation, culture change and institutional encouragement (eg, incentivization by inclusion in performance evaluation and recognition) are essential, as is clinicians’ access to communication skills training that uses all technologic advances to leverage compatibility with the demands of current oncology practice.

This is our values proposition.