Adapting and implementing the Serious Illness Care Programme for outpatient oncology, cardiology and palliative medicine clinics: a mixed-methods feasibility study

Abstract

Objectives

To evaluate the feasibility of implementing a coordinator-facilitated Serious Illness Care Programme (SICP) in outpatient oncology, cardiology and palliative medicine clinics.

Design

Single-arm, mixed-methods, prospective feasibility study conducted over three sequential phases across 9 months, guided by the Reach, Effectiveness, Adoption, Implementation, Maintenance framework.

Setting

Outpatient oncology, cardiology and palliative medicine clinics in two tertiary medical centres in Singapore.

Participants

Eleven clinicians (eight doctors and three nurses) participated. Clinicians had prior serious illness conversation (SIC) training and were purposively sampled for diversity in specialty, seniority and mode of care delivery. One participant disengaged midway due to concerns about intervention fit but completed endline measures. A total of 101 patients participated in an SIC during the intervention period.

Interventions

Implementation supports were developed with reference to the Capability, Opportunity, Motivation–Behaviour model of behaviour change, and adapted to the workflows and needs of participating clinicians. These included email reminders, in-person prompting by a coordinator, access to a locally adapted SIC guide, a structured documentation template and optional patient preparation materials. Supports were introduced in full during phase 2, with in-person prompting and support withdrawn in phase 3.

Primary and secondary outcome measures

Feasibility was the primary outcome, operationalised through clinician perceptions of implementation support (acceptability) and the proportionality of implementation effort to observed benefits (practicality). Secondary outcomes included SIC engagement rates (reach), clinician retention (adoption) and continuity intentions among clinicians (maintenance).

Results

Clinician retention was 91% (n=10/11) with the only dropout being in the cardiology setting. Most clinicians felt support was acceptable and adequate (n=9/11). While 101 patients had SICs, engagement activity in oncology and cardiology declined following the withdrawal of in-person prompting, while engagement among palliative medicine clinicians remained stable or increased. Coordinator time commitment decreased by 75.8% between phases 2 and 3. Key barriers faced by clinicians included the documentation burden. Additionally, there was a perceived lack of fit in outpatient cardiology.

Conclusions

A coordinator-facilitated SICP is feasible and acceptable in outpatient oncology and palliative care settings. Active coordination reduces clinician burden. As in-person prompting may be necessary to sustain engagement in non-palliative specialties, further research should focus on institutionalising supports in these settings.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Incorporated diverse clinical specialties and serious illness conversation delivery modes.

• Evaluation rigorously structured using Reach, Effectiveness, Adoption, Implementation, Maintenance framework.

• Featured a phased approach to specifically test the impact of in-person support withdrawal.

• Limited by non-randomised, single-arm design without control group.

• Limited by a small sample size and relatively short follow-up duration.

Introduction

Evidence from multiple studies suggests that goals-of-care discussions improve communication quality, documentation of care preferences, and alignment of treatment with patient goals.¹,³ Despite growing recognition of their importance and value to patient outcomes, these discussions remain inconsistently integrated into the routine management of patients living with serious illnesses.⁴,⁸

The Serious Illness Care Programme (SICP) was developed to address this gap by equipping clinicians with structured communication tools and system-level supports to facilitate earlier and better conversations about patient values, goals, and preferences.⁹ However, implementation of the SICP has been less extensively studied, particularly outside Western healthcare systems.

Most existing studies focus on outcomes of educational interventions¹⁰,¹² or perceptions of the Serious Illness Conversation Guide (SICG).¹³,¹⁵ Few examined programme-level delivery in routine outpatient practice.^{9 16 17} Yet healthcare systems differ markedly in clinical workflows, resource availability, and team structures, all of which influence how complex interventions are operationalised. These contextual differences underscore the importance of adapting the SICP to local service models and practical realities.

Further, time constraints are widely reported among clinicians as a barrier to integrating serious illness communication into routine clinical consultations.¹⁸,²⁰ Conventional implementation models for SICP typically rely on clinicians to identify and prepare patients, but given the high-volume nature of many outpatient settings, such an arrangement may contribute to significant cognitive and administrative burden for clinicians. Consequently, this study evaluates the feasibility of a coordinator-facilitated SICP, which introduces a dedicated intermediary to streamline preparatory workflows and support clinician initiation of serious illness conversations (SICs).

Aims

This study aims to evaluate the feasibility of implementing a coordinator-supported SICP tailored to the workflows of two tertiary centres in Singapore with different disease contexts.

Methods

Study design

This single-arm, non-randomised study adopted a sequential explanatory mixed-methods design. Quantitative data from clinician surveys and engagement metrics were collected first and subsequently informed the development of semi-structured interview guides to examine clinician experiences and the contextual factors influencing clinician engagement patterns.

This evaluation of programme feasibility was guided by the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) to identify and report implementation outcomes relevant to an evaluation of programme feasibility.^{21 22} Feasibility is operationalised with respect to two conditions: (1) clinician perceptions of implementation supports as enabling and (2) whether the effort in implementation was proportionate to observed benefits in SIC engagement and clinician satisfaction. These align with the constructs of acceptability, integration, and practicality commonly recommended for feasibility evaluations.²³

Setting

This study was conducted at the outpatient oncology, cardiology and palliative medicine clinics of National Cancer Centre Singapore (NCCS) and National Heart Centre Singapore with 11 clinicians, all of whom had provided their written informed consent to participate in this study.

Patient eligibility criteria

Patients were recruited from the caseloads of participating clinicians. Eligible patients had advanced cancer (stage III/IV) or symptomatic heart failure (stage C/D), were aged ≥21, and were able to communicate in English or Mandarin. Patients with cognitive impairment or poorly controlled mental illness were excluded.

Study phases

The study was conducted in three phases over 9 months, with pilot implementation spanning phases 2 and 3.

In phase 1 (pre-pilot), which ran from September to November 2024, we gathered feedback from four clinicians (three oncologists, one palliative care physician), nine patients, and four caregivers to refine implementation supports. Two resources—an adapted What Matters to You workbook and a clinician-completed conversation summary for patients—were excluded following negative feedback: patients found the workbook distressing, and clinicians cited concerns about added documentation burden.

In phases 2 and 3 (from December 2024 to May 2025), all implementation supports (see the Intervention section) were deployed across both phases. In-person prompting and support by the coordinator was implemented in phase 2 (December–February) but withdrawn in phase 3 (March–May) to assess the feasibility of phased support reduction of the most effortful support.

Patient and public involvement

Patients and caregivers were involved in the pre-pilot phase of this study to provide feedback on proposed implementation materials. Beyond this pre-pilot feedback, patients and caregivers were not involved in the study design, conduct, analysis, or dissemination planning. While patients and caregivers participated in SICs with their clinicians, they were not involved as partners in the research process. Patients and caregivers who participated in this study provided their written informed consent in the presence of a third-party witness.

Intervention

The SICP implemented in this pilot was a structured, system-level intervention designed to support clinicians in initiating and documenting SICs. Selection of implementation supports was informed by the COM-B model, which conceptualises behaviour change as a function of Capability, Opportunity, and Motivation.²⁴ In this study, the target behaviours were clinician-led SIC initiation and appropriate documentation of discussion outcomes (i.e., using a structured SIC template).

As outlined in table 1, the support provided in this pilot addressed all three behavioural domains, with particular focus on modifying Opportunity, as suggested by clinicians interviewed in phase 1.

Table 1. Implementation supports introduced.

Domain	Definition	Definition in context	Implementation supports
Capability	The individual’s psychological and physical capacity to engage in the activity concerned, including having the necessary knowledge and skills	Skills and confidence to initiate serious illness conversations with patients and to document them appropriately in patient records	Placement of SICG in consultation room (also attached in email reminder) Provision of documentation template in medical records system
Opportunity	External factors that make the behaviour possible or prompt it, including environmental and social influences	Structural and situational enablers that make it easier for clinicians to initiate and document SICs during routine consultations	Patient screening by coordinator Email and sticky-note reminders Pre-visit letters (for patients) Presence of SIC coordinator to prompt SIC initiation or assist with patient preparation (phase 2 only)
Motivation	Processes that energise and direct behaviour, including habitual processes, emotional responding and analytical decision-making	Internal drivers that influence clinicians’ willingness to engage patients in SICs and document appropriately	Monthly SIC engagement dashboard

SIC, serious illness conversation; SICG, Serious Illness Conversation Guide.

To reduce clinician burden, a coordinator (AN) screened clinic lists to identify suitable patients, with criteria iteratively refined based on clinician feedback. Shortlisted names and a digital copy of the locally adapted SICG were included in reminder emails sent ahead of clinic sessions. In addition to these reminder emails, the coordinator placed a printed SICG and a sticky note with the names of shortlisted patients in the consultation room before each clinic session.

Clinicians could either initiate SICs at the first clinic session following email identification of potentially eligible patients or prepare them for an SIC at subsequent visits through a pre-visit preparatory letter (online supplemental appendix S1). This letter may be distributed by the coordinator or by participating clinicians, if they prefer to do it themselves. Patients who received the letter were re-flagged in future reminders to support follow-through. In phase 2 only, the coordinator attended clinic sessions, provided real-time reminders in person, and assisted with patient preparation at the clinician’s request. The in-person prompting and support delivered by the coordinator were withdrawn in phase 3.

Clinician engagement was tracked via routine monitoring of SIC initiation and documentation. Monthly dashboards were generated, displaying both individual and aggregate data for the number of patient visits screened and highlighted by the coordinator, the number of SICs initiated and the number of SICs whose outcomes were documented. By comparing each clinician’s activity to the group average, the dashboard promoted SIC engagement as a social norm and encouraged participation through peer comparison (online supplemental appendix S2).

These implementation supports were made available to clinicians who held in-person outpatient consultations. Palliative care nurses, known as Supportive Care Nurses (SCNs) at NCCS, conducted phone-based consultations and received only a digital copy of the SICG and the documentation template. Unlike other clinicians, SCNs did not receive engagement dashboards or coordinator-provided screening and reminders, as their patient caseload was managed on a separate administrative system not accessible to the study coordinator (AN).

Data collection

AN maintained logs tracking screening decisions, recruitment outcomes, patient preparation, and clinician documentation for each SIC. All clinicians completed two Ariadne Labs instruments²⁵—the Clinician Practice Change (CPC) and Clinician Experience Survey (CES) (online supplemental appendix S3)—and participated in interviews exploring their experiences with SIC and the implementation supports. Interviews were audio-recorded, transcribed verbatim by AN and checked by S-MY for accuracy. Handwritten field notes from phase 2 consultation sit-ins were also collected by AN to verify if clinicians’ engagement of patients in SIC was appropriately documented.

Data analysis and reporting

Quantitative data (survey responses and SIC engagement figures) were summarised descriptively. To assess the impact of in-person prompting, Wilcoxon signed-rank tests were used to compare per-clinician SIC activity—defined as either introducing the conversation and providing preparatory materials or initiating the conversation during consultation—between phases 2 and 3. This non-parametric test was chosen due to the small sample size, skewed distributions, and a within-subject design. Analyses were conducted using Excel and RStudio (V.2025.05.1).

Qualitative data were analysed thematically using an applied, interpretive approach. Two researchers (AN and S-MY) independently coded transcripts and met regularly to iteratively refine a hybrid coding frame focused on clinicians’ perceptions of implementation supports, barriers to SIC engagement, and perceived value of SICs. Observational data were triangulated with interview findings to enhance credibility. Qualitative findings were reported in accordance with the Consolidated Criteria for Reporting Qualitative Research checklist (online supplemental appendix S4).²⁶

Data integration occurred at two levels. First, preliminary quantitative results informed the refinement of qualitative interview guides, ensuring the discussion addressed clinician engagement patterns and survey responses. Second, findings were integrated during the reporting phase using the RE-AIM framework: Adoption (clinician characteristics, participation and retention), Implementation and Effectiveness (experience with implementation supports), Reach (rates of SIC initiation and documentation), and Maintenance (sustainability and continuity intentions). This integrated approach allowed qualitative insights to explain the mechanisms and clinician experiences underlying the quantitative implementation outcomes. Participant identities were masked using alphanumeric study identifiers.

Results

Clinician characteristics (Adoption)

Eleven clinicians were recruited from three specialties: cardiology (n=2), medical oncology (n=4), and palliative medicine (n=5). Six were female, five of whom worked in palliative medicine. The palliative group comprised two physicians and three SCNs, one of whom (St05) is an Advanced Practice Nurse (APN) who conducted fortnightly outpatient clinics. The other two SCNs (St07, St08) engaged patients primarily through supportive care phone calls and did not lead or attend clinics independently. The participants’ clinical backgrounds are presented in table 2.

Table 2. Clinician participants’ characteristics.

Study ID	Gender	Specialty	Profession	Years of clinical experience
St01	M	Medical oncology	Doctor	10
St02	F	Palliative medicine	Doctor	20
St03	F	Medical oncology	Doctor	16
St04	M	Medical oncology	Doctor	15
St05	F	Palliative medicine	Nurse	25
St06	M	Medical oncology	Doctor	25
St07	F	Palliative medicine	Nurse	18
St08	F	Palliative medicine	Nurse	9
St09	M	Cardiology	Doctor	22
St10	F	Palliative medicine	Doctor	17
St11	M	Cardiology	Doctor	19

Participation in the pilot was by invitation and limited to these clinicians, yielding a 100% acceptance rate. However, by the end of the second month of phase 2, St09 effectively withdrew from the pilot, citing concerns about time constraints and the relative stability of his patients’ conditions. This yielded a clinician retention rate of 91% (n=10/11).

Clinician perceptions of support provided (Experience/Effectiveness and Implementation)

General perceptions of implementation support

Responses from the CES and CPC survey affirmed the utility of the implementation supports in facilitating SIC initiation. Most clinicians agreed or strongly agreed (n=9) that they felt ‘adequately supported to have serious illness conversations with patients (or surrogates) in (their) clinical practice’ (table 3). Further, the programme was largely deemed acceptable, as reflected in clinician satisfaction and endorsement, with 90.9% (n=10) reporting increased satisfaction with their role in patient care, and 100% (n=11) indicating they were likely to recommend the initiation of SICs to colleagues (table 3). (For additional results, see online supplemental appendix S5.)

Table 3. Results from CES and CPC (n=11).

Instrument	Survey item	Options	n (%)
CES	I feel adequately supported to have serious illness conversations with patients (or surrogates) in my clinical practice	Strongly agree	2 (18.2)
		Agree	7 (63.6)
		Disagree	2 (18.2)
		Strongly disagree	0 (0)
	When I finish the discussion using the Serious Illness Conversation Guide, I think the conversation made my patient’s emotional state …	Much better	1 (9.1)
		Slightly better	9 (81.8)
		Slightly worse	0 (0)
		Much worse	1 (9.1)
	Overall, how much did your discussion of these issues with your patient increase or decrease your satisfaction with your role in your patient’s care?	Greatly increased	8 (72.7)
		Slightly increased	2 (18.2)
		Slightly decreased	1 (9.1)
		Greatly decreased	0 (0)
CPC	How likely are you to recommend the use of the Serious Illness Conversation Guide to a friend or colleague? (on a scale from 0 to 10, with 10 representing ‘Very likely’)	0–6 (not likely)	0 (0)
		7–8 (neutrally likely)	8 (72.7)
		9–10 (very likely)	3 (27.3)
	How many serious illness conversations have you documented in SCM since your training?	1	1 (9.1)
		2	0 (0)
		3	3 (27.3)
		More than 3	7 (63.6)
		0, I have not had any yet	0 (0)
		0, I have had conversations, but I have not documented them	0 (0)

CES, Clinician Experience Survey; CPC, Clinician Practice Change; SCM, Sunrise Clinical Manager (Electronic Health Record system).

Those who expressed disagreement with the adequacy of support cited different concerns in their interviews. St01, an oncologist, emphasised the need for broader institutional support to create an enabling environment:

It has to come down from the leaders … whether it’s for more resources and have more of yourselves [coordinators] participating in this conversation, helping to facilitate it, or whether it’s by pushing the tech to improve … I think they have to be the ones driving this effort. It can’t be just a few of us doing this.

St11, a cardiologist, identified a need for enhanced instructional support, such as “a video showing how to do a good SIC’ or opportunities to observe “a palliative consultant or a very experienced person having an SIC with patients.” Despite the gaps identified, both were highly engaged in the pilot and valued tools like the SICG and physical reminders. Their feedback suggested that while additional system-level support was desired, the provided measures were broadly acceptable and perceived as helpful.

The following sections describe interview findings on clinician experiences with implementation supports in greater detail.

Measures prompting SIC initiation

Three types of clinician prompts were implemented in this pilot: email reminders, sticky notes, and in-person prompting. Emails were generally perceived to be less effective than sticky notes, as they were easily overlooked amidst the high volume of correspondence clinicians received. Competing demands and time constraints during clinics also limited their ability to access and act on these reminders. Nonetheless, some clinicians reported that email reminders were helpful in alerting them to the attendance of prospective SIC candidates and, when time permitted, prompting them to review the clinical notes of shortlisted patients.

Sticky notes, by contrast, served as a more timely and visually salient trigger, especially for clinicians unable to review emails before consultations. Observational field notes corroborated their utility, with clinicians seen reading and even annotating sticky notes before or during their clinic sessions.

In-person prompting during phase 2 elicited mixed reviews. Most clinicians claimed that the coordinator’s presence did not alert or motivate them to initiate an SIC, given that they were used to sit-ins and attachments from medical students, residents, and other healthcare professionals. Palliative care clinicians, in particular, considered SICs closely related to, if not synonymous with, the care planning discussions they routinely conducted with their patients, rendering in-person prompting unnecessary. Only St01 and St04 perceived in-person prompting as useful, with the latter reporting a sense of urgency to initiate discussions when the coordinator was present:

I tend to have more SIC if I see you, because I feel pressure—‘I must have SIC!’ And then when you’re not present, if I’m very busy, then I’m like, ‘No, I cannot have SIC, I need to move on!’

These findings suggest that while all three prompting strategies had value, their effectiveness varied depending on individual habits, clinical workloads, and disciplinary/specialty-specific practices. Email reminders were most meaningful to those who routinely reviewed them in advance, whereas sticky notes and in-person prompting were more effective as in-the-moment triggers.

Patient preparation

Throughout the pilot, clinicians were encouraged—through reminder emails and in-person prompting in phase 2 and reminder emails only in phase 3—to nominate patients to receive a preparatory letter designed to facilitate SIC engagement (online supplemental appendix S1). However, uptake of this implementation support was limited. There were common concerns about patients’ emotional readiness, and only two oncologists (St01, St03) viewed preparation as helpful for facilitating SICs.

As the sole practitioner of self-initiated patient preparation, St01 maintained his own stash of preparatory letters and distributed them directly to patients he deemed suitable for initiation—sometimes including patients outside the shortlist. He noted its instrumentality in scaffolding conversations:

Once they give me that [written reflections]—of course it’s just a few lines—I will just go through each line, try to expand it a little bit more, and just try to see if I can squeeze out a bit more information to guide the conversation.

Others occasionally identified patients for the coordinator’s intervention during phase 2, but by phase 3, with the withdrawal of in-person support, the distribution of preparatory materials effectively ceased.

These patterns of (dis)engagement suggest that coordinator-facilitated patient preparation was not perceived as helpful by clinicians, likely due to two factors. First, specialty-specific scheduling influenced perceived utility: oncologists cited regular follow-ups as natural preparation points, whereas longer intervals in cardiology and palliative care reduced the timeliness of preparatory materials. Second, although distribution was mostly managed by the coordinator, the additional task of identifying patients may have added to clinicians’ cognitive load and may have been perceived as extraneous to the routine workflow.

Provision of SICG

Clinicians expressed strong support for the SICG as an implementation support. All respondents either agreed or strongly agreed with CES statements, indicating that the Guide helped them gather important information, was easy to use, facilitated understanding of patients’ values and goals, enhanced clinical care and supported the development of trust within the clinician–patient relationship (online supplemental appendix S5). Only two participants (St10, St11) disagreed that it could be completed within an appropriate amount of time, but both, like others, adapted it by selectively raising questions relevant to each patient.

Most clinicians did not refer to the Guide directly during conversations, but were observed referring to it before consultations for a brief refresher. St04, an oncologist, was an exception; he read from the Guide during consultations, an approach which opened multiple lines of inquiry but occasionally led to hurried exchanges and confusion due to time constraints. For others, the Guide served as a flexible prompt. St11, a cardiologist, found reassurance in being able to “take a quick peek” at the Guide when he needed conversational direction. Even experienced palliative care clinicians, like St02, valued it as a menu of prompts to identify gaps in prior discussions.

The Guide also functioned as a strategic resource. St10, a palliative physician who found its phrasing was misaligned with her communication style, considered it a useful ‘scapegoat’ for broaching emotionally difficult topics:

If the question sounds harsh, then you can blame it on the Guide, so then the relationship with the patient [is preserved].

In sum, clinicians used the SICG variably—for preparation, guidance, assurance and relationship preservation—highlighting its adaptability as an implementation support within the SICP.

SIC documentation template

To facilitate documentation, a structured SIC template was embedded in the electronic health records (EHR), mirroring the SICG’s sequence and content. However, most clinicians preferred their usual documentation methods, citing workflow disruptions and the burden of duplicative data entry. St04’s feedback captured this sentiment:

Oftentimes I am already trying to type in one clin doc [clinical documentation] note already. If I have to save and then type in another clin doc … Ya, good idea but I don’t like to do more clinical documentation.

Despite regular reminders, SIC discussion outcomes were documented using the structured template for only 24 of 101 patients, half of which were submitted by nurses (including St05), with the rest authored by two physicians—St01 (n=7) and St02 (n=5). The use of the structured template seemed to be motivated by a felt responsibility among these clinicians to communicate SIC outcomes to the wider care team, as exemplified by St01’s reflections on his challenges in faithfully representing his patients’ values in terms that are meaningful to other providers:

How to sentence it in a way that is understandable for other healthcare professionals involved in her care, and how to distil what she’s [a patient] saying?

In contrast, primary physicians considered documenting SIC discussion findings in their consultation notes as sufficient, sometimes entering only brief phrases (e.g., “[SICP] volunteering to do good deeds, go on holidays”) meant as personal memory aids rather than communicative tools.

The consequences of fragmented documentation were evident in one case: a patient had SICs with both St11 and St04, but the latter was unaware of the prior conversation, as it was documented only in the former’s clinical notes. This led to an avoidable repetition and a missed opportunity to build on prior discussions.

SIC Engagement Dashboard

Clinicians’ responses to the SIC Engagement Dashboard were mixed. Among the nine clinicians who held outpatient consultations (St07 and St08 excluded), several expressed disengagement for different reasons: St11 cited time constraints; St09 (cardiologist) voiced a general aversion to dashboards and the use of extrinsic motivators; St05 (palliative medicine) questioned its relevance given her low clinic caseload; St03 (oncologist) critiqued its inability to reflect patient readiness for SIC.

Others, however, viewed the dashboard favourably, noting its usefulness in prompting SIC engagement. St04 appreciated the benchmarking aspect:

It kind of matches me up with my colleagues, so I know when I’m lagging behind. So it’s sort of like a gamification thing.

Similarly, St01 reflected on its role as an audit-and-feedback tool:

Once I see I didn’t do so well, … I panic a little bit myself. I just gave myself a mental nudge and reminder: ‘Okay this month, I gotta try to do a little bit more’, and then when the nudges and reminders come, ‘I must take them more seriously’.

Even among clinicians less responsive to competition, the dashboard signalled collective effort and encouraged sustained engagement. As St10 explained:

It’s more like: ‘Oh, good, good, there are people doing it’. … so you know there are more people sharing your same views.

SIC engagement levels (Reach)

Between December 2024 and May 2025, a total of 1764 patient visits were screened for SIC eligibility. Of these, 385 visits (corresponding to 278 patients) were raised to clinicians for potential SIC initiation. Across the pilot period, 33 patients received preparatory materials from either the coordinator or their clinician, of whom 19 participated in an SIC with their clinician during the study period.

In total, 101 patients had at least one SIC with their clinician, two of whom had SICs with two different participating clinicians. Of those, 82 had discussion outcomes documented, but only 24 had a dedicated SIC clinical note (23.8% of patients who had an SIC and 8.6% of patients potentially eligible for an SIC with clinician). Figure 1 visualises the changes in engagement figures across different stages.

Figure 1. Flowchart of engagement figures. SIC, serious illness conversation.

Key characteristics of the patients are presented in table 4. A total of 101 patients participated in at least one SIC during the pilot. Most were aged 60 and above (n=68) and male (n=58). The majority were Chinese (n=73), with smaller proportions identifying as Malay (n=13), Indian (n=8) or other ethnicities (n=7). Two-thirds (n=66) had a cancer diagnosis, most commonly breast (n=17), haematological (n=11), and genitourinary cancers (n=9), while the remainder had heart failure. Among patients with cancer, nearly 90% were at stage IV (n=59). Most heart failure patients were classified as stage C (n=29).

Table 4. Characteristics of patients who had an SIC with their clinician (n=101).

Characteristic	n
Age group
<40	4
40–59	29
60–69	27
>70	41
Sex
Female	43
Male	58
Ethnicity
Chinese	73
Malay	13
Indian	8
Other	7
Primary diagnosis
Cancer	66
Breast	17
Haematological (lymphoma, myelodysplastic syndrome)	11
Genitourinary (kidney, prostate, bladder)	9
Lung	9
GI (colorectal, gastric, pancreatic)	9
Melanoma and sarcoma	6
Head and neck (thyroid, nasopharynx)	3
Gynaecological (cervix, ovary)	2
Heart failure	36
Disease stage (cancer)
III	6
IV	59
Disease stage (heart failure)
C	29
D	7
Had SIC with …
Cardiologist	34
Oncologist	34
Palliative med physician	19
Supportive Care Nurse (SCN)	12
Palliative med physician and SCN	1
Cardiologist and oncologist	1

GI, gastrointestinal; SIC, serious illness conversation.

Of the 222 visits flagged for potential SIC initiation during phase 2, clinicians excluded 71 (32.0%), and their reasons for exclusion are presented in table 5. These clinician-specific judgements, shaped by perceived patient readiness and timing, contributed to variation in intervention reach between individual clinicians and specialties. Rather than indicating implementation failure, such variation suggests that some patient groups may require complementary approaches to facilitate SIC engagement in routine outpatient care.

Table 5. Reasons for exclusion from SIC engagement (number of visits: 71).

Reason provided by clinician	n (%)
Patient is well or responding to treatment	21 (29.6)
Patient has had goals-of-care/serious illness conversation before	11 (15.5)
Not a good time for SIC (e.g., patient is mid-treatment, emotionally unprepared for SIC)	11 (15.5)
No time for discussion	6 (8.5)
Communication barriers (e.g., language barriers, uncommunicative)	6 (8.5)
Patient is highly anxious	4 (5.6)
Lack of rapport	4 (5.6)
Other healthcare providers are better placed to engage patient in an SIC (e.g., home palliative care providers, renal team)	3 (4.2)
Patient is on curative treatment	2 (2.8)
Patient is receiving treatment overseas	1 (1.4)
Collusion in the family/patient is not aware of their diagnosis	1 (1.4)
Patient has an undiagnosed cognitive impairment	1 (1.4)

SIC, serious illness conversation.

Labour and sustainability of providing implementation supports (Maintenance)

In phase 2, the coordinator dedicated approximately four days per week to delivering the implementation supports. Weekly tasks included clinic list screening (~7 hours), drafting and sending reminder emails, distributing preparatory materials, in-person prompting of clinicians (~24 hours), and back-end documentation tracking and dashboard preparation (~2 hours). This support extended to 10 outpatient clinic sessions, with the APN clinic (led by St05) excluded from this analysis due to its low caseload.

In phase 3, total time required decreased significantly to ~8 hours per week—less than one workday—due to the phasing out of in-person support and a reduction in screening time (~5 hours). The latter was attributed to the increasing proportion of repeat follow-up visits, resulting in fewer unscreened notes. This represents a 75.8% reduction in overall time commitment compared with phase 2, with further scope for optimisation through automated EHR-integrated, algorithm-based reminders.²⁷

Transitioning into phase 3, we observed no statistically significant differences in clinician SIC engagement activity (SIC initiation and/or provision of preparatory materials) for the group at an aggregate level. Activity levels and rates, however, fell more sharply for all non-palliative care clinicians relative to the decline in the number of visits flagged. A subset analysis for non-palliative care clinicians using Wilcoxon signed-rank tests indicated a statistically non-significant difference in the number of visits flagged between phases 2 and 3 but nearly statistically significant differences for clinician-level activity counts (p=0.0579) and activity rates (ie, activity as a proportion of visits flagged) (p=0.0625), where statistical significance is defined with an alpha of 0.05 (supporting details in online supplemental appendix S6). In-person reminders and coordinator-provided support were not extended to the two SCNs (St07 and St08) who delivered care by phone due to workflow incompatibilities. Nonetheless, despite two major periods of system downtime (December 2024 and May 2025), these nurses conducted SICs with 10 patients, outperforming some physicians. This highlights the potential for expanding SIC delivery at minimal cost by empowering nurses and, potentially, other allied health professionals, to lead SIC engagement efforts.

Continuity intentions among clinicians (Maintenance)

While long-term outcomes were not directly assessed, clinician reflections offered insight into the sustainability of SIC engagement. Oncologists and palliative care clinicians, including SCNs, expressed strong intentions to continue incorporating SICs into routine practice. These clinicians highlighted the value of SICs in aligning care goals, strengthening therapeutic relationships, supporting complex decisions, and enhancing patient well-being, describing the conversations as “meaningful”, “fulfilling”, and “rewarding”. Their positive appraisal, along with favourable views of the implementation supports, suggests that long-term integration of SIC into oncology and palliative care is both feasible and appropriate.

In contrast, both cardiologists expressed reservations about the suitability of SIC within outpatient workflows. Both viewed the inpatient setting as more conducive, citing limited consultation time and perceived patient unreadiness as key barriers in the outpatient context. Notably, despite being the most consistently proactive in initiating SICs during the pilot, St11 reported through the CES that these discussions left patients “much worse” and slightly diminished his own sense of professional satisfaction (see table 3). His continued engagement, he noted, stemmed from a personal commitment to support the study team. Outside the context of a pilot, sustaining SIC engagement in cardiology may prove difficult without further adaptation, structural changes, or clinician support.

Integrated findings

The integration of survey metrics, study logs and interview data (table 6) reveals distinct implementation profiles that clarify the mechanisms of the coordinator-facilitated SICP.

Table 6. Joint display of quantitative and qualitative results.

		CES	Study logs	Interview data		Meta-inference
Specialty	ID	Perceived support: ”I feel adequately supported …”	Engagement trend (phase 2 vs phase 3 activity rates)*	Primary implementation supports enabling engagement	Additional support desired
Medical oncology	St01	Disagree	Decreased—57.1% (16/28 visits) vs 40.5% (15/37 visits)	In-person prompting by coordinator Patient preparatory materials Provision of documentation template Engagement dashboard	Institutional support and recognition of clinician efforts in SIC initiation Streamlined documentation procedures	Engagement declined upon withdrawal of in-person prompting, suggesting a role for in-person prompting in raising the salience of SIC engagement Systems-level integration of SIC into routine workflows is desired to sustain clinician engagement in SIC
	St04	Agree	Decreased—68.0% (17/25 visits) vs 20.0% (4/20 visits)	In-person prompting by coordinator Provision of physical copy of SICG Engagement dashboard	Streamlined documentation procedures
	St03	Agree	Decreased—15.8% (6/38 visits) vs 11.1% (3/27 visits)	Coordinator-led screening and sticky-note reminders Provision of physical copy of SICG	Streamlined documentation procedures	Neither deemed in-person prompting by coordinator important/ relevant to their clinical practice Decrease in engagement may reflect intervention fatigue, patient pool saturation or unconscious effects of being observed on clinician behaviours (Hawthorne effect)
	St06	Agree	Decreased—11.4% (4/35 visits) vs 5.6% (1/18 visits)	Coordinator-led screening and sticky-note reminders Provision of physical copy of SICG	Coordinator-initiated patient preparation
Cardiology	St09	Agree	N.A.—withdrew during phase 2	Coordinator-led screening and email reminders	Shifting SICP implementation to inpatient context	Despite differences in adoption and engagement trends, both cardiologists identified setting fit as a major barrier to SIC initiation For St11, engagement was potentially driven more by altruism (personal commitment to support research team) than the effectiveness of the implementation supports
	St11	Disagree	Decreased—62.5% (20/32 visits) vs 51.9% (14/27 visits)	Coordinator-led screening and sticky-note reminders Provision of physical copy of SICG	Continuing education and instructional guidance on SIC facilitation micro-skills Shifting SICP implementation to inpatient context
Palliative medicine	St02	Agree	Increased—27.3% (6/22 visits) vs 33.3% (6/18 visits)	Coordinator-led screening and sticky-note reminders Provision of documentation template	Streamlined documentation procedures	Increased engagement following the withdrawal of prompting corroborates clinicians’ claims that SIC is already embedded in palliative care practice Implementation measures served as adjunctive tools that refined targeting and fostered a sense of professional community, rather than acting as essential drivers of engagement
	St05	Strongly agree	Increased—0.0% (0/3 visits) vs 42.9% (3/7 visits)	Coordinator-led screening and email reminders Provision of physical copy of SICG	NIL
	St10	Agree	Increased—40.0% (6/15 visits) vs 46.7% (7/15 visits)	Provision of physical copy of SICG Coordinator-led screening and sticky-note reminders Engagement Dashboard	Streamlined documentation procedures
Palliative medicine (SCNs)	St07	Agree	N.A. (due to workflow incompatibilities, SCNs were not supported by coordinator-led screening and reminders)	Access to digital copy of SICG Provision of documentation template	NIL	High acceptability and sustained engagement underscore a strong role fit and high structural feasibility for SCNs, especially considering the limited coordinator-provided support
	St08	Strongly agree		Provision of documentation template	NIL

^*Activity rate is defined as activity as a proportion of visits flagged, with activity referring to the provision of preparatory materials to and/or initiation of SIC with a patient.

CES, Clinician Experience Survey; SCNs, Supportive Care Nurses; SIC, serious illness conversation; SICG, Serious Illness Conversation Guide; SICP, Serious Illness Care Programme.

In medical oncology and cardiology, engagement trends suggest a strong dependency on active prompting and coordination, as the withdrawal of in-person prompting in phase 3 was concomitant with a universal decline in activity rates, irrespective of the participants’ views of the implementation support. While clinicians may indeed be used to having observers in their clinic, awareness of being observed may have unconsciously encouraged patient engagement. At the same time, it is possible that the coordinator’s absence in phase 3 made patient preparation appear more effortful and the task of SIC initiation more prone to being forgotten. In time-pressured, high-caseload outpatient settings, the presence and support of the coordinator may nonetheless be useful in mitigating some processual frictions and motivating patient engagement.

Conversely, palliative medicine clinicians (St02, St05, St10) demonstrated sustained engagement despite the withdrawal of in-person support and prompting. The joint analysis confirms their qualitative claims that SIC is already embedded within their routine practice; for these specialists, the implementation supports functioned as adjunct tools. In stark contrast to the palliative medicine clinicians’ engagement profiles, the cardiologists approached the task of SIC initiation with hesitation and considered it to be at odds with the communication conventions in the outpatient setting. This was evidenced by St09’s withdrawal after a single engagement and St11’s concerns regarding the potential for patient distress, highlighting a misalignment between the intervention and existing specialty norms.

The SCNs’ profile reflected a unique intersection of high role fit and structural resilience. Despite the absence of coordinator-led screening and reminders, St07 and St08 reported high perceived support and maintained consistent engagement. This suggests that the SCN role—characterised by dedicated time for telephone-based consultations—lends well to patient engagement in SIC.

Discussion

This pilot study evaluated the feasibility of implementing a coordinator-facilitated SICP in outpatient oncology, cardiology, and palliative medicine settings. Clinicians generally viewed the implementation supports favourably, particularly appreciating reminders and ready access to the SICG. Challenges encountered with patient preparation and structured documentation highlight the potential value of technology-enabled documentation tools and upstream patient preparation in exploring and discussing their goals of care.

The pilot established feasibility based on two qualitative indicators: high perceived support and a viable effort-to-benefit ratio. Regarding the first condition, over 80% of clinicians felt adequately supported. Instances of perceived inadequacy highlighted systemic rather than programme gaps, such as St01’s call for broader institutional recognition and St11’s concerns regarding clinical distress in stable cardiology patients, which suggest a need for enhanced instructional scaffolding and setting-specific adaptations.

Regarding the second condition of proportionality, the transition from phase 2 to phase 3 demonstrated that a coordinator’s time commitment could be reduced by 75% once initial workflows are established, theoretically allowing a single coordinator to support up to 50 clinics weekly. However, the data suggest that feasibility is maximised through a tiered implementation strategy: oncology clinics may require a prolonged 6-month period of in-person coordination to integrate and routinise SIC engagement, whereas palliative medicine requires only adjunctive support. Conversely, the significant challenges encountered in outpatient cardiology suggest that future feasibility evaluations should pivot toward inpatient settings, where clinical triggers may better align with perceived patient needs.

This implementation differed in several important respects from previous SICP rollouts. Unlike earlier models that included formal clinician training and systematic distribution of preparatory and family materials,^{25 28 29} this pilot omitted training—given that participants were already trained—and took a clinician-led approach to patient preparation. Pre-pilot testing also revealed patient and caregiver aversion to receiving take-home resources, leading to the omission of a Family Guide.²⁸ Most notably, patient identification was coordinator-led and iteratively adapted to clinician preferences,^{30 31} thereby reducing clinician burden and extending programme reach.

The study’s strengths include its inclusion of diverse specialties and delivery modes (in-person and telephone), as well as its detailed documentation and triangulated analysis. Limitations include the small, non-random sample, and a relatively short duration of follow-up, which restricts the generalisability of study findings. In the absence of a control arm, our claims are limited to the feasibility and not the efficacy of the implementation supports in facilitating SIC initiation and documentation. Further, while the CPC and CES instruments from Ariadne Labs were used to enable comparisons with other SICP evaluations, they primarily assess experiences with the SICG (see online supplemental appendix S3), and thus did not fully capture the perceived utility of the broader suite of implementation supports introduced in this pilot. This limitation was partially addressed through follow-up interviews, which allowed for a more granular exploration of clinician experiences with each support.

Future research should focus on developing and testing strategies for streamlining documentation, identifying SIC-eligible patients, and alternative models of SIC delivery, such as nurse- or coordinator-led approaches. Longitudinal studies assessing patient-centred outcomes, including emotional well-being and goal-concordant care, will be essential to determine the broader impact of SICP implementation.

Conclusion

This is the first study to evaluate the feasibility of the SICP in an Asian context, offering practical insights into how the programme can be adapted to align with local clinical workflows and health system structures. The study demonstrates that a coordinator-facilitated model is feasible in outpatient oncology and palliative medicine settings, with feasibility established through high levels of perceived acceptability and adequacy of programme-level support, as well as a viable effort-to-benefit ratio. However, the suitability of SICP for the outpatient cardiology setting remains uncertain, warranting further adaptation and inpatient evaluation. Future implementations could move beyond the use of individual-level supports towards institutionalising changes at a larger scale, promoting professional recognition of clinician engagement in SICs, and involving other healthcare professionals in facilitating SICs.

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.