Key Points
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Delivery of the inpatient SICP by advanced practitioners and hematology/oncology fellows was feasible.
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The number of advance directives completed within 1 year after the SICP visit increased.
Visual Abstract
Abstract
The Serious Illness Care Program (SICP) is an evidence-based intervention designed to systemically implement serious illness conversations (SICs) into clinical practice. We previously piloted the SICP via telehealth for patients in the ambulatory setting. However, many patients with hematologic malignancies experience frequent hospitalizations, providing a key opportunity to conduct SICs in the inpatient setting. The purpose of this study was to assess the feasibility of an inpatient SICP and describe completion of advance directives and SIC documentation after SICP implementation. This was a single-arm pilot study including patients aged ≥60 years with hematologic malignancies and their caregivers. Clinicians (advanced practitioners; hematology/oncology fellows) completed a 2- to 3-hour virtual training on the SICP. The primary outcome was feasibility (retention rate: percentage of consented patients who completed the SICP visit, with >70% considered feasible). Secondary outcomes were advance directive completion (Health Care Proxy [HCP] and Medical Orders for Life-Sustaining Treatment [MOLST]) and documentation. We also collected data on advance care planning (ACP) engagement and disease understanding. We included 41 patients (mean age, 68 years), 24 caregivers, and 22 clinicians; 38 SICP visits were completed (retention rate of 92.7%). The number of HCP and MOLST forms completed increased from 23 to 31 and from 7 to 20 within 1 year of the SICP visits, respectively. All SICP visits were documented. ACP engagement numerically increased (P = .24), and patients found the intervention to be acceptable. Patient estimates of life expectancy may have shifted after the SICP visit. The inpatient SICP was feasible, with potential increase in advance directive completion. This trial was registered at www.clinicaltrials.gov as #NCT05433090.
Introduction
Serious illness conversations (SICs) aim to elicit patient preferences for current and future care, including care at the end of life (EOL).1,2 SICs are especially important for older patients with hematologic malignancies, who often experience high intensity care at the EOL, including high rates of hospitalization and inpatient mortality at the EOL.3, 4, 5 Nonetheless, relatively few patients with hematologic malignancies are referred to palliative care or enroll in hospice before death, and when hospice enrollment does occur, it is often late in the disease course.3,4,6 Whether the intensity of EOL care received by patients with hematologic malignancies is concordant with their goals and values remains unclear. Previous work has found that older adults with hematologic malignancies have variable values when it comes to treatment and their wishes for EOL, but most still die in the hospital.6,7 SICs are infrequently conducted early in the disease course.8 Furthermore, even if SICs occur, documentation of patients' EOL preferences is inconsistent, and not all patients have advance directive forms readily available or completed.9,10
The Serious Illness Care Program (SICP) is an evidence-based intervention designed to systemically implement SICs into clinical practice.11, 12, 13 However, there is no established gold standard regarding the optimal setting for conducting SICs among patients with hematologic malignancies. Previous work suggests that outpatient SICs conducted while patients are clinically stable may be beneficial, particularly because many older patients are receiving their care in the ambulatory setting. Nonetheless, outpatient implementation is often constrained by busy clinic workflows and limited visit time.8,14, 15, 16 Given these challenges, the inpatient setting represents a reasonable and complementary context for delivering SICs alongside ambulatory care. Patients with hematologic malignancies frequently use inpatient services, either for cancer-directed treatments or for management of associated complications.17 Previous studies demonstrate that many SICs currently occur during hospitalization but often late in the disease course, near the EOL, and in the context of high-intensity, life-sustaining care.6,8 Conducting SICs earlier during inpatient admissions may help shift these discussions upstream, rather than deferring them until immediately before death. The inpatient setting also offers several practical advantages for SIC implementation. Hospitalization provides greater flexibility in scheduling conversations with patients, caregivers, and interdisciplinary clinicians. Admissions for treatment-related complications are frequently accompanied by changes in clinical status, which may serve as appropriate inflection points to reassess patient values, goals, and preferences. In addition, inpatient care allows for close follow-up after SICs to address emerging questions and facilitate completion of advance care planning (ACP) documentation when appropriate.
In the inpatient setting in academic medical centers, advanced practice providers (APPs) and hematology-oncology fellows play a crucial role. They serve as the primary clinicians for many hospitalized patients, working closely with attending physicians. Previous research suggests that APP-initiated SICs can enhance patients' understanding of their values and increase the completion of advance directives.18 Despite their brief relationships with hospitalized patients, APPs and hematology-oncology fellows may offer particular benefits in conducting SICs compared with the patients' primary oncologists. Their involvement provides a fresh perspective on the patient's care and allows for an unbiased exploration of the patient's concerns and values.
We previously conducted a single-arm pilot study of the SICP delivered via telehealth in the outpatient setting.19 The SICP deepened relationships and enhanced trust between clinicians and their patients, and required uninterrupted, unrushed time for optimization.20 Therefore, we sought to understand whether the inpatient setting would be a useful location to optimize SICs. To our knowledge, the SICP has not been delivered in the inpatient setting specifically for patients with hematologic malignancies. The aim of this study was to assess the feasibility of an inpatient SICP and describe SIC documentation and completion of advance directives after SICP. We hypothesized that SICP delivery would be feasible in the inpatient setting and that the number of advance directives completed would increase within 1 year after the SICP.
Methods
Study design, population, and setting
We recruited patients, caregivers, and clinicians from November 2022 to October 2024. Eligibility criteria for patients were (1) age of ≥60 years, (2) a diagnosis of a hematologic malignancy, (3) ability to provide informed consent, (4) being managed in the inpatient setting, and (5) English speaking (the SICP is written in English). Eligibility criteria for caregivers were (1) age of ≥18 years, (2) selection by the patient when asked if there is a “family member, partner, friend, or caregiver with whom you discuss or who can be helpful in health-related matters,” (3) ability to provide informed consent, and (4) English speaking. Eligibility criteria for clinicians were (1) APP on the inpatient malignant hematology service (including both physician assistants and nurse practitioners), or (2) hematology-oncology fellows. This study was conducted in accordance with the Declaration of Helsinki.
Study procedure and data collection
The inpatient hematologic malignancy service list was screened daily by the study team for eligible patients. Patient eligibility was confirmed by the principal investigator. The primary outpatient oncologist for the patient provided permission to approach. The primary inpatient oncologist for the patient and the APP/fellow teams were notified of patient eligibility and that approach for consent would take place. The study team worked closely with APP/fellow teams to approach patients whose discharge was not anticipated to be imminent and who were clinically stable enough to participate in an SIC. APP and fellow workload as well as patient census were also considered before approaching patients. Eligible patients were then approached in person by the study team, and patients completed baseline measures (demographics and cancer health literacy).21 The study team extracted clinical characteristics from the electronic medical record (EMR). The study team then asked patients if they had a caregiver that they would like to be invited to participate in the study. If the patient responded, “yes,” the study team then approached the caregiver(s) and completed baseline measures (demographics). During the same hospital admission, clinicians conducted a 15- to 30-minute audio-recorded SICP visit with the patient (and caregivers, if applicable) in the patient’s hospital room. After the SICP visit, patients (and caregivers, if applicable) completed postintervention surveys and participated in an audio-recorded semistructured interview with the study team to elicit feedback on the experience. Postintervention surveys and interviews took place within 1 month of the SICP visit. Audio-recorded semistructured interviews were transcribed verbatim by a professional service and analyzed using MAXQDA software (VERBI Software GmbH).
Intervention description: inpatient SICP
The inpatient SICP includes previsit materials, a SICP visit with a clinician, and postvisit materials.11,12,14 We conducted 3 focus groups with APPs to adapt the SICP materials specifically to the inpatient setting before enrolling patients. Previsit materials included (1) a geriatric assessment (measures of physical, nutritional, psychological, and cognitive functions) completed by the study team and provided to the clinician before the SICP visit, and (2) the patient preparation pamphlet. The geriatric assessment offers a holistic understanding of the patient’s health status, which is important for aligning care with the patient’s goals. The patient preparation pamphlet provides patients with expectations for the SICP visit, including questions to think about before talking with their clinician. Postvisit materials included (1) a family guide and (2) an EMR template. The family guide provides patients with language to continue to talk about their care preferences with loved ones after the SICP visit. The EMR template allows clinicians to document the SICP visit in the patient’s chart. During the SICP visit, clinicians used the SIC guide, a printed script, to systematically elicit the patient’s understanding of their illness/treatment plan and to identify their preferences for current and future care, including preferences around life-sustaining treatments. Clinicians underwent a virtual 2- to 3-hour training on how to use the SIC guide for this study.
Geriatric assessment
The geriatric assessment included measures of physical, nutritional, psychological, and cognitive functions. Physical function was assessed using 3 questionnaires: (1) Katz Index of Independence in Activities of Daily Living (ADL),22 (2) Instrumental Activities of Daily Living subscale of the Multidimensional Functional Assessment Questionnaire: Older American Resources and Services,23 and (3) a self-reported history of falls in the past year. The Katz Index of ADLs is a 6-item questionnaire in which patients score “yes”/“no” for independence in 6 domains (bathing, dressing, toileting, transferring, continence, and feeding).22 The Instrumental Activities of Daily Living subscale is a 7-item questionnaire in which patients score “yes”/“mostly”/“no” for independence in 7 domains (using the telephone, getting to places out of walking distance, going shopping, preparing meals, doing housework, taking medications, and handling money).23 Nutrition was assessed using self-reported weight loss in the past 6 months and body mass index. Psychological health was assessed using the Geriatric Depression Scale-15, a 15-item screening instrument for depressive symptoms in older adults (range 0-15; higher score means more severe depression).24 Cognition was assessed using the Mini-Cog, a brief screening test used to evaluate cognition in older adults.25
Measures
Primary outcome
FEASIBILITY
Feasibility was assessed using retention rate (ie, percentage of consented patients who completed the visit). A retention rate of >70% was considered feasible.
Secondary outcomes
ADVANCE DIRECTIVE COMPLETION
We assessed completion of advance directives following SICP within 1 year after the visit. Advance directives included Medical Orders for Life-Sustaining Treatment (MOLST) and Health Care Proxy (HCP) forms that were scanned into the patients' EMRs.
EMR DOCUMENTATION
We collected data regarding use of the EMR documentation template that was provided to clinicians as part of the SICP.
Other outcomes
DISEASE UNDERSTANDING (PATIENTS ONLY)
Disease understanding was assessed using a 5-item questionnaire that assessed the patient’s prognostic understanding of their illness, including the patient’s estimate of the curability of their cancer and their life expectancy.26 This was completed at baseline and after intervention.
ACP ENGAGEMENT (PATIENTS ONLY)
ACP engagement was evaluated using a 15-item questionnaire that assessed the patient’s readiness and self-efficacy to identify a medical decision-maker, share their personal values, and discuss these topics with their physician (range 1-5; higher score is better).27 This was completed at baseline and after intervention.
ACCEPTABILITY (PATIENTS, CAREGIVERS, AND CLINICIANS)
Acceptability of the SICP was assessed by all study participants using the acceptability survey (Figure 2., Figure 3., Figure 4.). For patients and caregivers, this was a 23-item questionnaire to assess how helpful the questions asked at the SICP visit were and how helpful the overall visit was for patients and their caregivers.11,12 For clinicians, this was an 11-item questionnaire to assess the ease with which clinicians could implement the SICP and how helpful the SICP visit was for clinicians in caring for their patients.11,12 This was completed after intervention only.
Figure 2.
Patient acceptability of SICP. N/A, not applicable.
Figure 3.
Caregiver acceptability of SICP. N/A, not applicable.
Figure 4.
Clinician acceptability of SICP.
Data analysis
Quantitative
We used descriptive statistics to summarize demographic information for patients, caregivers, and clinicians, as well as patient clinical characteristics and geriatric assessment at baseline. We also described patient completion of advance directives within 1 year of the SICP visit; documentation of the SICP visit in the EMR; patient disease understanding at baseline and after intervention; and the acceptability of the SICP among patients, caregivers, and clinicians after intervention. To evaluate changes in patient ACP engagement from baseline to after intervention, we used a linear mixed model, with ACP engagement as the outcome. Fixed effects included time point, patient age, and patient gender; patients were treated as a random effect. We performed hypothesis testing at α = .10 (2-tailed) given the pilot nature. Quantitative analyses were conducted using SAS statistical software, version 9.4 (SAS Institute Inc, Cary, NC).
Qualitative
Open coding and focused content analysis was used to identify themes from transcripts of patient semistructured interviews regarding feedback on the SICP. We reported qualitative data using consolidated criteria for reporting qualitative research guidelines (supplemental Table 1).
This single-arm pilot study was approved by the University of Rochester research subjects review board and was conducted at the Wilmot Cancer Institute, Rochester, NY.
Results
Demographics
We included 41 patients, 24 caregivers, and 22 clinicians. Mean age of patients was 68 years (standard deviation [SD], 4.3; range, 60-80], and mean age of caregivers was 59 years (SD, 13.4; range, 34-73). Most patients and caregivers were White (97.6% and 95.8%, respectively) and non-Hispanic (100.0% and 87.5%, respectively). Approximately half of patients and caregivers were female (53.7% and 54.2%, respectively). Most clinicians were female (86.4%). On geriatric assessment, 70.7%, 20.0%, 22.5%, and 7.3% of patients had impairment in physical function, nutritional status, psychological health, and cognition, respectively (see Table 1; supplemental Table 2).
Table 1.
Participant demographics
| Patient N = 41 |
Caregiver N = 24 |
Clinician N = 22 |
|
|---|---|---|---|
| Age, mean (SD, range), y | 68 (4.3, 60-80) | 59 (13.4, 34-73)∗ | 32 (5.1, 24-46) |
| Clinician type, n (%) | |||
| APP | — | — | 15 (68.2) |
| Fellow | — | — | 7 (31.8) |
| Years in fellowship, mean (SD, range) | 2 (0.8, 1-3) | ||
| Gender, n (%) | |||
| Male | 19 (46.3) | 11 (45.8) | 3 (13.6) |
| Female | 22 (53.7) | 13 (54.2) | 19 (86.4) |
| Ethnicity, n (%) | |||
| Not Hispanic or Latino | 41 (100.0) | 21 (87.5) | 22 (100.0) |
| Unknown/not reported | — | 3 (12.5) | — |
| Race, n (%) | |||
| Asian | — | — | 2 (9.1) |
| Black or African American | 1 (2.4) | — | — |
| White | 40 (97.6) | 23 (95.8) | 20 (90.9) |
| Missing | — | 1 (4.2) | — |
| Education, n (%) | |||
| High school or below | 12 (29.3) | 5 (20.8) | — |
| Training after high school or some college/university | 12 (29.3) | 6 (25.0) | — |
| College/university graduate | 11 (26.8) | 9 (37.5) | — |
| Postgraduate level | 5 (12.2) | 4 (16.7) | — |
| Other | 1 (2.4) | — | — |
| Marital status, n (%) | |||
| Married/long-term, committed significant other | 24 (58.5) | 19 (79.2) | — |
| Divorced | 3 (7.3) | 2 (8.3) | — |
| Single | 5 (12.2) | 2 (8.3) | — |
| Widowed | 9 (22.0) | 1 (4.2) | — |
| Employment status, n (%) | |||
| Employed | 10 (24.4) | 10 (41.7) | — |
| Retired | 28 (68.3) | 11 (45.8) | — |
| Unemployed | 1 (2.4) | — | — |
| Homemaker | — | 2 (8.3) | — |
| Other | 2 (4.9) | 1 (4.2) | — |
| Caregiver’s relationship to the patient, n (%) | |||
| Partner (spouse/significant other) | — | 17 (70.8) | — |
| Child/children | — | 5 (20.8) | — |
| Other relative(s) | — | 2 (8.3) | — |
| Caregiver living with the patient, n (%) | |||
| Partner (spouse/significant other) | 25 (61.0) | — | — |
| Child/children | 1 (2.4) | — | — |
| None | 15 (36.6) | — | — |
| Caregiver not living with the patient, n (%) | |||
| Partner (spouse/significant other) | 5 (12.2) | — | — |
| Child/children | 8 (19.5) | — | — |
| Other relative(s) | 2 (4.9) | — | — |
| None | 26 (63.4) | — | — |
| Cancer diagnosis, n (%) | |||
| Acute lymphoblastic leukemia | 3 (7.3) | — | — |
| Acute myeloid leukemia | 25 (61.0) | — | — |
| Central nervous system lymphoma | 1 (2.4) | — | — |
| Lymphoma | 3 (7.3) | — | — |
| Multiple myeloma | 4 (9.8) | — | — |
| Myelodysplastic syndrome | 4 (9.8) | — | — |
| Plasma cell leukemia | 1 (2.4) | — | — |
| Cancer diagnosis duration, n (%) | |||
| <6 months | 24 (58.5) | — | — |
| ≥6 months | 17 (41.5) | — | — |
| Cancer health literacy, n (%) | |||
| Adequate literacy | 39 (95.1) | — | — |
| Limited literacy | 2 (4.9) | — | — |
Two missing values.
Primary outcome
Feasibility
We approached 57 patients, and 41 consented (consent rate of 71.9%). The most common reasons for declining participation included reluctance to complete surveys (n = 8), feeling overwhelmed by their current situation (n = 5), and the perception that discussing care preferences with the clinical team would not be helpful (n = 3). A total of 38 SICP visits were completed, with a retention rate of 92.7%. Three visits did not occur due to patients being discharged beforehand, 2 to home and 1 to hospice. The median time from first day of admission to consent was 4 days (mean, 6.7 days; range, 0-37). The average number of visits per clinician was 1.6 (SD, 1.3) and the average time per visit was 15.7 minutes (SD, 7.6; median, 15.7; interquartile range, 9.9-21.1).
Twenty patients identified 1 caregiver each; 2 patients identified 2 caregivers to join the SICP visit. Five caregivers were unable to attend the actual SIC visit; 1 caregiver was out of town, 2 could not be reached in person or by phone, and 2 were caregivers of patients whose visits did not take place.
Secondary outcome
Advance directive completion
The number of HCP forms completed increased from 23 to 31 within 1 year of SICP visits. Specifically, the number of HCP forms increased from 23 to 29 within 3 months of SICP visits and from 23 to 31 within 6 months of SICP visits. The number of MOLST forms completed increased from 7 to 20 within 1 year of SICP visits. Specifically, the number of MOLST forms increased from 7 to 16 within 3 months of SICP visits, from 7 to 19 within 6 months of SICP visits, and from 7 to 20 within 9 months of SICP visits.
SIC documentation in the EMR
All inpatient SICP visits (38/38 [100%]) were documented using the EMR template.
Other outcomes
Disease understanding
From baseline to after intervention, 16 patients changed their estimate of curability, and 5 patients changed their estimate of life expectancy (Figure 1). In general, patients shifted toward shorter life expectancy estimates after their SIC; however, this was not statistically significant. There was generally no change in patient understanding of curability.
Figure 1.
Disease understanding from baseline to after intervention.
ACP engagement
From baseline to after intervention, patients’ ACP engagement scores numerically increased (mean, +0.2; 95% confidence interval, −0.1 to 0.4; P = .24).
Acceptability
The inpatient SICP was acceptable (Figure 2., Figure 3., Figure 4.). Of patients who completed the acceptability survey, most agreed that they received the exact amount of information they wanted from the visit (24/32 [75.0%]), felt the visit took place at the right time (24/33 [72.7%]), and found the visit to be very or extremely worthwhile (21/32 [65.6%]). Patients and caregivers found it very or extremely helpful for the clinician to ask how much the family knows about the patient’s priorities and wishes (54.5% and 52.9%, respectively), to ask what the patient is willing to go through for the possibility of more time (51.5% and 58.8%, respectively), and to bring up what the patient’s personal goals are for the future (66.7% and 52.9%, respectively). Of clinicians who completed the acceptability survey, most agreed that the format of the SICP was simple (83.3%) and easy to use (83.3%). Clinicians felt that the SICP helped them a great deal to understand patient preferences regarding undergoing aggressive treatments (77.8%) and that they gained useful information from asking patients about their fears and worries (70.2%).
Qualitative feedback
In semistructured interviews, 20 of 31 patients interviewed said they would recommend a SICP visit to others. Three themes emerged from patient interviews:
Theme 1: SICP visits prepare patients for the future by providing more medical information and social/emotional support
Patients felt the SICP visits provided more information about their medical diagnosis and care plan. This information allowed patients to gain a better understanding of the reasons for and the goals of their hospitalization.
Patient 1: “I have a better understanding of why I’m here for so long. At least I know why I am here.”
The SICP included patients’ caregivers and loved ones, which made patients feel closer to their loved ones and established a shared understanding of the next steps for their medical care.
Patient 30: “I just felt that it made me more aware that everyone is kind of on the same page as far as with my treatment plan. There’s an openness with discussing it with the treatment team, with my family, and overall, it was very positive.”
Patients left the SICP visits feeling greater social support from their family and their care team, promoting feelings of peace.
Patient 5: “I thought it went very well, and it relieved some of my anxiety.”
Theme 2: After the SICP visits, patients began discussing parts of their care that they had not addressed before, such as preferences for life-sustaining treatments
Many patients appreciated that the SICP explored aspects of their care that they were hesitant to discuss, such as EOL treatment options.
Patient 14: “I feel like I’m on the road to somewhere, where before I was just like ‘What do I do next?’ I was very glad they brought up hospice. Like I say, it was in the back of my mind, but I wasn’t quite ready to bring it up myself. When they brought it up, it was like ‘Okay, let’s go with that’.”
Opening discussions about EOL and life-sustaining treatments helped patients understand the severity of their illness and feel better prepared for the future.
Patient 28: “She probably made me more aware of the magnitude of what’s going on.”
Patients valued learning more about life-sustaining treatments and being able to express their values regarding these interventions. They felt these conversations could be very difficult and that the format of the SICP addressed the topic of EOL well.
Patient 19: “I think it addressed the harder issues very well. I could see somebody going into a (spin) over because it’s talking about end of life and things of that nature. It was good to get that off my chest.”
Theme 3: SICP visits are most impactful for patients who are willing and interested in sharing their values and care preferences with their health care team
Some patients indicated that parts of the SICP visit could be perceived as intimidating or depressing. This included talking about EOL when the patient does not feel that they are approaching the end.
Patient 9: “Maybe I don’t want to think about these questions yet. I don’t know. I’m trying to stay positive, and then of course you hear some of the negatives and it’s hard to deal with that. I know you have to hear them because it could happen.”
To combat this concern, patients suggested offering SICP visits to patients who are ready and interested in discussing their values and preferences for EOL care with their team.
Patient 31: “You know you have to know your audience… If you can get a sense of that person and where they’re at, they could be devastated and fall into an absolute puddle of tears having to discuss what’s going on in their world. There are other people out there like me who say ‘Okay, this is what it is. This is what the ultimate outcome is going to be; how do I want to play it out on my terms?’ Really gearing it to your audience and knowing who you’re dealing with when you’re going in would be huge.”
Discussion
In this single-arm pilot study, delivery of the SICP in the hospital setting by APPs and hematology-oncology fellows was feasible, and patients, caregivers, and clinicians generally found the SICP to be an acceptable intervention. All clinicians used the EMR template to document SICP visits, and the number of advance directives completed within 1 year after the SICP visit increased.
Compared with our previous study of the outpatient telehealth SICP, feasibility rates were similar (92.5% inpatient vs 95.0% outpatient).19 However, there were higher acceptability scores in the outpatient telehealth SICP. For example, 88.2% of patients in the outpatient telehealth SICP found the intervention very or extremely worthwhile, as compared with 65.6% in the inpatient SICP.19 We hypothesize this is likely due to the greater clinical stability of patients in the ambulatory setting and that those patients completed the SICP with their primary hematologist who they likely have known for longer.
We found that SICs delivered through the SICP led to routine, standardized documentation of patients’ preferences for EOL care and an increased number of advance directives completed within 1 year of visits. Clinicians in this study found the SICP format and documentation to be simple and easy to use. Although not all patients completed MOLST or HCP forms after their SIC, there was 100% documentation of SICs using the EMR template. EMR note documentation of SIC has the potential to be more impactful than completion of advanced directives, especially given advanced directives may be difficult to locate and often lack nuance leading to possible misinterpretation of patient’s wishes.28 Additionally, structured note templates, although longer, have been shown to be clearer, more concise, and of higher quality than unstructured notes.29 Use of note templates has also been shown to save time for clinicians documenting clinical interactions.30 Many clinicians lack understanding of the benefits and uses of advance directives, which often leads to delay in their completion until late in the disease course.31 Clinicians are also reluctant to complete advance directives for patients who are full code.15 Similarly, gaps in patient understanding and discomfort with advance directives may pose barriers to completion. Therefore, EMR templates, such as the one used in this study, are a useful way to document patient wishes and values without having to complete formal paperwork.
Patients and caregivers felt that they received the exact amount of information they wanted from SICP visits and that the visits took place at the right time. Additionally, there is utility and benefit of conducting SICs in the hospital.32 For example, patients who are hospitalized often experience an acute change or decline in health status.32 Therefore, it may be beneficial to explore how the clinical change may affect patient preferences for future care. A previous study found that implementation of an adapted version of the SICP in the hospital for patients, not specific to cancer, led to earlier SICs (598.0 vs 180.8 days before death, P < .001) that were more frequently documented (89.1% vs 26.1% documented, P < .001).33 The conversations also included more key elements of an SIC.33 Although we did not report clinician perspectives on the SICP in this paper, we previously found that clinicians felt the SICP in the outpatient setting was easy to use and effective in understanding their patients’ values.20 We plan to report their perspective on the inpatient SICP in future work. The hospital setting is, therefore, a complementary environment in which to conduct high quality and meaningful SICs with patients who may be undergoing a clinical change.
Patients in our study highlighted the importance of having SICs with patients who are willing and interested in sharing their values with their care team. This stemmed from the concern that some of the language used in SICs can be perceived as focusing on EOL. Depending on the patient, EOL may be viewed as negative or giving up, leading to detrimental effects on psychological health.15,34 One solution for this concern is proper and thorough training for clinicians on how to present SICs and discuss values with their patients.11 Additionally, use of interventions, such as the SIC guide, can help ensure clinicians use sensitive language to build trust with patients without diminishing hope. Patients should have the option to opt in to an SIC after being informed of the purpose and empowered to invite caregivers or family members to the discussion. Previous work has shown that properly conducted SICs are not associated with worsening of psychological health.19,35
Our study has several strengths. First, we used both quantitative and qualitative analyses to thoroughly assess the impact of the SICP. Second, our study involved a vulnerable and often understudied group of older patients. Third, to our knowledge, this is one of the first studies to explore the delivery of SICs in the inpatient setting, as opposed to the ambulatory setting, for patients with hematologic malignancies. This is also one of very few studies to have APPs and fellows as the primary clinicians conducting SICs. Our study also has limitations. First, this was a single-center study with a relatively small sample size. Second, we did not compare the effects of SICs conducted by APP and fellows because the overall goal was feasibility; we will compare differences in SICP visit content in the future. Third, our participants were overwhelmingly White and non-Hispanic. Therefore, further research is warranted to adapt this intervention to meet the needs of a more diverse population.
In conclusion, the inpatient SICP was feasible and acceptable, and may increase the frequency and quality of SICs for older adults with hematologic malignancies. APPs and hematology-oncology fellows are a crucial part of in-hospital care and therefore the ideal clinicians to conduct inpatient SICs. The inpatient SICP has the potential to improve documentation of SICs that can subsequently be used to help provide goal-concordant care at EOL for older adults with hematologic malignancies.
Conflict-of-interest disclosure: The authors declare no competing financial interests.
Acknowledgments
The authors thank Susan Rosenthal for her editorial feedback on this manuscript.
This work was funded by the University of Rochester Quality Institute and supported by the University of Rochester Clinical and Translational Science award TL1 TR002000 (M.L.) from the National Center for Advancing Translational Sciences of the National Institutes of Health, National Cancer Institute grants UG1CA189961, K99CA237744l, and R00CA237744 (K.P.L.), a Conquer Cancer American Society of Clinical Oncology and Walther Cancer Foundation Career Development award (K.P.L.), and a Wilmot Research Fellowship award (K.P.L.).
The content of this report is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Authorship
Contribution: M.L. and K.P.L. were responsible for conceptualization and study design, data collection, data analysis and interpretation, manuscript writing and editing, and approval of the final manuscript; Y.W. was responsible for data collection, data analysis and interpretation, manuscript writing and editing, and approval of the final manuscript; A.B. was responsible for conceptualization and study design, data analysis and interpretation, and approval of the final manuscript; S.M.H. was responsible for data collection and approval of the final manuscript; T.N., J.L., N.Y., and J.P. approved the final manuscript; J.C. was responsible for manuscript writing and editing, and approved the final manuscript; T.Y. was responsible for data collection, data analysis and interpretation, and approval of the final manuscript; D.F., T.C., M.B., S.S., D.H., and N.K. were responsible for conceptualization and study design, and approval of the final manuscript; and J.H.M. was responsible for conceptualization and study design, manuscript writing and editing, and approval of the final manuscript.
Footnotes
J.H.M. and K.P.L are joint senior authors.
Original data are available from the corresponding author, Kah Poh Loh (kahpoh_loh@urmc.rochester.edu), on request; individual participant data will not be shared.
The full-text version of this article contains a data supplement.
Supplementary Material
References
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