Timely ‘Nudges’ Can Help Encourage More End-of-Life Conversations in Cancer

Reminders, or “nudges,” to both oncology clinicians and patients led to a significant increase in difficult conversations about poor-prognosis cancers, a large randomized study showed.

Involving more than 1,000 patients and their oncology providers, the study showed that patients who received a nudge along with their clinicians were 79% more likely to have serious illness conversations (SICs) within 60 days as compared with the no-nudge group. A nudge to only one or the other led to small, nonsignificant increases in conversations versus no nudge. SIC rates were low in all the groups, even after including clinician notes found in patient records, emphasizing the need for better strategies to encourage SICs.

The study revolved around the all-too-common issue of a patient dying without a documented SIC, reported Christopher R. Manz, MD, of Dana-Farber Cancer Institute (DFCI) in Boston, and colleagues in the Journal of the National Comprehensive Cancer Network (JNCCN).

“Past research has shown these conversations improve patient anxiety and quality of life and help them get care that matches their goals, especially near end of life,” Manz said in a statement. “Having the conversation with a provider they trust, and documenting it somewhere accessible, is what allows the rest of the team to honor the patients’ wishes, particularly if the patient is ill and unable to advocate for themself.”

The study limited participation to patients who were starting a type of treatment associated with poor prognosis and capped at three visits.

“The key is precision,” said co-author Cody E. Cotner, MD, of Harvard Medical School in Boston. “Nudging clinicians at the right time for the right patient rather than blasting reminders for every patient is how we turn this into a helpful quality-improvement initiative rather than a burdensome email. Burnout is real and alert fatigue undermines the goal of these nudges. When [nudges] feel like noise, they get ignored.”

The study offers “a practical dose of hope” for patients with advanced cancers and the clinicians who care for them, said Elise Carey, MD, of the Mayo Clinic in Rochester, Minnesota, who was not involved in the study.

“It shows that a relatively simple approach — identifying high-risk patients through existing oncology treatment pathways and sending simple reminders to both patients and clinicians — can meaningfully increase serious illness communication in routine cancer care,” said Carey, a member of the NCCN Clinical Practice Guidelines in Oncology Panel for Palliative Care.

“What is especially striking is that the benefit was driven largely by the clinician nudge, suggesting that small, well-timed supports can help clinicians make space for these essential conversations, even in a busy clinical practice,” she added.

Participants in the study were identified by means of the DFCI Clinical Pathways Program. Before initiating a new treatment regimen, oncologists specified patients’ cancer type and line of therapy. Two years prior to the trial, which started in late 2022, oncology subspecialists had prospectively identified poor-prognosis cancers associated with survival <1 year, a population appropriate for an SIC. Clinicians were offered SIC training, the authors noted in their background information.

Nudges used in the study were informed by the investigators’ previous research on the topic. The day before a patient’s next in-person visit, oncology clinicians received an email notice that encouraged an SIC. A clinician received two follow-up nudges, each a day before a patient’s next in-person visit, if the patient’s record showed no evidence of an SIC or advanced-care plan (ACP). The patient nudge consisted of a letter and questionnaire, mailed the week after randomization and encouraging patients to bring completed questionnaires to the next in-person visit.

Patients were randomized to four groups: a control arm with no nudges where patients and clinicians engaged in SICs without prompting, the mailed letter and questionnaire only, the clinician nudge only, or the mailed letter and clinician nudge. The primary outcome was the proportion of patients with ACP-SIC within 60 days after randomization for the comparison of both nudges versus none. A prespecified alternate primary outcome included SICs identified in the free text of clinician notes by means of natural language processing (ACP + NLP-SIC).

The results showed the following ACP-SIC rates:

• Control: 10.7%
• Clinician nudge: 16.7% (P=0.053 vs control)
• Mailed letter: 10.6%
• Both nudges: 17.3% (P=0.03 vs control)

The ACP + NLP-SIC rates were:

• Control: 22.6%
• Clinician nudge: 28.8% (P=0.12 vs control)
• Mailed letter: 22.3%
• Both nudges: 32.5% (P=0.01 vs control)

“Despite a median [overall survival] of 10.1 months and receipt of both clinician- and patient-directed interventions, the SIC rate in the combined-nudge group remained low at 32.5%, underscoring the need for more effective strategies to address barriers to SIC,” the authors acknowledged. “Although our patient-directed nudge did not improve SIC rates, future interventions incorporating a ‘human touch’ may enhance patient engagement.”