Communicating the Gist of Prognosis: Giving Information Simply and Transparently ("GIST") in Advanced Cancer

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Project Summary/Abstract Despite recent advances in cancer treatments, there still comes a time when the disease progresses, and patients can reliably be expected to have months, but not years, left to live. Although oncologists can reliably predict when patients have months to live, and 71% of advanced cancer patients report wanting prognostic information (with 83% deeming it extremely important), only 17.6% of patients a median of 5 months from death reported a prognostic discussion with their oncologist. Moreover, only 5% of these patients had accurate prognostic understanding. Not only does informed, patient-centered, shared decision-making rely on patients' having a basic understanding of their prognosis, but patients' prognostic understanding has been linked to significantly better end-of-life outcomes (e.g., less burdensome, unbeneficial care; more palliative and value- consistent care). Our prior work thus highlights the need for a communication technique that will prove acceptable to oncologists and that promotes patients' prognostic understanding. To address this need, we developed the “Giving Information Simply &Transparently” (GIST), Oncolo-GIST intervention -- a manualized oncologist communication intervention that simplifies how to impart prognostic information by focusing on 4 basic steps: 1) Giving scan information, 2) Informing prognosis, 3) Strategizing sensitively, and 4) Transparently asking what patients heard. 3 specific aims of the Oncolo-GIST approach will be tested: USpecific Aim #1:U will obtain feedback on Oncolo-GIST Version 1.0 from stakeholders/key informants (n=10 bereaved caregivers; n=10 oncology clinicians) using a modified Delphi approach. USpecific Aim #2:U will determine feasibility and acceptability of Oncolo-GIST Version 1.0 in an open trial of 10 advanced cancer patients. USpecific Aim #3:U will determine whether patients (n=25) meeting with an oncologist randomly assigned to training in Oncolo-GIST Version 2.0 are more likely than patients receiving usual care (n=25) to have better prognostic understanding (e.g., report they likely have months to live), our Uprimary outcomeU. Potential effects on patient: a) engagement in ACP, b) quality of life, receipt of: c) intensive care, d) palliative care, e) value-consistent end-of-life care, and oncologist-reported: f) satisfaction with prognostic discussions and g) therapeutic alliance with patients, will be explored. Results will lead to refinements in the Oncolo-GIST intervention, suggest its clinical feasibility and acceptability, and whether the Oncolo-GIST intervention promotes patients' prognostic understanding and hypothesized "downstream" effects (e.g., less intensive, more palliative care, better patient quality of life). Positive results will support the future testing of the Oncolo- GIST intervention in a multi-site R01 RCT of advanced cancer patients and suggest the potential broader applicability of this "gist" approach to informed end-of-life decision-making.