ASCO Keynote: Are your treatment goals what your patients really want?

June 2, 2019

Physician leader Atul Gawande believes that as treatment options proliferate for cancer care and other serious illnesses, it will create a new challenge: patient communication about quality of life.

As genomics and artificial intelligence (AI) change the delivery of medicine, physicians are entering an era where treatment choices will exponentially multiply, creating a new kind of management challenge: communication.

Atul Gawande, MD, MPH, CEO of Haven, the Amazon, Berkshire Hathaway, JPMorgan Chase healthcare venture, and a globally recognized surgeon, writer, and public health leader, says “It seems like our goal (as physicians) was simple: It was to improve health and independence (for our patients). People are coming with much larger questions. They want to know how we can help optimize the quantity and quality of life. They want to know it can be affordable and not bankrupt them along the way.”

Gawande, who made the remarks during a keynote address at the American Society of Clinical Oncology (ASCO) Annual Meeting in Chicago, May 31-June 4, says that physicians and other providers need to think differently about any patient fighting a severe illness. We need to ask ourselves about our goals for care and whether or not it is the same for friends and family.

Gawande says that a study published in the Journal of Clinical Oncology titled “Effects of Early Integrated Palliative Care in Patients with Lung and GI Cancer: A Randomized Clinical Trial” (Temel, et al, 2016),   offered insight about the impact of early integrated palliative care in patients with newly diagnosed lung and gastrointestinal cancer. The results showed that the group who received early palliative care noted an improvement in their quality of life. “They were 90 percent less likely in the final two weeks,” he adds. “They experienced less suffering; they spent more time at home and less in the hospital. They had fewer chemotherapy costs, and the kicker was they lived 25 percent longer.”

“As I talked to the palliative physicians, they said their job was to bring the best of medicine to improve the quality of a patient’s life. And they were doing it successfully by asking simple questions.

•    What are your goals for your quality of life?

•    What are your priorities?

•    What matters most?

•    What will you accept and not accept in the course of treatment?

Physicians ask questions like this only 25 percent of the time. “We have learned that when we don’t ask, the care is out of alignment with people’s priorities. The result of that can be suffering.

A better understanding of what patient’s want from their treatment has created common questions physicians can ask patients:

1.    What is your understanding of your illness?

2.    How much information would you like about what might be ahead for you?

3.    What are your goals if your health situation worsens?

4.    What are your biggest fears and worries?

5.    What is the minimum quality of life you would find acceptable?

Gawande asked these questions to one of his patients, and he was surprised by the man’s response. “Well, if I could eat chocolate ice cream and watch football on television, that would be good enough for me. Keep me going as long as I can do that. It was the best living will ever.”

In a recently published randomized control trial of the Ariadne Labs Serious Illness Care Program at Dana-Farber Cancer Institute, including 91 oncologists and 278 patients with advanced cancer, Gawande learned that 90 percent of patients in the intervention group discussed their values and goals with their clinicians, compared to 44 percent in the control group receiving usual care.

Gawande says a palliative care nurse he shadowed made a profound impact on how he thinks about serious illness by telling him: “Medicine’s goal is to sacrifice people’s time now for gain more time later. My goal is to use the same medical capabilities to give patients their best day today.

“Is that worth hoping for? Is that worth fighting for? What are we fighting for? Imagine with patients their life worth living and use your medical capability to enable it.”