Coaching in Palliative Surgical Oncology

Serious Illness Coaching for Patients With Advanced Cancer Undergoing Palliative Interventions

This study aims to evaluate the effectiveness of a serious illness coaching intervention (CONCORD) in improving quality of serious illness conversation (SIC), treatment decision-making, goal-concordant care delivery and quality of life in patients with advanced cancer considered for palliative interventions. CONCORD will be delivered by lay healthcare providers. We compare outcomes between participants receiving CONCORD vs usual care.

Patients with advanced cancer often suffer from tumor-related complications requiring palliative interventions. These interventions are aimed at relieving symptoms or improving quality of life and may include surgery, endoscopy, or other interventional radiology procedures. Decision-making for palliative interventions often require careful consideration of patients' values and treatment preferences. These decisions are also high-stakes given the risks of significant procedural-related morbidity and mortality. Prior studies in high risks surgical cohorts have found that peri-operative communication was often suboptimal, contributed by a lack of clarification of patients' health goals and treatment preferences. Decisional regret following palliative surgery was also common.

Patient-directed coaching has been shown improving disease coping and end-of-life decision making in patients with advanced cancer. However, their role in palliative surgical or other interventional decision-making is unclear. As such, we propose a serious illness coaching intervention to improve readiness and decision-making (CONCORD) for patients with advanced cancer considered for palliative surgery or other interventions. Coaching sessions will be delivered by a trained lay care coach and focus on decision-making and future planning aspects of palliative care before and for up to 6 months after consideration for palliative interventions. CONCORD will be implemented in the context of primary palliative care trained surgeons who are adept in delivering primary palliative care interventions, including the conduct of serious illness conversations (SIC).

In this study, we evaluate the effectiveness and implementational process of CONCORD intervention in patients with advanced cancer considered for palliative interventions. To evaluate effectiveness, we conduct randomized controlled trial (RCT) comparing patient-centric outcomes (quality of SIC, decisional conflict, goal-concordant care delivery, quality of life) before and up to 6 months after enrollment, between those receiving CONCORD vs usual care. We also explore the impact of CONCORD on family caregivers. Usual care will include patients managed by primary palliative care trained surgeons without patient coaching sessions. We embed an implementational process evaluation in our RCT in a hybrid type 1 effectiveness-implementation design, using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, to enhance understanding of the proposed program, its interaction with contextual factors, barriers and facilitators, and how these together influence outcomes.

Inclusion Criteria:

(i) Patient:

1. Aged 21 or above;
2. Diagnosis of advanced cancer, i.e. stage 3 or 4 solid organ
3. Consulted for palliative surgery or other interventions, i.e. procedures aimed at relieving symptoms and improving quality of life
4. Able to speak English or Mandarin;

(ii) Caregiver

1. Aged 21 or above;
2. Self-endorsed or identified by the enrolled patient as an unpaid spouse/partner, relative or friend who knows them well and who provides regular care, who does not have to live in the same dwelling
3. Able to speak English or Mandarin.

Exclusion Criteria:

(i). Patient

1. Patient refusal,
2. Active mental illness or severe dementia, or being certified unfit to make medical decision by a specialist physician,
3. Pregnant Women

(ii). Caregiver

1. Self-reported severe mental illness, dementia, active suicidal ideation, uncorrected hearing loss;
2. Unable to complete caregiver-reported outcomes.