A nudge helps doctors bring up end-of-life issues with their dying cancer patients

Article by Ravi Parikh et al: “When conversations about goals and end-of-life wishes happen early, they can improve patients’ quality of life and decrease their chances of dying on a ventilator or in an intensive care unit. Yet doctors treating cancer focus so much of their attention on treating the disease that these conversations tend to get put off until it’s too late. This leads to costly and often unwanted care for the patient.Related: 

This can be fixed, but it requires addressing two key challenges. The first is that it is often difficult for doctors to know how long patients have left to live. Even among patients in hospice care, doctors get it wrong nearly 70% of the time. Hospitals and private companies have invested millions of dollars to try and identify these outcomes, often using artificial intelligence and machine learning, although most of these algorithms have not been vetted in real-world settings.

In a recent set of studies, our team used data from real-time electronic medical records to develop a machine learning algorithm that identified which cancer patients had a high risk of dying in the next six months. We then tested the algorithm on 25,000 patients who were seen at our health system’s cancer practices and found it performed better than relying only on doctors to identify high-risk patients.

But just because such a tool exists doesn’t mean doctors will use it to prompt more conversations. The second challenge — which is even harder to overcome — is using machine learning to motivate clinicians to have difficult conversations with patients about the end of life.

We wondered if implementing a timely “nudge” that doctors received before seeing their high-risk patients could help them start the conversation.

To test this idea, we used our prediction tool in a clinical trial involving nine cancer practices. Doctors in the nudge group received a weekly report on how many end-of-life conversations they had compared to their peers, along with a list of patients they were scheduled to see the following week who the algorithm deemed at high-risk of dying in the next six months. They could review the list and uncheck any patients they thought were not appropriate for end-of-life conversations. For the patients who remained checked, doctors received a text message on the day of the appointment reminding them to discuss the patient’s goals at the end of life. Doctors in the control group did not receive the email or text message intervention.

As we reported in JAMA Oncology, 15% of doctors who received the nudge text had end-of-life conversations with their patients, compared to just 4% of the control doctors….(More)”.