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.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SUPPORTIVE_CARE
Masking
NONE
Enrollment
220
The care coach will focus on improving readiness and preparedness for components that will be discussed during serious illness conversations (SICs) - (disease understanding/prognosis, fear/worry, goals of care, treatment expectations, informational preferences, trade-offs, caregiver involvement). The coach will also equip patients with basic tools for treatment decision-making and advanced care planning (ACP). The session will be conducted in-person over 30-to-45 minutes. All coaching content is adapted from the serious illness care program developed by Ariadne Labs. This includes an adapted version of the advanced cancer and surgery question prompt list, elements of the serious illness conversations and the "What Matters to Me" serious illness care program booklet. The SICs are conducted at least 12 hours prior to palliative intervention and findings conveyed to surgical team. Coaching sessions would be focused on decision-making and future planning aspects of palliative care.
Singapore General Hospital
Singapore, Singapore
RECRUITINGQuality of serious illness conversations (SIC) with patients
We measured the quality of the SIC conducted based on number of components explored. The seven components explored were disease understanding/prognosis, fear/worry, goals of care, treatment expectations, informational preferences, trade-offs, caregiver involvement. The team will ask questions from Serious Illness Conversations Guide (Ariadne Labs), which enable Healthcare providers to understand patients' values and goals. This would be used as part of a palliative care delivery quality indicator. Team members will share with the caregivers of the patient's goals and palliative care needs when the patient is being coached by the care coach.
Time frame: Baseline 1 (pre-coaching), Baseline 2 (post-coaching), 1 month, 3 months, 6 months after Baseline 1 (pre-coaching)
Health-Related Quality of Life (HRQoL) in patients
We measured HRQoL in patients with the Functional Assessment of Cancer Therapy - General (FACT-G). FACT-G is a well-validated HRQoL questionnaire that covers 4 domains - physical well-being (7 items), social/family well-being (7 items), emotional well-being (6 items) and functional well-being (7 items). Each item has response choices in a 5-point Likert-type scale, with a maximum value of 4 (being, "Very much") and a minimum value of 0 (being "Not at all"). Higher scores indicate a better quality of life.
Time frame: Baseline 1 (pre-coaching), Baseline 2 (post-coaching), 1 month, 3 months, 6 months after Baseline 1 (pre-coaching)
Health-Related Quality of Life (HRQoL) in patients
We also measured HRQoL in patients with the 5-level EuroQol-5 Dimension instrument (EQ-5D-5L). EQ-5D-5L is a HRQoL questionnaire with five domains (mobility, selfcare, usual activities, pain/discomfort, anxiety/depression) and has five levels for each domain. Scores from all five items will be used to derive a single utility score ranging from 0 to 1, with 0 representing the worst possible health to 1 representing perfect health. It also contains a health state component and a visual analog scale.
Time frame: Baseline 1 (pre-coaching), Baseline 2 (post-coaching), 1 month, 3 months, 6 months after Baseline 1 (pre-coaching)
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Decisional Conflict in patients
We measured decisional conflict in patients using the Traditional Decisional Conflict Scale (DCS). DCS is a validated 16-item instrument that measures personal perceptions of uncertainty in choosing among options, the factors contributing to uncertainty, and the quality of the decision made. Items are rated on a 5-point Likert scale (0 = Strongly agree to 4 = Strongly disagree). Scores are summed, divided by 16, and multiplied by 25 to produce a total score ranging from 0 (no decisional conflict) to 100 (extremely high decisional conflict). Lower scores indicate less decisional conflict and better decision support.
Time frame: Baseline 1 (pre-coaching), Baseline 2 (post-coaching), 1 month, 3 months, 6 months after Baseline 1 (pre-coaching)
Goals of care and life priorities in patients
We determined the goals of care and life priorities in patients by using the Life Priorities Survey (LPS). LPS assesses patients' goals and priorities for their medical care across five domains: prolonging life, curing a disease, establishing a diagnosis, preserving function or independence, and relieving symptoms. This tool identifies patients' primary goals of care and will be used to assess concordance between patient-reported priorities and the treatments and interventions received. Changes in life priorities over the cancer and surgical journey will also be examined.
Time frame: Baseline 1 (pre-coaching), Baseline 2 (post-coaching), 1 month, 3 months, 6 months after Baseline 1 (pre-coaching)
Understanding of the patient's goals and SIC components in caregivers
We measured the caregiver's understanding of the patient's goals and SIC components by using modified questions based on the Serious Illness Conversations Guide (Ariadne Labs). The outcome measure will be assessed by alignment and concordance with the SIC responses and seven components provided by the caregiver's respective patient. The seven components assessed are disease understanding/prognosis, fear/worry, goals of care, treatment expectations, informational preferences, trade-offs, caregiver involvement.
Time frame: Baseline 1 (pre-coaching), Baseline 2 (post-coaching), 1 month, 3 months, 6 months after Baseline 1 (pre-coaching)
Decisional conflict in caregivers
We measured decisional conflict in patients using a modified Decisional Conflict Scale (DCS) tailored to the perspective of the caregivers. DCS is a validated 16-item instrument that measures personal perceptions of uncertainty in choosing among options, the factors contributing to uncertainty, and the quality of the decision made. Items are rated on a 5-point Likert scale (0 = Strongly agree to 4 = Strongly disagree). Scores are summed, divided by 16, and multiplied by 25 to produce a total score ranging from 0 (no decisional conflict) to 100 (extremely high decisional conflict). Lower scores indicate less decisional conflict and better decision support.
Time frame: Baseline 1 (pre-coaching), Baseline 2 (post-coaching), 1 month, 3 months, 6 months after Baseline 1 (pre-coaching)
Satisfaction with care in caregivers
We measured the caregiver satisfaction by using the Family Satisfaction with the End-of-Life Care-2 (FAMCARE-2). FAMCARE-2 is a validated 17-item instrument measuring family caregiver satisfaction with palliative care. It assesses satisfaction across four domains: management of physical symptoms and comfort, provision of information, family support, and patient psychological care. Each item is rated on a 5-point Likert scale (1 = "Very satisfied" to 5 = "Very dissatisfied"). Scores are summed to produce a total score ranging from 17 to 85, with lower scores indicating greater satisfaction with care. The FAMCARE-2 will be used to evaluate caregivers' perceived quality of communication, support, and overall satisfaction with the surgical and palliative care provided throughout the surgical journey.
Time frame: Baseline 1 (pre-coaching), Baseline 2 (post-coaching), 1 month, 3 months, 6 months after Baseline 1 (pre-coaching)
Quality of life in caregivers
We measured the caregiver quality of life with the Singapore Caregiver Quality of Life Scale (SCQOLS-15). SCQOLS-15 is a validated 15-item instrument developed and normed specifically for caregivers of patients in the Singapore context. It assesses caregiver quality of life across multiple domains capturing the physical, emotional, social, and practical impact of caregiving for a patient with serious illness. The SCQOLS-15 will be used to evaluate the broader impact of the patient's advanced cancer and surgical journey on caregiver well-being, and to assess whether the CONCORD coaching program - through improved communication, goal alignment, and caregiver preparedness - translates into meaningful improvements in caregiver quality of life over the study period.
Time frame: Baseline 1 (pre-coaching), Baseline 2 (post-coaching), 1 month, 3 months, 6 months after Baseline 1 (pre-coaching)
Healthcare utilization of patients
We determined the healthcare utilization of patients by extracting the length of index hospitalization, all-cause emergency department visits, and total hospital days up to 6 months post-surgery.
Time frame: Up to 6 months post Baseline 1 (pre-coaching)
Cost of intervention(s) for patients
We determined the cost of intervention(s) by extracting inpatient and outpatient billing records will be considered in total all-cause healthcare costs up to 6 months post-surgery.
Time frame: Up to 6 months post Baseline 1 (pre-coaching)