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More effective palliative care intervention is introduced early in the treatment of patients with advanced cancer. This is true whether the patient is in hospital or at home. However, many patients do not receive this specialized care because of a shortage of palliative care specialists in this country. To address this, a multi-institutional group of nurses and physicians developed CONNECT (Care Management by Oncology Nurses to Address Supportive Care Needs). CONNECT is described as a primary palliative care intervention delivered by the oncology nurse.1
The researchers conducted a cluster randomized clinical trial to compare the CONNECT program with standard care. The trial included patients from 17 community oncology practices in Pennsylvania between 2016 and 2020. Potential participants were chosen from lists of patients with upcoming appointments at the oncology clinic, using whether their oncologists would agree with this statement: I would not be surprised if the patient died in the next year.
Of 1188 eligible patients, 672 were enrolled (360 women, 312 men; mean age, 69 years). Their most common diagnoses were lung and gastrointestinal cancers. Participants were randomly assigned to either the CONNECT group or the standard care group. Each group comprised 336 patients.
The CONNECT intervention comprised 23 infusion room nurses who underwent in-depth palliative care training that focused on symptom assessment and management, emotional support, advance care planning, and care coordination. All the nurses had existing clinical roles, and reported being well prepared in key skills after completing the palliative care training.
The Intervention
CONNECT visits were conducted monthly over a 3-month period. Each visit was completed before and/or after the patient’s regularly scheduled appointment at the oncology clinic, and each was recorded. Appointments were in person or by telephone with the same nurse each time. Nurses followed a checklist comprised of key goals, using best practices in palliative oncology and the patient’s symptoms as a guide.
The first visit established rapport between patient and clinician, addressed symptoms, and helped the patient choose a surrogate decision maker. In subsequent conversations, the patient and nurse discussed types of treatment and which ones the patient preferred. A shared care plan and the patient’s advance directive were completed.
The patient’s oncologist was also involved. The nurse communicated the shared care plan and advance directive to the oncologist, as well as conducted follow-up telephone calls with the patient after each appointment. They also had weekly supervision by telephone with the nurse project manager.
In the standard care group, care was based on best oncology care practices. Participants received all necessary supportive measures that the oncology team advised including advance directives, if they chose.
Conclusions
The CONNECT intervention did not achieve the trial’s primary outcome of improved quality of life for the participants. When compared with results from the standard care group at 3 months, participants in the CONNECT group scored lower on the Functional Assessment of Chronic Illness Therapy-Palliative care (FACIT-Pal; 130.7 vs 134.1) and the Edmonton Symptom Assessment Scale (ESAS; 23.2 vs 16.6); and no differences in anxiety and depression were noted by Hospital Anxiety and Depression Scale (HADS) scores between the 2 groups.
The researchers offered a number of possible reasons for these results, including the “dose intensity” of the intervention simply was not enough to improve outcomes. They hypothesized that more visits over a longer period of time might have led to better results.
Physicians or nurse practitioners had previously led successful palliative care interventions. However, this program was led by nurses who had been recently trained in palliative care but were still active in their regular clinical roles. Did that allow them enough time to properly perform the palliative care intervention?
Although there were regular communications with the participants’ oncologists after each appointment, the researchers reported that “more involvement from prescribing clinicians may be required to make an impact on quality of life and symptom burden.”
Reference
Schenker Y, Althouse AD, Rosenzweig M, et al. Effect of an oncology nurse-led primary palliative care intervention on patients with advanced cancer: the CONNECT Cluster Randomized Clinical Trial. JAMA Intern Med. 2021;181(11):1451-1460. doi:10.1001/jamainternmed.2021.5185
