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Design and Participants: This qualitative study recruited (purposive sampling) and interviewed (semi-structured) clinicians to gather perspectives on serious illness communication and care coordination for older adults with advanced cancer after discharge to SNF, to guide ALIGN refinements. The Practical Robust Implementation and Sustainability Model framework developed the interview guide exploring barriers to care, prognosis discussions, and hospice recommendations. Thematic content analysis was used.
Results: Participants (81% female, 2.7% American Indian/Alaska Native, 11% Asian, 89% White, 97% non-Hispanic) were experienced in hospital medicine (n=12), oncology (n=9), PC (n=12), home health care (n=6), and hospice (n=4). Themes were: (1) discharge to SNF is recognized as a time of worsening prognosis (concern that SNF would be inadequate to meet complex medical and psychosocial needs); (2) care silos create communication and information barriers during a period of increasing PC need (concern that medical chart information was ineffectively communicated during transitions and not given proper attention); (3) family caregiver distress escalates following transitions (managing medications and appointments, and providing increased support with activities of daily living); and (4) lack of clarity of roles and respect for the patient-oncologist relationship limits prognostic communication and changes in focus of treatment (lacking information about oncologists’ assessment of prognosis and whether further treatment was available).
Commentary: This study aims to identify barriers to high-quality end-of-life care for older adults with cancer. The authors used structured interviews to clarify common themes around serious illness communication for cancer patients receiving postacute care. While this insight is helpful, it is difficult not to think about the many additional barriers that exist in this complex patient population (eg, lack of community supports, differences in reimbursement for rehabilitative vs custodial care). The clinicians surveyed in this study were from the same geographic area, racially homogenous, and predominantly female. There are many other barriers that might be identified by a more diverse group of clinicians. It is only by working to identify more of these barriers that we can start to think about how to overcome them.
Bottom Line: This study identifies barriers to high-quality end-of-life communication in cancer, but its results are limited by a lack of diversity in its clinician participants.
Reviewer: Kate Lally, MD, Dana-Farber Cancer Institute, Boston, MA
References:
1. Singh S, Eguchi M, Min SJ, et al. Outcomes of patients with cancer discharged to a skilled nursing facility after acute care hospitalization. J Natl Compr Canc Netw. 2020;18:856-865.
2. Singh S, Dafoe A, Lahoff D, et al. Pilot trial of a social work intervention to provide palliative care for adults with cancer in skilled nursing facilities. J Palliat Med. 2023;26:527-538.
3. Kelley AS, Morrison RS. Palliative care for the seriously ill. N Engl J Med. 2015;373:747-755.
Source: Singh S, Dafoe A, Cagle J, et al. Respect for the patient-oncologist relationship may limit serious illness communication by acute and postacute care clinicians after discharge to a skilled nursing facility. JCO Oncol Pract. 2025;21(2):163-169. doi:10.1200/OP.24.00197.
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