What is the recommended approach for managing treatment plans during oncology rounds?

Managing Treatment Plans During Oncology Rounds

Oncology rounds should prioritize structured communication and advance care planning, with systematic integration of palliative care discussions, regular reassessment of patient goals aligned with disease status, and documentation of treatment decisions that balance patient preferences with realistic prognostic information. 1

Core Framework for Treatment Plan Management

Essential Communication Elements

During oncology rounds, clinicians must address four critical domains that directly impact morbidity, mortality, and quality of life 1:

• Explore patient understanding first - Begin each discussion by assessing what the patient comprehends about their disease status and collaboratively set the agenda for the conversation 1
• Provide diagnostic and prognostic information tailored to the patient's needs, offering hope and reassurance without misleading them about realistic outcomes 1
• Document all significant discussions in the medical record to ensure continuity across the care team 1

Treatment Goals Clarification

Before discussing specific treatment options, explicitly clarify whether the goal is cure, prolongation of survival, or improved quality of life so patients can relate treatment goals to their personal care goals 1:

• Present standard treatment options first, then discuss clinical trials if the patient expresses interest 1
• Discuss the potential benefits and burdens of each treatment option (proportionality) and verify patient understanding 1
• Make patients aware of all options including clinical trials and palliative care as a sole focus 1
• When appropriate, discuss initiating palliative care simultaneously with other treatment modalities 1

Advance Care Planning Integration

Initiate conversations about end-of-life preferences early in the course of incurable illness and readdress periodically based on clinical events 1:

• Identify and engage surrogate decision makers, as delirium and cognitive impairment are prevalent during treatment and disease progression 1
• Use an organized framework to guide bidirectional communication about end-of-life care 1
• Explore how culture, religion, or spiritual beliefs affect end-of-life decision making 1
• Recognize that approximately 28% of patients with advanced cancer suffer confusion in their last days, making early surrogate identification critical 1

Sentinel Events Requiring Goals Reassessment

Reassess patient goals, priorities, and desire for information whenever a significant change in care is being considered 1:

• Disease progression requiring treatment change
• Transition from curative to palliative intent
• Development of treatment-limiting toxicities
• New comorbidities affecting treatment tolerance

Quality Assurance in Treatment Planning

For radiation oncology specifically, prospective peer review is essential 2:

• Plans reviewed before treatment initiation are 4.5 times more likely to be appropriately modified compared to retrospective review 2
• Individual review assignments embedded in clinical workflow ensure prospective evaluation for all patients 2
• Common issues identified include inadequate target coverage (36%), suboptimal dose/fractionation (27%), and setup errors (27%) 3

Multidisciplinary Coordination

Maintain clear communication with the entire oncology team throughout diagnosis, treatment, and post-treatment care 1:

• The oncology team should provide concrete recommendations when needed by other providers 1
• Clearly delineate respective roles of different team members to ensure successful care transitions 1
• Encourage inclusion of caregivers, spouses, or partners in survivorship care discussions, as they provide consistent care involvement for 14-24 months post-diagnosis 1

Common Pitfalls to Avoid

Physicians often avoid explicit discussion of poor prognosis due to concerns about engendering despair, yet understanding prognosis is essential for informed decision-making 1:

• Prognosis is rarely documented in medical records despite its importance 1
• Time constraints during clinical encounters may impede difficult conversations 1
• Aggressive cancer treatments continue to increase even among patients with poor prognosis, with 18.5% receiving chemotherapy within 2 weeks of death 1
• Among patients preferring comfort care, one in ten received care incongruent with their stated preferences 1

Empathic Response to Emotion

When patients display emotion through verbal or nonverbal behavior, respond empathically 1:

• Recognize and respond to grief and loss among patients, families, and clinicians themselves 1
• Refer to psychosocial team members (social workers, counselors, psychologists, psychiatrists, clergy) when appropriate 1
• Identify and suggest local resources for robust support during transitions to end-of-life care 1