Barriers to Serious Illness Conversations Among Patients with Advanced Cancer: A Qualitative Study

Serious illness conversations (SICs) are discussions between clinicians and cancer patients about illness understanding, information preferences, and goals of care. Interventions to prompt SICs increase SIC rates and improve care delivery near the end of life. This embedded substudy examined SIC barriers and facilitators among "refractory" patients without an SIC despite enrollment in an SIC clinical trial.

We recruited advanced cancer patients with no documented SIC 60 days after randomization in a clinical trial of patient- and clinician-nudges to engage in SICs. We conducted semi-structured interviews with patients and their caregivers if present and brief email surveys with patients' oncologists. We used qualitative content analysis to identify themes related to SIC barriers and facilitators and to identify strategies to improve SICs.

Of 44 participants, 19 were patients, 10 were caregivers, and 15 were oncologists. Themes of SIC barriers and facilitators included (1) how patients coped with their illness, which shaped their readiness for SICs; (2) clinician communication style, which shaped ease of having an SIC; (3) prognostic uncertainty and disease stability, which could prompt or justify delaying an SIC; and (4) family members' presence, which could instigate an SIC. Regarding ways to improve SIC nudges, patients and caregivers had mixed perspectives but often highlighted a preference for interventions with personal touches.

Patient readiness remains an important barrier even after targeted SIC interventions. Future SIC interventions should consider approaches tailored to patient communication preferences and interventions involving personal interactions.