Pathways to Advance Targeted and Helpful Serious Illness Conversations (PATH-SIC): A Randomized Clinical Trial

Serious illness conversations (SICs) aim to elicit patient preferences and are associated with improved quality of life and reduced care utilization, but they occur infrequently. Sustainable interventions that encourage SICs are needed.

This pragmatic 4-arm randomized controlled trial enrolled adult patients at 5 disease-based oncology clinics at 2 sites of an academic cancer center between December 4, 2022, and July 31, 2024. All patients had pathways data indicating they were starting a treatment associated with a poor prognosis without documentation of an SIC in the Advance Care Planning module of the electronic health record (ACP-SICs) in the prior 6 months. Patients were randomized to 1 of 4 groups: (1) a nudge consisting of a mailed letter and questionnaire encouraging SICs; (2) a clinician nudge comprising an email reminder sent the day prior to the clinic visit to prompt an SIC; (3) both nudges; or (4) no nudges. The primary outcome was the proportion of patients with ACP-SICs within 60 days of randomization comparing the control (no-nudge) and combined-nudge arms; a prespecified alternate primary outcome included SICs identified in the free text of clinician notes using natural language processing (ACP + NLP-SIC).

A total of 1,051 patients (median age, 65 years; 60% female; 79% White) were randomized to the control (n=261), clinician-nudge (n=240), patient-nudge (n=273), and combined-nudge arms (n=277). The ACP-SIC rates were 10.7%, 16.7%, 10.6%, and 17.3% for the control, clinician-nudge, patient-nudge, and combined-nudge arms, respectively, and the ACP + NLP-SIC rates were 22.6%, 28.8%, 22.3%, and 32.5%, respectively. Patients in the combined-nudge group had significantly higher ACP-SIC and ACP + NLP-SIC rates than the control group (P=.045 and P=.01, respectively), whereas the clinician-nudge and patient-nudge groups did not.

Combined clinician- and patient-directed nudges resulted in higher SIC rates in 60 days, driven largely by the clinician nudge. NLP increased detection of SICs, demonstrating the importance of evaluating SICs in free-text notes.