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Purpose: To explore general practitioners‘ (GP) perspectives on initiation and conduction of end-of-life (EOL) conversations in patients with metastatic lung cancer and how they perceive the interaction with the oncologists of a cancer center. Methods: Qualitative design with in-depth interviews with GPs that refer patients with metastatic lung cancer to a cancer center; thematic analysis following Braun and Clarke. Results: We identified three main themes: timing and conduction of EOL-conversations, factors influencing EOL-conversations, and modes of GP-oncologist interaction. All themes showed important challenges in regard to communication strategies or procedures within the cancer center and between general practitioners and oncologists. Aside from known challenges of EOL-communication, important problems arise from the difficulties in keeping pace with advances in oncology and the increasing prognostic uncertainty. Additionally, the lack of standardized communication in EOL-topics between GPs and oncologists is underlined. Options in the mode of interaction include written information and direct phone calls. Conclusions: Because of the growing complexity in modern oncology, strategies for improvement in EOL-communication and GP-oncologist interaction have to consider information and education about therapeutic advances and prognosis of patients. The written interaction in reports or digital platforms should include information about EOL-communication. As prognostic uncertainty may hinder the adequate provision and conduction of conversations, a trustful personal interaction through direct contact via phone calls between GPs and oncologists should be encouraged.

Der Nationale Krebsplan empfiehlt bei der Behandlung von Patienten mit begrenzter Prognose neben der Kontinuitat der Versorgung auch spezialisierte Kommunikation und die fruhe Integration von Palliative Care (PC). Die Heidelberger Meilenstein-Kommunikation (HeiMeKOM) ist eine komplexe Intervention und beinhaltet strukturierte Gesprache im Arzt-Pflege-Tandem gemeinsam mit Patienten und Angehorigen zu Hochbelastungszeitpunkten im Erkrankungsverlauf. Prozesse und Ergebnisse von HeiMeKOM sollten evaluiert werden. In einem Multiphase-Mixed-Methods-Design wurden eine Evaluation mit folgenden Methoden durchgefuhrt: Interviews mit Pflegenden (n = 12), Fokusgruppen mit Arzten (n = 10) in Phase 1; eine Dokumentenanalyse der Verlaufsbogen (n = 302) sowie Interviews mit Patienten und Angehorigen von HeiMeKOM (n = 13) in Phase 2 und eine randomisierte Studie zu Unterstutzungsbedarfen (primares Outcome), Lebensqualitat, Angststorung und Depressivitat sowie Distress (n = 174) in Phase 3. Relevante Implementierungsfaktoren wurden in Phase 1 identifiziert und in Phase 2 berucksichtigt. Die qualitativen Interviews mit Patienten und Angehorigen zeigen, dass HeiMeKOM diese in ihrer Erkrankung hinsichtlich Verstehbarkeit, Handhabbarkeit und Bedeutsamkeit des eigenen Lebens unterstutzt. Patienten mit HeiMeKOM-Intervention zeigten nach 3 Monaten weniger Unterstutzungsbedarfe (n = 52, M = 33,4, SD = 27,5) als Patienten der Kontrollgruppe (n = 50, M = 43,1, SD = 29,9; p = 0,033; Effektstarke: Cohens d = −0,0,37). Patientenorientierte Kommunikation im Sinne des HeiMeKOM-Konzepts ist im Praxisalltag umsetzbar und wirkungsvoll. Die nachhaltige Finanzierung von Gesprachen ist Voraussetzung, um die Kommunikationsbedarfe von Patienten mit limitierter Prognose erfullen zu konnen.

Purpose Oncological societies advocate the continuity of care, specialized communication, and early integration of palliative care. To comply with these recommendations, an interprofessional, longitudinally-structured communication concept, the Milestone Communication Approach (MCA), was previously developed, implemented, and evaluated. Our research question is: what are possible explanations from the patient perspective for prognosis and advance care planning being rarely a topic and for finding no differences between MCA and control groups concerning distress, quality of life, and mood? Methods A pragmatic epistemological stance guided the study. A mixed-methods design was chosen including a pragmatic randomized trial (n = 171), qualitative interviews with patients (n = 13) and caregivers (n = 12), and a content analysis (133 milestone conversations, 54 follow-up calls). Data analysis involved the pillar integration process. Results Two pillar themes emerged: 1 “approaching prognosis and advance care planning”; 2 “living with a life-threatening illness”. Information on prognosis seemed to be offered, but patients’ reactions were diverse. Some patients have to deal with having advanced lung cancer while nonetheless feeling healthy and seem not to be ready for prognostic information. All patients seemed to struggle to preserve their quality of life and keep distress under control. Conclusion Attending to patients’ questions, worries and needs early in a disease trajectory seems key to helping patients adjust to living with lung cancer. If necessary clinicians should name their predicament: having to inform about prognosis versus respecting the patients wish to avoid it. Research should support better understanding of patients not wishing for prognostic information to successfully improve communication strategies. Trial registration Registration: German Clinical Trial Register No. DRKS00013649, registration date 12/22/2017, (https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013649) and No. DRKS00013469, registration date 12/22/2017, (https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013469).

ZusammenfassungDer Nationale Krebsplan hebt die Bedeutung der ärztlichen Kommunikation hervor und fordert deren Integration in die medizinische Aus- und Weiterbildung. In diesem Sinne begegnet das Konzept der Heidelberger Meilenstein Kommunikation den besonderen Herausforderungen im Umgang mit Lungenkrebspatientnnen mit einem interprofessionellen, strukturierten und vorausschauenden Ansatz. Interprofessionelle Tandems, bestehend aus ÄrztInnen und Pflegefachpersonen, führen gemeinsam strukturierte Gespräche zu definierten Zeitpunkten im Erkrankungsverlauf mit LungenkrebspatientInnen und deren Angehörigen durch. Das Konzept zielt auf Sensitivität im Hinblick auf die Präferenzen der PatientInnen und hat die vorausschauende gemeinsame Entscheidungsfindung, Kontinuität in der Betreuung von LungenkrebspatientInnen sowie das frühe Erkennen und Behandeln palliativer Erkrankungsstadien zum Ziel. Im Rahmen eines abschließenden Symposiums zur Heidelberger Meilenstein Kommunikation (30.–31.01.2020) wurden Empfehlungen zur Versorgungssituation von LungenkrebspatientInnen im fortgeschrittenen Stadium erarbeitet. Darüber hinaus wurden die weiterführende Übertragbarkeit von HeiMeKOM in andere Settings und Kliniken und auf andere Erkrankungen sowie die Möglichkeit der Abbildung eines solchen Konzeptes in der Regelversorgung diskutiert. Dieser Artikel stellt die im Rahmen des Symposiums diskutierten Erfahrungen, Best Practice Beispiele und Empfehlungen vor, um deren Übertragbarkeit auf andere, ähnlich ausgerichtete Projekte zu ermöglichen. Langfristig angestrebt wird die Übertragung des Meilenstein-Konzeptes in andere Kliniken, vorrangig zertifizierte Lungenkrebszentren sowie die Überführung in eine dauerhafte Finanzierung. Für die Weiterverbreitung dieser therapeutischen Innovation und vor allem für die Überführung in die Regelversorgung ist neben der Integration des Konzeptes in Kompetenzkataloge der ärztlichen Weiterbildung sowie der Pflegefortbildung v. a. gesundheitspolitische Unterstützung erforderlich.

The purpose of this study is to investigate changes over time in quality of life (QoL) in incurable lung cancer patients and the impact of determinants like molecular alterations (MA).In a prospective, longitudinal, multicentric study, we assessed QoL, symptom burden, psychological distress, unmet needs, and prognostic understanding of patients diagnosed with incurable lung cancer at the time of the diagnosis (T0) and after 3 (T1), 6 (T2) and 12 months (T3) using validated questionnaires like FACT-L, National Comprehensive Cancer Network (NCCN) Distress Thermometer (DT), PHQ-4, SCNS-SF-34, and SEIQoL.Two hundred seventeen patients were enrolled, 22 (10%) with reported MA. QoL scores improved over time, with a significant trend for DT, PHQ-4, and SCNS-SF-34. Significant determinants for stable or improving scores over time were survival 6 months, performance status at the time of diagnosis, and presence of MA. Patients with MA showed better QoL scores (FACT-L at T1 104.4 vs 86.3; at T2 107.5 vs 90.0; at T3 100.9 vs 92.8) and lower psychological distress (NCCN DT at T1 3.3 vs 5; at T2 2.7 vs 4.5; at T3 3.7 vs 4.5; PHQ-4 at T1 2.3 vs 4.1; at T2 1.7 vs 3.6; at T3 2.2 vs 3.6), but also a worsening of the scores at 1 year and a higher percentage of inaccurate prognostic understanding (27 vs 17%) compared to patients without MA.Patients with tumors harboring MA are at risk of QoL deterioration during the course of the disease. Physicians should adapt their communication strategies in order to maintain or improve QoL.

Background To address the support needs of newly diagnosed patients with lung cancer with limited prognosis, the Milestone Communication Approach (MCA) was developed and implemented. The main elements of the MCA are situation‐specific conversations along the disease trajectory conducted by an interprofessional tandem of physician and nurse. The aim of the study was to evaluate the effects of MCA on addressing support needs, quality of life, and mood as compared with standard oncological care. Patients and Methods A randomized trial was conducted with baseline assessment and follow‐up assessments at 3, 6, and 9 months in outpatients with newly diagnosed lung cancer stage IV at a German thoracic oncology hospital. The primary outcome was the Health System and Information Needs subscale of the Short Form Supportive Care Needs Survey (SCNS‐SF34‐G) at 3‐month follow‐up. Secondary outcomes included the other subscales of the SCNS‐SF34‐G, the Schedule for the Evaluation of Individual Quality of Life, the Functional Assessment of Cancer Therapy lung module, the Patient Health Questionnaire for Depression and Anxiety, and the Distress Thermometer. Results At baseline, 174 patients were randomized, of whom 102 patients (MCA: n = 52; standard care: n = 50) provided data at 3‐month follow‐up. Patients of the MCA group reported lower information needs at 3‐month follow‐up (mean ± SD, 33.4 ± 27.5; standard care, 43.1 ± 29.9; p = .033). No effects were found for secondary outcomes. Conclusion MCA lowered patient‐reported information needs but did not have other effects. MCA contributed to tailored communication because an adequate level of information and orientation set the basis for patient‐centered care. Implications for Practice By addressing relevant issues at predefined times, the Milestone Communication Approach provides individual patient‐centered care facilitating the timely integration of palliative care for patients with a limited prognosis. The needs of patients with lung cancer must be assessed and addressed throughout the disease trajectory. Although specific topics may be relevant for all patients, such as information about the disease and associated health care, situations of individual patients and their families must be considered. Additionally, using the short form of the Supportive Care Needs Survey in clinical practice to identify patients’ problems might support individually targeted communication and preference‐sensitive care., Addressing patient information needs in a timely fashion is of paramount importance for preference‐sensitive decisions and patient‐centered care. This article evaluates the Milestone Communication Approach to oncological care.