Doctors should have hard patient conversation for everyone’s good, argues Ranjana Srivastava
A new study has found that the most effective way to increase the number of difficult conversations about serious illness in oncology is to nudge the doctor, rather than the patient alone.
Researchers tested two simple prompts: a letter sent to patients encouraging them to think about end-of-life issues, and an email to the oncologist before an appointment suggesting that the patient might benefit from such a discussion. A third group of patients received both nudges, while a control group received neither. The findings were clear: reminding patients to raise the topic had no effect on whether a serious illness conversation was documented, but reminding clinicians made a significant difference.
When the researchers looked only at the dedicated advance care planning section of medical records, they found that just 10% of patients in the control group and in the patient-only nudge group had a documented conversation. That figure rose to 16% when the clinician was nudged, and to 17% when both clinician and patient were nudged. However, when an AI algorithm scanned the entire medical record, including routine clinic notes, the numbers improved further. Again, nudging the patient alone made no difference – 22% of both the control group and the patient-only group had documented conversations. A clinician nudge increased that to 28%, and the combined nudge reached 32%.
The study underscores a persistent failure in modern medicine: serious illness conversations do not happen nearly as often as they should, and when they do occur they are frequently not recorded in the right place. This matters most when patients are met in crisis by paramedics or emergency staff who have no time to mine the records. As one oncologist put it, there is still something to be said for the old tradition of putting an advance care directive on the fridge door.
Why doctors hesitate
The reluctance of clinicians to initiate these discussions stems from a mix of practical and emotional barriers. Communication training for doctors in this area remains negligible, and time pressures – though contested – are a real concern. Burnout is a major factor: a 2014 survey found that 52% of UK oncologists reported symptoms of burnout, a figure that rose to 59% in 2023. Poor work-life balance, high patient numbers, and lack of support are all contributing to a workforce that is less willing to take on emotionally demanding conversations.
There is also a deeper difficulty. In an era of abundant treatment options, there is always something else to offer desperate patients, which keeps hope alive and defers the hardest conversations. Many oncologists worry about taking away hope, even when the prognosis is poor. A study on communication breakdowns found that 68% of patients rated their survival differently from their oncologist, and 89% of those patients were unaware of the discrepancy. This mismatch means patients often continue aggressive treatment when palliative care might be more appropriate, and families are left shocked when a sudden deterioration occurs because “no one knew”.
Systemic issues compound the problem. The logistics of matching the right doctor with the right patient at the right time for a consequential discussion about death and dying are daunting, given how often appointments are mis-scheduled. Nonetheless, the study’s key lesson is simple: reminding doctors to have these conversations works, and reminding both doctors and patients simultaneously works even better.
Broader context and cost savings
The findings come against a backdrop of widespread public support for advance care planning. Research from the end-of-life charity Marie Curie shows that 71% of people in the UK believe their preferences around death and dying should take priority over the wishes of their next of kin or their doctor’s advice. While 90% agree that planning for end of life is essential, only 14% have actually done so formally. The tools exist – Advance Decisions to Refuse Treatment (ADRTs), Lasting Powers of Attorney for health and welfare, and Advance Statements in England and Wales, and Advance Directives in Scotland – but uptake remains low. Only 5% of hospital admissions have an associated advance care plan.
Barriers include a lack of formal training for healthcare professionals and hesitancy among some GPs to discuss or record such documents. The National Institute for Health and Care Excellence (NICE) recommends offering advance care planning to anyone at risk of losing capacity, yet implementation lags. The cost argument is clear: one study estimated savings of £2,100 per advance care plan, driven by fewer hospital admissions and shorter stays. The Parliamentary and Health Service Ombudsman has also called for urgent improvements in communication around “do not attempt CPR” decisions.
Artificial intelligence is beginning to play a role in improving documentation. Tools such as CogStack, used in some NHS trusts, can analyse unstructured data in medical records, standardise information, and make it easier for clinicians to find documented conversations. Such systems could help address the problem that serious illness conversations are often buried in lengthy clinic notes, invisible to anyone who does not read them carefully.
Training initiatives are also emerging. The Serious Illness Care Programme UK, adapted from a model developed by Ariadne Labs in the United States, offers structured guidance for clinicians to have and document these conversations. Compassionate Conversations programmes are being rolled out in the NHS, and online learning pathways are available for health professionals. The COVID-19 pandemic exacerbated existing challenges in advance care planning, particularly around personalised approaches and information sharing, making the need for systemic change more urgent.
A personal account
For one oncologist, the study’s findings resonate deeply. Dr Ranjana Srivastava, who has treated a woman with cancer for ten years, describes the difficulty of shifting a patient’s thinking when she still feels well but could deteriorate without warning. The patient, a survivor who has always preferred honesty, insists she will “fight”. Yet the doctor knows that each new treatment offers less benefit, and that the family may be unprepared if nothing is said.
In the consultation, Dr Srivastava gently tells her patient that she hopes her health stays strong but stresses the importance of planning for a time when it worsens – for the sake of the family who love her and want to do the right thing. The patient nods thoughtfully and leaves. A moment later she returns, ducks her head in, and says: “Thank you, I needed to hear that.” The doctor exhales, then goes back out to do it all over again.
