 Next speaker is Lisa Vig, who's an associate professor of medicine at the University of Washington. She practices geriatrics and palliative care at the VA Puget Sound Healthcare System, where she also chairs the hospital's ethics committee, and her research interest is in end-of-life decision-making. Lisa, welcome back. Thanks. Well, thanks for the opportunity to be here and to participate in the conference. I'm going to talk about a pilot project that I've been working on that was funded by the American Cancer Society. So we'll start with some background information. So cancer is prevalent in older adults. Cancer management decisions are complex, and older adults may engage in decision-making differently than younger adults, meaning there are some older adults who are going to go for the cure and act just like a younger adult, but there are other older adults who are going to value quality of life and their functional status over cure, and more older adults may also be more apt to delegate decision-making to someone else. Therefore, oncologists may not be able to use a standardized approach to this group. Older patients and their oncologists also may not be on the same page. An example of this is that oncologists may not ask about quality of life issues, whereby it may be really important to the patient, but they don't bring it up. Therefore, you know, the two don't get a chance to talk about that. And finally, patient navigators have been a group who've been able to help patients with cancer. This comes from a previous study I was involved with, and a quote for you guys just to illustrate this. A 71-year-old woman with cancer, she said, we haven't talked about that, meaning her prognosis. I just think I'm going to be okay. He, the physician, hasn't volunteered anything because I imagine he thinks I'm going to get through this. And then when our group interviewed the physician, he said that he described her as being aware of her poor prognosis and accepting death. And unfortunately, she died within a month of the interview, and this is sort of an extreme case where the patient and the oncologist were not on the same page. So that leads to this research question. Can a patient navigator help facilitate communication and shared decision-making between older patients and their oncologists? So Dr. Saunders mentioned patient navigators this morning, but a little bit more for you. Patient navigators were started by a surgeon, Dr. Harold Freeman at Harlem Hospital in 1990. The aim was to reduce cancer disparities. The role of the navigators were to help patients from underserved groups, navigate the healthcare system, obtain cancer screenings, get to appointments, tests, et cetera. And the navigators were traditionally cancer survivors from the patient's racial or ethnic community. Prior to our study, navigators hadn't been used to help with medical decision-making. So there were two phases to this study. In the first phase, we wanted to know more about what patients, their families, and the oncologists' perspectives on decision-making were. We wanted to get input from all the different stakeholders on using a navigator to help facilitate communication. And then we wanted to use the results from phase one to inform how we rolled out phase two. In phase two, we tried to pilot the intervention and what was it? Well, the navigator would meet with the patient prior to an oncology appointment to discuss the patient's questions and concerns with them. The navigator would then go with them to the appointment to help advocate for them during the appointment, if needed. And then we also evaluated the feasibility and acceptability of the intervention. Now, I got 15 minutes. Well, not even that anymore. So I'm only going to talk about phase one today. We don't have time for phase two. Sorry. So what happened in phase one? Who were the participants? We recruited oncologists from two Seattle hospitals. The oncologists then selected two English-speaking patients who were 65 years or older from their panels. And we wanted the patients to be cognitively intact for this study so that they were able to provide us with descriptions of how they were making decisions. The patients then could pick a family member to participate if they wanted them to. The oncologists, patients, and families were all interviewed separately. The interviews were digitally recorded and transcribed verbatim. And what did we ask people during these interviews? We asked the oncologists to tell us about their challenges caring for older patients, how a navigator might help with this. We asked the patients to tell us about their care preferences, their concerns, how they made decisions, and again, how a navigator might help. And then we asked the families how their loved ones made decisions, how they helped their families, and again, how a navigator might help. Now, the data analysis, the quantitative data, the numbers were analyzed using descriptive statistics. The qualitative data from the interviews was analyzed using what we call grounded theory methods where we developed codes, and I'll talk about this a little more in the next slide too, to capture all the important information we were finding in the transcripts. We then went through and coded them once we had our coding scheme, and then we tried to make sense of what we had coded. And I think I showed this slide last year with my buckets. So the way I think of coding is just a bucket. So as an example in this study was a lot of people talked about burden. So we came up with a code that was burden, and anytime anybody talked about burden, we took that, you know, part of the transcript and basically plunked it in the burden bucket. Then we could go back and look at everything that was in that bucket. And of course we have fancy computer programs that do this, but it's basically the same thing. Now, are there first-year fellows in the audience? Raise your hand? Anybody? Well, there are not too many of you. Everybody's slacking off. Okay, well, too bad because what I was going to tell you guys is that in research, sometimes things don't go the way you'd planned and you'd hoped. There's sort of a Murphy's law of research, and unfortunately that hit this study in a big way. So our enrollment was much smaller than we had hoped for reasons I'm just not going to go into. I'll get all riled up. So nine oncologists, 12 patients, three family members, as you can see the patients were all older, more than half of them were men, more than half of them were married, 25% were non-white, different cancers, and actually the people who were recruited for our study were people who had had cancer for a really long time. You know, when we started out, I would have liked to have people with brand new diagnoses because I think maybe we could have had more of an impact, and yet, you know, things get in the way, things don't go as planned, so what can you do? So I'm going to talk about some of the results. The oncologist's perception of their challenges in caring for older patients, the oncologist's perception of older patients' decision making, and again what everybody said about using a navigator. I'm not going to have a lot of the patient and family quotes because what they said are things that we've already found or others have found previously. So what did the oncologist say about the challenges in caring for older patients? They talked about the difficulty in determining what the appropriate treatment for that person should be. You know, given their baseline, is treatment going to be worth it? They talked about how important it is to actually know the patient and know what's important to them. They talked about how they struggle with the good patient who just seems like they're going along with whatever the oncologist says and really putting their own preferences on the table. They also spoke about patients who just defer decision making, you know, whatever you want, Doc, and again, aren't putting their preferences out there. And then talked about what do you do if you're not sure the patient really understands everything you're talking about. So let me give you a few examples. Here's an example from an oncologist talking about his treatment worth it. People sort of build up illnesses over time, but once they get older, some of them are quite depilitated. And my job is trying to figure out where they are in their life, what's important to them, so that we can then determine what appropriate treatment is. I think that's the hardest part. Or an example of knowing the patient. You've actually got to know who they are before you can hit play. Or managing the good patient. I'm concerned that some patients, especially the elderly, think they might talk less about what they prefer in order to avoid hurting the doctor's feelings. Older patients, they tend to obey recommendations instead of putting their interests in the first place. And then one of the oncologists say about how older people made decisions. They said that often their patients were thinking of others, were concerned about burdening their loved ones when they were considering whether to get treatment for cancer. They talked about caregiving responsibilities, meaning they didn't want treatments that were going to make them too debilitated because there was actually somebody more debilitated than they were who they needed to be able to take care of. They talked about refusing beneficial or low-risk treatments. And the oncologist spoke about patients they had known who had had friends and family members who had had cancer treatments 20, 30 years ago when those treatments were really brutal to have a lot of the nausea medicines, et cetera, that we have now. And because of that experience, there was no way they were going to have cancer treatment even though it wouldn't have been so bad. The oncologist also talked about recognizing what a heterogeneous group the older population is. And here's an example of that. The sicker patients are more concerned about symptoms. They're concerned more about becoming dependent. They're concerned a lot about becoming a burden to their caregivers. But sometimes the elderly are age 70 or older and they feel like they're 30 and they prioritize being cured just like a 50-year-old. And these kind of patients have similar expectations as younger patients. So there really is a wide range of preferences in this group. What did the oncologists say about using navigators to help facilitate some of this decision-making? They said they wanted the navigators to help patients navigate the system, help with logistics, bring up questions the patient forgets to ask, make sure the patient understands what was said, provide a written summary. The oncologist did not want the navigator translating medical terms, however. And the patients and families, on the other hand, said that they wanted the navigators to help review information with the patient and family, help the patients prepare and ask questions. They did want them translating medical terms, wanted them to provide emotional support and to stand in for patients who didn't have family members. In thinking about Phase 2 and in thinking about rolling this out, we had to keep in mind the fact that we had done the pilot at two different places that really were different. So Harborview Medical Center is one of the places that Seattle's County Hospital, and we found there, one, there were fewer older patients who actually went to that clinic. Palliative care was already present in the clinic in helping with a lot of the decision-making already. There were also cultural interpreters in the clinic, and there were also traditional patient navigators in the clinic, so they had all kinds of resources. Then you go to the VA where there were lots of older men. A lot of them didn't have any family members who helped support them through the process, and they didn't have any of these other resources in the clinic. So that's all I was going to say. Thanks to the team that helped, Ruth Engelberg, Karlyn Clark, everybody who participated, the American Cancer Society who funded this, Tony Bach and Randy Curtis who helped along the way. We do have enough time for a question or two. I'd ask the questioners to keep the questions brief so that we can stay on time if anybody has a question. When we started this study, there really wasn't very much published on patient navigators, and in the years since this has happened, there actually is getting to be a lot more awareness in the oncology community about geriatric assessments. So that doesn't really answer, but... Is that up? Thank you. Thank you very much. Thank you.