When a patient is in the ICU, she may not communicate as easily and is likely to die in the most expensive medical environment, Dr Goldberg said.

Moving these conversations to earlier points in the disease trajectory helps make sure that a patient’s wishes and values are honored and avoids waste, he added.

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With colleagues, Dr Goldberg developed a 7-item questionnaire that can be administered at the start of every cycle of chemotherapy.3

“These are very nonthreatening questions: are you having pain? Are you able to get out of bed? Do you have financial difficulties? These are basic questions about issues that can cause distress,” he said.

Collectively, distress on multiple fronts — dealing with pain and depression, and concern about being a burden to loved ones, for example — can indicate that the end of a patient’s life is approaching.

“Being generally distressed correlates very strongly with how many months a patient may have left to live,” Dr Goldberg said. “So what we found was you can ask how distressed patients are, and if you observe a total distress score that is high, then, well, that is when you talk not just about distress but the patient’s goals for therapy, and whether palliative care or hospice might be more appropriate.”

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That approach “flips the paradigm,” Dr Goldberg said.

Critics of the Affordable Care Act raised the specter of “death panels,” he said. “The idea was, doctors would look at tables and say ‘this patient will die so we shouldn’t do something.’ But if you let the patient tell you when they feel distressed, since we know that correlates with survival, we can deal with the distress by offering aggressive care or palliative care.”

“That allows us to get the timing right for end-of-life discussions,” he said. “These discussions are important. Even Medicare has started to pay for palliative care consultations. These conversations align treatments with patient wishes, and probably save money.”

Stuart Goldberg, MD, is a hematologist/oncologist at the John Theurer Cancer Center at Hackensack University Medical Center in New Jersey and chief scientific officer at Cota, a health care data and analytics company that bridges precision medicine to population health.


  1. Hunter WG, Zafar SY, Hesson A, et al. Discussing health care expenses in the oncology clinic: analysis of cost conversations in outpatient encounters. J Oncol Pract. 2017 August 23. doi: 10.1200/JOP.2017.022855 [Epub ahead of print]
  2. Gilligan T, Coyle N, Frankel RM, et al. Patient-clinician communication: American Society of Clinical Oncology consensus guideline. J Clin Oncol. 2017 Sep 11. doi: 10.1200/JCO.2017.75.2311 [Epub ahead of print]
  3. Goldberg SL, Paramanathan D, Arunajadai S, et al. Predictive value of the patient reported outcome “living with cancer” instrument on overall survival in advanced cancer patients: a tool for guiding timing of palliative care. J Clin Oncol. 2017;35(suppl; abstr 10025).