Recently, I cared for a patient in his early 60s with advanced gastric cancer. When diagnosed months earlier, he had the standard “goals of care” conversation with his oncology team—focused primarily on treatment options, not his deeper values.

His disease followed the unpredictable pattern so common in modern cancer care: treatment, stabilization, progression, and new treatment. Then, suddenly, everything changed. He deteriorated rapidly during hospitalization and was discharged with recommendations for hospice care, with a prognosis of days to weeks. His family was shocked. Within days, he was barely able to communicate with his loved ones. He died shortly after, having never had the chance to process this transition or make meaningful choices about his final days.

Could this story have unfolded differently? Modern cancer care offers unprecedented treatment options, but it also demands a new approach to patient communication. Instead of relying on crisis-driven conversations that focus mainly on the next treatment option, imagine if his team had engaged in small, iterative discussions at each visit—weaving questions about values and preferences naturally into conversations about treatments and scan results.

Like most patients, he initially said, “I’ve got to try everything”—the socially expected response. But with the right approach, a different picture might have emerged through multiple brief conversations, allowing him to shape his journey rather than being overtaken by it. Hospice care could have been a conscious choice aligned with his values, not a crisis response.

The “big goals of care conversation” conducted during crises cannot capture this complexity; what works better, in my experience, are multiple smaller moments across different settings and providers, each adding another piece to the patient’s story.

Modern Cancer Care’s Hidden Challenge

This story illustrates a profound irony: Our success in cancer treatment has created an unexpected communication challenge. While medical advances have transformed many cancers into chronic diseases with complex trajectories, our approach to patient conversations remains stuck in an era when advanced cancer meant a predictable decline.

The Mismatch Between Disease and Discussion

These changing disease patterns have exposed the limitations of our traditional approach, as illustrated below. When cancer meant a predictable decline (blue line), a single conversation made sense. But today’s reality (yellow line) shows multiple cycles of stability and decline—each phase bringing new questions and choices. How can one conversation possibly capture this complexity?

“But We Already Do This”

Many clinicians would respond, “We already have goals of care conversations. We just need to do them better.” Others might argue that multiple conversations are impractical in today’s time-pressured environment or worry that repeatedly discussing serious illness planning could undermine patient hope.

These objections reflect genuine concerns, but they rest on outdated assumptions:

Time Pressure: These conversations don’t require dedicated appointments. During routine visits, natural explorations of patient values can be more effective than formal, time-intensive discussions.

Patient Anxiety: Research shows patients experience less anxiety when serious illness discussions are normalized as part of routine care rather than saved for crisis moments.

Documentation Burden: While capturing these conversations requires effort, the cost of not doing so is far greater—leading to misaligned care, family distress, and rushed decisions during crises.

Why Traditional Approaches Fall Short

Given this new reality, our traditional communication model faces four critical challenges:

The Hope Paradox: Clinicians fear destroying hope, yet research shows well-timed conversations help patients maintain realistic hope.

The Timing Trap: With unpredictable trajectories, there’s never a “perfect” moment for these discussions.

The Continuity Challenge: Different providers see different aspects of the patient’s story, but no one holds the complete narrative.

The Documentation Dilemma: Critical insights from informal conversations often get lost in fragmented medical records.

Recent research reveals a more profound truth: These conversations are not only difficult but also fundamentally mismatched with how patients and clinicians naturally process serious illness. Patients cope by focusing on the present, while clinicians hesitate to disturb this coping mechanism. When conversations do happen, doctors and patients often walk away with different understandings of what was discussed.

These barriers help explain why simply trying to “do better goals of care conversations” isn’t enough. We need a fundamentally different approach.

A New Model for a New Era

If traditional approaches don’t work, and common fixes fall short, what’s the alternative? I imagine a model that matches the complexity of modern cancer care and is based on:

Progressive Revelation: Instead of seeking complete answers upfront, accept that patient preferences emerge gradually through multiple interactions.

Distributed Responsibility: Every team member contributes to understanding the patient’s story. Make sure to include them and listen to their opinions.

Value Tracking: Systematically capture and share insights about what matters to patients across the care team.

Making It Work: The Role of Technology

The principles above sound good in theory, but how do we implement them in busy clinical practice? This is where emerging technologies, particularly AI, become crucial.

Recent innovations suggest AI could be crucial in this new approach. Research from Dana-Farber demonstrates that AI can identify and synthesize patient values from routine clinical notes, creating a complete picture of what matters to each person.

Imagine starting each visit with an AI-generated summary:

“Over the past three months, Sarah has consistently mentioned wanting to attend her daughter’s wedding in June. She’s expressed more concern about cognitive side effects than physical symptoms and strongly prefers avoiding hospitalizations.”

However, early attempts at technological solutions have revealed important lessons. When healthcare systems tried using automated prompts to remind patients about advance care planning, many patients ignored or resented these messages. The key insight? Technology should enhance, not replace, human connection.

Consider these contrasting approaches:

What Doesn’t Work:

– Automated reminder messages about advance care planning

-Standardized questionnaires without clinical context

-Technology-driven prompts that bypass the clinical team

What Shows Promise:

-AI-synthesized insights presented naturally by trusted clinicians and discussed with patients and caregivers

-Smart documentation tools that capture informal conversations

-Systems that help teams build on each other’s interactions with patients

Moving Forward: A Call to Action

We have the knowledge to transform how we communicate about serious illness. We have the technology to support this transformation. What’s missing is coordinated implementation. Here’s how different stakeholders can make this vision a reality:

For Clinicians:

– Embrace smaller, iterative conversations as valuable opportunities

– Document subtle insights about patient values, not just medical decisions

– If available, use AI-generated insights as conversation starters, not conclusions

For Healthcare Organizations:

– Invest in systems that capture and share patient values across teams

– Train staff to recognize and document meaningful moments in routine care

– Develop metrics that value ongoing communication, not just formal conversations

For Technology Developers:

– Design AI tools that enhance rather than replace human connection

– Create interfaces that make it easy to capture and share patient values

– Build systems that respect the evolving nature of patient preferences

Success Looks Like:

– Patients report feeling heard and understood throughout their illness journey

– Families face fewer crisis decisions about care preferences

– Clinicians spend less time searching for documented preferences and more time having meaningful conversations

– Healthcare systems see better alignment between patient values and care delivered

Together, we can create a communication model that genuinely serves patients and families navigating modern cancer care.