What makes serious illness conversations acceptable? A mixed-methods study of patient and caregiver experiences in oncology and cardiology.

OBJECTIVES

This study aimed to identify how contextual, dispositional, and relational factors intersect to shape the participant experience of serious illness conversations (SICs) while exploring the nuances of appraisal across different clinical specialties.

METHODS

A convergent parallel mixed-methods study was conducted as part of a Serious Illness Care Programme pilot at two Singaporean tertiary centres. Participants with advanced cancer or heart failure were recruited from oncology, cardiology, and palliative medicine clinics. We conducted semi-structured interviews and a Patient Experience Survey (PES) that explored participants views on their communication experience. .Qualitative data were analysed via a case-based thematic approach. Findings were summarized by coders into experience categories of "Good," "Moderate," or "Poor." Quantitative comparisons between patient-reported PES scores and coder-assigned ratings were performed using the Kruskal-Wallis rank-sum test.

RESULTS

Forty participants were recruited (33 patients, 7 caregivers), with 32 (26 patients, 6 caregivers) completing interviews, and 24 patients completing the PES. Among interviewed patients, 19 had advanced cancer and 7 had heart failure. While 96% of patients rated their SICs as "mostly" or "extremely" worthwhile in the PES, qualitative analysis revealed a complex landscape of acceptance, ambivalence, and distress. Discrepancies between patient-reported and coder-assigned ratings indicated that participants appraised encounters as "Worthwhile" even when experiencing significant distress. Four themes were identified as primary influences on participant experience: subjective illness understandings, clinician conversational practices, personal readiness, and relational dynamics. The analysis suggests that trust established through longitudinal therapeutic relationships functioned as a buffer against negative appraisals, offer a possible explanation for why "Worthwhile" scores remained largely experience-invariant.

CONCLUSION

This study demonstrates that SIC acceptability is a dynamic appraisal refracted through subjective illness understandings and relational contexts. Future research should investigate specific communicative mechanisms that foster affective readiness and rapport, ensuring that serious illness communication aligns with, rather than disrupts, patient and caregiver expectations of healthcare communication.