Implementation of a Social Work-Led Advance Care Planning Clinic for CAR T-Cell Therapy Patients

Introduction Chimeric antigen receptor (CAR) T-cell therapies offer encouraging results for a subset of patients with advanced hematological malignancies; 5-year progression free survival for patients who undergo CAR T-cell therapy as third line therapy is approximately 31% (Chong et al, 2021). Despite this, advance care planning (ACP) discussions with patients prior to treatment are not routinely offered. ACP discussions allow patients an opportunity to reflect on their wishes and values, and to let the people that matter to them, as well as their healthcare team, know what kind of health and personal care they wish to receive now, and in the future as their health changes. Objectives To demonstrate the feasibility of implementing a social work-led ACP clinic for patients embarking on CAR T-cell therapy at the Princess Margaret Cancer Centre (PM), Toronto, Canada. Methods An interdisciplinary team comprising a social worker, hematologists, palliative care physicians, a hematology nurse coordinator, and cancer care education specialists reviewed the ACP literature and informed the content of a dedicated ACP clinic. Patients enrolled in the CAR T-cell therapy program at PM were invited to meet one-on-one with a hematology social worker. The meeting comprised a guided interview where ACP was explained and explored across key domains of illness understanding; exploring goals and values; and planning for the future. The consultation was documented in the patients’ electronic medical record. Results Of 34 patients approached since June 2023, 28 patients have completed or are scheduled for an ACP consultation. All participating patients have identified their preferred substitute decision-maker. Key learnings from the clinic to date include the importance of a dedicated team member with whom patients can reflect on prognostic uncertainty as well as discuss their goals and values; providing practical support around legal and financial planning for the future; and opportunities for healthcare navigation including introducing the concept of integrated palliative care alongside, rather than instead of, CAR T-cell therapy. Conclusions A structured social work-led ACP clinic for patients embarking on CAR T-cell therapy is feasible and provides valuable support. Future studies should explore the impact of the clinic on patient outcomes and aggressiveness of care at the end-of-life; as well as different models for integrating ACP discussions into routine care for patients with advanced hematological malignancies. Expansion of the clinic for other advanced malignancies can be considered.