Planning for Future Care With Patients With Advanced Cancer: Examining the Feasibility of Using the Trajectory Touchpoint Technique for Advance Care Planning.
Conditions: Advance Care Planning
Sponsor: Liverpool University Hospitals NHS Foundation Trust

End of Study Report 
Planning for Future Care with Patients with Advanced Cancer: Examining the feasibility of 
using the Trajectory Touchpoint Technique for Advance Care Planning. 
NCT04499872 
1st February 2020 
 
 

End of Study Report 
Planning for Future Care with Patients with Advanced Cancer: Examining the feasibility of 
using the Trajectory Touchpoint Technique for Advance Care Planning. 
 
Executive Summary 
Advance Care Planning can be a hard topic to talk about. The patients, relatives and 
clinicians that agreed to be part of this study all liked the way the Trajectory Touchpoint 
Technique helped in the ACP. 
 The pictures helped the patients to lead their ACP and to make decisions.  
 The pictures easily showed what topics can be spoken about without limiting the 
discussion in any way. 
 The pictures helped the patients to talk about their motivations behind their 
decisions. 
 Clinicians felt that the ACP talks were more focused and deeper with the pictures 
than without. 
It is suggested that the TTT approach should be tried in other healthcare settings. These 
could be earlier in a patient’s diagnosis where talking about and making decisions about the 
future would help the patient. 
 
 

Background to the study 
Advance Care Planning (ACP) is a process where patients talk with their healthcare team 
about what may happen as their illness progresses. Close relatives often participate in the 
talk which can include the support and care the family needs. The decisions made are 
written in the patient notes and used to guide and inform future care. ACP has shown to 
help patients and their families to make decisions for the future and to prepare for end of 
life. ACP helps healthcare teams to understand what a patient wants for themselves. 
However, few people with a life limiting illness (such as cancer) have an ACP. Patients and 
families often find future and end of life care a difficult subject to talk about. Doctors and 
nurses may not mention ACP because they don’t want to upset the patient or their family. 
Training on how to start difficult conversations may also be part of the reason healthcare 
teams don’t always start ACP conversations. 
This study used a new way to try to start ACP conversations. The Trajectory Touchpoint 
Technique (TTT) uses cartoon pictures printed on paper. The images are simple 
representations of important topics that many people find it helpful to talk about at end of 
life or if they have a life limiting illness. The TTT helps people to talk about what they feel 
comfortable with, and in their own time. These are often the topics they are most worried 
about or things that may be hard to talk about. Rather than responding to a long list of 
questions, patients talk about the pictures that have meaning for them. The TTT was first 
used to understand experiences of Hospice Care. So far the TTT has been used in over 240 
detailed interviews. 
 
Research question 
Is the Trajectory Touchpoint Technique a feasible intervention to support Advance Care 
Planning in patients/families with advanced cancer? 
 
Study methods 
• 
Develop the TTT - In this study the TTT was tested to find out if it could be used for 
ACP conversations. A literature review was completed to find out what topics 

patients at end of life found it important to talk about. Cartoon pictures were then 
found that represented those topics.  
• 
Train the healthcare team - Once the pictures were chosen, the clinicians were 
trained on how to use the TTT. 
• 
Have ACP conversations - Patients that agreed to participate in the study used the 
TTT pictures to lead their own ACP conversation with their doctor or nurse.  
• 
Interviews - After the ACP talk, the patient and their relative were interviewed to 
find out how helpful the cartoon pictures were for them. The doctors and nurses 
were also interviewed 1:1 so they could share what they thought about using the 
TTT pictures in ACP talks. All interviews were recorded with the consent of the 
patients, relatives and healthcare team. 
• 
Analysis – the interview recordings were transcribed. Thematic analysis was done on 
the transcriptions to understand the opinions of the patients, the relatives, and the 
clinicians.  
 
Analysis 
Data was collected over 4 weeks in a single acute in-patient palliative care unit. Patients 
(n=4), relatives (n=2), and clinicians (n=3) took part in the study. 
Every participant felt that the pictures were easy to talk about and that the approach helped 
them in their ACP conversation. Patients and relatives commented that it is a good way to 
start a conversation: “Yeah, I think it’s a good starter if they’re not doing it or they don’t 
know where to start” (Relative). “This is for kids. But I can apply it to myself which is 
fascinating. Simplicity!” (Patient). The clinicians also found the approach a helpful way to 
start a conversation:  “positive introduction to the conversation. And I think that’s how it 
should be. It’s sort of what’s important to you and then you move from that into other 
areas” (Clinician).  
The pictures were chosen to represent important topics for patients at end of life or with 
life limiting illnesses. Participants understood the images and chose to talk about the ones 
they felt were important for them: “[That image] still strike me… Well, it’s me husband and 
meself” (Patient). The cartoons also helped to soften the conversation without taking away 

any importance, as can be seen in the cheery way that participants responded to some of 
the pictures: “… And I thought, ‘Well that’s me and you’ [Laughs]” (Relative). Other pictures 
have shown patients that it is okay to talk about what they want, when they are ready to 
talk about it: “People have also looked at that [image] and said immediately where they 
want to be when they die… which sometimes is a difficult thing to raise. Particularly when 
someone’s earlier in their journey or trajectory in terms of cancer” (Clinician).  
Clinicians said that the TTT pictures also help staff to understand and to become more 
comfortable with ACP, as is shown by this comment: “She [junior colleague] actually did say, 
‘Oh, it’s not as scary as I thought it was.’ So, yeah, I think it would help these people into ACP 
conversations really” Clinician.  
 
Findings 
• 
The TTT approach helped patients to start talking about the things they felt 
comfortable with and that were most important to them.  
• 
The TTT pictures helped relatives to know what was okay to talk about. 
• 
Clinicians found the visual aid helped focus the talk. 
• 
People reacted to the pictures that had meaning for them in an open and honest 
way. 
• 
Clinicians felt that the ACP with the TTT approach helped to make the talk deeper 
than those they had done in the past. 
 
Recommendations & Next Steps 
We suggest that the findings from this study show that the TTT is a useful way to start 
difficult conversations, like ACP. New studies in primary and secondary care should be 
planned for patients in end of life or with life limiting illnesses. These new studies should 
focus on difficult conversations in different settings. 
 
 

 
Deliverables 
Status 
Submission of a minimum of one scientific 
study paper to peer reviewed journal (Social 
Science and Medicine) 
One paper is being edited. 
Submission of abstracts to national and 
international academic conferences 
Done. 
Summary Report (4 Pages) with 
recommendations for commissioners and 
future research studies to develop the 
evidence base for the TTT in ACP. 
Done. 
Summary articles (1 page) will be submitted 
to the RLBUTH Newsletter, University of 
Liverpool News Website; the LCCG Website 
and popular media. 
 
Post on Social Media (Twitter/Facebook) will 
briefly detail study progress and findings, and 
link to published outputs outlined here. 
 
A videocast will be hosted on the Palliative 
Care Institute Website.