Evaluating the Impact of VOICE (Values and Outcomes to Improve Cancer Experiences), a Values-Clarification Tool, among Older Adults with Advanced Cancer: A Randomized Study in Simulated Clinical Settings

Background: Patients often report that clinical guidance does not reflect personal values, such as balancing survival with quality of life. Values-clarification tools can improve treatment alignment but have been understudied. Objective: To evaluate the impact of the Values and Outcomes to Improve Cancer Experiences (VOICE) tool on values clarification and shared decision making (SDM) in simulated encounters. Methods: Adults (age ≥60 y) with advanced cancer were randomized to receive VOICE or an American Cancer Society (ACS) communication guide. Participants completed 2 simulated decision-making encounters in randomized order, values based (VB; clinician-initiated discussion of patient values) and non–values based (NVB; values addressed only if patient initiates), with medical students. Two independent raters assessed values‑clarification and SDM behaviors (interrater reliability = 0.82). Patient-reported SDM was assessed with validated measures. Postsimulation interviews were thematically analyzed. Results: Forty-four adults (aged 60–88 y) participated in 88 simulated encounters focused on discussing a secondary cancer diagnosis and treatment options. VOICE recipients demonstrated higher rater-assessed values clarification than those receiving the ACS guide in VB (91.5 vs 80.1, P = 0.01) and NVB (25.2 vs 16.2, P = 0.01) encounters. During NVB encounters, more participants receiving VOICE initiated a values discussion (48% vs 13%). Values-clarification ratings were higher when clinicians initiated VB discussions than patient-initiated discussions (92.9 vs 35.7; P < 0.001). Patient-reported SDM was better in VB versus NVB encounters (relative risk [RR] = 1.71, P = 0.04). VOICE better prepared participants for SDM (70.0 vs 0.0; P < 0.001). Qualitative findings suggest VOICE led to greater self-reflection and values clarification. Conclusions: In this randomized simulation study, VOICE improved older adults’ preparation for values-based discussions and supported reflection on how treatment options align with what matters most to them. Findings highlight the importance of pairing values-clarification tools with clinician-initiated values-based discussions and for further evaluation in real-world settings.