The Effect of Prognostic Communication on Patient Outcomes in Palliative Cancer Care: a Systematic Review

BACKGROUND

While prognostic information is considered important for treatment decision-making, physicians struggle to communicate prognosis to advanced cancer patients. This systematic review aimed to offer up-to-date, evidence-based guidance on prognostic communication in palliative oncology.

METHODS

PubMed and PsycInfo were searched until September 2019 for literature on the association between prognostic disclosure (strategies) and patient outcomes in palliative cancer care, and its moderators. Methodological quality was reported.

RESULTS

Eighteen studies were included. Concerning prognostic disclosure, results revealed a positive association with patients' prognostic awareness. Findings showed no or positive associations between prognostic disclosure and the physician-patient relationship or the discussion of care preferences. Evidence for an association with the documentation of care preferences or physical outcomes was lacking. Findings on the emotional consequences of prognostic disclosure were multifaceted. Concerning disclosure strategies, affective communication seemingly reduced patients' physiological arousal and improved perceived physician's support. Affective and explicit communication showed no or beneficial effects on patients' psychological well-being and satisfaction. Communicating multiple survival scenarios improved prognostic understanding. Physicians displaying expertise, positivity and collaboration fostered hope. Evidence on demographic, clinical and personality factors moderating the effect of prognostic communication was weak.

CONCLUSION

If preferred by patients, physicians could disclose prognosis using sensible strategies. The combination of explicit and affective communication, multiple survival scenarios and expert, positive, collaborative behaviour likely benefits most patients. Still, more evidence is needed, and tailoring communication to individual patients is warranted.

IMPLICATIONS

Future research should examine the effect of prognostic communication on psychological well-being over time and treatment decision-making, and focus on individualising care.

Parent Perspectives of Receiving Early Information About Palliative and End-of-Life Care Options From Their Child's Pediatric Providers

BACKGROUND

Parents of children diagnosed with cancer may experience decision regret about cancer treatment decisions and dissatisfaction with the perceived clarity in information received from their child's providers.

OBJECTIVE

The aim of this study was to describe parental perspectives about receiving an early palliative care and end-of-life (PC/EOL) communication intervention titled "Communication Plan: Early through End of Life Intervention" (COMPLETE) from an interprofessional team of physician and registered nurse providers.

METHODS

Ten parents participated in semistructured interviews after receiving the COMPLETE intervention. The COMPLETE intervention included 3 sessions delivered shortly after diagnosis and at the next 2 cancer treatment evaluations. Sessions of COMPLETE focused on early PC/EOL care discussions at diagnosis and after tumor response evaluations with their child's providers.

RESULTS

Results included 2 theme categories: (1) COMPLETE nurtures realistic hope and meaningful dialogue by parents connecting with healthcare providers as a dyad, and (2) benefits of COMPLETE helped parents to make informed decisions. In addition, there were offered suggestions to improve COMPLETE.

CONCLUSION

The COMPLETE intervention provided a unique mechanism to foster early discussions about PC/EOL options between parents and an interprofessional team during the first 6 months of the child's cancer treatment. Future study is needed using a randomized clinical control-group design to evaluate COMPLETE with a large sample of parents.

IMPLICATIONS FOR PRACTICE

Findings provide promising evidence of parents' preference and receptivity to receive early information about PC/EOL care options for a child with a brain tumor with a poor prognosis. The COMPLETE intervention provided a mechanism to help encourage parental consideration of realistic hoped-for goals for their child's condition and care.

Prescribers' experiences of, and attitudes to, use of morphine for palliative care at a tertiary hospital in Zambia

OBJECTIVE

To explore medical doctors' experiences of, and attitudes to, use of morphine for palliative care at a tertiary hospital in Zambia.

METHODS

A qualitative, exploratory case study was undertaken. Semi-structured interviews were used to collect data from 14 medical doctors working in the fields of oncology, pediatrics, and internal medicine at a tertiary hospital in Lusaka, Zambia, regarding their experiences and attitudes to prescribing morphine for palliative care. Thematic analysis of interview transcripts was carried out to establish common themes in the data. The study was approved by BSMS and UNZA research ethics committees.

RESULTS

All participants agreed that doctors were becoming more comfortable with the prescribing of morphine, although experiences were notably different for doctors working in oncology, compared to other departments. Themes of difficulty discussing end-of-life, poor recognition of pain, and fear of patient addiction, were more prominent in the responses of non-cancer doctors. Morphine use was generally restricted to cancer and sickle cell disease patients, with most non-cancer doctors stating that they rarely prescribe morphine for outpatient use. Training in pain management and the presence of a palliative care team were perceived to be facilitators to morphine prescribing.

CONCLUSIONS

Although there is an increased willingness to prescribe morphine, limited knowledge of pain management, especially for nonmalignant disease, underlies many of the findings in this study. Opportunity exists for professional development in pain management to further improve the acceptance and use of opioids in palliative care, especially for out-patients.

Prognosticating for Adult Patients With Advanced Incurable Cancer: a Needed Oncologist Skill

Patients with advanced cancer and their families commonly seek information about prognosis to aid decision-making in medical (e.g. surrounding treatment), psychological (e.g. saying goodbye), and social (e.g. getting affairs in order) domains. Oncologists therefore have a responsibility to identify and address these requests by formulating and sensitively communicating information about prognosis. Current evidence suggests that clinician predictions are correlated with actual survival but tend to be overestimations. In an attempt to cultivate prognostic skills, it is recommended that clinicians practice formulating and recording subjective estimates of prognosis in advanced cancer patient’s medical notes. When possible, a multi-professional prognostic estimate should be sought as these may be more accurate than individual predictions alone. Clinicians may consider auditing the accuracy of their predictions periodically and using feedback from this process to improve their prognostic skills.

Clinicians may also consider using validated prognostic tools to complement their clinical judgements. However, there is currently only limited evidence about the comparative accuracy of different prognostic tools or the extent to which these measures are superior to clinical judgement. Oncologists and palliative care physicians should ensure that they receive adequate training in advanced communication skills, which builds upon their pre-existing skills, to sensitively deliver information on prognosis. In particular, clinicians should acknowledge their own prognostic uncertainty and should emphasise the supportive care that can continue to be provided after stopping cancer-directed therapies.

Family sense of coherence and its associations with hope, anxiety and symptoms of depression in persons with cancer in palliative phase and their family members: A cross-sectional study

BACKGROUND

There is evidence indicating that family sense of coherence predicts quality of family life and promotes family well-being. In families living with the palliative phase of cancer, low hope, anxiety and symptoms of depression are common in both persons with cancer and their family members.

AIM

To determine whether family sense of coherence was associated with hope, anxiety and symptoms of depression, respectively, in persons with cancer in the palliative phase and their family members.

DESIGN

An observational, cross-sectional, multicentre study was conducted. Nested linear regression analyses were performed in two blocks to determine whether family sense of coherence was associated with hope, anxiety and symptoms of depression.

SETTING/PARTICIPANTS

Persons with cancer (n = 179) and their family members (n = 165) were recruited from two oncology clinics and two palliative centres in three regions in Sweden.

RESULTS

The main findings showed that family sense of coherence was significantly and independently associated with hope, anxiety and symptoms of depression. Stronger family sense of coherence was associated with higher hope and lower anxiety and symptoms of depression levels in both persons with cancer and their family members.

CONCLUSION

Health care providers should strive to identify families with weak family sense of coherence, because of its associations with hope, anxiety and symptoms of depression, in order to offer them professional support and thereby achieve increased well-being during the palliative phase of cancer. Future studies should expand our knowledge of family sense of coherence and how to identify families at risk of lower levels of well-being.

Challenges in delivering bad news in a multi-ethnic intensive care unit: An ethnographic study

OBJECTIVE

During critical care, physicians are frequently confronted with bad-news communication because of patients' frail conditions. Delivering bad news is not easy, certainly not when patients from ethnic minority groups are involved. In this study we investigate the delivery of bad news in a multi-ethnic critical care context.

METHODS

Ethnographic fieldwork in one intensive care unit of a multi-ethnic urban hospital in Belgium. Data were collected through negotiated interactive observation, in-depth interviews and from reading patients' medical records. Data were thematically analysed.

RESULTS

Bad-news communication was primarily dominated by physicians. Patients' and relatives' input and other professionals' involvement in the communication was limited. Staff encountered ethno-cultural related difficulties, firstly, in choosing suitable conversation partner(s); secondly, in choosing the place of conversations and thirdly, in the information exchange. Staff usually tried to address these problems themselves on the spot in a quick, pragmatic way. Sometimes their approaches seemed to be more emotion-driven than well thought-out.

CONCLUSION

Delivering bad news in a multi-ethnic intensive care unit has a number of specific difficulties. These can have negative consequences for parties involved.

PRACTICE IMPLICATIONS

The challenges of an adequate delivery of bad news need a team-approach and a well thought-out protocol.

CMS-01 Genetic testing for familial amyotrophic lateral sclerosis (ALS): insights and challenges

Background: Pathogenic variants in ALS genes are known to be present in up to 70% of familial and 10% of apparently sporadic ALS cases, and can be associated with risks for ALS only, or risks for other neurodegenerative diseases (eg. frontotemporal dementia). While there are no changes to medical management for patients confirmed as pathogenic variant carriers, genetic testing may be important for future drug trials. Confirmation of a pathogenic variant also provides relatives with the opportunity to consider predictive and/or reproductive genetic testing. Genetic counselling is an important aspect of testing decision-making as it enables individuals to make informed decisions about genetic testing while minimising adverse psychological, ethical and legal outcomes. Few studies have explored how individuals decide whether to pursue testing, nor the needs and experiences of familial ALS families.Objective: To identify factors that influence patient and family member decision-making about genetic testing for ALS genes, assess the impact of familial disease on the patient and their family, and identify information and support needs.Methods: In-depth, semi-structured interviews with individuals from Australian ALS families with known pathogenic gene variants explored experiences of familial ALS, and factors that influenced genetic testing decision-making. Interviews were analysed using an inductive approach.Results: Thirty-four individuals from 24 families were interviewed and included patients (n = 4), spouses (n = 4), and asymptomatic at-risk relatives (n = 26). Life stage, experience of disease, costs, research opportunities, and attitudes to familial ALS and/or reproductive options influenced decision-making. Some patients and relatives experienced difficulty gaining accurate information from their health professionals about the costs and implications of genetic counselling or testing, resulting in a reluctance to proceed.Discussion and conclusion: This study provides new insight into the Australian experience of genetic testing and counselling for familial ALS. It highlights the need to work together with other health professionals to ensure the complexities of genetic testing decision-making, and referral pathways are better understood.

Association Between the Timing of Goals-of-Care Discussion and Hospitalization Outcomes in Patients With Metastatic Cancer

BACKGROUND

Patients with cancer often require acute hospitalizations, many of which are unplanned. These hospitalizations have been shown to increase in frequency near the end of life. The American College of Physicians recommends that goals-of-care (GOC) discussions be initiated early for metastatic cancers. We hypothesized that discussing GOC during hospitalization could help reduce readmissions. Our aim was to examine the association between the timing of GOC discussion, length of hospital stay, and the time to readmission.

METHODS

We conducted a retrospective review of medical records of patients with stage IV cancers hospitalized between August 2017 and July 2018. We recorded timing of GOC discussion, use of palliative care services, and hospital readmissions within 90 days. χ² tests were used to identify independent associations with GOC discussion, and logistic regression was used to examine association with readmission within 90 days.

RESULTS

Of all study patients (N = 241), 40.6% were female, 46% (n = 112) had a GOC discussion, and 34% (n = 82) had a palliative care consultation. Having a palliative care consult and being admitted to critical care were independently associated with having a GOC discussion. Early timing of GOC discussion was inversely associated with admission to critical care units (P < .05). Thirty-eight percent (n = 92) had unplanned hospital readmission within 90 days. Having a GOC discussion was independently associated with a reduction in the odds of an unplanned hospital readmission within 90 days by 79% (odds ratio = 0.21, 95% confidence interval: 0.12-0.37).

CONCLUSION

Among hospitalized patients with stage IV cancer, performing an early GOC discussion has an important association with lower hospital readmission rates and increased rates of goal-congruent patient care.

Navigating the Murky Waters of Hope, Fear, and Spiritual Suffering: An Expert Co-Captain's Guide

How can surgeons deliver compassionate, holistic care to patients who are beyond cure? Interacting emotionally and understanding hope, fear, and spiritual suffering is key. Responsibly reframing hope to underlying meanings, and away from specific outcomes, is critical. Facilitating moves from cure to comfort to a peaceful dying process requires some retooling of the surgical toolbox. Surgeons possess a unique set of skills, including imagination and an undying sense of hope. Surgeons who have the courage to delve into their emotions and sustain realistic hope for their patients, all the way to the end, will reap deep personal and professional rewards.

Advanced communication: A critical component of high quality gynecologic cancer care: A Society of Gynecologic Oncology evidence based review and guide

Effective communication between gynecologic oncology providers and patients is vital to patient-centered care. Skilled communication improves the patient's knowledge retention, builds trust in providers, enhances shared decision-making, and alleviates anxiety of both patients and caregivers. Effective communication is also associated with reduced provider burnout due to improved comfort from possessing the skills to handle emotionally charged situations. Therefore, training in serious illness communication skills is critically important to gynecologic oncology practice and benefits patients, providers, and the healthcare system. Like surgical skills, communication skills can be learned and improved upon, particularly by making use of communication skills courses and other resources. While the purpose of each conversation will vary based on the medical setting, most communication roadmaps incorporate four basic components: 1) Assess patient knowledge and understanding, 2) inform patient in accordance with her communication preferences, 3) recognize and respond to emotion 4) elicit patient values, and create a plan that aligns with those values. Improved patient outcomes associated with addressing patient emotions underscore a critical need to recognize and address emotional cues during difficult conversations. We present strategies for delivering serious news, and for discussing prognosis and goals of care. In each strategy, we highlight skills for recognizing and responding to patient and family emotional cues.

Clinician barriers and facilitators to heart failure advance care plans: a systematic literature review and qualitative evidence synthesis

BACKGROUND

Clinicians hesitate to engage with advance care planning (ACP) in heart failure. We aimed to identify the disease-specific barriers and facilitators for clinicians to engage with ACP.

METHODS

We searched Medline, Embase, CINAHL, PubMed, Scopus, the British Nursing Index, the Cochrane Library, the EPOC register, ERIC, PsycINFO, the Science Citation Index and the Grey Literature from inception to July 2018. We conducted the review according to Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. Two reviewers independently assessed original and empirical studies according to Critical Appraisal Skills Programme criteria. The SURE framework and thematic analysis were used to identify barriers and facilitators.

RESULTS

Of 2308 articles screened, we reviewed the full text of 42 studies. Seventeen studies were included. The main barriers were lack of disease-specific knowledge about palliative care in heart failure, high emotional impact on clinicians when undertaking ACP and lack of multidisciplinary collaboration between healthcare professionals to reach consensus on when ACP is indicated. The main facilitators were being competent to provide holistic care when using ACP in heart failure, a patient taking the initiative of having an ACP conversation, and having the resources to deliver ACP at a time and place appropriate for the patient.

CONCLUSIONS

Training healthcare professionals in the delivery of ACP in heart failure might be as important as enabling patients to start an ACP conversation. This twofold approach may mitigate against the high emotional impact of ACP. Complex interventions are needed to support clinicians as well as patients to engage with ACP.

Barriers to access to palliative care services perceived by gastric cancer patients, their caregivers and physicians in Santander, Colombia

Gastric cancer (GC) is a public health issue with high incidence and mortality in Colombia due to tardy diagnosis and barriers to access to curative treatment; this leaves palliative care (PC) as the only option. Our aim is to describe the access barriers to PC perceived by adults with GC, caregivers and physician in Santander, Colombia. A qualitative study was carried out with the analysis of the grounded theory (Strauss and Corbin), through semi-structured interviews, after sampling for convenience we found that the access barriers were: administrative, economic, cultural, knowledge, communication, institutional and geographical; strategies to overcome barriers: screening programs, governmental surveillance, and investment in health. In conclusion, access to PC requires remove barriers to timely and integral access and strengthen health and education policies to facilitate procedures and services that ensure the attention required by the adult with GC.

Breast Cancer Patients' Preferences for Truth Versus Hope Are Dynamic and Change During Late Lines of Palliative Chemotherapy

CONTEXT

Women with metastatic breast cancer often receive many lines of palliative chemotherapy, which might be beneficial but also harmful. Still, little is known about the patients' perception of the patient-doctor communication regarding late lines of noncurative treatment.

OBJECTIVES

Our aim was to explore breast cancer patients' preferences and perceptions of patient-doctor communication regarding continuous late lines of palliative chemotherapy.

PATIENTS AND METHODS

A qualitative study was conducted with semiguided face-to-face interviews with 20 women, 40-80 years old, on at least their second line of palliative chemotherapy (second to eighth line). We used a qualitative conventional content analysis.

RESULTS

All women knew they had incurable breast cancer but expressed hope for cure. Patients' definition of a good compassionate doctor was one who gives positive news and leaves room for hope. Ongoing chemotherapy, positive news from the doctors, and support from relatives encouraged hope. The women often expressed they accepted chemotherapy to please their doctor and relatives. The informants appreciated the doctor to be honest, but within positive limits. Over time, they stopped asking questions afraid of getting bad news, and left more and more treatment decisions to the doctor.

CONCLUSIONS

The women's preferences for truth versus hope in patient-doctor communication changed over time, which increase the risk for continuous late lines of palliative chemotherapy by common collusion. Doctors need to individualize information, help patients make sense of their life, and allow hope to endure without further chemotherapy.

A Qualitative Study of Serious Illness Conversations in Patients with Advanced Cancer

Background: Conversations with seriously ill patients about their values and goals have been associated with reduced distress, a better quality of life, and goal-concordant care near the end of life. Yet, little is known about how such conversations are conducted. Objective: To characterize the content of serious illness conversations and identify opportunities for improvement. Design: Qualitative analysis of audio-recorded, serious illness conversations using an evidence-based guide and obtained through a cluster randomized controlled trial in an outpatient oncology setting. Setting/Measurements: Clinicians assigned to the intervention arm received training to use the "Serious Illness Conversation Guide" to have a serious illness conversation about values and goals with advanced cancer patients. Conversations were de-identified, transcribed verbatim, and independently coded by two researchers. Key themes were analyzed. Results: A total of 25 conversations conducted by 16 clinicians were evaluated. The median conversation duration was 14 minutes (range 4-37), with clinicians speaking half of the time. Thematic analyses demonstrated five key themes: (1) supportive dialogue between patients and clinicians; (2) patients' openness to discuss emotionally challenging topics; (3) patients' willingness to articulate preferences regarding life-sustaining treatments; (4) clinicians' difficulty in responding to emotional or ambiguous patient statements; and (5) challenges in discussing prognosis. Conclusions: Data from this exploratory study suggest that seriously ill patients are open to discussing values and goals with their clinician. Yet, clinicians may struggle when disclosing a time-based prognosis and in responding to patients' emotions. Such skills should be a focus for additional training for clinicians caring for seriously ill patients.

Care staff's self-efficacy regarding end-of-life communication in the long-term care setting: Results of the PACE cross-sectional study in six European countries

BACKGROUND

An important part of palliative care is discussing preferences at end of life, however such conversations may not often occur. Care staff with greater self-efficacy towards end-of-life communication are probably more likely to have such discussions, however, there is a lack of research on self-efficacy towards end-of-life discussions among long-term care staff in Europe and related factors.

OBJECTIVES

Firstly, to describe and compare the self-efficacy level of long-term care staff regarding end-of-life communication across six countries; secondly, to analyse characteristics of staff and facilities which are associated to self-efficacy towards end-of-life communication.

DESIGN

Cross-sectional survey.

SETTINGS

Long-term care facilities in Belgium, England, Finland, Italy, the Netherlands and Poland (n = 290).

PARTICIPANTS

Nurses and care assistants (n = 1680) completed a self-efficacy scale and were included in the analyses.

METHODS

Care staff rated their self-efficacy (confidence in their own ability) on a scale of 0 (cannot do at all) to 7 -(certain can do) of the 8-item communication subscale of the Self-efficacy in End-of-Life Care survey. Staff characteristics included age, gender, professional role, education level, training in palliative care and years working in direct care. Facility characteristics included facility type and availability of palliative care guidelines, palliative care team and palliative care advice. Analyses were conducted using Generalized Estimating Equations, to account for clustering of data at facility level.

RESULTS

Thde proportion of staff with a mean self-efficacy score >5 was highest in the Netherlands (76.4%), ranged between 55.9% and 60.0% in Belgium, Poland, England and Finland and was lowest in Italy (29.6%). Higher levels of self-efficacy (>5) were associated with: staff over 50 years of age (OR 1.86 95% CI[1.30-2.65]); nurses (compared to care assistants) (1.75 [1.20-2.54]); completion of higher secondary or tertiary education (respectively 2.22 [1.53-3.21] and 3.11 [2.05-4.71]; formal palliative care training (1.71 [1.32-2.21]); working in direct care for over 10 years (1.53 [1.14-2.05]); working in a facility with care provided by onsite nurses and care assistants and offsite physicians (1.86 [1.30-2.65]); and working in a facility where guidelines for palliative care were available (1.39 [1.03-1.88]).

CONCLUSION

Self-efficacy towards end-of-life communication was most often low in Italy and most often high in the Netherlands. In all countries, low self-efficacy was found relatively often for discussion of prognosis. Palliative care education and guidelines for palliative care could improve the self-efficacy of care staff.

Understanding the Barriers to Introducing Early Palliative Care for Patients with Advanced Cancer: A Qualitative Study

Background: Palliative care is often underutilized or initiated late in the course of life-threatening illness. Randomized clinical Early Palliative Care (EPC) trials provide an opportunity for changing oncologists' perceptions of palliative care and their attitudes to referring patients to palliative care services. Aim: To describe French oncologists' perceptions of EPC and their effects on referral practices before a clinical EPC trial was launched. Design: A qualitative study involving semistructured face-to-face interviews. The data were analyzed using the Grounded Theory coding method. Setting/Participants: Thirteen oncologists and 19 palliative care specialists (PCSs) working at 10 hospitals all over France were interviewed. Most of them were involved in clinical EPC trials. Results: The findings suggest that referral to PCSs shortly after the diagnosis of advanced cancer increases the terminological barriers, induces avoidance patterns, and makes early disclosure of poor prognosis harder for oncologists. This situation is attributable to the widespread idea that palliative care means terminal care. In addition, the fact that the EPC concept is poorly understood increases the confusion between EPC and supportive care. Conclusion: Defining the EPC concept more clearly and explaining to health professionals and patients what EPC consists of and what role it is intended to play, and the potential benefits of palliative care services could help to overcome the wording barriers rooted in the traditional picture of palliative care. In addition, training French oncologists how to disclose "bad news" could help them cope with the emotional issues involved in referring patients to specialized palliative care.

Advance care planning conversations with palliative patients: looking through the GP's eyes

Background

Although it is often recommended that general practitioners (GPs) initiate advance care planning (ACP), little is known about their experiences with ACP. This study aimed to identify GP experiences when conducting ACP conversations with palliative patients, and what factors influence these experiences.

Methods

Dutch GPs (N = 17) who had participated in a training on timely ACP were interviewed. Data from these interviews were analysed using direct content analysis.

Results

Four themes were identified: ACP and society, the GP’s perceived role in ACP, initiating ACP and tailor-made ACP. ACP was regarded as a ‘hot topic’. At the same time, a tendency towards a society in which death is not a natural part of life was recognized, making it difficult to start ACP discussions. Interviewees perceived having ACP discussions as a typical GP task. They found initiating and timing ACP easier with proactive patients, e.g. who are anxious of losing capacity, and much more challenging when it concerned patients with COPD or heart failure. Patients still being treated in hospital posed another difficulty, because they often times are not open to discussion. Furthermore, interviewees emphasized that taking into account changing wishes and the fact that not everything can be anticipated, is of the utmost importance. Moreover, when patients are not open to ACP, at a certain point it should be granted that choosing not to know, for example about where things are going or what possible ways of care planning might be, is also a form of autonomy.

Conclusions

ACP currently is a hot topic, which has favourable as well as unfavourable effects. As GPs experience difficulties in initiating ACP if patients are being treated in the hospital, future research could focus on a multidisciplinary ACP approach and the role of medical specialists in ACP. Furthermore, when starting ACP with palliative patients, we recommend starting with current issues. In doing so, a start can be made with future issues kept in view. Although the tension between ACP’s focus on the patient’s direction and the right not to know can be difficult, ACP has to be tailored to each individual patient.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0868-5) contains supplementary material, which is available to authorized users.

Advance Care Planning Communication: Oncology Patients and Providers Voice their Perspectives

Advance care planning helps to ensure that patients' end-of-life preferences are understood and discussed with providers. It is an important component of patient-centered care, particularly when patients are facing life-limiting illness. It also has ethical implications for providers, yet evidence suggests that these conversations are not always occurring, particularly in underserved populations. The aim of this study was to understand the challenges and personal beliefs regarding ACP through interviews with patients undergoing active cancer treatment and their oncology providers. This study took place at an urban, multispecialty cancer center in the mid-Atlantic region where approximately 1400 patients are treated each year. Findings revealed differences among both patients and providers in terms of their ACP knowledge, preferences, and practices. Overall, 70% of patients were familiar with advance directives (100% of White patients and 45.5% of Black patients), yet only 35% of them reported having completed one (55.6% of White patients and 18.2% of Black patients, although not statistically significant). Most providers (70%) held ACP conversations with patients with advanced illness only. They tended to make assumptions about the amount of information that patients desired and noted the significant challenges that were inherent with these types of conversations. Overall, ethical implications are inherent in ACP as patients are making medical decisions without always having necessary information. There are various reasons why providers may not supply information regarding potential outcomes and end-of-life planning and why patients may not request (or know to request) more medical information.

Are older long term care residents accurately prognosticated and consequently informed about their prognosis? Results from SHELTER study data in 5 European countries

BACKGROUND

Informing residents in long term care facilities (LTCFs) about their prognosis can help them prepare for the end of life. This study aimed to examine which proportion of European LTCF residents, close to death, are accurately prognosticated and consequently informed about their prognosis; and to examine factors related to accurate prognostication and discussion of prognosis.

METHODS

A subsample of SHELTER study data was used, consisting of: 500 residents from 5 European countries, who died within 6 months after their last assessment, and had a valid answer on the item 'End stage disease, 6 or fewer months to live'. This item was used to indicate whether an accurate prognosis was established and discussed with residents. Generalized estimating equations were used to examine factors related to establishment and discussion of accurate prognosis.

RESULTS

86.4% of residents close to death did not receive an accurate prognosis. Residents with cancer; fatigue; dehydration; and normal mode of nutritional intake were more likely to have an accurate prognosis established and discussed. Accurate prognostication and prognosis discussion was less likely for residents who: had a diagnosis under 'other'; initiated interactions; and residents from Germany, Italy and the Netherlands.

CONCLUSIONS

The great majority of residents close to death did not receive an accurate prognosis. Prognostication tools might help clinicians to increase their prognostic accuracy and communication training might help to discuss prognosis with residents.

[Prolonged weaning during early neurological and neurosurgical rehabilitation : S2k guideline published by the Weaning Committee of the German Neurorehabilitation Society (DGNR)]

Prolonged weaning of patients with neurological or neurosurgery disorders is associated with specific characteristics, which are taken into account by the German Society for Neurorehabilitation (DGNR) in its own guideline. The current S2k guideline of the German Society for Pneumology and Respiratory Medicine is referred to explicitly with regard to definitions (e.g., weaning and weaning failure), weaning categories, pathophysiology of weaning failure, and general weaning strategies. In early neurological and neurosurgery rehabilitation, patients with central of respiratory regulation disturbances (e.g., cerebral stem lesions), swallowing disturbances (neurogenic dysphagia), neuromuscular problems (e.g., critical illness polyneuropathy, Guillain-Barre syndrome, paraplegia, Myasthenia gravis) and/or cognitive disturbances (e.g., disturbed consciousness and vigilance disorders, severe communication disorders), whose care during the weaning of ventilation requires, in addition to intensive medical competence, neurological or neurosurgical and neurorehabilitation expertise. In Germany, this competence is present in centers of early neurological and neurosurgery rehabilitation, as a hospital treatment. The guideline is based on a systematic search of guideline databases and MEDLINE. Consensus was established by means of a nominal group process and Delphi procedure moderated by the Association of the Scientific Medical Societies in Germany (AWMF). In the present guideline of the DGNR, the special structural and substantive characteristics of early neurological and neurosurgery rehabilitation and existing studies on weaning in early rehabilitation facilities are examined.Addressees of the guideline are neurologists, neurosurgeons, anesthesiologists, palliative physicians, speech therapists, intensive care staff, ergotherapists, physiotherapists, and neuropsychologists. In addition, this guideline is intended to provide information to specialists for physical medicine and rehabilitation (PMR), pneumologists, internists, respiratory therapists, the German Medical Service of Health Insurance Funds (MDK) and the German Association of Health Insurance Funds (MDS). The main goal of this guideline is to convey the current knowledge on the subject of "Prolonged weaning in early neurological and neurosurgery rehabilitation".

Healthcare users' experiences of communicating with healthcare professionals about children who have life-limiting conditions: a qualitative systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to identify and synthesize the best international qualitative evidence on healthcare users' experiences of communication with healthcare professionals about children who have life-limiting conditions. For the purposes of this review, "healthcare users" will be taken to include children who have life-limiting conditions and their families. The question to be addressed is:What are healthcare users' experiences of communicating with healthcare professionals about children who have life-limiting conditions?

BACKGROUND

The prospect of the death of a child from an incurable medical condition is harrowing, yet finding a way to discuss this prospect is crucial to maximize the quality of life for such children and their families. High-quality communication is well recognized as a core skill health care professionals need to maximize the quality of care they provide. This skill is valued by service users, who consistently rate it as one of the highest priorities for the care they receive. Evidence suggests, however, that healthcare professionals can feel ill-equipped or uncomfortable communicating with and about such children. Therefore, it is important to understand what represents high-quality communication and what is involved in accomplishing this within pediatric palliative care.In recent decades there has been an increased focus on providing palliative care for children who have life-limiting conditions. These are conditions for which no cure is available and for which the probable outcome is premature death. Palliative care may also be appropriate for children who have life-threatening conditions; these are conditions where there is not only a high probability of premature death but also a chance of long-term survival into adulthood Although pediatric palliative care is underpinned by the same philosophy as adult palliative care, children who have life-limiting conditions and their families have particular needs that distinguish them from users of adult palliative care. For example, at a physical level children are more likely than adults to have non-malignant conditions that follow trajectories in which children oscillate between feeling relatively well and acutely unwell. The social dynamic of their care is also radically different, particularly given the role of parents or guardians in making surrogate decisions about their child's care. Such factors warrant considering pediatric palliative care as distinct from palliative care more generally.Although the particular circumstances of children who have life-limiting conditions have led to development of pediatric palliative care, the particular provisions of this care differs among countries. One aspect of variation is the age range of patients. Pediatric palliative care is usually provided to neonates, infants, children, adolescents and young adults, but international variations in the definitions of these age ranges, particularly for adolescents and young adults, means pediatric palliative care is provided to different age groups in different countries. This review therefore adopts a pragmatic rather than an age-based definition of a pediatric palliative care, considering all studies relating to service users who are being cared for by pediatric rather than adult healthcare services.In catering for the unique needs of children who have life-limiting conditions and their families, pediatric palliative care aims to achieve pain and symptom management, enhanced dignity and quality of life, and psychosocial and spiritual care. It also seeks to incorporate care for patients' broader families and facilitating access to appropriate services and support. High-quality communication is crucial for achieving these aims. It enables healthcare users and providers to make decisions that underpin the care that is provided and the quality of the life that is possible for patients and their families.Although both users and providers recognize the value of high-quality communication with and about children who have life-limiting conditions, this does not mean that these stakeholders necessarily share the same perspective of what constitutes high-quality communication and the best way of accomplishing this. Focusing on healthcare users' experiences of communication with healthcare professionals about children who have life-limiting conditions, the present review will explore the subjective impact of professionals' communication on the people for whom they provide care.It may be necessary to consider a range of contextual factors to understand healthcare users' experiences of communicating with healthcare professionals about children who have life-limiting conditions. For instance, age, developmental stage, cognitive capacity, emotional and social strengths, and family dynamics can influence a child's level of involvement in discussions about their condition and care. Although there are factors that appear more consistent across the range of pediatric palliative care users, such as parents' preferences for being treated by healthcare professionals as partners in making decisions about the care of their child, there is not always such consistency. Nor is it clear whether such findings can be generalized across different cultural contexts. In appraising existing research, this systematic review will therefore consider the relationship between the context of individual studies and their reported findings.The primary aim of this review is to identify, appraise and synthesize existing qualitative evidence of healthcare users' experiences of communicating with healthcare professionals about children who have life-limiting conditions. The review will consider relevant details of these findings, particularly whether factors like age are relevant for understanding particular experiences of communication. An outcome of this review will be the identification of best available qualitative evidence that can be used to inform professional practice, as well as an identification of priorities for future research in pediatric palliative care.A preliminary search in MEDLINE and CINAHL found primary studies exploring healthcare users' experiences of aspects of communicating with healthcare professionals about children who have life-limiting conditions. A search was also conducted for existing systematic reviews in PubMed, CINAHL, EMBASE, PsycINFO, the Cochrane Database of Systematic Reviews, the JBI Database of Systematic Reviews and Implementation Reports, and PROSPERO. No systematic reviews on this topic were found.

Physicians’ Perceptions of Hope and How Hope Informs Interactions With Patients: A Qualitative, Exploratory Study

Objectives:

Today some studies of physicians’ perceptions of hope are available, but not studies of how hope informs patient care. The objectives of this qualitative study were to describe the ways physicians conceptualize hope and how these may inform interactions with their patients.

Methods:

Ten physicians working in a large tertiary care teaching hospital were interviewed. They represented palliative care, oncology, and 7 other specialties. Minimal amount of background information was collected. In-depth interviews were conducted during spring of 2016. Open coding and the constant comparison method were used to identify emerging themes from the transcribed data. Validation method included member checking.

Results:

Hope was defined as an abstract, evolving concept characterized by future-oriented wishes; offering possibilities for reframing and shaping new meaning; an attitude of positivity or optimism; an attribute of the human condition with emotional and relational roots; and as a response to the existential inevitability of suffering and death. Three themes describing hope emerged: “assessing hope,” “fostering and sustaining hope,” and “attributes and outcomes of hope.”

Conclusions:

The findings show how physicians conceptualize hope and how these conceptions differ in the empirical light of the study. Physicians’ perceptions of “hope” may evolve when entering into a therapeutic relationship exploring the needs and desires of patients. Physicians’ perspectives about “hope” may at times not be solely their own but are those of their patients and thus resulting in an amalgamation, or a rebuilding/rekindling of hope amidst hopelessness, that suits a particular relationship.

How long do I have? Observational study on communication about life expectancy with advanced cancer patients

OBJECTIVE

To examine how communication about life expectancy is initiated in consultations about palliative chemotherapy, and what prognostic information is presented.

METHODS

Patients with advanced cancer (n=41) with a median life expectancy <1year and oncologists (n=6) and oncologists-in-training (n=7) meeting with them in consultations (n=62) to discuss palliative chemotherapy were included. Verbatim transcripts of audio-recorded consultations were analyzed using MAXqda10.

RESULTS

Life expectancy was addressed in 19 of 62 of the consultations. In all cases, patients took the initiative, most often through direct questions. Estimates were provided in 12 consultations in various formats: the likelihood of experiencing a significant event, point estimates or general time scales of "months to years", often with an emphasis on the "years". The indeterminacy of estimates was consistently stressed. Also their potential inadequacy was regularly addressed, often by describing beneficial prognostic predictors for the specific patient. Oncologists did not address the reliability or precision of estimates.

CONCLUSION

Oncologists did not initiate talk about life expectancy, they used different formats, emphasized the positive and stressed unpredictability, yet not ambiguity of estimates.

PRACTICE IMPLICATIONS

Prognostic communication should be part of the medical curriculum. Further research should address the effect of different formats of information provision.

Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline

Purpose To provide guidance to oncology clinicians on how to use effective communication to optimize the patient-clinician relationship, patient and clinician well-being, and family well-being. Methods ASCO convened a multidisciplinary panel of medical oncology, psychiatry, nursing, hospice and palliative medicine, communication skills, health disparities, and advocacy experts to produce recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. The systematic review focused on guidelines, systematic reviews and meta-analyses, and randomized controlled trials published from 2006 through October 1, 2016. Results The systematic review included 47 publications. With the exception of clinician training in communication skills, evidence for many of the clinical questions was limited. Draft recommendations underwent two rounds of consensus voting before being finalized. Recommendations In addition to providing guidance regarding core communication skills and tasks that apply across the continuum of cancer care, recommendations address specific topics, such as discussion of goals of care and prognosis, treatment selection, end-of-life care, facilitating family involvement in care, and clinician training in communication skills. Recommendations are accompanied by suggested strategies for implementation. Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki .

'Just gripping my heart and squeezing': Naming and explaining the emotional experience of receiving bad news in the paediatric oncology setting

OBJECTIVE

To explore recipients' perspectives on the range and origins of their emotional experiences during their 'bad news' consultations.

METHODS

Participants were four bereaved families of children who had changed from active treatment to palliative care in paediatric oncology. Data was collected using emotional touchpoint storytelling. The names (descriptors) given to the emotional experiences were linguistically classified. Explanations of their perceived origins were examined using applied thematic analysis.

RESULTS

26 descriptors were given, relating to bodily sensations, affective states, evaluations and cognitive conditions. Three themes were identified in the origins of these experiences - 'becoming aware', 'the changes' and 'being in this situation'. Parents described strong emotional displays during the consultation including physical collapse. These related to the internal process of 'becoming aware'. Three descriptors were given as originating from the clinicians and their delivery of the news - 'supported', 'included', 'trusting'.

CONCLUSIONS

Recipients perceive their emotional experiences as mainly originating from the news itself, and perceived consequences of it, rather than its delivery. Strong emotional reactions during the interaction are not necessarily an indicator of ineffectual delivery.

PRACTICE IMPLICATIONS

Findings offer a thematic framing that may support and deepen practitioners understanding of recipients' emotional reactions during bad news consultations.

The will to live - breast cancer patients perceptions' of palliative chemotherapy

BACKGROUND

For women with metastatic breast cancer, late lines of chemotherapy might be beneficial but also harmful. Ongoing chemotherapy late in life increase the risk of late or absent discussions of palliative care and access to symptom relief by other options than chemotherapy. Our aim was, therefore, to investigate breast cancer patients' motives, perceptions, and experiences of late lines of palliative oncologic treatment.

MATERIAL AND METHODS

A qualitative study with semi-guided face-to-face interviews with 20 women on at least their second line of palliative chemotherapy (second-eighth line). All women had breast cancer and were 40-80 years old. The interviews were analyzed by a phenomenographical approach according to seven steps, which uses a second-order perspective, i.e., how the informants experience the world.

RESULTS

The categories that surrounded the decision to continue with palliative chemotherapy were: The decision, Personal motives and goals and The treatment. All women acknowledged that they knew they had incurable breast cancer and that the treatment goal was to slow down cancer growth. Fear of death was a strong motive for all women in addition to experience of new values of life, still they preferred the doctor to make the decision. Cancer symptoms, especially pain triggered death anxiety, whereas the patients patiently accepted similar side effects from the treatment. There were also external motives for treatment like wishes from family, friends, but also health care staff.

CONCLUSIONS

All women knew they had disseminated breast cancer, still they expressed hopes for cure, therefore, death was more of a threat than a reality of an imminent death. None of the women had perceived there was an option to stop treatment. They felt both their families and doctors expected them to continue. Death threat was their main motive for accepting treatment.

The Effect of Communication Skills Training for Generalist Palliative Care Providers on Patient-Reported Outcomes and Clinician Behaviors: A Systematic Review and Meta-analysis

CONTEXT

As most end-of-life care is provided by health care providers who are generalists rather than specialists in palliative care, effective communication skills training for generalists is essential.

OBJECTIVES

To determine the effect of communication training interventions for generalist palliative care providers on patient-reported outcomes and trainee behaviors.

METHODS

Systematic review from searches of 10 databases to December 2015 (MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, CENTRAL, Web of Science, ICTRP, CORDIS, and OpenGrey) plus hand searching. Randomized controlled trials of training interventions intended to enhance generalists' communication skills in end-of-life care were included. Two authors independently assessed eligibility after screening, extracted data, and graded quality. Data were pooled for meta-analysis using a random-effects model. PRISMA guidelines were followed.

RESULTS

Nineteen of 11,441 articles were eligible, representing 14 trials. Eleven were included in meta-analyses (patients n = 3144, trainees n = 791). Meta-analysis showed no effect on patient outcomes (standardized mean difference [SMD] = 0.10, 95% CI -0.05 to 0.24) and high levels of heterogeneity (chi-square = 21.32, degrees of freedom [df] = 7, P = 0.003; I² = 67%). The effect on trainee behaviors in simulated interactions (SMD = 0.50, 95% CI 0.19-0.81) was greater than in real patient interactions (SMD = 0.21, 95% CI -0.01 to 0.43) with moderate heterogeneity (chi-square = 8.90, df = 5, P = 0.11; I² = 44%; chi-square = 5.96, df = 3, P = 0.11; I² = 50%, respectively). Two interventions with medium effects on showing empathy in real patient interactions included personalized feedback on recorded interactions.

CONCLUSIONS

The effect of communication skills training for generalists on patient-reported outcomes remains unclear. Training can improve clinicians' ability to show empathy and discuss emotions, at least in simulated consultations. Personalized feedback on recorded patient interactions may be beneficial.

REGISTRATION NUMBER

CRD42014014777.

Palliative care physicians' experiences of end-of-life communication: A focus group study

The aim of this study was to explore palliative home care physicians' experiences regarding end-of-life breakpoint communication (BPC). This is a qualitative study where focus group interviews were conducted and analysed using qualitative content analysis. The results show that the participants saw themselves as being responsible for accomplishing BPC, and they were convinced that it should be regarded as a process of communication initiated at an early stage, i.e. proactively. However, BPC was often conducted as a reaction to the patient's sudden deterioration or sometimes not at all. The barriers to achieving proactive BPC included physicians' uncertainty regarding the timing of BPC, primarily due to difficulties in prognostication in terms of time of death, and uncertainty as to what BPC should include and how it should best be approached. Furthermore, there was insufficient documentation regarding previous BPC, which impeded proactive BPC. Although our study shows that physicians are ambitious when it comes to the communication of information to patients and families, there is a need for further training in how to conduct BPC and when to initiate the BPC process. Furthermore, there should be documentation that different professionals can access as this would appear to facilitate a proactive BPC process.

Optimistic honesty: understanding surgeon and patient perspectives on hopeful communication in pancreatic cancer care

BACKGROUND

Prognosis conversations between surgical oncologists and patients with pancreatic cancer are critically important and challenging. Surgeons and their patients often have discrepant understandings of prognosis despite extensive conversations. Little is known about how surgeons approach prognosis conversations with these patients; patients' experiences with these conversations are also not well understood. This qualitative study sought to better understand surgeon and patient perspectives on communication in pancreatic cancer care with a view toward improvement.

METHODS

Grounded theory methodology was used. Semi-structured interviews were conducted with surgical oncologists and patients who had undergone surgical resection with curative intent for periampullary cancer. Data were collected and analyzed inductively and iteratively to the point of theoretical saturation.

RESULTS

10 surgeons and 10 patients participated. Three inter-linking concepts were found to drive surgeon-patient conversations: understanding, trust and hope. Surgeons delicately and purposefully tailored information for patients, striving to deliver essential though honest, empathetic and hopeful messages. Patients desired simple, truthful explanations that demonstrated caring and fostered optimism.

CONCLUSION

Surgeons and patients with pancreatic cancer value optimistic honesty in tailored prognosis conversations. Perceived discrepancies in surgeon-patient understanding must be contextualized within efforts to establish a sufficient understanding, high level of trust, and optimistic stance of hope.

Conveying hope in consultations with patients with life-threatening diseases: the balance between supporting and challenging the patient

OBJECTIVE

There is limited knowledge about the communication of hope and denial in consultations with patients with life-threatening diseases on a practical level. In this study, we explored a real-life medical consultation between a doctor and a patient with incurable cancer, focusing on conveying hope.

DESIGN AND METHODS

We found one consultation especially suited for illustrating how a physician can convey and reinforce hope without attaching it to curative treatment. The consultation was analysed using a method for discourse analysis, where we took as a point of departure that discourse means language in use.

RESULTS

The doctor communicated in a recognising manner, expressing respect for the patient as a subject and an authority of his own experiences. The doctor and patient succeeded in creating a good working alliance characterised by warmth and trust. Within this context, there was room for the doctor to challenge the patient's views and communicate disagreement.

CONCLUSIONS

The doctor succeeds in conveying and maintaining hope. Within a good working alliance with the patient the doctor can convey hope by balancing between supporting and challenging him. Exploring and grasping the patient's real concerns is essential for being able to relieve and comfort him and convey hope.

Qualitative Study on the Perceptions of Terminally Ill Cancer Patients and Their Family Members Regarding End-of-Life Experiences Focusing on Palliative Sedation

CONTEXT

Patients with terminal cancer experience refractory symptoms in the last days of life. Although palliative sedation (PS) is recommended for patients suffering unbearable symptoms with imminent death, it requires clear communication between physicians and patients/caregivers. Understanding the demands and perceptions of patients and caregivers in the end-of-life phase are needed for effective communication.

OBJECTIVE

To explore patient experiences regarding end-of-life status and PS.

METHODS

The study was performed between October and December, 2013 with eligible terminal cancer patients and their families in a non-religious, tertiary healthcare facility in Korea. Eligibility criteria were a hospitalized cancer patient with a life expectancy of less than three months and who had never experienced PS. Data were collected via face-to-face in-depth interviews and analyzed using the constant comparative method of qualitative analysis. Saturation was achieved after conducting interviews with 13 patients or care-giving family members.

RESULTS

Enrolled patients raised the following issues: 1) simultaneously harboring the hope of prolonging life and wishing for a peaceful death, 2) experiencing difficulties in having honest conversations with caregivers regarding death, 3) possessing insufficient knowledge and information regarding PS, and 4) hoping for the decision on PS to be made before suffering becomes too great.

CONCLUSION

Terminally ill cancer patients and their caregivers expressed conflicting desires in hoping to prolong life and simultaneously wishing to experience a peaceful death. Improvements in the communications that occur among physicians, patients, and caregivers on the issues of prognosis and PS are needed.

The difficulties experienced by nurses and healthcare staff involved in the process of breaking bad news

AIMS

The aim of this study was to explore the difficulties experienced by nurses and healthcare professionals when engaging in the process of breaking bad news.

BACKGROUND

The challenges faced by staff when breaking bad news have previously been researched in relation to particular settings or participants. This study involved staff from diverse settings and roles to develop broader insights into the range of difficulties experienced in clinical practice.

DESIGN

The study used a descriptive survey design involving self-reported written accounts and framework analysis.

METHODS

Data were collected using a structured questionnaire containing a free text section that asked participants to describe a difficult experience they had encountered when involved in the process of breaking bad news. Data were collected from healthcare staff from hospital, community, hospice and care home settings attending training days on breaking bad news between April 2011 and April 2014.

FINDINGS

Multiple inter-related factors presented challenges to staff engaging in activities associated with breaking bad news. Traditional subjects such as diagnostic and treatment information were described but additional topics were identified such as the impact of illness and care at the end of life. A descriptive framework was developed that summarizes the factors that contribute to creating difficult experiences for staff when breaking bad news.

CONCLUSION

The framework provides insights into the scope of the challenges faced by staff when they engage in the process of breaking bad news. This provides the foundation for developing interventions to support staff that more closely matches their experiences in clinical practice.

How should realism and hope be combined in physician–patient communication at the end of life? An online focus-group study among participants with and without a Muslim background

Objective:

Maintaining false hope may result in prolonged curative aggressive treatments until the very last stage of life. In this study, we sought to explore how people think that realistic and hopeful information should best be combined in physician–patient communications at the end of life.

Method:

During a period of 15 days, participants of five online focus groups (OFGs) could log in onto a closed discussion site and offer responses to several topics. A variety of people participated: patients, older people, relatives, and healthcare professionals with and without a Muslim background. Participants with a Muslim background constituted a separate group, because previous research indicated that they might have distinct views on good end-of-life care and communication. Transcripts were analyzed following the principles of thematic analysis.

Results:

Participants from all focus groups preferred that physicians provide realistic information in an empathic way, stating that the patient would never be left on his own and that withholding curative treatment was not equal to withholding care, explicitly asking how the patient could be helped during the time remaining, and involving other professionals in the care process and communications. As such, physicians could support patients' transition from “hope for a cure” to “hope for a good death.” Muslims specified the way they wished to receive realistic information: first from a relative, and not by using the term “incurable illness,” but rather by informing the patient that they had no remaining curative treatments available.

Significance of results:

Realism and hope are not necessarily mutually exclusive and can be combined when providing realistic information in a delicate and culturally sensitive way. This study provides suggestions on how physicians can do so. Communication skills training as well as anchoring knowledge of the diversity of cultural and religious views into physicians' education could improve end-of-life communication.

Factors associated with patient preferences for communication of bad news

OBJECTIVE

Communication based on patient preferences can alleviate their psychological distress and is an important part of patient-centered care for physicians who have the task of conveying bad news to cancer patients. The present study aimed to explore the demographic, medical, and psychological factors associated with patient preferences with regard to communication of bad news.

METHODS

Outpatients with a variety of cancers were consecutively invited to participate in our study after their follow-up medical visit. A questionnaire assessed their preferences regarding the communication of bad news, covering four factors-(1) how bad news is delivered, (2) reassurance and emotional support, (3) additional information, and (4) setting-as well as on demographic, medical, and psychosocial factors.

RESULTS

A total of 529 outpatients with a variety of cancers completed the questionnaire. Multiple regression analyses indicated that patients who were younger, female, had greater faith in their physician, and were more highly educated placed more importance on "how bad news is delivered" than patients who were older, male, had less faith in their physician, and a lower level of education. Female patients and patients without an occupation placed more importance on "reassurance and emotional support." Younger, female, and more highly educated patients placed more importance on "additional information." Younger, female, and more highly educated patients, along with patients who weren't undergoing active treatment placed more importance on "setting."

SIGNIFICANCE OF RESULTS

Patient preferences with regard to communication of bad news are associated with factors related to patient background. Physicians should consider these characteristics when delivering bad news and use an appropriate communication style tailored to each patient.

[Quality of diagnosis information given to terminal cancer patients]

AIM

To determine the information that terminal cancer patients have about their diagnosis, identifying key words used, and quantifying the conspiracy of silence.

METHOD

A cross-sectional, analytical study was conducted by reviewing the hospice support team data base which contains the medical history and a semi-structured interview with terminal cancer patients in the first visit to the hospice. Demographic and socioeconomic data was collected, as well as relevant clinical information (diagnosis, prevalent symptoms, number of symptoms, patient functionality, QoL, information given, and words used).

RESULTS

Out of total of sample of 723 records, 77.87% (95% CI: 74.70-80.74) of the patients were properly informed about their diagnosis. The most used words were cancer in 26% of the patients, tumour in 51.59%, and for the remaining 10.65%, the word inflammation was used. Statistically significant differences of information were found between sexes, age, types of cancer, and hospital ward.

CONCLUSIONS

Terminal cancer patients have knowledge on their diagnosis, suggesting that the conspiracy of silence is present to a lesser extent. This knowledge is transmitted using different words and with euphemisms.

Factors Affecting Physicians' Intentions to Communicate Personalized Prognostic Information to Cancer Patients at the End of Life: An Experimental Vignette Study

PURPOSE

To explore the effects of personalized prognostic information on physicians' intentions to communicate prognosis to cancer patients at the end of life, and to identify factors that moderate these effects.

METHODS

A factorial experiment was conducted in which 93 family medicine physicians were presented with a hypothetical vignette depicting an end-stage gastric cancer patient seeking prognostic information. Physicians' intentions to communicate prognosis were assessed before and after provision of personalized prognostic information, while emotional distress of the patient and ambiguity (imprecision) of the prognostic estimate were varied between subjects. General linear models were used to test the effects of personalized prognostic information, patient distress, and ambiguity on prognostic communication intentions, and potential moderating effects of 1) perceived patient distress, 2) perceived credibility of prognostic models, 3) physician numeracy (objective and subjective), and 4) physician aversion to risk and ambiguity.

RESULTS

Provision of personalized prognostic information increased prognostic communication intentions (P < 0.001, η(2) = 0.38), although experimentally manipulated patient distress and prognostic ambiguity had no effects. Greater change in communication intentions was positively associated with higher perceived credibility of prognostic models (P = 0.007, η(2) = 0.10), higher objective numeracy (P = 0.01, η(2) = 0.09), female sex (P = 0.01, η(2) = 0.08), and lower perceived patient distress (P = 0.02, η(2) = 0.07). Intentions to communicate available personalized prognostic information were positively associated with higher perceived credibility of prognostic models (P = 0.02, η(2) = 0.09), higher subjective numeracy (P = 0.02, η(2) = 0.08), and lower ambiguity aversion (P = 0.06, η(2) = 0.04).

CONCLUSIONS

Provision of personalized prognostic information increases physicians' prognostic communication intentions to a hypothetical end-stage cancer patient, and situational and physician characteristics moderate this effect. More research is needed to confirm these findings and elucidate the determinants of prognostic communication at the end of life.

Exploring the utility of the vignette technique in promoting advance care planning discussions with cancer patients and caregivers

OBJECTIVE

We aimed to specifically examine patients' and caregivers' perspectives about the use of the vignette technique (VT) integrating clinical scenarios, as a potential tool for facilitating advance care planning (ACP) discussions.

METHODS

Secondary analysis of data from three studies that incorporated the VT, focusing on statements specific to use of the VT and using a qualitative descriptive design informed by grounded theory.

RESULTS

Data from 85 participants were analyzed. Participants varied in their personal identification with scenarios, with caregivers being more accurate. Scenarios prompted consideration and participation in ACP discussions, sometimes steering conversations in directions that participants were ready to consider. However, scenarios also risked evoking distress in participants who may have chosen to avoid discussions.

CONCLUSIONS

For some patients, scenarios of possible clinical outcomes may provide a neutral platform to promote ACP conversations in a non-threatening manner and allow for exploration of ACP domains to greater depth.

PRACTICE IMPLICATIONS

Vignettes may be used in staff training through role-play or case discussions; as part of face-to-face interventions to improve knowledge and information processing and to facilitate the initiation of sensitive conversations. Its use in audio-visual formats may further enhance end-of-life dialogue and warrants further consideration.

Journey of a Woman With Terminal Cervical Cancer

When a cervical cancer diagnosis is made during a terminal stage, a woman is faced with many challenges. Although a terminal illness has many negative effects, such as physical pain, scarring, fear, and sexual dysfunction, women may experience a positive impact on their life, such as improved well-being and a greater appreciation of daily life. The individual experience can lead to personal revelations. Sometimes, the diagnosis can even be seen as a blessing. Understanding a personal experience in a real-life context of the terminal stages of disease is important. This story shares the day-to-day journey of a woman living with a terminal illness of cervical cancer.

The Oncologist's Duty to Provide Hope: Fact or Fiction?

There are many sources of conflict in oncology. Conflicts arise because there are numerous therapeutic options, each of which is imperfect, and these conflicts produce ethical dilemmas. A recent American Medical Association (AMA) publication outlined the principles of medical ethics for managing conflicts. Common conflicts in oncology include whether to resuscitate, to give more chemotherapy, and how much truth to tell. These conflicts are magnified because of the life and death scenario of advanced cancer. Denial, avoidance, and hope are psychologic mechanisms that enable adaptation to the life-threatening circumstances. Hope is widely written about though poorly understood and defined. Ethical statements regarding its virtue and importance to preserve are frequently given. In an effort to progress the understanding of hope, two critical features are defined: (1) hope as a thought process only exists in the future, and (2) hope is only ever associated with positive and good thoughts. The future is unknown and uncertain; therefore, hoping can be manipulated by presenting statistics in a way to boost hoping. Thus a dilemma and specific ethical responsibility falls on oncologists when discussing conflicts. Furthermore, since hope is a subjective assessment of a possibility that is considered "good" by the hoper, it cannot be perceived as "false." "False hope" is an erroneous assessment. Finally, this article introduces the concept that there might be a role to stop hoping-since hope of the future is also filled with doubt and fear-and instead live in the present and try to find joy and meaning today.