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Clarke G, Johnston S, Corrie P, Kuhn I, Barclay S. Withdrawal of anticancer therapy in advanced disease: a systematic literature review. BMC Cancer 2015; 15:892. [PMID: 26559912 PMCID: PMC4641339 DOI: 10.1186/s12885-015-1862-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 10/27/2015] [Indexed: 01/23/2023] Open
Abstract
Background Current guidelines set out when to start anticancer treatments, but not when to stop as the end of life approaches. Conventional cytotoxic agents are administered intravenously and have major life-threatening toxicities. Newer drugs include molecular targeted agents (MTAs), in particular, small molecule kinase-inhibitors (KIs), which are administered orally. These have fewer life-threatening toxicities, and are increasingly used to palliate advanced cancer, generally offering additional months of survival benefit. MTAs are substantially more expensive, between £2-8 K per month, and perceived as easier to start than stop. Methods A systematic review of decision-making concerning the withdrawal of anticancer drugs towards the end of life within clinical practice, with a particular focus on MTAs. Nine electronic databases searched. PRISMA guidelines followed. Results Forty-two studies included. How are decisions made? Decision-making was shared and ongoing, including stopping, starting and trying different treatments. Oncologists often experienced ‘professional role dissonance’ between their self-perception as ‘treaters’, and talking about end of life care. Why are decisions made? Clinical factors: disease progression, worsening functional status, treatment side-effects. Non-clinical factors: physicians’ personal experience, values, emotions. Some patients continued treatment to maintain ‘hope’, often reflecting limited understanding of palliative goals. When are decisions made? Limited evidence reveals patients’ decisions based upon quality of life benefits. Clinicians found timing withdrawal particularly challenging. Who makes the decisions? Decisions were based within physician-patient interaction. Conclusions Oncologists report that decisions around stopping chemotherapy treatment are challenging, with limited evidence-based guidance outside of clinical trial protocols. The increasing availability of oral MTAs is transforming the management of incurable cancer; blurring boundaries between active treatment and palliative care. No studies specifically addressing decision-making around stopping MTAs in clinical practice were identified. There is a need to develop an evidence base to support physicians and patients with decision-making around the withdrawal of these high cost treatments. Electronic supplementary material The online version of this article (doi:10.1186/s12885-015-1862-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- G Clarke
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.
| | - S Johnston
- Carroll Lab Cambridge Research Institute, Cancer Research UK Cambridge Research Institute, Cambridge, United Kingdom.
| | - P Corrie
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom.
| | - I Kuhn
- Medical Library, University of Cambridge, Cambridge, United Kingdom.
| | - S Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.
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Gorini A, Mazzocco K, Pravettoni G. Decision-Making Process Related to Participation in Phase I Clinical Trials: A Nonsystematic Review of the Existing Evidence. Public Health Genomics 2015; 18:359-65. [PMID: 26529420 DOI: 10.1159/000441559] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Due to the lack of other treatment options, patient candidates for participation in phase I clinical trials are considered the most vulnerable, and many ethical concerns have emerged regarding the informed consent process used in the experimental design of such trials. Starting with these considerations, this nonsystematic review is aimed at analyzing the decision-making processes underlying patients' decision about whether to participate (or not) in phase I trials in order to clarify the cognitive and emotional aspects most strongly implicated in this decision. Considering that there is no uniform decision calculus and that many different variables other than the patient-physician relationship (including demographic, clinical, and personal characteristics) may influence patients' preferences for and processing of information, we conclude that patients' informed decision-making can be facilitated by creating a rigorously developed, calibrated, and validated computer tool modeled on each single patient's knowledge, values, and emotional and cognitive decisional skills. Such a tool will also help oncologists to provide tailored medical information that is useful to improve the shared decision-making process, thereby possibly increasing patient participation in clinical trials.
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Affiliation(s)
- Alessandra Gorini
- Department of Health Science, University of Milan, and European Institute of Oncology, Milan, Italy
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Fujisawa D, Temel JS, Traeger L, Greer JA, Lennes IT, Mimura M, Pirl WF. Psychological factors at early stage of treatment as predictors of receiving chemotherapy at the end of life. Psychooncology 2015; 24:1731-7. [DOI: 10.1002/pon.3840] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 03/25/2015] [Accepted: 04/09/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Daisuke Fujisawa
- Massachusetts General Hospital Cancer Center; Boston MA USA
- Department of Neuropsychiatry; Keio University School of Medicine; Tokyo Japan
| | | | - Lara Traeger
- Massachusetts General Hospital Cancer Center; Boston MA USA
| | | | - Inga T. Lennes
- Massachusetts General Hospital Cancer Center; Boston MA USA
| | - Masaru Mimura
- Department of Neuropsychiatry; Keio University School of Medicine; Tokyo Japan
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Wildes TM, Rosko A, Tuchman SA. Multiple myeloma in the older adult: better prospects, more challenges. J Clin Oncol 2014; 32:2531-40. [PMID: 25071143 DOI: 10.1200/jco.2014.55.1028] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Multiple myeloma (MM) is disproportionately diagnosed in older adults; with the aging of the population, the number of older adults diagnosed with MM will increase by nearly 80% in the next two decades. Duration of survival has improved dramatically over the last 20 years, but the improvements in older adults have not been as great as those in younger adults with MM. METHODS In this article, we address treatment approaches in older adults who are eligible for and those ineligible for high-dose therapy with autologous stem-cell transplantation as well as supportive care considerations and the potential role for geriatric assessment in facilitating decision making for older adults with MM. RESULTS The evidence from recent studies demonstrates that combinations of novel and conventional antimyeloma agents result in improved response rates and, in some cases, improved progression-free and overall survival. However, some older adults are particularly vulnerable to toxicities of therapy and discontinuation of therapy and, consequently, they have poorer survival. In addition, older adults may prioritize other outcomes of therapy, such as quality of life, over more conventional end points such as disease response and duration of survival. Geriatric assessment can facilitate risk-stratification of older adults at greater risk for adverse events from therapy and aid in personalizing therapy for vulnerable or frail older adults. CONCLUSION Survival in older adults with MM is improving with novel therapeutics, but efficacy must be balanced with risk of toxicity of therapy and maintenance of quality of life. Novel instruments such as geriatric assessment tools may facilitate these aims.
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Tang ST, Liu TW, Liu LN, Chiu CF, Hsieh RK, Tsai CM. Physician-patient end-of-life care discussions: correlates and associations with end-of-life care preferences of cancer patients-a cross-sectional survey study. Palliat Med 2014; 28:1222-30. [PMID: 24965755 DOI: 10.1177/0269216314540974] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Honoring patients' treatment preferences is a key component of high-quality end-of-life care. Connecting clinical practices to patients' preferences requires effective communication. However, few cancer patients reported discussing end-of-life-care preferences with their physicians. AIM To identify correlates of physician-patient end-of-life-care discussions and to investigate associations of physician-patient end-of-life-care discussions with patient end-of-life-care preferences. DESIGN A cross-sectional survey from April 2011 through November 2012. SETTING/PARTICIPANTS A convenience sample of 2467 cancer patients (89.3% participation rate) whose disease was diagnosed as terminal and unresponsive to current curative cancer treatment was recruited from 23 teaching hospitals throughout Taiwan. RESULTS Only 7.8% of respondents reported discussing end-of-life-care preferences with their physicians. Physicians were more likely to discuss end-of-life-care preferences with cancer patients who accurately understood their prognosis but less likely to do so if patients were married or received care in a hospital with an inpatient hospice unit. Furthermore, physician-patient end-of-life-care discussions were significantly, positively associated with the likelihood of preferring comfort-oriented care and hospice care, but negatively associated with preferences for receiving cardiopulmonary resuscitation when life is in danger and aggressive life-sustaining treatments at end of life, including intensive care unit admission, cardiac massage, intubation, and mechanical ventilation support. CONCLUSION Physician-patient end-of-life-care discussions are correlated with accurate prognostic awareness, marital status, and institutional characteristics and negatively associated with terminally ill cancer patients' preferences for aggressive end-of-life care. Interventions should be developed to facilitate timely end-of-life-care discussions between at-risk patients and their physicians, thus honoring patients' end-of-life-care preferences and possibly avoiding futile life-sustaining treatments.
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Affiliation(s)
- Siew Tzuh Tang
- School of Nursing, Chang Gung University, Tao-Yuan, Taiwan
| | - Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Taipei, Taiwan
| | - Li Ni Liu
- Department of Nursing, Fu Jen Catholic University, Taipei, Taiwan
| | - Chang-Fang Chiu
- Division of Hematology-Oncology and Comprehensive Cancer Center, China Medical University Hospital, Taichung, Taiwan
| | - Ruey-Kuen Hsieh
- Division of Hematology and Oncology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chun-Ming Tsai
- Chest Department, Taipei Veterans General Hospital, Taipei, Taiwan
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Greer JA, Pirl WF, Jackson VA, Muzikansky A, Lennes IT, Gallagher ER, Prigerson HG, Temel JS. Perceptions of health status and survival in patients with metastatic lung cancer. J Pain Symptom Manage 2014; 48:548-57. [PMID: 24680623 DOI: 10.1016/j.jpainsymman.2013.10.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 10/09/2013] [Accepted: 10/30/2013] [Indexed: 10/25/2022]
Abstract
CONTEXT Cognitive awareness of having a terminal illness is associated with critical treatment decisions and outcomes. However, little is known about the course and correlates of such perceptions in patients with metastatic lung cancer. OBJECTIVES We explored changes in perceptions of health status over time in patients with metastatic non-small cell lung cancer (NSCLC) and whether awareness of having a terminal illness was associated with survival. METHODS For this secondary analysis of clinical trial data, we assessed perceptions of health status at baseline, 12, 18, and 24 weeks. At each time point, patients with metastatic NSCLC completed a measure of quality of life (Functional Assessment of Cancer Therapy-Trial Outcome Index) and also reported whether they were "relatively healthy," "seriously but not terminally ill," or "seriously and terminally ill." We reviewed patients' medical records to gather data on clinical characteristics. RESULTS At baseline, 49.3% reported being relatively healthy, whereas the remainder self-identified as seriously but not terminally ill (38.2%) or seriously and terminally ill (12.5%). Over multiple assessments, 24.8% reported having a terminal illness. Adjusting for known prognostic factors, patients' time-varying perceptions of health status remained a significant predictor of survival (hazards ratio = 1.50, 95% CI = 1.07-2.09, P = 0.019). CONCLUSION A minority of patients with metastatic NSCLC acknowledged being terminally ill. Those reporting that they were seriously and terminally ill had shorter survival compared with those who did not consider themselves terminally ill, even after adjusting for decline in physical and functional well-being.
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Affiliation(s)
- Joseph A Greer
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA.
| | - William F Pirl
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Vicki A Jackson
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Alona Muzikansky
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Inga T Lennes
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Emily R Gallagher
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | | | - Jennifer S Temel
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
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Brinkman-Stoppelenburg A, Rietjens JAC, van der Heide A. The effects of advance care planning on end-of-life care: a systematic review. Palliat Med 2014; 28:1000-25. [PMID: 24651708 DOI: 10.1177/0269216314526272] [Citation(s) in RCA: 909] [Impact Index Per Article: 90.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Advance care planning is the process of discussing and recording patient preferences concerning goals of care for patients who may lose capacity or communication ability in the future. Advance care planning could potentially improve end-of-life care, but the methods/tools used are varied and of uncertain benefit. Outcome measures used in existing studies are highly variable. AIM To present an overview of studies on the effects of advance care planning and gain insight in the effectiveness of different types of advance care planning. DESIGN Systematic review. DATA SOURCES We systematically searched PubMed, EMBASE and PsycINFO databases for experimental and observational studies on the effects of advance care planning published in 2000-2012. RESULTS The search yielded 3571 papers, of which 113 were relevant for this review. For each study, the level of evidence was graded. Most studies were observational (95%), originated from the United States (81%) and were performed in hospitals (49%) or nursing homes (32%). Do-not-resuscitate orders (39%) and written advance directives (34%) were most often studied. Advance care planning was often found to decrease life-sustaining treatment, increase use of hospice and palliative care and prevent hospitalisation. Complex advance care planning interventions seem to increase compliance with patients' end-of-life wishes. CONCLUSION The effects of different types of advance care planning have been studied in various settings and populations using different outcome measures. There is evidence that advance care planning positively impacts the quality of end-of-life care. Complex advance care planning interventions may be more effective in meeting patients' preferences than written documents alone. More studies are needed with an experimental design, in different settings, including the community.
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Affiliation(s)
| | - Judith A C Rietjens
- Department of Public Health, Erasmus University Medical Center (Erasmus MC), Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center (Erasmus MC), Rotterdam, The Netherlands
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Hasson-Ohayon I, Goldzweig G, Dorfman C, Uziely B. Hope and social support utilisation among different age groups of women with breast cancer and their spouses. Psychol Health 2014; 29:1303-19. [DOI: 10.1080/08870446.2014.929686] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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59
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Janssen-Heijnen MLG. How safe is chemotherapy and chemoradiation in elderly patients with small-cell lung cancer? Lung Cancer Manag 2014. [DOI: 10.2217/lmt.13.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Maryska LG Janssen-Heijnen
- Department of Clinical Epidemiology, VieCuri Medical Centre, Venlo, The Netherlands and Department of Epidemiology, Maastricht University Medical Center, GROW School for Oncology & Developmental Biology, Maastricht, The Netherlands
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Tang ST, Liu TW, Chow JM, Chiu CF, Hsieh RK, Chen CH, Liu LN, Feng WL. Associations between accurate prognostic understanding and end-of-life care preferences and its correlates among Taiwanese terminally ill cancer patients surveyed in 2011-2012. Psychooncology 2014; 23:780-7. [DOI: 10.1002/pon.3482] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 12/15/2013] [Accepted: 12/17/2013] [Indexed: 01/03/2023]
Affiliation(s)
- Siew Tzuh Tang
- School of Nursing; Chang Gung University; Tao-Yuan Taiwan
| | - Tsang-Wu Liu
- National Health Research Institutes; National Institute of Cancer Research; Taipei Taiwan
| | - Jyh-Ming Chow
- Section of Hematology and Medical Oncology; Wan-Fang Hospital; Taipei Taiwan
| | - Chang-Fang Chiu
- Division of Hematology-Oncology and Comprehensive Cancer Center; China Medical University Hospital; Taichung Taiwan
| | - Ruey-Kuen Hsieh
- Division of Hematology and Oncology, Department of Internal Medicine; Mackay Memorial Hospital; Taipei Taiwan
| | - Chen H. Chen
- School of Nursing; Kang-Ning Junior College of Medical Care and Management; Taipei Taiwan
| | - Li Ni Liu
- Department of Nursing; Fu Jen Catholic University; Taipei Taiwan
| | - Wei-Lien Feng
- National Health Research Institutes; National Institute of Cancer Research; Taipei Taiwan
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Zhang Z, Chen ML, Gu XL, Liu MH, Cheng WW. Cultural and Ethical Considerations for Cardiopulmonary Resuscitation in Chinese Patients With Cancer at the End of Life. Am J Hosp Palliat Care 2014; 32:210-5. [DOI: 10.1177/1049909113520215] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
End-of-life (EOL) decision making is based on the values and wishes of terminally ill patients. However, little is known on the extent to which cultural factors affect personal attitudes toward life-sustaining treatments (LSTs) such as cardiopulmonary resuscitation (CPR) in China. This study evaluated the cultural and ethical considerations during EOL decisions and assessed the factors that affect pursuing LSTs in China. We used a case–control study design and compared their baseline characteristics with the provided EOL care and treatments. The CPR treatment among patients with cancer at EOL was affected by Chinese family traditions and Western influences. Our results reflect the need to improve EOL care and treatment in China.
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Affiliation(s)
- Zhe Zhang
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Meng-Lei Chen
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiao-Li Gu
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ming-Hui Liu
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wen-Wu Cheng
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Abdallah MS, Wang K, Magnuson EA, Spertus JA, Farkouh ME, Fuster V, Cohen DJ. Quality of life after PCI vs CABG among patients with diabetes and multivessel coronary artery disease: a randomized clinical trial. JAMA 2013; 310:1581-90. [PMID: 24129463 PMCID: PMC4370776 DOI: 10.1001/jama.2013.279208] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE The FREEDOM trial demonstrated that among patients with diabetes mellitus and multivessel coronary artery disease, coronary artery bypass graft (CABG) surgery resulted in lower rates of death and myocardial infarction but a higher risk of stroke when compared with percutaneous coronary intervention (PCI) using drug-eluting stents. Whether there are treatment differences in health status, as assessed from the patient's perspective, is unknown. OBJECTIVES To compare the relative effects of CABG vs PCI using drug-eluting stents on health status among patients with diabetes mellitus and multivessel coronary artery disease. DESIGN, SETTING, AND PARTICIPANTS Between 2005 and 2010, 1900 patients from 18 countries with diabetes mellitus and multivessel coronary artery disease were randomized to undergo either CABG surgery (n = 947) or PCI (n = 953) as an initial treatment strategy. Of these, a total of 1880 patients had baseline health status assessed (935 CABG, 945 PCI) and comprised the primary analytic sample. INTERVENTIONS Initial revascularization with CABG surgery or PCI. MAIN OUTCOMES AND MEASURES Health status was assessed using the angina frequency, physical limitations, and quality-of-life domains of the Seattle Angina Questionnaire at baseline, at 1, 6, and 12 months, and annually thereafter. For each scale, scores range from 0 to 100 with higher scores representing better health. The effect of CABG surgery vs PCI was evaluated using longitudinal mixed-effect models. RESULTS At baseline, mean (SD) scores for the angina frequency, physical limitations, and quality-of-life subscales of the Seattle Angina Questionnaire were 70.9 (25.1), 67.3 (24.4), and 47.8 (25.0) for the CABG group and 71.4 (24.7), 69.9 (23.2), and 49.2 (25.7) for the PCI group, respectively. At 2-year follow-up, mean (SD) scores were 96.0 (11.9), 87.8 (18.7), and 82.2 (18.9) after CABG and 94.7 (14.3), 86.0 (19.3), and 80.4 (19.6) after PCI, with significantly greater benefit of CABG on each domain (mean treatment benefit, 1.3 [95% CI, 0.3-2.2], 4.4 [95% CI, 2.7-6.1], and 2.2 [95% CI, 0.7-3.8] points, respectively; P < .01 for each comparison). Beyond 2 years, the 2 revascularization strategies provided generally similar patient-reported outcomes. CONCLUSIONS AND RELEVANCE For patients with diabetes and multivessel CAD, CABG surgery provided slightly better intermediate-term health status and quality of life than PCI using drug-eluting stents. The magnitude of benefit was small, without consistent differences beyond 2 years, in part due to the higher rate of repeat revascularization with PCI. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00086450.
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Affiliation(s)
- Mouin S Abdallah
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri 64111, USA
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Greer JA, Jackson VA, Meier DE, Temel JS. Early integration of palliative care services with standard oncology care for patients with advanced cancer. CA Cancer J Clin 2013; 63:349-63. [PMID: 23856954 DOI: 10.3322/caac.21192] [Citation(s) in RCA: 191] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 04/01/2013] [Accepted: 04/02/2013] [Indexed: 12/25/2022] Open
Abstract
Scientific advances in novel cancer therapeutics have led to remarkable changes in oncology practice and longer lives for patients diagnosed with incurable malignancies. However, the myriad options for treatment have established a culture of cancer care that has not been matched with a similar availability of efficacious supportive care interventions aimed at relieving debilitating symptoms due to progressive disease and treatment side effects. Accumulating data show that the introduction of palliative care services at the time of diagnosis of advanced cancer leads to meaningful improvement in the experiences of patients and family caregivers by emphasizing symptom management, quality of life, and treatment planning. In this review article, the rationale and evidence base for this model of early palliative care services integrated into standard oncology care are presented. In addition, the implications and limitations of the existing data to 1) elucidate the mechanisms by which early palliative care benefits patients and families; 2) guide the dissemination and application of this model in outpatient settings; and 3) inform health care policy regarding the delivery of high-quality, cost-effective, and comprehensive cancer care are discussed.
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Affiliation(s)
- Joseph A Greer
- Assistant Professor of Psychology, Harvard Medical School, and Assistant in Psychology, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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Saltbaek L, Michelsen HM, Nelausen KM, Gut R, Nielsen DL. Old age and poor prognosis increase the likelihood of disagreement between cancer patients and their oncologists on the indication for resuscitation attempt. Support Care Cancer 2013; 21:3363-70. [DOI: 10.1007/s00520-013-1916-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 07/22/2013] [Indexed: 11/24/2022]
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Step MM, Kypriotakis GM, Rose JH. An Exploration of the relative influence of patient's age and cancer recurrence status on symptom distress, anxiety, and depression over time. J Psychosoc Oncol 2013; 31:168-90. [PMID: 23514253 PMCID: PMC10161869 DOI: 10.1080/07347332.2012.761318] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Past research suggests that psychosocial responses to advanced or recurrent cancer vary by age. This study compares the relative influences of patients' age and recurrence status on indicators of symptom distress, anxiety, and depression following a diagnosis of advanced cancer. A prospective study of advanced cancer support provided patient outcome data reported at baseline, 3-, and 6-month intervals. Cohorts were defined by age group and recurrence status and latent growth curves fit to anxiety, depression, and symptom distress outcomes. Middle-age recurrent patients reported the highest symptom distress, depression, and anxiety across time points. Older recurrent patients fared worse at baseline than older nonrecurrent patients, but outcome scores converged across time points. Recurrent cancer presents a distinct challenge that, for middle-age patients, persists across time. It may be beneficial to develop targeted educational and support resources for middle-age patients with recurrent disease.
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Affiliation(s)
- Mary M Step
- Case Western Reserve University School of Medicine and Case Comprehensive Cancer Center Program on Aging and Cancer, Cleveland, OH, USA.
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66
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Lopez-Acevedo M, Havrilesky LJ, Broadwater G, Kamal AH, Abernethy AP, Berchuck A, Alvarez Secord A, Tulsky JA, Valea F, Lee PS. Timing of end-of-life care discussion with performance on end-of-life quality indicators in ovarian cancer. Gynecol Oncol 2013; 130:156-61. [PMID: 23587882 DOI: 10.1016/j.ygyno.2013.04.010] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 04/03/2013] [Accepted: 04/07/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVES (1) To describe the prevalence, timing and setting of documented end-of-life (EOL) discussions in patients with advanced ovarian cancer; and (2) to assess the impact of timing and setting of documented end-of-life discussions on EOL quality care measures. METHODS A retrospective study of women who died of ovarian cancer diagnosed between 1999 and 2008 was conducted. The following are the EOL quality measures assessed: chemotherapy in the last 14 days of life, >1 hospitalization in the last 30 days, >1 ER visit in the last 30 days, intensive care unit (ICU) admission in the last 30 days, dying in an acute care setting, admitted to hospice ≤3 days. RESULTS One hundred seventy-seven (80%) patients had documented end-of-life discussions. Median interval from EOL discussion until death was 29 days. Seventy-eight patients (44%) had EOL discussions as outpatient and 99 (56%) as inpatient. Sixty-four out of 220 (29%) patients' care did not conform to at least one EOL quality measure. An EOL discussion at least 30 days before death was associated with a lower incidence of: chemotherapy in the last 14 days of life (p=0.003), >1 hospitalization in the last 30 days (p<0.001), ICU admission in the last 30 days (p=0.005), dying in acute care setting (p=0.01), admitted to hospice ≤3 days (p=0.02). EOL discussion as outpatient was associated with fewer patients hospitalized >1 in the last 30days of life (p<0.001). CONCLUSIONS End-of-life care discussions are occurring too late in the disease process. Conformance with EOL quality measures can be achieved with earlier end-of-life care discussions.
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Affiliation(s)
- Micael Lopez-Acevedo
- Division of Gynecologic Oncology, Duke University Medical Center, Durham, NC 27710, USA.
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Lennes IT, Temel JS, Hoedt C, Meilleur A, Lamont EB. Predictors of newly diagnosed cancer patients' understanding of the goals of their care at initiation of chemotherapy. Cancer 2013; 119:691-9. [PMID: 23011902 PMCID: PMC3531571 DOI: 10.1002/cncr.27787] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 06/18/2012] [Accepted: 07/03/2012] [Indexed: 11/12/2022]
Abstract
BACKGROUND The American Society of Clinical Oncology Quality Oncology Practice Initiative endorses in their core measures that providers should discuss the goals of care (GOC) at the time of chemotherapy consent. GOC refers to chemotherapy treatment intent: cure versus noncure. In this study, the authors sought to determine whether attributes of patients and initial patient-physician encounters were associated with patients' understanding of their GOC. METHODS In total, the authors surveyed 125 consecutive, newly diagnosed patients who were receiving chemotherapy for solid malignancies at a single academic cancer center and performed a medical record review for additional data. Patient understanding of their oncologist's GOC and oncologist's reported GOC were compared. The primary outcome was concordance of patient-physician dyads regarding the GOC (cure vs noncure). RESULTS One hundred twenty-five of 137 of eligible patients (91%) completed the survey. Only 95 of 125 patient-physician pairs (75%) patient-physician pairs were concordant regarding the GOC. In a multivariable logistic regression, both older patients (odds ratio, 0.21; 95% confidence interval, 0.08-0.57) and non-native English speakers had an almost 80% lower odds (odds ratio, 0.23; 95% confidence interval, 0.05-0.93) of GOC concordance compared with younger patients and native English speakers. Patients who received printed chemotherapy information during the patient-physician consent process had almost 3 times greater odds (odds ratio, 2.88; 95% confidence interval, 1.24-6.68) of GOC concordance with their physician compared with those who did not receive materials. CONCLUSIONS Patient misunderstanding of GOC was substantial, with 25% of cancer patients misunderstanding the goal of their chemotherapy treatment. Key predictors of GOC misunderstanding included factors that potentially were amenable to interventions at the time of chemotherapy consent.
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Affiliation(s)
- Inga T Lennes
- Massachusetts General Hospital Cancer Center, Boston, MA 02114, USA.
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68
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Morden NE, Chang CH, Jacobson JO, Berke EM, Bynum JPW, Murray KM, Goodman DC. End-of-life care for Medicare beneficiaries with cancer is highly intensive overall and varies widely. Health Aff (Millwood) 2012; 31:786-96. [PMID: 22492896 DOI: 10.1377/hlthaff.2011.0650] [Citation(s) in RCA: 173] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Studies have shown that cancer care near the end of life is more aggressive than many patients prefer. Using a cohort of deceased Medicare beneficiaries with poor-prognosis cancer, meaning that they were likely to die within a year, we examined the association between hospital characteristics and eleven end-of-life care measures, such as hospice use and hospitalization. Our study revealed a relatively high intensity of care in the last weeks of life. At the same time, there was more than a twofold variation within hospital groups with common features, such as cancer center designation and for-profit status. We found that these hospital characteristics explained little of the observed variation in intensity of end-of-life cancer care and that none reliably predicted a specific pattern of care. These findings raise questions about what factors may be contributing to this variation. They also suggest that best practices in end-of-life cancer care can be found in many settings and that efforts to improve the quality of end-of-life care should include every hospital category.
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Miesfeldt S, Murray K, Lucas L, Chang CH, Goodman D, Morden NE. Association of age, gender, and race with intensity of end-of-life care for Medicare beneficiaries with cancer. J Palliat Med 2012; 15:548-54. [PMID: 22468739 DOI: 10.1089/jpm.2011.0310] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To measure intensity of end-of-life (EOL) care for Medicare cancer patients and variations in care by age, gender, and race. PATIENTS AND METHODS This retrospective cohort analysis of Medicare claims (20% sample) examined 235,821 Medicare Parts A and B fee-for-service patients dying with poor-prognosis cancers between 2003 and 2007. Logistic regression models quantified associations between care intensity and age, gender, and race. Measures included hospitalizations, emergency department (ED) visits, intensive care unit (ICU) admissions, in-hospital deaths, late-life chemotherapy administration, overall and late hospice enrollment within six months of death. RESULTS Within 30 days of death, 61.3% of patients were hospitalized, 10.2% were hospitalized more than once, 10.2% visited an ED more than once, 23.7% had ICU admissions, and 28.8% died in-hospital. Within two weeks of death, 6% received chemotherapy. In their final six months, 55.2% accessed hospice, 15.1% within three days of death. Older age (≥75 versus <75) was associated with lower odds ratios (ORs) of 0.49 to 0.89 for aggressive care, and an OR of 0.92 (95% CI 0.89-0.95) for late hospice enrollment. Female gender was associated with lower ORs (0.82 to 0.86) for aggressive care, and an OR of 0.84 (95% CI 0.81-0.86) for late hospice enrollment. Black (versus nonblack) race was associated with higher ORs (1.08 to 1.38) for aggressive acute care, lower ORs for late chemotherapy, OR 0.76 (95% CI 0.71-0.81), and late hospice enrollment, OR 0.81 (95% CI 0.76-0.86). CONCLUSIONS Seniors dying with poor-prognosis cancer experience high-intensity care with rates varying by age, gender, and race.
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Affiliation(s)
- Susan Miesfeldt
- Maine Medical Center Research Institute, Maine Medical Center, Portland, Maine, USA.
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Borreani C, Brunelli C, Bianchi E, Piva L, Moro C, Miccinesi G. Talking about end-of-life preferences with advanced cancer patients: factors influencing feasibility. J Pain Symptom Manage 2012; 43:739-46. [PMID: 22464353 DOI: 10.1016/j.jpainsymman.2011.05.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 05/03/2011] [Accepted: 05/12/2011] [Indexed: 11/30/2022]
Abstract
CONTEXT The End-of-Life Preferences Interview (ELPI) was developed with the purpose of supporting physicians in communicating with advanced cancer patients. OBJECTIVES This study aimed to evaluate ELPI feasibility and compare home care/hospice (HC-H) vs. outpatient (OU) care settings. METHODS Twenty-eight physicians were trained in the use of the ELPI and were asked to apply the new instrument in their daily clinical practice for two months. ELPI feasibility was evaluated through three indices: the percentage of eligible patients, the percentage of patients to whom the ELPI was proposed, and the percentage of completed interviews. RESULTS The 23 physicians participating in the data collection screened 633 patients, and 156 of them (25%, 95% confidence interval 21%-28%) were judged to be eligible. Eligibility in HC-H was lower than that in the OU setting (18% vs. 46%; P<0.0001), whereas the differences were reduced when looking at patients to whom the ELPI was proposed (12% vs. 20%; P=0.017) and who completed the ELPI (8% vs. 18%; P<0.001). The percentage of eligible patients refusing the interview was very low in the entire sample (1.9%). CONCLUSION Results indicate that discussing end-of-life preferences in an earlier disease phase, such as in the OU setting, could be preferable but that its accomplishment in this setting may be more difficult, mainly as a result of organizational reasons. This observation could indicate that the system is not yet ready to offer patients such an opportunity and although communication on these sensitive issues cannot be reduced to a procedure, the ELPI can become a useful tool to help physicians in accomplishing this difficult task.
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Affiliation(s)
- Claudia Borreani
- Clinical Psychology Unit, IRCCS Foundation, National Cancer Institute, Milan, Italy.
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Greer JA, Pirl WF, Jackson VA, Muzikansky A, Lennes IT, Heist RS, Gallagher ER, Temel JS. Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer. J Clin Oncol 2011; 30:394-400. [PMID: 22203758 DOI: 10.1200/jco.2011.35.7996] [Citation(s) in RCA: 398] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Prior research shows that introducing palliative care soon after diagnosis for patients with metastatic non-small-cell lung cancer (NSCLC) is associated with improvements in quality of life, mood, and survival. We sought to investigate whether early palliative care also affects the frequency and timing of chemotherapy use and hospice care for these patients. PATIENTS AND METHODS This secondary analysis is based on a randomized controlled trial of 151 patients with newly diagnosed metastatic NSCLC presenting to an outpatient clinic at a tertiary cancer center from June 2006 to July 2009. Participants received either early palliative care integrated with standard oncology care or standard oncology care alone. By 18-month follow-up, 133 participants (88.1%) had died. Outcome measures included: first, number and types of chemotherapy regimens, and second, frequency and timing of chemotherapy administration and hospice referral. RESULTS The overall number of chemotherapy regimens did not differ significantly by study group. However, compared with those in the standard care group, participants receiving early palliative care had half the odds of receiving chemotherapy within 60 days of death (odds ratio, 0.47; 95% CI, 0.23 to 0.99; P = .05), a longer interval between the last dose of intravenous chemotherapy and death (median, 64.00 days [range, 3 to 406 days] v 40.50 days [range, 6 to 287 days]; P = .02), and higher enrollment in hospice care for longer than 1 week (60.0% [36 of 60 patients] v 33.3% [21 of 63 patients]; P = .004). CONCLUSION Although patients with metastatic NSCLC received similar numbers of chemotherapy regimens in the sample, early palliative care optimized the timing of final chemotherapy administration and transition to hospice services, key measures of quality end-of-life care.
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Affiliation(s)
- Joseph A Greer
- Massachusetts General Hospital Cancer Center, Yawkey Building, Suite 9A, 55 Fruit St, Boston, MA 02114, USA.
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Temel JS, Greer JA, Admane S, Gallagher ER, Jackson VA, Lynch TJ, Lennes IT, Dahlin CM, Pirl WF. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: results of a randomized study of early palliative care. J Clin Oncol 2011; 29:2319-26. [PMID: 21555700 DOI: 10.1200/jco.2010.32.4459] [Citation(s) in RCA: 478] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Understanding of prognosis among terminally ill patients impacts medical decision making. The aims of this study were to explore perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer (NSCLC) and to examine the effect of early palliative care on these views over time. PATIENTS AND METHODS Patients with newly diagnosed metastatic NSCLC were randomly assigned to receive either early palliative care integrated with standard oncology care or standard oncology care alone. Participants completed baseline and longitudinal assessments of their perceptions of prognosis and the goals of cancer therapy over a 6-month period. RESULTS We enrolled 151 participants on the study. Despite having terminal cancer, one third of patients (46 of 145 patients) reported that their cancer was curable at baseline, and a majority (86 of 124 patients) endorsed getting rid of all of the cancer as a goal of therapy. Baseline perceptions of prognosis (ie, curability) and goals of therapy did not differ significantly between study arms. A greater percentage of patients assigned to early palliative care retained or developed an accurate assessment of their prognosis over time (82.5% v 59.6%; P = .02) compared with those receiving standard care. Patients receiving early palliative care who reported an accurate perception of their prognosis were less likely to receive intravenous chemotherapy near the end of life (9.4% v 50%; P = .02). CONCLUSION Many patients with newly diagnosed metastatic NSCLC hold inaccurate perceptions of their prognoses. Early palliative care significantly improves patient understanding of prognosis over time, which may impact decision making about care near the end of life.
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Affiliation(s)
- Jennifer S Temel
- Massachusetts GeneralHospital Cancer Center, 55 Fruit Street, Massachusetts General Hospital, Boston, MA 02114, USA.
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Malin JL, O'Neill SM, Asch SM, Dy SM, Walling AM, Tisnado D, Antonio AL, Lorenz KA. Quality of Supportive Care for Patients with Advanced Cancer in a VA Medical Center. J Palliat Med 2011; 14:573-7. [DOI: 10.1089/jpm.2010.0464] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jennifer L. Malin
- VA Greater Los Angeles Healthcare System, RAND Health, David Geffen School of Medicine, University of California, Los Angeles
| | - Sean M. O'Neill
- Pardee RAND Graduate School, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Steven M. Asch
- VA Greater Los Angeles Healthcare System, RAND Health, David Geffen School of Medicine, University of California, Los Angeles
| | - Sydney M. Dy
- Departments of Health Policy and Management, Oncology, and Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Anne M. Walling
- VA Greater Los Angeles, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles
| | - Diana Tisnado
- VA Greater Los Angeles, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles
| | - Anna Liza Antonio
- VA Greater Los Angeles, School of Public Health, University of California, Los Angeles
| | - Karl A. Lorenz
- VA Greater Los Angeles Healthcare System, RAND Health, David Geffen School of Medicine, University of California, Los Angeles
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Backshall A, Sharma R, Clarke SJ, Keun HC. Pharmacometabonomic profiling as a predictor of toxicity in patients with inoperable colorectal cancer treated with capecitabine. Clin Cancer Res 2011; 17:3019-28. [PMID: 21415219 DOI: 10.1158/1078-0432.ccr-10-2474] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE Endogenous metabolic profiles have been shown to predict the fate and toxicity of drugs such as acetaminophen in healthy individuals. However, the clinical utility of metabonomics in oncology remains to be defined. We aimed to evaluate the effect of pretreatment serum metabolic profiles generated by (1)H NMR spectroscopy on toxicity in patients with inoperable colorectal cancer receiving single agent capecitabine. EXPERIMENTAL DESIGN Serum was collected from 54 patients with a diagnosis of locally advanced or metastatic colorectal cancer prior to treatment with single agent capecitabine. (1)H NMR spectroscopy was used to generate metabolic profile data for each patient. Toxicities were graded according to National Cancer Institute Common Toxicity Criteria version 2.0. RESULTS Higher levels of low-density lipoprotein-derived lipids, including polyunsaturated fatty acids and choline phospholipids predicted for higher grade toxicity over the treatment period. Statistical analyses revealed a "pharmacometabonomic" lipid profile that correlated with severity of toxicity. CONCLUSIONS This study suggests that metabolic profiles can delineate subpopulations susceptible to adverse events and have a potential role in the assessment of treatment viability for cancer patients prior to commencing chemotherapy.
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Affiliation(s)
- Alexandra Backshall
- Department of Surgery & Cancer, Faculty of Medicine, Imperial College London South Kensington Campus, London, United Kingdom
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75
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Maida V, Peck J, Ennis M, Brar N, Maida AR. Preferences for active and aggressive intervention among patients with advanced cancer. BMC Cancer 2010; 10:592. [PMID: 21029455 PMCID: PMC2988029 DOI: 10.1186/1471-2407-10-592] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Accepted: 10/28/2010] [Indexed: 12/02/2022] Open
Abstract
Background Intrinsic to "Patient-Centered Care" is being respectful and responsive to individual patient preferences, expressed needs, and personal values. Establishing a patient's preferences for active and aggressive intervention is imperative and foundational to the development of advance care planning. With the increasing awareness and acceptance of palliative philosophies of care, patients with advanced cancer are increasingly transitioning from active and aggressive medical management (AAMM) to conservative palliative management (CPM). Methods A cross-sectional study based on a prospective and sequential case series of patients referred to a regional palliative medicine consultative program was assembled between May 1, 2005 and June 30, 2006. Patients and/or their substitute decision makers (SDM) completed a questionnaire, at baseline, that assessed their preferences for AAMM en route to their eventual deaths. Seven common interventions constituting AAMM were surveyed: cardiopulmonary resuscitation (CPR) & mechanical ventilation (MV), chemotherapy, antibiotics, anticoagulants, blood transfusions, feeding tubes, and artificial hydration. Multivariable analyses were conducted on the seven interventions individually as well as on the composite score that summed preferences for the seven interventions. Results 380 patients with advanced cancer agreed to participate in the study. A trend to desire a mostly conservative palliative approach was noted as 42% of patients desired one or fewer interventions. At baseline, most patients and their SDM's were relatively secure about decisions pertaining to the seven interventions as the rates of being "undecided" ranged from a high of 23.4% for chemotherapy to a low of 3.9% for feeding tubes. Multivariable modeling showed that more AAMM was preferred by younger patients (P < 0.0001), non-Caucasians (P = 0.042), patients with higher baseline Palliative Performance Scale scores (P = 0.0002) and where a SDM was involved in the decision process (p = 0.027). Non-statistically significant trends to prefer more AAMM was observed with male gender (p = 0.077) and higher levels of the Charlson Comorbidity index (p = 0.059). There was no association between treatment preferences and cancer class. Conclusions Although the majority of patients with advanced cancer in this study expressed preferences for CPM, younger age, higher baseline PPSv2, and involvement of SDMs in the decision process were significantly associated with preferences for AAMM.
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Affiliation(s)
- Vincent Maida
- Division of Palliative Medicine, William Osler Health System, Toronto, Ontario, Canada.
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76
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Parr JD, Zhang B, Nilsson ME, Wright A, Balboni T, Duthie E, Paulk E, Prigerson HG. The influence of age on the likelihood of receiving end-of-life care consistent with patient treatment preferences. J Palliat Med 2010; 13:719-26. [PMID: 20597704 DOI: 10.1089/jpm.2009.0337] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Age differences may help to explain discrepancies in medical care received by cancer patients near death. OBJECTIVES Understanding age differences in advanced cancer patients' end-of-life experiences. DESIGN NCI and NIMH funded multi-site prospective cohort study. PARTICIPANTS 396 deceased cancer patients, mean age (58.6 +/- 12.5), in the Coping with Cancer study. MEASUREMENTS Baseline interviews (Treatment Preference) and 1 week postmortem chart reviews (Treatment Received). RESULTS 14.1% of patients were 20-44 years old, 54.0% were 45-64 years old, and 31.8% were > or = 65 years old. Compared to younger patients, middle-aged patients wanted less life-prolonging care (OR 0.32; CI 0.16-0.64). In the last week of life, older patients were less likely to undergo ventilation (OR 0.27; CI 0.07-1.00) than younger patients. Middle-aged patients who preferred life-prolonging care were less likely to receive it than younger patients (OR 0.21; CI 0.08-0.54), but were more likely to avoid unwanted life-prolonging care (OR 2.38; CI 1.20-4.75) than younger patients. Older patients were less likely to receive desired life-prolonging care than younger patients (OR 0.23; CI 0.08-0.68), however, they were not more likely to avoid unwanted life-prolonging care than younger patients (OR 1.74; CI 0.87-3.47). CONCLUSIONS Likelihood of a patient's treatment preference being consistent with care differ by age and treatment preferences. Older patients preferring life-prolonging therapies are less likely to receive them than younger patients; middle-aged patients who want to avoid life-prolonging care are more likely to do so than younger patients. Both findings have implications for patients' quality-of-death, indicating a need for further research.
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Affiliation(s)
- John D Parr
- Department of Medical Education, Medical College of Wisconsin, Milwoukee, Wisconsin 53213, USA.
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Wright AA, Mack JW, Kritek PA, Balboni TA, Massaro AF, Matulonis UA, Block SD, Prigerson HG. Influence of patients' preferences and treatment site on cancer patients' end-of-life care. Cancer 2010; 116:4656-63. [PMID: 20572030 PMCID: PMC3670423 DOI: 10.1002/cncr.25217] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Research suggests that patients' end-of-life (EOL) care is determined primarily by the medical resources available, and not by patient preferences. The authors examined whether patients' desire for life-extending therapy was associated with their EOL care. METHODS Coping with Cancer is a multisite, prospective, longitudinal study of patients with advanced cancer. Three hundred one patients were interviewed at baseline and followed until death, a median of 4.5 months later. Multivariate analyses examined the influence of patients' preferences and treatment site on whether patients received intensive care or hospice services in the final week of life. RESULTS Eighty-three of 301 patients (27.6%) with advanced cancer wanted life-extending therapy at baseline. Patients who understood that their disease was terminal or who reported having EOL discussions with their physicians were less likely to want life-extending care compared with others (23.4% vs 42.6% and 20.7% vs 44.4%, respectively; P≤.003). Patients who were treated at Yale Cancer Center received more intensive care (odds ratio [OR], 3.14; 95% confidence interval [CI], 1.16-8.47) and less hospice services (OR, 0.52; 95% CI, 0.29-0.92) compared with patients who were treated at Parkland Hospital. However, in multivariate analyses that controlled for confounding influences, patients who preferred life-extending care were more likely to receive intensive care (adjusted OR [AOR], 2.91; 95% CI, 1.09-7.72) and were less likely to receive hospice services (AOR, 0.45; 95% CI, 0.26-0.78). Treatment site was not identified as a significant predictor of EOL care. CONCLUSIONS The treatment preferences of patients with advanced cancer may play a more important role in determining the intensity of medical care received at the EOL than previously recognized. Future research is needed to determine the mechanisms by which patients' preferences for care and treatment site interact to influence EOL care.
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Affiliation(s)
- Alexi A Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts 02115, USA.
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Kumar G, Markert RJ, Patel R. Assessment of Hospice Patients’ Goals of Care at the End of Life. Am J Hosp Palliat Care 2010; 28:31-4. [DOI: 10.1177/1049909110371469] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To evaluate satisfaction with inpatient hospice goals at the end of life and to determine steps for program improvement. Study design and setting: Prospective observational study of patients admitted to an inpatient Veterans Affairs Medical Center hospice unit, located in an urban setting with dedicated 16 hospice and 20 palliative care beds. Patients and their families are cared for by an interdisciplinary team. Population: Veteran population receiving care in an inpatient hospice unit whose goals are comfort care. Intervention: Two anonymous surveys of patient goals were distributed upon admission to hospice unit patients and families, who were asked to complete the first survey within 1 to 5 days of admission and the second survey 2 weeks after admission or later. Outcome measure: Patient and family centered end-of-life care outcomes, including meeting goals of care with desired symptom management, emotional support to the dying patient, coordinated care, shared decision making, and attending to the emotional needs of families. Results: Fifty patients were given surveys between June and September 2009. Response rate was 52% for the first survey and 36% for the second survey. Most important goals for 90% of veterans were control of symptoms and being with family. More than 90% of our patients’ families, responding to our second survey, strongly agreed that these goals were achieved. We also identified other needs of hospice veterans, and family surveys showed that these were also accomplished. Conclusion: Clarification and focus on goals of care improves satisfaction with end-of-life care.
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Affiliation(s)
- Geetika Kumar
- Dayton VA Medical Center, Dayton, OH, USA, Wright State University Boonshoft School of Medicine, Dayton, OH, USA,
| | - Ronald J. Markert
- Wright State University Boonshoft School of Medicine, Dayton, OH, USA
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Rose JH, O'Toole EE, Koroukian S, Berger NA. Geriatric oncology and primary care: promoting partnerships in practice and research. J Am Geriatr Soc 2010; 57 Suppl 2:S235-8. [PMID: 20122017 DOI: 10.1111/j.1532-5415.2009.02500.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This supplement is a compilation of original work that was presented at an interdisciplinary conference on "Geriatric Oncology and Primary Care: Promoting Partnerships in Practice and Research" held in Cleveland, Ohio, April 3 to 4, 2008. An audience of 77 clinicians and researchers attended this conference, primarily coming from Ohio and adjacent states. Articles are organized around a conceptual framework to consider primary and shared care roles of primary care physicians (PCPs) and oncologists in the care of older patients with cancer and their families. Articles in Section One focus on evidence-based clinical practice and recommendations. Section Two includes articles on original psychosocial and health services research that inform this topic. Papers in this conference were developed in recognition of the greater prevalence and growing incidence of cancer in older adults; the unique geriatric expertise and practice considerations essential to the prevention and control of cancer in older adults; the important and effective roles that PCPs may play in such care; and the need to develop shared care models that foster collaboration between PCPs and oncologists, from cancer prevention through long-term survivorship and end-of-life care of older adults. Models of shared care between oncologists and PCPs should be tested and compared for optimal care of older patients with cancer and their families. Potential implications of ideally shared care include more-informed patient-centered decision-making, better adherence to treatment, improved match between older patient goals and treatments, and thus better outcomes.
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Affiliation(s)
- Julia Hannum Rose
- School of Medicine, Case Western Reserve University, Cleveland, Ohio 44106-4971, USA
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Mack JW, Weeks JC, Wright AA, Block SD, Prigerson HG. End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences. J Clin Oncol 2010; 28:1203-8. [PMID: 20124172 DOI: 10.1200/jco.2009.25.4672] [Citation(s) in RCA: 588] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Physicians have an ethical obligation to honor patients' values for care, including at the end of life (EOL). We sought to evaluate factors that help patients to receive care consistent with their preferences. METHODS This was a longitudinal multi-institutional cohort study. We measured baseline preferences for life-extending versus symptom-directed care and actual EOL care received in 325 patients with advanced cancer. We also measured associated sociodemographic, health, and communication characteristics, including EOL discussions between patients and physicians. RESULTS Preferences were assessed a median of 125 days before death. Overall, 68% of patients (220 of 325 patients) received EOL care consistent with baseline preferences. The proportion was slightly higher among patients who recognized they were terminally ill (74%, 90 of 121 patients; P = .05). Patients who recognized their terminal illness were more likely to prefer symptom-directed care (83%, 100 of 121 patients; v 66%, 127 of 191 patients; P = .003). However, some patients who were aware they were terminally ill wished to receive life-extending care (17%, 21 of 121 patients). Patients who reported having discussed their wishes for EOL care with a physician (39%, 125 of 322 patients) were more likely to receive care that was consistent with their preferences, both in the full sample (odds ratio [OR] = 2.26; P < .0001) and among patients who were aware they were terminally ill (OR = 3.94; P = .0005). Among patients who received no life-extending measures, physical distress was lower (mean score, 3.1 v 4.1; P = .03) among patients for whom such care was consistent with preferences. CONCLUSION Patients with cancer are more likely to receive EOL care that is consistent with their preferences when they have had the opportunity to discuss their wishes for EOL care with a physician.
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Affiliation(s)
- Jennifer W Mack
- Dana-Farber Cancer Institute, Department of Pediatric Oncology, 44 Binney St-454, Boston, MA 02115, USA.
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Hill QA. Intensify, resuscitate or palliate: Decision making in the critically ill patient with haematological malignancy. Blood Rev 2010; 24:17-25. [DOI: 10.1016/j.blre.2009.10.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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82
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A population-based study on the prevalence and determinants of cardiopulmonary resuscitation in the last month of life for Taiwanese cancer decedents, 2001–2006. Resuscitation 2009; 80:1388-93. [DOI: 10.1016/j.resuscitation.2009.08.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Revised: 08/03/2009] [Accepted: 08/07/2009] [Indexed: 11/18/2022]
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83
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Rose JH, Bowman KF, Radziewicz RM, Lewis SA, O'Toole EE. Predictors of Engagement in a Coping and Communication Support Intervention for Older Patients with Advanced Cancer. J Am Geriatr Soc 2009; 57 Suppl 2:S296-9. [DOI: 10.1111/j.1532-5415.2009.02517.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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84
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Aspects psycho-oncologiques des cancers urologiques chez le sujet âgé. Prog Urol 2009; 19 Suppl 3:S110-5. [DOI: 10.1016/s1166-7087(09)73355-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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85
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Step MM, Siminoff LA, Rose JH. Differences in Oncologist Communication Across Age Groups and Contributions to Adjuvant Decision Outcomes. J Am Geriatr Soc 2009; 57 Suppl 2:S279-82. [DOI: 10.1111/j.1532-5415.2009.02512.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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86
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Rose JH, Kypriotakis G, Bowman KF, Einstadter D, O'Toole EE, Mechekano R, Dawson NV. Patterns of adaptation in patients living long term with advanced cancer. Cancer 2009; 115:4298-310. [DOI: 10.1002/cncr.24584] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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87
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Abstract
The adverse prognostic impact of advanced age in multiple myeloma is multi-factorial. In this review we explore the various contributory factors to this phenomenon. These include general biological and psychosocial factors, which impact on cancer in the elderly population such as the presence of multiple co morbidities and poor performance status at diagnosis and variation in patient's expectations of treatment. Factors specific to myeloma include the ability to deliver optimum therapy in older patients and the impact of this on disease response, possible biological differences of myeloma in older patients, and how these various factors impact on the efficacy of conventional-dose, high-dose (HDT) and newer disease modifying therapies. Selected elderly patients can gain equal benefit to younger patients from effective therapies such as HDT. However, the use of specific assessment tools for the elderly, apart from chronological age, should be used to select elderly patients who will benefit. Future testing of newer therapies in patients with myeloma must include older patients, who will make up an increasing proportion of the myeloma population in the future and should incorporate assessment of effect of these therapies on quality of life.
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Affiliation(s)
- Linda Mileshkin
- Division of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett St, Victoria 8006, Australia.
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88
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Yun YH, Lee MK, Chang YJ, You CH, Kim S, Choi JS, Lim HY, Lee CG, Choi YS, Hong YS, Kim SY, Heo DS, Jeong HS. The life-sustaining treatments among cancer patients at end of life and the caregiver’s experience and perspectives. Support Care Cancer 2009; 18:189-96. [DOI: 10.1007/s00520-009-0644-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Accepted: 04/06/2009] [Indexed: 11/29/2022]
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89
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Kahana E, Kahana B, Wykle M, Kulle D. Marshalling Social Support: A "Care-Getting" Model for Persons Living with Cancer. JOURNAL OF FAMILY SOCIAL WORK 2009; 12:168-193. [PMID: 20107524 PMCID: PMC2811383 DOI: 10.1080/10522150902874834] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
This paper offers a stress theory based conceptual framework for understanding proactive options for care-getting for patients living with cancer that is also relevant to patients living with other chronic or life threatening illnesses. Barriers and facilitators to active efforts for obtaining responsive care from both informal and formal sources are discussed. This "Care-Getting" model explores benefits of proactive care-getting for diminishing physical discomfort/suffering, burden of illness and disability, and psychological distress. We highlight unique issues in care-getting that patients face at different stages of the life course. Implications of prior research related to the model for practice and intervention are discussed.
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Affiliation(s)
- Eva Kahana
- Department of Sociology, Case Western Reserve University, Cleveland, OH, USA
| | - Boaz Kahana
- Department of Psychology, Cleveland State University, Cleveland, OH, USA
| | - May Wykle
- Department of Sociology, Case Western Reserve University, Cleveland, OH, USA
| | - Diana Kulle
- Department of Sociology, Case Western Reserve University, Cleveland, OH, USA
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90
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Wiltshire JC, Roberts V, Brown R, Sarto GE. The effects of socioeconomic status on participation in care among middle-aged and older adults. J Aging Health 2008; 21:314-35. [PMID: 19091692 DOI: 10.1177/0898264308329000] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study assesses the effects of socioeconomic status (education and poverty) on seeking health information and subsequent use of this information during the medical encounter. METHOD Data on 19,944 adults (aged 45 and older) were drawn from the 2000-2001 Household Component of the Community Tracking Study, a nationally representative survey of non-institutionalized individuals. RESULTS Higher levels of education were associated with a greater likelihood of seeking health information and mentioning information to physicians. The poor and near poor were less likely to seek health information, but only the near poor were significantly less likely to mention information to the physician. DISCUSSION These findings underscore the importance of education in the acquisition and use of health information among middle-aged and older adults.
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91
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Sheinfeld Gorin S, Gauthier J, Hay J, Miles A, Wardle J. Cancer screening and aging: Research barriers and opportunities. Cancer 2008; 113:3493-504. [DOI: 10.1002/cncr.23938] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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92
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93
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Pautex S, Herrmann FR, Zulian GB. Role of advance directives in palliative care units: a prospective study. Palliat Med 2008; 22:835-41. [PMID: 18718993 DOI: 10.1177/0269216308094336] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Advance directives (ADs) might be useful in achieving improved communication and satisfaction with decision making at the end-of-life. Our aims were to better characterise patients with advanced oncological disease who decided to complete ADs and to measure the effect of ADs completion on the satisfaction level with end-of-life care from both patients and their relatives. A prospective study was conducted in three palliative care units. Patients with advanced cancer were included if they met the following criteria: an estimated life expectancy of <6 months, fluency in French, Mini Mental State Examination >20 and not yet completed ADs. All the patients received information about ADs and decided whether to complete ADs or not. The level of satisfaction with involvement in the decision process concerning end-of-life care was assessed by means of a written questionnaire. In all, 53 of 228 patients were included, and 12 decided to complete ADs. Patients who completed ADs had statistically less depression one week after inclusion (P = 0.030), had a lower anxiety score on the second week and had a lower depression score on the third week. There was a trend towards a higher satisfaction level with the involvement of the patients in end-of-life care for those completing ADs (P = 0.878). In conclusion, each patient with an advanced progressive disease should be informed about ADs and be encouraged to complete the ADs with the aim to ease many fears as well as to improve communication.
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Affiliation(s)
- S Pautex
- Department of Rehabilitation and Geriatrics, Service of Palliative Medicine, Geneva University Hospitals, Geneva.
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94
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Kaldjian LC, Curtis AE, Shinkunas LA, Cannon KT. Review Article: Goals of Care Toward the End of Life: A Structured Literature Review. Am J Hosp Palliat Care 2008; 25:501-11. [DOI: 10.1177/1049909108328256] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Goals of care are often mentioned as an important component of end-of-life discussions, but there are diverse assessments regarding the type and number of goals that should be considered. To address this lack of consensus, we searched MEDLINE (1967—2007) for relevant articles and identified the number, phrasing, and type of goals they addressed. An iterative process of categorization resulted in a list of 6 practical, comprehensive goals: (1) be cured, (2) live longer, (3) improve or maintain function/quality of life/ independence, (4) be comfortable, (5) achieve life goals, and (6) provide support for family/caregiver. These goals can be used to articulate goal-oriented frameworks to guide decision making toward the end of life and thereby harmonize patients' treatment choices with their values and medical conditions.
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Affiliation(s)
- Lauris C. Kaldjian
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center,
| | - Ann E. Curtis
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center
| | - Laura A. Shinkunas
- Program in Bioethics and Humanities, University of Iowa Carver College of Medicine
| | - Katrina T. Cannon
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center
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95
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Rose JH, O'Toole EE, Einstadter D, Love TE, Shenko CA, Dawson NV. Patient Age, Well-Being, Perspectives, and Care Practices in the Early Treatment Phase for Late-Stage Cancer. J Gerontol A Biol Sci Med Sci 2008; 63:960-8. [DOI: 10.1093/gerona/63.9.960] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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96
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Temel JS, McCannon J, Greer JA, Jackson VA, Ostler P, Pirl WF, Lynch TJ, Billings JA. Aggressiveness of care in a prospective cohort of patients with advanced NSCLC. Cancer 2008; 113:826-33. [PMID: 18618579 DOI: 10.1002/cncr.23620] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Jennifer S Temel
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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97
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Abstract
Providing effective and tolerable cancer treatment for the growing number of older adult patients who have cancer requires an understanding of the role of aging, comorbidity, functional status, and frailty on treatment outcomes. The incorporation of comprehensive geriatric assessment (CGA) into the care of older patients who have cancer ensures that the cognitive, physical, and psychosocial strengths and limitations of individual patients are considered in the development of treatment plans. CGA also may improve outcomes by identifying and optimally treating comorbid conditions and functional impairments. Optimal treatment of the older adult patient who has cancer starts with careful delineation of goals through conversation. The treatment plan should be comprehensive and address cancer-specific treatment, symptom-specific treatment, supportive treatment modalities, and end-of-life care.
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98
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Douglas SL, Daly BJ, O'Toole EE, Kelley CG, Montenegro H. Age differences in survival outcomes and resource use for chronically critically ill patients. J Crit Care 2008; 24:302-10. [PMID: 19327287 DOI: 10.1016/j.jcrc.2008.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Revised: 02/12/2008] [Accepted: 02/18/2008] [Indexed: 11/25/2022]
Abstract
PURPOSE Chronically critically ill (CCI) patients use a disproportionate amount of resources, yet little research has examined outcomes for older CCI patients. The purpose of this study was to compare outcomes (mortality, disposition, posthospital resource use) between older (> or =65 years) and middle-aged (45-64 years) patients who require more than 96 hours of mechanical ventilation while in the intensive care unit. METHODS Data from 2 prospective studies were combined for the present examination. In-hospital as well as posthospital discharge data were obtained via chart abstraction and interviews. RESULTS One thousand one hundred twenty-one subjects were enrolled; 62.4% (n = 700) were older. Older subjects had a 1.3 greater risk for overall mortality (from admission to 4 months posthospital discharge) than middle-aged subjects. The Acute Physiology Score (odds ratio [OR], 1.009), presence of diabetes (OR, 2.37), mechanical ventilation at discharge (OR, 3.17), and being older (OR, 2.20) were statistically significant predictors of death at 4 months postdischarge. Older subjects had significantly higher charges for home care services, although they spent less time at home (mean, 22.1 days) than middle-aged subjects (mean, 31.3 days) (P = .03). CONCLUSION Older subjects were at higher risk of overall mortality and used, on average, more postdischarge services per patient when compared with middle-aged subjects.
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Affiliation(s)
- Sara L Douglas
- Case Western Reserve University, Frances Payne Bolton School of Nursing, Cleveland, OH 44106-4904, USA.
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99
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Briquet L, Gavra C. Le patient, entre volonté et désir de poursuivre ou ne pas poursuivre les traitements en oncologie. ONCOLOGIE 2008. [DOI: 10.1007/s10269-008-0855-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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100
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Rose JH, Radziewicz R, Bowmans KF, O'Toole EE. A coping and communication support intervention tailored to older patients diagnosed with late-stage cancer. Clin Interv Aging 2008; 3:77-95. [PMID: 18488881 PMCID: PMC2544372 DOI: 10.2147/cia.s1262] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
As our society ages, increasing numbers of older Americans will be diagnosed and eventually will die of cancer. To date, psycho-oncology interventions for advanced cancer patients have been more successful in reaching younger adult age groups and generally have not been designed to respond to the unique needs and preferences of older patients. Theories and research on successful aging (Baltes and Baltes 1990; Baltes 1997), health information processing style (Miller 1995; Miller et al 2001) and non-directive client-centered therapy (Rogers 1951, 1967), have guided the development of a coping and communication support (CCS) intervention. Key components of this age-sensitive and tailored intervention are described, including problem domains addressed, intervention strategies used and the role of the CCS practitioner. Age group comparisons in frequency of contact, problems raised and intervention strategies used during the first six weeks of follow up indicate that older patients were similar to middle-aged patients in their level of engagement, problems faced and intervention strategies used. Middle-aged patients were more likely to have problems communicating with family members at intervention start up and practical problems as well in follow up contacts. This is the first intervention study specifically designed to be age sensitive and to examine age differences in engagement from the early treatment phase for late-stage cancer through end of life. This tailored intervention is expected to positively affect patients' quality of care and quality of life over time.
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Affiliation(s)
- Julia Hannum Rose
- Case Western Reserve University, School of Medicine, Cleveland, Ohio 44109, USA
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