What are terminally ill cancer patients told about their expected deaths? A study of cancer physicians' self-reports of prognosis disclosure

Prognostic awareness, prognostic communication, and cognitive function in patients with malignant glioma

Background

Malignant glioma (MG) is a devastating neuro-oncologic disease with almost invariably poor prognosis. Prognostic awareness (PA) is the awareness of incurable disease and shortened life expectancy (LE). Accurate PA is associated with favorable psychological outcomes at the end of life (EoL) for patients with cancer; however, little is known about PA or prognostic communication in MG. Moreover, research has yet to evaluate the impact of cognitive impairment on PA and preferred forms of communication.

Methods

Fifty MG patients and 32 paired caregivers were evaluated in this exploratory study with a semi-structured PA assessment aimed to measure their awareness of MG incurability and LE. Full PA was defined as awareness of MG incurability and accurate estimate of LE. The assessment included a survey about preferences for prognostic communication (items from the Prognosis and Treatment Perceptions Questionnaire), neurocognitive assessment (Hopkins Verbal Learning Test-Revised, Trail Making Test Parts A and B, and the Controlled Oral Word Association Test), and measurements of mood (Hospital Anxiety and Depression Scale) and quality of life (Functional Assessment of Cancer Therapy-Brain [FACT-Br]).

Results

Twenty (40%) patients and 22 (69%) caregivers had full PA. Thirty (60%) patients and 23 (72%) caregivers reported that prognostic information was extremely or very important, and 21 (42%) patients and 16 (50%) caregivers desired more prognostic information. Patients with memory impairment more frequently believed that prognostic information was important (P = 0.04, P = 0.03) and desired more information (P = 0.05, P = 0.003) as compared with those without impairment.

Conclusions

Most MG patients were unaware of their LE. Memory impairment may influence preferences for prognostic information.

Ambulatory Advanced Cancer Patients' and Oncologists' Estimates of Life Expectancy Are Associated with Patient Psychological Characteristics But Not Chemotherapy Use

BACKGROUND

Patients with advanced cancer often face distressing decisions about chemotherapy. There are conflicting data on the relationships among perceived prognosis, psychological characteristics, and chemotherapy use, which impair the refinement of decision support interventions.

OBJECTIVE

Clarify the relationships among patient and oncologist estimates of life expectancy for 6 and 12 months, chemotherapy use, and patient psychological characteristics.

DESIGN

Secondary analysis of data from two cross-sectional studies.

SETTING/SUBJECTS

One hundred sixty-six patients with advanced stage cancer recruited from ambulatory cancer clinics.

MEASUREMENTS

All data were obtained at study enrollment. Patients completed the Adult Hope Scale, Hospital Anxiety and Depression Scale, and Life Orientation Test-Revised. Patients and their oncologists provided estimates of surviving beyond 6 and 12 months. Chemotherapy use was determined by chart review.

RESULTS

There were no significant associations between life-expectancy estimates and chemotherapy use nor patient anxiety, depression, hope, or optimism and chemotherapy use. Patients' life expectancy estimates for 12 months and oncologists' for 6 months were associated with higher patient anxiety and depression. Finally, both oncologist and patient estimates of life expectancy for 6 and 12 months were associated with increased levels of trait hope.

CONCLUSION

Advanced cancer patients who provide less optimistic estimates of life expectancy have increased anxiety and depression, but do not use chemotherapy more often. Increased patient trait hope is associated with more favorable oncologist estimates. These findings highlight the need for interventions to support both patients and oncologists as they clarify prognostic expectations and patients cope with the psychological distress of a limited life expectancy.

"How Much Time Do I Have?": Communicating Prognosis in the Era of Exceptional Responders

Prognostication is the science by which clinicians estimate a patient's expected outcome. A robust literature shows that many patients with advanced cancer have inaccurate perceptions of their prognosis, thus raising questions about whether patients are truly making informed decisions. Clinicians' ability to communicate prognostic information is further complicated today by the availability of novel, efficacious immunotherapies and genome-guided treatments. Currently, clinicians lack tools to predict which patients with advanced disease will achieve an exceptional response to these new therapies. This increased prognostic uncertainty on the part of clinicians further complicates prognostic communication with patients. Evidence also suggests that many oncologists avoid or rarely engage in prognosis-related communication and/or lack skills in this area. Although communication skills training interventions can have a positive impact on complex communication skills for some clinicians, there is no one-size-fits-all approach to improving patient-clinician communication about prognosis. Yet improving patient understanding of prognosis is critical, because patient understanding of prognosis is linked with end-of-life care outcomes. Solutions to this problem will likely require a combination of interventions beyond communication skills training programs, including enhanced use of other cancer clinicians, such as oncology nurses and social workers, increased use of palliative care specialists, and organizational support to facilitate advance care planning.

Investigator Disclosure and Advanced Cancer Patient Understanding of Informed Consent and Prognosis in Phase I Clinical Trials

PURPOSE

Advanced cancer patients (ACPs) who participate in phase I clinical trials often report a less-than-ideal understanding of the required elements of informed consent (IC) and unrealistic expectations for anticancer benefit and prognosis. We examined phase I clinical trial enrollment discussions and their associations with subsequent ACP understanding.

METHODS

Clinical encounters about enrollment in phase I trials between 101 ACPs and 29 oncologists (principal investigators [PIs] and fellows) at three US academic medical institutions were recorded. The Roter Interaction Analysis System was used for analysis. ACPs completed follow-up questionnaires to assess IC recall.

RESULTS

PIs disclosed the following phase I IC elements to ACPs in encounters: trial purpose in 40%; specific physical risks in 60%; potential specific medical benefits gained by trial participation (eg, disease stabilization) in 48.2%; and alternatives to phase I trial participation in 47.1%, with 1.1% of encounters containing palliative and 2.3% hospice information. PIs provided ACP-specific prognoses in 29.0% of encounters but used precise terms of death in only 4.7% and terminal in 1.2%. A significant association existed between PI disclosure of the trial purpose as dosage/toxicity, and ACPs subsequently correctly recalled trial purpose versus PIs who did not disclose it (85% v 13%; P < .05).

CONCLUSION

Many oncologists provide incomplete disclosures about phase I trials to ACPs. When disclosure of certain elements of IC occurs, it seems to be associated with better recall, especially with regard to the research purpose of phase I trials.

Defining the Scope of Prognosis: Primary Care Clinicians' Perspectives on Predicting the Future Health of Older Adults

CONTEXT

Studies examining the attitudes of clinicians toward prognostication for older adults have focused on life expectancy prediction. Little is known about whether clinicians approach prognostication in other ways.

OBJECTIVES

To describe how clinicians approach prognostication for older adults, defined broadly as making projections about patients' future health.

METHODS

In five focus groups, 30 primary care clinicians from community-based, academic-affiliated, and Veterans Affairs primary care practices were given open-ended questions about how they make projections about their patients' future health and how this informs the approach to care. Content analysis was used to organize responses into themes.

RESULTS

Clinicians spoke about future health in terms of a variety of health outcomes in addition to life expectancy, including independence in activities and decision making, quality of life, avoiding hospitalization, and symptom burden. They described approaches in predicting these health outcomes, including making observations about the overall trajectory of patients to predict health outcomes and recognizing increased risk for adverse health outcomes. Clinicians expressed reservations about using estimates of mortality risk and life expectancy to think about and communicate patients' future health. They discussed ways in which future research might help them in thinking about and discussing patients' future health to guide care decisions, including identifying when and whether interventions might impact future health.

CONCLUSION

The perspectives of primary care clinicians in this study confirm that prognostic considerations can go beyond precise estimates of mortality risk and life expectancy to include a number of outcomes and approaches to predicting those outcomes.

Intended and unintended consequences: Ethics, communication, and prognostic disclosure in pediatric oncology

BACKGROUND

The majority of patients desire all available prognostic information, but some physicians hesitate to discuss prognosis. The objective of the current study was to examine outcomes of prognostic disclosure among the parents of children with cancer.

METHODS

The authors surveyed 353 parents of children with newly diagnosed cancer at 2 tertiary cancer centers, and each child's oncologist. Using multivariable logistic regression, the authors assessed associations between parental report of elements of prognosis discussions with the oncologist (quality of information/communication and prognostic disclosure) and potential consequences of these discussions (trust, hope, peace of mind, prognostic understanding, depression, and anxiety). Analyses were stratified by oncologist-reported prognosis.

RESULTS

Prognostic disclosure was not found to be associated with increased parental anxiety, depression, or decreased hope. Among the parents of children with less favorable prognoses (<75% chance of cure), the receipt of high-quality information from the oncologist was associated with greater peace of mind (odds ratio [OR], 5.23; 95% confidence interval [95% CI], 1.81-15.16) and communication-related hope (OR, 2.54; 95% CI, 1.00-6.40). High-quality oncologist communication style was associated with greater trust in the physician (OR, 2.45; 95% CI, 1.09-5.48) and hope (OR, 3.01; 95% CI, 1.26-7.19). Accurate prognostic understanding was less common among the parents of children with less favorable prognoses (OR, 0.39; 95% CI, 0.17-0.88). Receipt of high-quality information, high-quality communication, and prognostic disclosure were not found to be significantly associated with more accurate prognostic understanding.

CONCLUSIONS

The results of the current study demonstrate no evidence that disclosure is associated with anxiety, depression, or decreased hope. Communication processes may increase peace of mind, trust, and hope. It remains unclear how best to enhance prognostic understanding. Cancer 2018;124:1232-41. © 2017 American Cancer Society.

The Doctor–Patient Relationship and Information-Seeking Behavior

Background:

In cancer communication, patients and physicians often understand a patient’s experience and situation differently. This can negatively impact health outcomes and the physician–patient relationship.

Aim:

To explore how cancer patients’ interpretations of the physician’s role as information giver affect the communication relationship with the physician and their information-seeking behavior regarding different aspects of their cancer care.

Design:

Participants completed a semistructured qualitative interview addressing their treatment experience and communication with their physician. Interviews were coded and analyzed using inductive thematic analysis.

Setting/Participants:

Ten patients with cancer treated at a regional cancer center in central Illinois participated in the study. Cancer stages I to IV and 4 cancer types were represented.

Results:

Participants’ orientations to the relationship with their physician (and their information-seeking behavior) were classified into 4 general categories: (1) “questioners” have a general mistrust toward their physicians and the information doctors are giving; (2) “the undecided” focuses on physician “fit,” often requiring time to step away in order to make decisions and process information; (3) “cross-checkers” are concerned with content of their treatment protocol, often double-checking the treatment plan; and (4) “the experience-oriented” feel a gap between their experience and their physician’s experience (and perspective), often seeking information from other survivors. All categories described a perceived lack of adequate exchange of information and the need to seek information outside of the physician–patient relationship to compensate.

Conclusion:

Participants exhibited different information-seeking behaviors based on how they interpreted the role of their physician as information giver. This affected what kind of information they sought and how they understood the information received, which in turn affected understanding of their broader experience and care.

Unpacking cancer patients' preferences for information about their care

OBJECTIVE

Patient-centered decision making requires cancer patients be actively involved and feel sufficiently informed about their care, but patients' preferences for information are often unrecognized or unmet by their oncologist, particularly for more distressing topics. This study examined cancer patients' preferences for information about three care-related topics: (1) diagnostic information, (2) treatment costs, and (3) prognosis. We tested whether factors known to influence information preferences (psychological distress, control preferences, and financial distress) were differently associated with information preferences for each topic.

METHODS

Cancer patients (N = 176) receiving ongoing treatment completed a questionnaire that assessed their out-of-pocket treatment costs, psychological distress, preferences for control over their medical decisions, and the amount of information they desired and received from their oncologists about the three topics.

RESULTS

Patients' preferences were less often met for treatment cost information than for the other topics, p < 0.001, with half wanting more cost information than they received. One-third of patients also wanted more prognostic information than they received. Patients' preferences for diagnostic information did not differ as a function of financial burden, distress, or control preferences, ps > 0.05. Preferences for cost information were greater among patients who preferred more control over their medical decisions, p = 0.016. Patients' preferences for prognostic information were greater among those desiring more control and with lower distress, ps < 0.05. Financial burden was not associated with information preferences.

CONCLUSION

Appreciating the variability in information preferences across topics and patients may aid efforts to meet patients' information needs and improve outcomes.

Truth Telling in the Setting of Cultural Differences and Incurable Pediatric Illness: A Review

IMPORTANCE

Navigating requests from parents or family caregivers not to disclose poor prognosis to seriously ill children can be challenging, especially when the requests seem culturally mediated. Pediatric clinicians must balance obligations to respect individual patient autonomy, professional truth telling, and tolerance of multicultural values.

OBSERVATIONS

To provide suggestions for respectful and ethically appropriate responses to nondisclosure requests, we used a hypothetical case example of a Middle Eastern adolescent patient with incurable cancer and conducted an ethical analysis incorporating (1) evidence from both Western and Middle Eastern medical literature and (2) theories of cultural relativism and justice. While Western medical literature tends to prioritize patient autonomy and corresponding truth telling, the weight of evidence from the Middle East suggests high variability between and within individual countries, patient-physician relationships, and families regarding truth-telling practices and preferences. A common reason for nondisclosure in both populations is protecting the child from distressing information. Cultural relativism fosters tolerance of diverse beliefs and behaviors by forbidding judgment on foreign societal codes of conduct. It does not justify assumptions that all individuals within a single culture share the same values, nor does it demand that clinicians sacrifice their own codes of conduct out of cultural respect. We suggest some phrases that may help clinicians explore motivations behind nondisclosure requests and gently confront conflict in order to serve the patient's best interest.

CONCLUSIONS AND RELEVANCE

It is sometimes ethically permissible to defer to family values regarding nondisclosure, but such deferral is not unique to cultural differences. Early setting of expectations and boundaries, as well as ongoing exploration of family and health care professional concerns, may mitigate conflict.

Information of patients with life-threatening diseases: A survey of the attitude of Portuguese family practitioners

Highlights

The attitudes of family physicians regarding breaking bad news are heterogeneous.Younger doctors seem to see the delivery of bad news more positively.This trend suggests that there will be a more open communication in the future.

Background

Family practice is the specialty with the highest number of doctors and covers all of Portugal, but, as far as we know, no studies have been carried out on the attitudes and practices of Portuguese family practice doctors about breaking bad news. However, the attitude of these doctors may have a high impact on patients.

Objective

To study the practice of family physicians on breaking bad news.

Methods

A questionnaire, specifically developed for this survey, was given to 196 doctors about 10% of the family physicians of Northern Portugal.

Results

One hundred fifty-nine (81%) of them participated in this study. The median age was 43 (26-64) and 108 (68%) of them were female. One hundred and seven (67%) doctors disclosed on principle the diagnosis and that rate rose to 81% when patients requested the disclosure. One hundred and two (64%) proactively questioned patients about their wish to know the diagnosis and then decided whether to convey it or not. Forty-seven 47 (30%) doctors disclosed the prognosis on principle and that rate rose to 48% when patients requested the disclosure. Seventy-three (46%) often questioned patients proactively about their wish to know the prognosis and then decided whether to convey it or not. One hundred and two (64%) doctors frequently include patients in treatment decisions. Physicians think that the disclosure may affect hope but may also give patients more control of the situation.

Conclusion

Family practitioners disclose the diagnosis of a chronic life-threatening disease often, especially at patients' request. General practitioners do not disclose the prognosis of a life-threatening disease often, even at patients' request.

Transitions in Prognostic Awareness Among Terminally Ill Cancer Patients in Their Last 6 Months of Life Examined by Multi-State Markov Modeling

BACKGROUND

Developing accurate prognostic awareness, a cornerstone of preference-based end-of-life (EOL) care decision-making, is a dynamic process involving more prognostic-awareness states than knowing or not knowing. Understanding the transition probabilities and time spent in each prognostic-awareness state can help clinicians identify trigger points for facilitating transitions toward accurate prognostic awareness. We examined transition probabilities in distinct prognostic-awareness states between consecutive time points in 247 cancer patients' last 6 months and estimated the time spent in each state.

METHODS

Prognostic awareness was categorized into four states: (a) unknown and not wanting to know, state 1; (b) unknown but wanting to know, state 2; (c) inaccurate awareness, state 3; and (d) accurate awareness, state 4. Transitional probabilities were examined by multistate Markov modeling.

RESULTS

Initially, 59.5% of patients had accurate prognostic awareness, whereas the probabilities of being in states 1-3 were 8.1%, 17.4%, and 15.0%, respectively. Patients' prognostic awareness generally remained unchanged (probabilities of remaining in the same state: 45.5%-92.9%). If prognostic awareness changed, it tended to shift toward higher prognostic-awareness states (probabilities of shifting to state 4 were 23.2%-36.6% for patients initially in states 1-3, followed by probabilities of shifting to state 3 for those in states 1 and 2 [9.8%-10.1%]). Patients were estimated to spend 1.29, 0.42, 0.68, and 3.61 months in states 1-4, respectively, in their last 6 months.

CONCLUSION

Terminally ill cancer patients' prognostic awareness generally remained unchanged, with a tendency to become more aware of their prognosis. Health care professionals should facilitate patients' transitions toward accurate prognostic awareness in a timely manner to promote preference-based EOL decisions.

IMPLICATIONS FOR PRACTICE

Terminally ill Taiwanese cancer patients' prognostic awareness generally remained stable, with a tendency toward developing higher states of awareness. Health care professionals should appropriately assess patients' readiness for prognostic information and respect patients' reluctance to confront their poor prognosis if they are not ready to know, but sensitively coach them to cultivate their accurate prognostic awareness, provide desired and understandable prognostic information for those who are ready to know, and give direct and honest prognostic information to clarify any misunderstandings for those with inaccurate awareness, thus ensuring that they develop accurate and realistic prognostic knowledge in time to make end-of-life care decisions.

Why are patients with blood cancers more likely to die without hospice?

BACKGROUND

Although patients with blood cancers have significantly lower rates of hospice use than those with solid malignancies, data explaining this gap in end-of-life care are sparse.

METHODS

In 2015, we conducted a mailed survey of a randomly selected sample of hematologic oncologists in the United States to characterize their perspectives regarding the utility and adequacy of hospice for blood cancer patients, as well as factors that might impact referral patterns. Simultaneous provision of care for patients with solid malignancies was permitted.

RESULTS

We received 349 surveys (response rate, 57.3%). The majority of respondents (68.1%) strongly agreed that hospice care is helpful for patients with hematologic cancers; those with practices including greater numbers of solid tumor patients (at least 25%) were more likely to strongly agree (odds ratio, 2.10; 95% confidence interval, 1.26-3.52). Despite high levels of support for hospice in general, 46.0% felt that home hospice is inadequate for their patients' needs (as compared to inpatient hospice with round-the-clock care). Although more than half of the respondents reported that they would be more likely to refer patients to hospice if red cell and/or platelet transfusions were available, those who considered home hospice inadequate were even more likely to report that they would (67.3% vs 55.3% for red cells [P = .03] and 52.9% vs 39.7% for platelets [P = .02]).

CONCLUSIONS

These data suggest that although hematologic oncologists value hospice, concerns about the adequacy of services for blood cancer patients limit hospice referrals. To increase hospice enrollment for blood cancer patients, interventions tailoring hospice services to their specific needs are warranted. Cancer 2017;123:3377-84. © 2017 American Cancer Society.

Family physicians' opinions on and difficulties with breaking bad news

Highlights

Breaking bad news is still deemed a difficult task by family physicians.Family physicians feel they need training in breaking bad news.The family physicians' attitude to this issue is different from what they would wish if they themselves had a life-threatening disease.

Background

Family practice is the specialty with the highest number of doctors and covers all of Portugal. Therefore, the attitude of these doctors may have a high impact on patients.

Objective

To explore the opinion and difficulties of Portuguese family doctors on dealing with communication with patients with life threatening diseases.

Methods

A questionnaire was sent to about 10% of family doctors of Northern Portugal. The questionnaire included questions about the disclosure of information, if they feel they need training courses and what they would want if they had a life-threatening disease.

Results

A questionnaire was given to 196 doctors and 159 (81%) participated in this study. The median age was 43 years (26-64) and 108 (68%) were females. One hundred thirty-five (85%) consider that breaking bad news is a difficult task. One hundred twenty-four (78%) feel they need training in breaking bad news. For many doctors, the disclosure of diagnoses and prognoses has a detrimental psychological effect and affects patients' hope, but gives patients' control of the situation. Given a situation where the doctors themselves had a life-threatening disease, the vast majority would want to know the diagnosis and the prognosis and to participate in treatment decisions.

Conclusions

Breaking bad news is still a difficult task. Their attitude to this duty is different from what they would wish if they themselves had a life-threatening disease. One important conclusion is the need of specific training in communication for family physicians that should begin in the training phase of their specialty.

Characterizing the Nature of Scan Results Discussions: Insights Into Why Patients Misunderstand Their Prognosis

INTRODUCTION

Patients with incurable cancer have poor prognostic awareness. We present a detailed analysis of the dialogue between oncologists and patients in conversations with prognostic implications.

METHODS

A total of 128 audio-recorded encounters from a large multisite trial were obtained, and 64 involved scan results. We used conversation analysis, a qualitative method for studying human interaction, to analyze typical patterns and conversational devices.

RESULTS

Four components consistently occurred in sequential order: symptom-talk, scan-talk, treatment-talk, and logistic-talk. Six of the encounters (19%) were identified as good news, 15 (45%) as stable news, and 12 (36%) as bad news. The visit duration varied by the type of news: good, 15 minutes (07:00-29:00); stable, 17 minutes (07:00-41:00); and bad, 20 minutes (07:00-28:00). Conversational devices were common, appearing in half of recordings. Treatment-talk occupied 50% of bad-news encounters, 31% of good-news encounters, and 19% of stable-news encounters. Scan-talk occupied less than 10% of all conversations. There were only four instances of frank prognosis discussion.

CONCLUSION

Oncologists and patients are complicit in constructing the typical encounter. Oncologists spend little time discussing scan results and the prognostic implications in favor of treatment-related talk. Conversational devices routinely help transition from scan-talk to detailed discussions about treatment options. We observed an opportunity to create prognosis-talk after scan-talk with a new conversational device, the question "Would you like to talk about what this means?" as the oncologist seeks permission to disclose prognostic information while ceding control to the patient.

What are the barriers to initiating end-of-life conversations with patients in the last year of life?

INTRODUCTION

Improving end of life care is a national imperative. Unsatisfactory care persists particularly in acute hospitals, with shortcomings, variability in communication and advance care planning identified as fundamental issues. This review explored the literature to identify what is known about the barriers to initiating end-of-life conversations with patients from the perspective of doctors and nurses in the acute hospital setting.

METHOD

Six electronic databases were searched for potentially relevant records published between 2008 and 2015. Studies were included if the authors reported on barriers to discussing end of life with families or patients as described by doctors or nurses in hospital settings, excluding critical care.

RESULTS

Of 1267 potentially relevant records, 12 were included in the review. Although there is limited high-quality evidence available, several barriers were identified. Recurrent themes within the literature related to a lack of education and training, difficulty in prognostication, cultural differences and perceived reluctance of the patient or family.

CONCLUSIONS

This study illustrated that, in addressing barriers to communication, consideration needs to be extended to include how to embed good communication practice between patients and health professionals into the culture of this setting. Board level commitment is required to raise awareness of, and familiarity with, policies and protocols concerning communication and end-of-life care. Communication training should include practical skills and tools, opportunities to explore the personal beliefs of practitioners and managing their emotions, opportunities to analyse the local organisational (physical and social environment) and team barriers.

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.

Preclinical Medical Students' Diverse Educational and Emotional Responses to a Required Hospice Experience

BACKGROUND

Physicians' lack of comfort and skill in communicating about hospice care results in deficits and delays in hospice referrals. Preclinical exposure to hospice may lay a foundation to improve medical students' knowledge and comfort with hospice care.

OBJECTIVE

To understand how preclinical medical student (MS)-2s respond both educationally and emotionally to a required hospice care experience (HCE).

DESIGN

Accompanied by hospice clinicians, MS-2s spent 3 hours seeing inpatient or home hospice patients followed by a 1-hour debriefing. Students submitted written reflections to e-mailed educational and emotional prompts.

SETTING/PATIENTS

Two hundred and two MS-2s from 2 academic cohorts completed the HCE at 1 of 2 hospice sites.

MEASUREMENTS

Written reflective responses were analyzed qualitatively, where salient themes extracted and responses were coded.

RESULTS

Ninety-two students submitted 175 responses to Prompt #1 (educational impact) and 85 students entered 85 responses to prompt #2 (emotional impact) of the HCE. Eleven themes were identified for prompt #1, most frequently focusing on hospice services and goals and hospice providers' attitudes and skills. Prompt #2 elicited a diverse spectrum of emotional responses, spanning positive and negative emotions. Most often, students reported "no specified emotional reaction," "sad/depressed," "difficult /challenging," "heartened/encouraged," and "mixed emotions."

CONCLUSION

In an HCE, preclinical students reported learning core aspects of hospice care and experiencing a broad spectrum of emotional responses. These findings may assist educators in the planning of HCEs for preclinical students, including debriefing sessions with skilled clinicians and opportunities for triggered reflection.

Discussions of Life Expectancy and Changes in Illness Understanding in Patients With Advanced Cancer

Purpose

Accurate illness understanding enables patients to make informed decisions. Evidence of the influence of prognostic discussions on the accuracy of illness understanding by patients would demonstrate the value of discussions.

Methods

Recent and past oncology provider-patient discussions about prognosis/life expectancy were examined for their association with changes in illness understanding by patients. Patients (N = 178) with advanced cancers refractory to prior chemotherapy whom oncologists expected to die within 6 months were interviewed before and after a visit in which cancer restaging scan results were discussed. Illness understanding scores were the sum of four indicator variables: patient terminal illness acknowledgment, recognition of incurable disease status, knowledge of the advanced stage of the disease, and expectation to live months as opposed to years.

Results

Before the restaging scan visit, nine (5%) of 178 patients had completely accurate illness understanding (ie, correctly answered each of the four illness understanding questions). Eighteen patients (10%) reported only recent discussions of prognosis/life expectancy with their oncologists; 68 (38%) reported only past discussions; 24 (13%) reported both recent and past discussions; and 68 (38%) reported that they never had discussions of prognosis/life expectancy with their oncologists. After adjustment for potential confounders (ie, education and race/ethnicity), analysis identified significant, positive changes in illness understanding scores for patients in groups that reported recent only (least-squares mean change score, 0.62; 95% CI, 0.23 to 1.01; P = .002) and both recent and past (least-squares mean change score, 0.37; 95% CI, 0.04 to 0.70; P = 0.028) discussions of prognosis/life expectancy with their oncologists.

Conclusion

Patients with advanced cancer who report recent discussions of prognosis/life expectancy with their oncologists come to have a better understanding of the terminal nature of their illnesses.

Surgeons' Perspectives of Contralateral Prophylactic Mastectomy

BACKGROUND

Contralateral prophylactic mastectomy (CPM) is commonly performed for the treatment of breast cancer, despite its limited oncologic benefit. Little is known about surgeons' perceptions of performing CPM. We hypothesized that a proportion of surgeons would report discomfort with performing CPM, particularly when there is discordance between patients' perceived benefit from CPM and the expected oncologic benefit.

METHODS

A survey was sent to members of the American Society of Breast Surgeons seeking self-reports of surgeons' practice patterns, perceptions, and comfort levels with CPM.

RESULTS

Of the 2436 members surveyed, 601 responded (response rate = 24.7 %). The median age of respondents was 52 years, and 59 % of responders were women. The majority (58 %) reported that 80 % of their practice was devoted to the treatment of breast disease. Fifty-seven percent (n = 326) of respondents reported discomfort with performing CPM at some point in their practice. While most surgeons (95 %) were comfortable with CPM on a patient with a deleterious BRCA mutation, only 34 % were comfortable performing CPM on an average-risk patient. The most common reasons reported for surgeon discomfort with CPM were a concern for overtreatment, an unfavorable risk/benefit ratio, and inadequate patient understanding of the anticipated risks and benefits of CPM.

CONCLUSIONS

Despite the increasing use of CPM for the treatment of breast cancer, many surgeons report discomfort with CPM. Concerns with performing CPM predominantly focus on ambiguities surrounding the oncologic benefit and relative risk of this procedure. Further research is needed to define optimal shared decision-making practices in this area.

Outcomes of Prognostic Disclosure: Associations With Prognostic Understanding, Distress, and Relationship With Physician Among Patients With Advanced Cancer

PURPOSE

To determine how prognostic conversations influence perceptions of life expectancy (LE), distress, and the patient-physician relationship among patients with advanced cancer.

PATIENTS AND METHODS

This was a multicenter observational study of 590 patients with metastatic solid malignancies with progressive disease after ≥ one line of palliative chemotherapy, undergoing follow-up to death. At baseline, patients were asked whether their oncologist had disclosed an estimate of prognosis. Patients also estimated their own LE and completed assessments of the patient-physician relationship, distress, advance directives, and end-of-life care preferences.

RESULTS

Among this cohort of 590 patients with advanced cancer (median survival, 5.4 months), 71% wanted to be told their LE, but only 17.6% recalled a prognostic disclosure by their physician. Among the 299 (51%) of 590 patients willing to estimate their LE, those who recalled prognostic disclosure offered more realistic estimates as compared with patients who did not (median, 12 months; interquartile range, 6 to 36 months v 48 months; interquartile range, 12 to 180 months; P < .001), and their estimates were less likely to differ from their actual survival by > 2 (30.2% v 49.2%; odds ratio [OR], 0.45; 95% CI, 0.14 to 0.82) or 5 years (9.5% v 35.5%; OR, 0.19; 95% CI, 0.08 to 0.47). In adjusted analyses, recall of prognostic disclosure was associated with a 17.2-month decrease (95% CI, 6.2 to 28.2 months) in patients' LE self-estimates. Longer LE self-estimates were associated with lower likelihood of do-not-resuscitate order (adjusted OR, 0.439; 95% CI, 0.296 to 0.630 per 12-month increase in estimate) and preference for life-prolonging over comfort-oriented care (adjusted OR, 1.493; 95% CI, 1.091 to 1.939). Prognostic disclosure was not associated with worse patient-physician relationship ratings, sadness, or anxiety in adjusted analyses.

CONCLUSION

Prognostic disclosures are associated with more realistic patient expectations of LE, without decrements to their emotional well-being or the patient-physician relationship.

Caregiver Expectations: Predictors of a Worse Than Expected Caregiving Experience at the End of Life

CONTEXT

The gap between informal caregivers' expectations of caregiving at the end of life and their actual caregiving experience has important affective and behavioral consequences.

OBJECTIVES

This study analyzes for the first time the characteristics of those caregivers who report a worse or much worse than expected caregiving experience, providing a potential for future targeted intervention into the caregiving experience.

METHODS

The South Australian Health Omnibus is an annual, random, face-to-face, and cross-sectional survey. From 2000 to 2007, respondents were asked a range of questions about end-of-life care, including in several years a question about how the caregiving experience compared with caregivers' expectation(s). Family members and friends who reported a worse or much worse than expected caregiving experience were the focus of this analysis. Univariable and multivariable logistic regression models were created to better define this group.

RESULTS

Of the 1628 active caregivers for people at the end of life, almost half (48.3%) reported a worse or much worse than expected caregiving experience. A worse or much worse than expected caregiving experience was significantly associated with gender and with level of care provided. Women who provided daily hands-on care were significantly more likely to have a worse than expected experience compared with women who provided intermittent care (odds ratio [OR] 0.65; 95% CI 0.48-0.88; P = 0.005) or rare care (OR 0.39; 95% CI 0.27-0.56; P < 0.001). Of all those providing rare care, women were significantly less likely than men to report a worse than expected caregiving experience (OR 0.61; 95% CI 0.41-0.93; P = 0.020).

CONCLUSION

Caregiver expectations represent a novel and important focus for investigation into the caregiver experience. Explicitly eliciting expectations may in future lead to ways of better supporting caregivers.

Patient characteristics associated with prognostic awareness: a study of a Canadian palliative care population using the InterRAI palliative care instrument

CONTEXT

Awareness of their medical prognosis enables terminally ill patients to make decisions on treatments and end-of-life care/planning, and to reach acceptance. Yet, many patients receiving palliative care (PC) are unaware of their prognosis, even when death is imminent and has been discussed with health care providers. A better understanding of patient characteristics associated with prognostic awareness (PA) is needed to develop interventions aimed at improving it.

OBJECTIVES

To identify patient characteristics associated with PA in a PC population.

METHODS

The sample comprised 2090 palliative home care patients in Ontario, Canada, assessed using the interRAI Palliative Care Assessment. Independent variables included sociodemographic, cognitive/physical functioning, mood, psychological well-being, and social support. Using cross-sectional data, an adjusted logistic regression model was developed to identify key patient characteristics associated with PA. A multifaceted definition of PA was assumed and represented dichotomously in the model. Multiple imputation was used to address missing data, generating results similar to the complete case analysis.

RESULTS

The PA was higher in patients with: a shorter prognosis (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.93-4.33), increased hours of informal care (OR 1.71, 95% CI 1.15-2.52), less cognitive impairment (OR 1.61, 95% CI 1.14-2.28), and in patients at peace with life (OR 1.79, 95% CI 1.27-2.53). Site differences were observed but do not reflect differences in age, gender, prognosis, or diagnosis.

CONCLUSION

Some patient characteristics are amenable to clinical intervention to raise PA, such as being at peace, cognitive impairment, and depression. Prognostic communications vary in timing and quality and may underlie our site differences, but further research is required to confirm this.

Prognosis terminal: truth-telling in the context of end-of-life care

Recent contributions to the medical literature have raised yet again the issue of whether the term "terminal" is an intelligible one and whether there is a consensus view of its meaning that is sufficient to justify or even require its use in discussing end-of-life care and treatment options with patients. Following a review of the history and development of informed consent, persistent problems with the communication of prognosis and the breaking of bad news are analyzed. The author argues that candid but compassionate communication between physicians and patients about prognosis is essential to informed decisions about both disease-directed (curative) and palliative therapies.

Does the Approach of Disclosing More Detailed Information of Cancer for the Terminally Ill Patients Improve the Quality of Communication Involving Patients, Families, and Medical Professionals?

Purpose:

Effective and faithful communication between patients and medical professionals could improve patients' quality of life and is an essential and fundamental factor in cancer treatment. The purpose of this study was to examine whether disclosing more detailed information about disease progression toterminally ill patients could improve the quality of communication.

Methods:

This was a before/after study of 91 consecutive terminal cancer patients. Based on the previous studies, we categorized cancer disclosure into 4 groups: A;“non-disclosure”, B;“disclosure of cancer diagnosis”, C;“disclosureof life-threatening disease”, and D;“disclosure of poor prognosis”. We disclosed more detailed information based on the SPIKES protocol and compared the scores of 3 communication items of Support Team Assessment Schedule (Japanese version) measured between at admission and one-week after this approach.

Results:

A, B, C and D groups included 8, 25, 40, and 18 cases, respectively. This approach to cancer disclosure was implemented in 37.5% of group A, 60% of group B, and 40% of group C. In group B, all 3 communications were significantly improved (2.40 ± 0.51 vs 1.53 ± 0.83, 1.93 ± 0.96 vs 1.00 ± 0.38, 2.13 ± 0.64 vs 1.13 ± 0.64; p = 0.0035, 0.0062, 0.0013). In group C, all 3 communications were significantly improved (1.25 ± 0.58 vs 0.81 ± 0.66, 1.13 ± 0.34 vs 0.69 ± 0.48, 1.31±0.60 vs 0.56 ± 0.63; p = 0.020, 0.0082, 0.0057).

Conclusions:

This study revealed that disclosing more detailed information of cancer for terminally ill cancer patients contributed to improving the quality of communication, irrespective of the stage of disclosure.

Incidental findings of nonparentage: a case for universal nondisclosure

We advocate for the incorporation of a new clause into the consent forms for pediatric genetic testing that clearly states that any incidental information about parentage will not be revealed, regardless of the result. Using a case of misattributed maternity, we examine both the pro- and antidisclosure arguments. In the absence of arguments that clearly demonstrate irrevocable harm from nondisclosure and against a backdrop of arguments that compellingly highlight the potential for serious harms from disclosing incidental findings of nonparentage, we advocate for a universal, institution-wide policy of nondisclosure. Our proposed policy of universal nondisclosure not only provides a viable solution to the disclosure dilemma but also empowers patients to know what testing is available to them and to seek it out on their own terms, fully informed. With an easily implemented consent change, clinics can take a clear and firm stance in the disclosure debate. As a result, patients will be protected, policy will be widely understood, and cases will be resolved consistently and clearly.

Clinicopathological prognostic implicators of oral squamous cell carcinoma: need to understand and revise

In spite of the vast amount of research and the advances, oral squamous cell carcinoma implies quite significant mortality and morbidity rates. This has motivated the search of factors with prognostic relevance. A web based search was initiated for all published articles by using Medline/PubMed, Google Scholar with key words such as prognosis, survival rate, risk factors associated with oral squamous cell carcinoma, prognosis of oral squamous cell carcinoma. The search was restricted to articles published in English language with no restriction to date of publication. This review was focused on clinical, pathological and molecular factors associated with survival and prognosis of oral squamous cell carcinoma patients. Most articles had described one or two parameters related to prognosis. Considering the biological behavior and nature of cancer, all the parameters were interrelated and so could not predict the prognosis independently. Consideration of all the parameters was required to assess the prognosis. We hypothesize the use of combination of clinical and pathological indicators together to assess the prognosis. The care givers can assess the prognosis in a more better and definitive way by using prognosis assessment sheet.

Truth-telling to patients' terminal illness: what makes oncology nurses act individually?

PURPOSE

Nurses encounter the challenge of truth-telling to patients' terminal illness (TTPTI) in their daily care activities, particularly for nurses working in the pervasive culture of family protectiveness and medical paternalism. This study aims to investigate oncology nurses' major responses to handling this issue and to explore what factors might explain oncology nurses' various actions.

METHODS

A pilot quantitative study was designed to describe full-time nurses' (n = 70) truth-telling experiences at an oncology centre in Taipei. The potential influencing factors of nurses' demographic data, clinical characteristics, and truth-telling attitudes were also explored.

RESULTS

Most nurses expressed that truth-telling was a physician's responsibility. Nevertheless, 70.6% of nurses responded that they had performed truth-telling, and 20 nurses (29.4%) reported no experience. The reasons for inaction were "Truth-telling is not my duty", "Families required me to conceal the truth", and "Truth-telling is difficult for me". Based on a stepwise regression analysis, nurses' truth-telling acts can be predicted based on less perceived difficulty of talking about "Do not resuscitate" with patients, a higher perceived authorisation from the unit, and more oncology work experience (adjusted R² = 24.1%).

CONCLUSIONS

Oncology care experience, perceived comfort in communication with terminal patients, and unit authorisation are important factors for cultivating nurses' professional accountability in truth-telling. Nursing leaders and educators should consider reducing nursing barriers for truth-telling, improving oncology nurses' professional accountability, and facilitating better quality care environments for terminal patients.

Physicians' propensity to discuss prognosis is associated with patients' awareness of prognosis for metastatic cancers

BACKGROUND

Prognosis discussion is an essential component of informed decision-making. However, many terminally ill patients have a limited awareness of their prognosis and the causes are unclear.

OBJECTIVE

To explore the impact of physicians' propensity to discuss prognosis on advanced cancer patients' prognosis awareness.

DESIGN

Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study, a prospective cohort study with patient and physician surveys.

SETTING/SUBJECTS

We investigated 686 patients with metastatic lung or colorectal cancer at diagnosis who participated in the CanCORS study and reported about their life expectancy. Data were linked to the physician survey from 486 physicians who were identified by these patients as filling important roles in their cancer care.

RESULTS

Few patients with metastatic cancers (16.5%) reported an accurate awareness of their prognosis, defined as reporting a life expectancy of less than 2 years for lung cancer or less than 5 years for colorectal cancer. Patients whose most-important-doctor (in helping patient make decisions) reported discussing prognosis with terminally ill patients earlier were more likely than those whose doctors deferred these discussions to have an accurate prognosis awareness (adjusted proportion, 18.5% versus 7.6%; odds ratio, 3.23; 95% confidence interval, 1.39-7.52; p=0.006).

CONCLUSIONS

Few patients with advanced cancer could articulate an accurate prognosis estimate, despite most having received chemotherapy and many physicians reported they would discuss prognosis early. Physicians' propensity to discuss prognosis earlier was associated with more accurate patient reports of prognosis. Enhancing the communication skills of providers with important roles in cancer care may help to improve cancer patients' understanding of their prognosis.

Physicians' perceptions of the value of prognostic models: the benefits and risks of prognostic confidence

BACKGROUND

The communication of prognosis in end-of-life (EOL) care is a challenging task that is limited by prognostic uncertainty and physicians' lack of confidence in their prognostic estimates. Clinical prediction models (CPMs) are increasingly common evidence-based tools that may mitigate these problems and facilitate the communication and use of prognostic information in EOL care; however, little is known about physicians' perceptions of the value of these tools.

OBJECTIVE

To explore physicians' perceptions of the value of CPMs in EOL care.

DESIGN

Qualitative study using semi-structured individual interviews which were analysed using a constant comparative method.

SETTING AND PARTICIPANTS

Convenience sample of 17 attending physicians representing five different medical specialties at a single large tertiary care medical centre.

RESULTS

Physicians perceived CPMs as having three main benefits in EOL care: (i) enhancing their prognostic confidence; (ii) increasing their prognostic authority; and (iii) enabling patient persuasion in circumstances of low prognostic and therapeutic uncertainty. However, physicians also perceived CPMs as having potential risks, which include producing emotional distress in patients and promoting prognostic overconfidence in EOL care.

DISCUSSION AND CONCLUSIONS

Physicians perceive CPMs as a potentially valuable means of increasing their prognostic confidence, communication and explicit use of prognostic information in EOL care. However, physicians' perceptions of CPMs also indicate a need to establish broad and consistent implementation processes to engage patients in shared decision making in EOL care, to effectively communicate uncertainty in prognostic information and to help both patients and physicians manage uncertainty in EOL care decisions.

General internists' preferences and knowledge about the care of adult survivors of childhood cancer: a cross-sectional survey

BACKGROUND

Adult childhood cancer survivors (CCSs) are at high risk for illness and premature death. Little is known about the physicians who provide their routine medical care.

OBJECTIVE

To determine general internists' self-reported attitudes and knowledge about the care of CCSs.

DESIGN

Cross-sectional survey.

SETTING

Mailed survey delivered between September 2011 and August 2012.

PARTICIPANTS

Random sample of 2000 U.S. general internists.

MEASUREMENTS

Care preferences, comfort levels with caring for CCSs (7-point Likert scale: 1 = very uncomfortable, 7 = very comfortable), familiarity with available surveillance guidelines (7-point Likert scale: 1 = very unfamiliar, 7 = very familiar), and concordance with Children's Oncology Group Long-Term Follow-Up Guidelines in response to a clinical vignette.

RESULTS

The response rate was 61.6% (1110 of 1801). More than half the internists (51.1%) reported caring for at least 1 CCS; 72.0% of these internists never received a treatment summary. On average, internists were "somewhat uncomfortable" caring for survivors of Hodgkin lymphoma, acute lymphoblastic leukemia, and osteosarcoma. Internists reported being "somewhat unfamiliar" with available surveillance guidelines. In response to a clinical vignette about a young adult survivor of Hodgkin lymphoma, 90.6% of respondents did not appropriately recommend yearly breast cancer surveillance, 85.1% did not appropriately recommended cardiac surveillance, and 23.6% did not appropriately recommend yearly thyroid surveillance. Access to surveillance guidelines and treatment summaries were identified as the most useful resources for caring for CCSs.

LIMITATION

Findings, based on self-report, may not reflect actual clinical practice.

CONCLUSION

Although most general internists report involvement in the care of CCSs, many seem unfamiliar with available surveillance guidelines and would prefer to follow patients in collaboration with a cancer center.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Truth-telling and hematopoietic stem cell transplantation

Background:

Hematopoietic stem cell transplantation is a potential cure for a range of life-threatening diseases, but is also associated with a high mortality rate. Nurses encounter a variety of situations wherein they are faced with discussing bad news with hematopoietic stem cell transplantation patients.

Research objective:

The aim of this study was to explore the experiences and strategies used by Iranian nurses related to truth-telling and communicating bad news to hematopoietic stem cell transplantation patients.

Research design:

A qualitative approach using content analysis of interview data was conducted.

Participants and research context:

A total of 18 nurses from the main hematopoietic stem cell transplantation center in Iran participated in semi-structured interviews.

Ethical considerations:

The Institutional Review Board of the Tabriz University of Medical Sciences and the Hematology-Oncology and Stem Cell Transplantation Research Center affiliated with the Tehran University of Medical Sciences approved the study.

Findings:

In the first main category, not talking about the disease and potential negative outcomes, the nurses described the strategies of not naming the disease, talking about the truth in indirect ways and telling gradually. In the second main category, not disclosing the sad truth, the nurses described the strategies of protecting patients from upsetting information, secrecy, denying the truth and minimizing the importance of the problem. The nurses used these strategies to minimize psychological harm, avoid patient demoralization, and improve the patient’s likelihood of a fast and full recovery.

Discussion:

The priority for Iranian hematopoietic stem cell transplantation nurses is to first do no harm and to help patients maintain hope. This reflects the Iranian healthcare environment wherein communicating the truth to hematopoietic stem cell transplantation patients is commonly considered inappropriate and avoided.

Conclusion:

Iranian nurses require education and support to engage in therapeutic, culturally appropriate communication that emphasizes effective techniques for telling the truth and breaking bad news, thereby potentially improving patient outcomes and protecting patient rights.

Family physician preferences and knowledge gaps regarding the care of adolescent and young adult survivors of childhood cancer

PURPOSE

Childhood cancer survivors are at risk for long-term morbidity and early mortality. Since most adult and some adolescent survivors of childhood cancer will receive their long-term care from a primary care physician, we sought to determine family physicians' comfort with caring for this population.

METHODS

A survey was mailed to 2,520 United States (US) and Canadian family physicians to assess their attitudes and knowledge regarding the care of adolescent and young adult survivors of childhood cancer.

RESULTS

One thousand one hundred twenty-four family physicians responded (704 US, 420 Canadian). Median age was 53 years; 63 % were men; 81 % had cared for ≤2 childhood cancer survivors in the past 5 years. Of those who had cared for a survivor, 48 % had never or almost never received a treatment summary from the referring cancer center; 85 % preferred to care for survivors in consultation with a cancer center-based physician or long-term follow-up program. Only 33, 27, and 23 % of respondents were very comfortable caring for survivors of childhood Hodgkin lymphoma, acute lymphoblastic leukemia or osteosarcoma, respectively. Only 16, 10, and 74 % of respondents correctly identified the guideline recommended surveillance for secondary breast cancer, cardiac dysfunction and hypothyroidism in response to a vignette describing a Hodgkin lymphoma survivor. Respondents rated access to clinical care guidelines and receipt of a patient-specific letter from specialists with surveillance recommendations as the modalities most likely to assist them in caring for survivors.

CONCLUSIONS

Most family physicians are willing to care for childhood cancer survivors in consultation with a cancer center, and with specific tools to facilitate this care.

IMPLICATIONS FOR CANCER SURVIVORS

Adult and adolescent survivors of childhood cancer who receive their follow-up care from a family physician must be empowered to choose a physician who is comfortable with caring for survivors. Further, the survivor must ensure that their physician has access to a treatment summary as well as to patient-specific recommendations for surveillance for late effects of cancer therapy.

Systematic review: Health-related characteristics of elderly hospitalized adults and nursing home residents associated with short-term mortality

OBJECTIVES

To identify the domains of health-related characteristics of older hospitalized adults and nursing home residents most strongly associated with short-term mortality.

DESIGN

Systematic review.

SETTING

Studies published in English in MEDLINE, Scopus, or Web of Science before August 1, 2010.

PARTICIPANTS

Prospective studies consisting of persons aged 65 and older that evaluated the association between at least one health-related participant characteristic and mortality within a year in multivariable analysis.

MEASUREMENTS

All health-related characteristics associated with mortality in multivariable analysis were extracted and categorized into domains. The frequency, with all studies combined, with which particular domains were associated with mortality in multivariable analysis was determined.

RESULTS

Thirty-three studies (28 in hospitalized individuals, five in nursing home residents) reported a large number of characteristics associated with mortality that could be categorized in seven domains: cognitive function, disease diagnosis, laboratory values, nutrition, physical function, pressure ulcers, and shortness of breath. Measures of physical function and nutrition were the domains most frequently associated with mortality up to 1 year from the time of evaluation for hospitalized individuals and nursing home residents; measures of physical function, cognitive function, and nutrition were the domains most frequently associated with in-hospital mortality for hospitalized individuals.

CONCLUSION

Of a large number of health-related characteristics of older persons shown to be associated with short-term mortality, measures of nutrition, physical function, and cognitive function were the domains of health most frequently associated with mortality. These domains provide easily measurable factors that may serve as helpful markers for individuals at high mortality risk.

A predictive model to identify hospitalized cancer patients at risk for 30-day mortality based on admission criteria via the electronic medical record

BACKGROUND

This study sought to develop a predictive model for 30-day mortality in hospitalized cancer patients, by using admission information available through the electronic medical record.

METHODS

Observational cohort study of 3062 patients admitted to the oncology service from August 1, 2008, to July 31, 2009. Matched numbers of patients were in the derivation and validation cohorts (1531 patients). Data were obtained on day 1 of admission and included demographic information, vital signs, and laboratory data. Survival data were obtained from the Social Security Death Index.

RESULTS

The 30-day mortality rate of the derivation and validation samples were 9.5% and 9.7% respectively. Significant predictive variables in the multivariate analysis included age (P < .0001), assistance with activities of daily living (ADLs; P = .022), admission type (elective/emergency) (P = .059), oxygen use (P < .0001), and vital signs abnormalities including pulse oximetry (P = .0004), temperature (P = .017), and heart rate (P = .0002). A logistic regression model was developed to predict death within 30 days: Score = 18.2897 + 0.6013*(admit type) + 0.4518*(ADL) + 0.0325*(admit age) - 0.1458*(temperature) + 0.019*(heart rate) - 0.0983*(pulse oximetry) - 0.0123 (systolic blood pressure) + 0.8615*(O2 use). The largest sum of sensitivity (63%) and specificity (78%) was at -2.09 (area under the curve = -0.789). A total of 25.32% (100 of 395) of patients with a score above -2.09 died, whereas 4.31% (49 of 1136) of patients below -2.09 died. Sensitivity and positive predictive value in the derivation and validation samples compared favorably.

CONCLUSIONS

Clinical factors available via the electronic medical record within 24 hours of hospital admission can be used to identify cancer patients at risk for 30-day mortality. These patients would benefit from discussion of preferences for care at the end of life.

Survival of patients with non-small cell lung cancer without treatment: a systematic review and meta-analysis

BACKGROUND

Lung cancer is considered a terminal illness with a five-year survival rate of about 16%. Informed decision-making related to the management of a disease requires accurate prognosis of the disease with or without treatment. Despite the significance of disease prognosis in clinical decision-making, systematic assessment of prognosis in patients with lung cancer without treatment has not been performed. We conducted a systematic review and meta-analysis of the natural history of patients with confirmed diagnosis of lung cancer without active treatment, to provide evidence-based recommendations for practitioners on management decisions related to the disease. Specifically, we estimated overall survival when no anticancer therapy is provided.

METHODS

Relevant studies were identified by search of electronic databases and abstract proceedings, review of bibliographies of included articles, and contacting experts in the field. All prospective or retrospective studies assessing prognosis of lung cancer patients without treatment were eligible for inclusion. Data on mortality was extracted from all included studies. Pooled proportion of mortality was calculated as a back-transform of the weighted mean of the transformed proportions using the random-effects model. To perform meta-analysis of median survival, published methods were used to pool the estimates as mean and standard error under the random-effects model. Methodological quality of the studies was examined.

RESULTS

Seven cohort studies (4,418 patients) and 15 randomized controlled trials (1,031 patients) were included in the meta-analysis. All studies assessed mortality without treatment in patients with non-small cell lung cancer (NSCLC). The pooled proportion of mortality without treatment in cohort studies was 0.97 (95% CI: 0.96 to 0.99) and 0.96 in randomized controlled trials (95% CI: 0.94 to 0.98) over median study periods of eight and three years, respectively. When data from cohort and randomized controlled trials were combined, the pooled proportion of mortality was 0.97 (95% CI: 0.96 to 0.98). Test of interaction showed a statistically non-significant difference between subgroups of cohort and randomized controlled trials. The pooled mean survival for patients without anticancer treatment in cohort studies was 11.94 months (95% CI: 10.07 to 13.8) and 5.03 months (95% CI: 4.17 to 5.89) in RCTs. For the combined data (cohort studies and RCTs), the pooled mean survival was 7.15 months (95% CI: 5.87 to 8.42), with a statistically significant difference between the two designs. Overall, the studies were of moderate methodological quality.

CONCLUSION

Systematic evaluation of evidence on prognosis of NSCLC without treatment shows that mortality is very high. Untreated lung cancer patients live on average for 7.15 months. Although limited by study design, these findings provide the basis for future trials to determine optimal expected improvement in mortality with innovative treatments.

Evaluating a patient's request for life-prolonging treatment: an ethical framework

Contrary to the widespread concern about over-treatment at the end of life, today, patient preferences for palliative care at the end of life are frequently respected. However, ethically challenging situations in the current healthcare climate are, instead, situations in which a competent patient requests active treatment with the goal of life-prolongation while the physician suggests best supportive care only. The argument of futility has often been used to justify unilateral decisions made by physicians to withhold or withdraw life-sustaining treatment. However, we argue that neither the concept of futility nor that of patient autonomy alone is apt for resolving situations in which physicians are confronted with patients' requests for active treatment. Instead, we integrate the relevant arguments that have been put forward in the academic discussion about 'futile' treatment into an ethical algorithm with five guiding questions: (1) Is there a chance that medical intervention will be effective in achieving the patient's treatment goal? (2) How does the physician evaluate the expected benefit and the potential harm of the treatment? (3) Does the patient understand his or her medical situation? (4) Does the patient prefer receiving treatment after evaluating the benefit-harm ratio and the costs? (5) Does the treatment require many resources? This algorithm shall facilitate approaching patients' requests for treatments deemed futile by the physician in a systematic way, and responding to these requests in an ethically appropriate manner. It thereby adds substantive considerations to the current procedural approaches of conflict resolution in order to improve decision making among physicians, patients and families.

Prognostic categories and timing of negative prognostic communication from critical care physicians to family members at end-of-life in an intensive care unit

Negative prognostic communication is often delayed in intensive care units, which limits time for families to prepare for end-of-life. This descriptive study, informed by ethnographic methods, was focused on exploring critical care physician communication of negative prognoses to families and identifying timing influences. Prognostic communication of critical care physicians to nurses and family members was observed and physicians and family members were interviewed. Physician perception of prognostic certainty, based on an accumulation of empirical data, and the perceived need for decision-making, drove the timing of prognostic communication, rather than family needs. Although prognoses were initially identified using intuitive knowledge for patients in one of the six identified prognostic categories, utilizing decision-making to drive prognostic communication resulted in delayed prognostic communication to families until end-of-life (EOL) decisions could be justified with empirical data. Providers will better meet the needs of families who desire earlier prognostic information by separating prognostic communication from decision-making and communicating the possibility of a poor prognosis based on intuitive knowledge, while acknowledging the uncertainty inherent in prognostication. This sets the stage for later prognostic discussions focused on EOL decisions, including limiting or withdrawing treatment, which can be timed when empirical data substantiate intuitive prognoses. This allows additional time for families to anticipate and prepare for end-of-life decision-making.

Are physicians ethically obligated to address hospice as an alternative to "usual" treatment of advancing end-stage disease?

Hospice care is ideally suited to meet the psychosocial and spiritual needs of dying patients, providing the opportunity to settle financial, property, and inheritance issues; to mend lacerations in important lifetime relationships, including forgiving and asking forgiveness; and to assure a degree of autonomous control over the environment and the social and spiritual processes that attend one's death. Physicians are not only imprecise in prognosticating a patient's time to die, they tend to be over-optimistic in their predictions. A "no" answer to the question, "Would I be surprised if this patient died in the next year?" is a reasonable starting-point for discussing hospice care as a potential treatment plan, now or in the future. Physicians have a duty to present palliative care in hospice as an alternative to the recurrent hospital interventions that are typical in the last six to 12 months of life tor patients who are failing and have declining prospects for one-year survival.

Specific Training Program Improves Oncologists' Palliative Care Communication Skills in a Randomized Controlled Trial

Purpose

The aim of the study was to demonstrate that COM-ON-p, concise and individualized communication skills training (CST), improves oncologists' communication skills in consultations focusing on the transition to palliative care.

Methods

Forty-one physicians were randomly assigned to a control (CG) or intervention group (IG). At t0, all physicians held two video-recorded consultations with actor-patient pairs. Afterward, physicians in the IG participated in COM-ON-p. Five weeks after t0, a second assessment took place (t1). COM-ON-p consists of an 11-hour workshop (1.5 days), pre- and postassessment (2 hours), and coaching (0.5 hours). Physicians focused on practicing individual learning goals with actor patients in small groups. To evaluate the training, blinded raters assessed communication behavior of the physicians in video-recorded actor-patient consultations using a specific checklist. Data were analyzed using a mixed model with baseline levels as covariates.

Results

Participants in the IG improved significantly more than those in the CG in all three sections of the COM-ON-Checklist: skills specific to the transition to palliative care, global communication skills, and involvement of significant others (all P < .01). Differences between the CG and IG on the global items of communication skills and involvement of significant others were also significant (P < .01). Effect sizes were medium to large, with a 0.5-point improvement on average on a five-point rating scale.

Conclusion

Physicians can be trained to meet better core challenges during the transition to palliative care through developed concise CST. Generalization and transfer into clinical practice must be proven in additional studies.