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Chu C, Anderson R, White N, Stone P. Prognosticating for Adult Patients With Advanced Incurable Cancer: a Needed Oncologist Skill. Curr Treat Options Oncol 2020; 21:5. [PMID: 31950387 PMCID: PMC6965075 DOI: 10.1007/s11864-019-0698-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patients with advanced cancer and their families commonly seek information about prognosis to aid decision-making in medical (e.g. surrounding treatment), psychological (e.g. saying goodbye), and social (e.g. getting affairs in order) domains. Oncologists therefore have a responsibility to identify and address these requests by formulating and sensitively communicating information about prognosis. Current evidence suggests that clinician predictions are correlated with actual survival but tend to be overestimations. In an attempt to cultivate prognostic skills, it is recommended that clinicians practice formulating and recording subjective estimates of prognosis in advanced cancer patient’s medical notes. When possible, a multi-professional prognostic estimate should be sought as these may be more accurate than individual predictions alone. Clinicians may consider auditing the accuracy of their predictions periodically and using feedback from this process to improve their prognostic skills. Clinicians may also consider using validated prognostic tools to complement their clinical judgements. However, there is currently only limited evidence about the comparative accuracy of different prognostic tools or the extent to which these measures are superior to clinical judgement. Oncologists and palliative care physicians should ensure that they receive adequate training in advanced communication skills, which builds upon their pre-existing skills, to sensitively deliver information on prognosis. In particular, clinicians should acknowledge their own prognostic uncertainty and should emphasise the supportive care that can continue to be provided after stopping cancer-directed therapies.
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Affiliation(s)
- Christina Chu
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Rebecca Anderson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Nicola White
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
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Chan CWH, Chow MCM, Chan S, Sanson-Fisher R, Waller A, Lai TTK, Kwan CWM. Nurses' perceptions of and barriers to the optimal end-of-life care in hospitals: A cross-sectional study. J Clin Nurs 2020; 29:1209-1219. [PMID: 31889355 DOI: 10.1111/jocn.15160] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/04/2019] [Accepted: 12/20/2019] [Indexed: 12/25/2022]
Abstract
AIMS AND OBJECTIVES To assess nurses' perceptions of what constitutes optimal end-of-life (EOL) care in hospital and evaluate nurses' perceived barriers to EOL care delivery. BACKGROUND Care of dying patients is common in hospitals. However, little is known about the important elements of and barriers to optimal EOL care from key service providers' perspective, which is crucial for quality EOL care in hospital settings. METHOD This is a cross-sectional survey. Nurses practising in hospitals recruited by convenience sampling completed self-report survey questionnaires. STROBE checklist was used in study reporting. RESULTS One hundred and-seventy-five nurses participated in the survey. The majority (70%) had experience in caring for dying patients. The five most highly perceived factors constituting optimal EOL care included the following: "families know and follow patient's EOL wishes"; "patients emotional concerns identified and managed well"; "patients participating in decision-making"; "EOL care documents stored well and easily accessed"; and "provide private rooms and unlimited visiting hours for families of dying patients". Top five barriers were "doctors are too busy"; "nurses are too busy"; "insufficient private room/space"; "nurses have limited training in EOL care"; and "families have unrealistic expectations of patient's prognosis." Multivariate regression analysis identified that nurses without experience in caring for dying patients reported a significantly higher number of perceived barriers towards EOL care (p = .012). Those with postgraduate degree training reported significantly fewer perceived barriers (p = .007). CONCLUSION Findings identified essential elements for optimal hospital EOL care not only involving patients and families in EOL decision and care, but also documentation and environmental issues in the healthcare system level and the needs for strengthening manpower and expertise at palliative care policy level. RELEVANCE TO CLINICAL PRACTICE This study revealed quantitative data to inform health service managers and policy makers in terms of training and service development/ re-design for EOL care in hospital settings.
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Affiliation(s)
- Carmen W H Chan
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | | | - Sally Chan
- The University of Newcastle, Newcastle, NSW, Australia
| | - Robert Sanson-Fisher
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle and Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Amy Waller
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle and Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Theresa T K Lai
- Society for the Promotion of Hospice Care, Jockey Club Home for Hospice, Hong Kong SAR, China
| | - Cecilia W M Kwan
- Bradbury Hospice, New Territories East Cluster, Hospital Authority, Hong Kong SAR, China
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Brand DA. The Stage IV Shuffle: Elusiveness of Straight Talk About Advanced Cancer. J Gen Intern Med 2019; 34:2637-2642. [PMID: 31385215 PMCID: PMC6848670 DOI: 10.1007/s11606-019-05158-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 04/30/2019] [Accepted: 06/13/2019] [Indexed: 01/14/2023]
Abstract
During the initial consultation with a patient to communicate a diagnosis of late-stage cancer, the oncologist may refrain from giving survival statistics, redirecting the conversation from the bad news (incurability) to the practical aspects of the patient's care (treatments, timetables, appointments, and testing to monitor response to treatment). Whether conscious or unconscious, this diversion helps cushion the impact of the disturbing news. This paper shows that clinicians' gingerly handling of harsh facts when they talk with patients also applies to health educators and researchers when they write about late-stage cancer. As a result, these cancer patients typically lack an understanding of their poor prognosis and the limited effectiveness of most available treatments, possibly compromising their ability to make informed choices. To remedy this problem, I describe an approach to straight talk about late-stage cancer that can give a patient realistic hopes instead of false hopes that are apt to betray later on. I also propose an enhanced method of displaying and interpreting comparative efficacy data that can facilitate understanding and serve as a basis for shared decision making.
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Affiliation(s)
- Donald A Brand
- NYU Long Island School of Medicine, 101 Mineola Boulevard, Suite 3-041, Mineola, NY, 11501, USA.
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Kerkham T, Brain M. Goals of care conversations and documentation in patients triggering medical emergency team calls. Intern Med J 2019; 50:1373-1376. [PMID: 31661181 DOI: 10.1111/imj.14667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is widely accepted that early discussions about goals of care (GOC) should occur during a hospital admission. Whilst rapid response systems such as Medical Emergency Team (MET) calls were designed to identify patients at risk of deterioration early enough in their illness to intervene, it is becoming apparent that these teams frequently diagnose the dying patient. AIMS To determine how frequently Launceston General Hospital MET doctors are involved in discussions surrounding GOC. METHODS A retrospective audit of all MET calls and Code Blues at the Launceston General Hospital over an 18 month period was performed. RESULTS 50% of MET calls occurred in patients with no valid GOC form completed prior. At 3% of events, the GOC form was completed for the first time, and at 3% it was modified. At a further 3% the notes implied there had been a modification to the GOC but the form had not been completed. CONCLUSIONS This audit confirms that documentation surrounding GOC is inadequate, and that at 9% of MET calls, MET doctors are involved in discussions surrounding treatment limitations. This suggests that further education and training is required for doctors working in inpatient care, including those who staff the MET.
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Affiliation(s)
- Telena Kerkham
- Department of General and Acute Care Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Matthew Brain
- Intensive Care Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
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General practitioners' perceptions of best practice care at the end of life: a qualitative study. BJGP Open 2019; 3:bjgpopen19X101660. [PMID: 31581119 PMCID: PMC6970580 DOI: 10.3399/bjgpopen19x101660] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/21/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND GPs can play a central role in palliative care delivery. However, little is known about their views on what constitutes best practice care at the end of life. AIM To explore, in a sample of Australian GPs, their perceptions of best practice palliative care and their ideal role in its delivery. DESIGN & SETTING A qualitative interview study of 25 GPs practising in metropolitan and non-metropolitan locations in New South Wales, Australia. METHOD Semi-structured telephone interviews were conducted. Data were analysed using qualitative content analysis. RESULTS Participants had a mean age of 51 years, and had practised between 3 and 38 years (mean 19 years). Best practice palliative care was perceived to be proactive and responsive to a wide range of patient and family needs. Many participants indicated a need for relational continuity, which involves GPs establishing a care pathway from diagnosis to palliation, coordinating care across the pathway, and collaborating with other healthcare providers. A number of participants perceived palliative care as a natural extension of primary care and indicated that best practice palliative care mainly requires experiential knowledge and good communication skills, rather than specialised medical knowledge. Participants listed a number of communication strategies to offer patients and their families choice and ongoing negotiation about the recommended treatments. CONCLUSION This study provides novel in-depth insights into GPs' perceptions of best practice palliative care. Future research should further investigate the identified features of care, and whether they can maximise the outcomes of patients and their families.
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Sprange A, Ismond KP, Hjartarson E, Chavda S, Carbonneau M, Kowalczewski J, Watanabe SM, Brisebois A, Tandon P. Advance Care Planning Preferences and Readiness in Cirrhosis: A Prospective Assessment of Patient Perceptions and Knowledge. J Palliat Med 2019; 23:552-557. [PMID: 31618102 DOI: 10.1089/jpm.2019.0244] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: In 2014, the province of Alberta launched a campaign to promote public awareness of advance care planning (ACP) and its associated two-part documentation-a Goals of care designation (GCD, a medical order written by a health care practitioner detailing wishes for care) and a personal directive (PD, a document naming a surrogate decision maker). Notably, unlike the GCD, the PD can be self-initiated independent of a health practitioner. Objective: Two years after the campaign, we aimed to assess knowledge and recall of participation in ACP among cirrhosis patients. Design/Setting: Consecutive adult cirrhosis patients attending one of two specialty cirrhosis clinics in Edmonton, Alberta, were surveyed. Results: Ninety-seven patients were included. Mean model for end-stage liver disease was 12. Although 97% of patients indicated it was extremely important to know the reality of their illness, only 53% understood that cirrhosis would affect their future quality of life. Thirty-three percent of patients had completed a PD and 14% had completed a GCD. Seventy-eight percent of patients believed a GCD was important to them and 85% preferred to complete it in an outpatient clinic setting. Only a minority of patients who had taken the initiative to complete a PD in the community also had a GCD. Conclusions: Despite efforts to raise awareness of and educate Albertans about ACP, <20% of cirrhosis patients have a completed GCD. Additional strategic prioritization is required in both patients and providers to ensure that health practitioner-facilitated ACP is carried out as standard-of-care in all patients with cirrhosis.
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Affiliation(s)
- Ashleigh Sprange
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Kathleen P Ismond
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Emma Hjartarson
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Swati Chavda
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle Carbonneau
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jan Kowalczewski
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Sharon M Watanabe
- Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Amanda Brisebois
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Puneeta Tandon
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Rumpold T, Lütgendorf-Caucig C, Löffler-Stastka H, Roider-Schur S, Pötter R, Kirchheiner K. Attitude Towards End of Life Communication of Austrian Medical Students. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2019; 34:743-748. [PMID: 29687186 DOI: 10.1007/s13187-018-1366-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Medical students have to acquire theoretical knowledge, practical skills, and a personal attitude to meet the emerging needs of palliative care. The present study aimed to assess the personal attitude of Austrian medical students towards end of life communication (EOLC), as key part of palliative care. This cross-sectional, mono-institutional assessment invited all medical students at the Medical University of Vienna in 2015. The assessment was conducted web-based via questionnaire about attitudes towards EOLC. Additional socio-demographic and medical education-related parameters were collected. Overall, 743 medical students participated in the present report. Differences regarding the agreement or disagreement to several statements concerning the satisfaction of working with chronically ill patients, palliative care, and health care costs, as well as the extent of information about palliative disease, were found for age, gender, and academic years. The overall attitude towards EOLC in the present sample can be regarded as quite balanced. Nevertheless, a considerable number of medical students are still reluctant to inform patients about their incurable disease. Reservations towards palliative care as part of the health care system seem to exist. The influence of the curriculum as well as practical experiences seems to be important but needs further investigation.
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Affiliation(s)
- Tamara Rumpold
- Department of Radiation Oncology, Comprehensive Cancer Center Medical University of Vienna, Waehringer Straße 18-20, 1090, Vienna, Austria
| | | | - Henriette Löffler-Stastka
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Waehringer Straße 18-20, 1090, Vienna, Austria
| | - Sophie Roider-Schur
- Division of Palliative Care, Department of Internal Medicine I, Comprehensive Cancer Center, Medical University of Vienna, Waehringer Straße 18-20, 1090, Vienna, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center Medical University of Vienna, Waehringer Straße 18-20, 1090, Vienna, Austria
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center Medical University of Vienna, Waehringer Straße 18-20, 1090, Vienna, Austria
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Abstract
An accurate prognosis about how long a terminally ill patient has left to live, when disclosed sensitively in open discussions, can facilitate patient-centred care and shared decision making. In addition, several guidelines, policies and funding streams rely, to some extent, on a clinician estimated prognosis. However, clinician predictions alone have been shown to be unreliable and over-optimistic. The factors underlying clinicians' prognostic decisions (particularly at the very end of life) are beginning to be elucidated. As an alternative to clinicians' subjective estimates, a number of prognostic algorithms and scores have been developed and validated, but only a few have consistently shown superiority to clinician predictions. Therefore, an element of uncertainty remains and this needs to be acknowledged when having conversations with patients and their families. Guidelines are available to advise clinicians about how to prepare for, participate in and record prognostic conversations.
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Affiliation(s)
- Christina Chu
- University College London, London, UK and specialty trainee in palliative medicine, Barts Health NHS Trust, London, UK
| | - Nicola White
- Marie Curie Palliative Care Research Department, University College London, London, UK
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Mori M, Fujimori M, van Vliet LM, Yamaguchi T, Shimizu C, Kinoshita T, Morishita-Kawahara M, Inoue A, Inoguchi H, Matsuoka Y, Bruera E, Morita T, Uchitomi Y. Explicit prognostic disclosure to Asian women with breast cancer: A randomized, scripted video-vignette study (J-SUPPORT1601). Cancer 2019; 125:3320-3329. [PMID: 31206639 DOI: 10.1002/cncr.32327] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/31/2019] [Accepted: 04/30/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Nondisclosure of a poor prognosis to patients with advanced cancer remains a typical practice in Asia. Although the importance of prognostic communication has increasingly been recognized worldwide, little is known about whether explicit prognostic disclosure positively affects Asian patients with advanced cancer. The objective of this study was to examine the effects of explicit prognostic communication on patients with cancer recurrence. METHODS In this randomized, video-vignette study, Japanese women with breast cancer who had undergone curative surgery viewed videos of prognostic communication between a patient with recurrent, incurable breast cancer and her oncologist. The videos differed only in the presence or absence of explicit prognostic disclosure. The primary outcome was participants' uncertainty (rated from 0 to 10), and the secondary outcomes included anxiety (measured on the State-Trait Anxiety Inventory-State: range, 20-80), satisfaction (Patient Satisfaction Questionnaire; range 0-10), self-efficacy (range, 0-10), and willingness to discuss advance care planning (range, 1-4). RESULTS In total, 105 women participated (mean ± SD age, 53.8 ± 8.2 years). After viewing the video with more versus less explicit disclosure, participants showed significantly lower uncertainty (mean ± SE scores, 5.3 ±0.2 vs 5.7 ± 0.2, respectively; P = .032) and higher satisfaction (5.6 ± 0.2 vs 5.2 ± 0.2, respectively; P = .010) without increasing anxiety (changes in scores on the State-Trait Anxiety Inventory-State: 0.06 ± 0.5 vs 0.6 ± 0.5, respectively; P = .198). No significant differences were observed in self-efficacy (5.2 ± 0.2 vs 5.0 ± 0.2, respectively; P = .277) or willingness to discuss advance care planning (2.7 ± 0.1 vs 2.7 ± 0.1, respectively; P = .240). CONCLUSIONS Explicit prognostic disclosure prompted better outcomes than nondisclosure in Japanese women with breast cancer. When asked about the prognosis by Asian patients with cancer, clinicians may be encouraged to respect their wishes and explicitly discuss the prognosis if deemed appropriate.
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Affiliation(s)
- Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan.,Division of Health Care Research, Behavioral Science and Survivorship Research Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Maiko Fujimori
- Division of Health Care Research, Behavioral Science and Survivorship Research Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan.,Division of Cohort Consortium Research, Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Liesbeth M van Vliet
- Department of Communication, Nivel-Netherlands Institute for Health Services Research, Utrecht, Netherlands.,Department of Health, Medical, and Neuropsychology, Leiden University, Leiden, Netherlands
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Chikako Shimizu
- Department of Breast Medical Oncology, National Center for Global Health and Medicine, Shinjuku-ku, Japan
| | - Takayuki Kinoshita
- Department of Breast Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Miki Morishita-Kawahara
- Division of Health Care Research, Behavioral Science and Survivorship Research Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Akira Inoue
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Hironobu Inoguchi
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Matsuoka
- Division of Health Care Research, Behavioral Science and Survivorship Research Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Yosuke Uchitomi
- Division of Health Care Research, Behavioral Science and Survivorship Research Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan.,Innovation Center for Supportive, Palliative, and Psychosocial Care, National Cancer Center Hospital, Tokyo, Japan
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Mori M, Fujimori M, Ishiki H, Nishi T, Hamano J, Otani H, Uneno Y, Oba A, Morita T, Uchitomi Y. The Effects of Adding Reassurance Statements: Cancer Patients' Preferences for Phrases in End-of-Life Discussions. J Pain Symptom Manage 2019; 57:1121-1129. [PMID: 30818028 DOI: 10.1016/j.jpainsymman.2019.02.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 11/23/2022]
Abstract
CONTEXT When discussing end-of-life issues with cancer patients, the addition of reassurance statements is considered helpful. However, patients' preferences for such statements have not been systematically demonstrated. OBJECTIVES The objectives of this study were to clarify if phrases with additional reassurance statements would be more preferable to phrases without them and explore variables associated with patients' preferences. METHODS In a cross-sectional survey, 412 cancer patients assessed their own preferences for phrases with/without additional statements using a six-point scale (1 = not at all preferable; 6 = very preferable). These included the statements of "hope for the best and prepare for the worst" ("hope/prepare") when discussing prognosis; symptom palliation when discussing code status; and specific goals, continuity of care, and nonabandonment when discussing hospice referral. We evaluated demographic data and the coping style and conducted multivariate regression analysis. RESULTS Compared with the phrase of life expectancy (i.e., median + typical range) alone [mean (SD), 3.5 (1.2); 95% CI, 3.4-3.6], the phrase with the additional "hope/prepare" statement was more preferable [3.8 (1.4); 3.7-3.9]. Compared with the phrase of do-not-resuscitate alone (3.1(1.3); 3.0-3.3), the phrase with the additional statement of symptom palliation was more preferable [3.9 (1.3); 3.7-4.0]. Compared with the phrase of hospice referral alone [3.4 (1.2); 3.3-3.5], phrases with the addition of a specific goal [3.9 (1.0); 3.8-4.0], specific goal and continuity (4.4(1.0); 4.3-4.5), and specific goal, continuity, and nonabandonment [4.8 (1.2); 4.7-4.9] were more preferable. In multivariate analyses, task-oriented coping was significantly correlated with preferences for phrases including additional reassurance statements. CONCLUSION Cancer patients systematically preferred reassurance statements. In end-of-life discussions, especially with patients with task-oriented coping, clinicians may provide additional reassurance statements.
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Affiliation(s)
- Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan; Division of Health Care Research, QOL Research Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan.
| | - Maiko Fujimori
- Division of Health Care Research, QOL Research Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan; Division of Cohort Consortium Research, Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center, Tokyo, Japan
| | - Tomohiro Nishi
- Kawasaki Comprehensive Care Center, Kawasaki Municipal Ida Hospital, Kawasaki, Japan
| | - Jun Hamano
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hiroyuki Otani
- Department of Palliative Care Team, and Palliative and Supportive Care, National Kyushu Cancer Center, Fukuoka, Japan
| | - Yu Uneno
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Akira Oba
- Patient Support Center, Gunma Prefectural Cancer Center, Ota, Gunma, Japan
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Yosuke Uchitomi
- Division of Cohort Consortium Research, Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan; Innovation Center for Supportive, Palliative and Psychosocial Care, National Cancer Center Hospital, Tokyo, Japan
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61
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The impact of communication style on patient satisfaction. Breast Cancer Res Treat 2019; 176:349-356. [DOI: 10.1007/s10549-019-05232-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/10/2019] [Indexed: 10/27/2022]
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Kirkebøen G. "The median isn't the message": How to communicate the uncertainties of survival prognoses to cancer patients in a realistic and hopeful way. Eur J Cancer Care (Engl) 2019; 28:e13056. [PMID: 31016812 PMCID: PMC9285825 DOI: 10.1111/ecc.13056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/08/2019] [Accepted: 03/21/2019] [Indexed: 11/26/2022]
Abstract
This study investigated how doctors communicate the uncertainties of survival prognoses to patients recently diagnosed with life‐threatening cancer, and suggests ways to improve this communication. Two hundred thirty‐eight Norwegian oncologists and general practitioners (GPs) participated in Study 1. The study included both a scenario and a survey. The scenario asked participants to respond to a hypothetical patient who wanted to know how long (s)he could be expected to live. There were marked differences in responses within both groups, but few differences between the GPs and oncologists. There was a strong reluctance among doctors to provide patients with a prognosis. Even when they were presented with a statistically well‐founded right‐skewed survival curve, only a small minority provided hope by communicating the variation in survival time. In Study 2, 177 healthy students rated their preferences for different ways of receiving information regarding the uncertainty of a survival prognosis. Participants who received an explicitly described right‐skewed survival curve believed that they would feel more hopeful. These participants also obtained a more realistic understanding of the variation in survival than those who did not receive this information. Based on the findings of the two studies and on extant psychological research, the author suggests much‐needed guidelines for communicating survival prognoses in a realistic and optimistic way to patients recently diagnosed with life‐threatening cancer. In particular, the guidelines emphasise that the doctor explains the often strongly right‐skewed variation in survival time, and thereby providing the patient with realistic hope.
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Affiliation(s)
- Geir Kirkebøen
- Department of Psychology, University of Oslo, Oslo, Norway
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Park HY, Kim YA, Sim JA, Lee J, Ryu H, Lee JL, Maeng CH, Kwon JH, Kim YJ, Nam EM, Shim HJ, Song EK, Jung KH, Kang EJ, Kang JH, Yun YH. Attitudes of the General Public, Cancer Patients, Family Caregivers, and Physicians Toward Advance Care Planning: A Nationwide Survey Before the Enforcement of the Life-Sustaining Treatment Decision-Making Act. J Pain Symptom Manage 2019; 57:774-782. [PMID: 30593911 DOI: 10.1016/j.jpainsymman.2018.12.332] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 11/29/2022]
Abstract
CONTEXT To respect a patient's wish for end-of-life care, "the Act on Decisions on Life-Sustaining Treatment for Patients at the End-of-Life" was enacted in South Korea in 2016. Current understanding of people who would be involved in advance care planning (ACP) is crucial to disseminate it systematically. OBJECTIVES The objective of this study was to investigate awareness and attitudes toward ACP in South Korea. METHODS A multicenter, nationwide cross-sectional study was conducted, a survey regarding ACP among four groups that would have different positions and experiences: 1001 cancer patients, 1006 family caregivers, 928 physicians, and 1241 members of the general public. RESULTS A total of 15% of the general population, 33% of the patients and caregivers, and 61% of the physicians had knowledge of advance directives. More than 64% of the general population, above 72% of the patients and caregivers, and 97% of the physicians were willing to do so when the disease status was aggravated or terminal. The possibility for changing the plan, uncertainty as to whether directives would actually be followed, and psychological discomfort were common reasons for not wanting to engage in ACP. Routine recommendations for a specific medical condition, heightened accessibility, and health insurance support were common factors that could help facilitate ACP. CONCLUSION Our findings suggest that strategies for promoting ACP should reflect different perspectives among the general public, patients, family caregivers, and physicians. Public advocacy, resources for approaching and integrating ACP into routine health care, as well as systematic support provisions are needed.
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Affiliation(s)
- Hye Yoon Park
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Ae Kim
- National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Jin-Ah Sim
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jihye Lee
- Department of Biomedical Informatics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyewon Ryu
- Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jung Lim Lee
- Department of Hemato-oncology, Daegu Fatima Hospital, Daegu, Republic of Korea
| | - Chi Hoon Maeng
- Department of Medical Oncology and Hematology, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Jung Hye Kwon
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Yu Jung Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Eun Mi Nam
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Jeong Shim
- Department of Hemato-Oncology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Eun-Kee Song
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Republic of Korea
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eun Joo Kang
- Division of Hemato-Oncology, Department of Internal Medicine, Korea University College of Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Jung Hun Kang
- Department of Internal Medicine, Postgraduate Medical School, Gyeongsang National University, Jinju, Republic of Korea
| | - Young Ho Yun
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Family Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Institute of Health Policy and Management, Seoul National University, Seoul, Seoul, Republic of Korea.
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LeBlanc TW, Marron JM, Ganai S, McGinnis MM, Spence RA, Tenner L, Tap WD, Hlubocky FJ. Prognostication and Communication in Oncology. J Oncol Pract 2019; 15:208-215. [DOI: 10.1200/jop.18.00647] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Sabha Ganai
- Southern Illinois University School of Medicine, Springfield, IL
| | | | | | - Laura Tenner
- University of Texas Health Cancer Center at San Antonio, San Antonio, TX
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Sanson-Fisher R, Fakes K, Waller A, Mackenzie L, Bryant J, Herrmann A. Assessing patients' experiences of cancer care across the treatment pathway: a mapping review of recent psychosocial cancer care publications. Support Care Cancer 2019; 27:1997-2006. [PMID: 30891626 DOI: 10.1007/s00520-019-04740-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/07/2019] [Indexed: 01/09/2023]
Abstract
PURPOSE Patients are a critical source of information about the quality of the components of cancer care that contributes to optimal psychosocial outcomes. Recently published research was examined to determine the: (1) proportion of studies that examined at least one of 14 components of cancer care, (2) the proportion of studies that included multiple components of care, and (3) the phase of the cancer care pathway in which data collection occurred (i.e. pre-, during and post-treatment). METHODS MEDLINE was searched to retrieve all data-based publications indexed for two international psychosocial cancer care journals (Supportive Care in Cancer and Psycho-Oncology) over a 2-year period. A total of 333 publications yielded 214 eligible publications that were assessed against the 14 components of care for which measurement by healthcare providers at multiple phases during cancer care is recommended. Publications were coded based on the: (1) specific component/s of care focused upon in the research, (2) number of components examined and (3) timing of data collection. RESULTS The most frequently assessed component of care was physical and psychosocial screening (n = 198, 93%). Most studies (n = 187, 87%) examined a single component of care. No studies assessed all 14 components. Only seven studies (2.1%) examined components of care across multiple phases of the care pathway. CONCLUSIONS Recently published studies have examined limited segments of patients' experiences of cancer care. To improve psychosocial outcomes among people living with and beyond cancer, there should be a greater focus on patients' experiences across multiple components and the whole care pathway.
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Affiliation(s)
- Rob Sanson-Fisher
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, HMRI Building Level 4, Callaghan, NSW, 2308, Australia. .,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia. .,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.
| | - Kristy Fakes
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, HMRI Building Level 4, Callaghan, NSW, 2308, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Amy Waller
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, HMRI Building Level 4, Callaghan, NSW, 2308, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Lisa Mackenzie
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, HMRI Building Level 4, Callaghan, NSW, 2308, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Jamie Bryant
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, HMRI Building Level 4, Callaghan, NSW, 2308, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Anne Herrmann
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, HMRI Building Level 4, Callaghan, NSW, 2308, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
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Mori M, Fujimori M, Ishiki H, Nishi T, Hamano J, Otani H, Uneno Y, Oba A, Morita T, Uchitomi Y. Adding a Wider Range and "Hope for the Best, and Prepare for the Worst" Statement: Preferences of Patients with Cancer for Prognostic Communication. Oncologist 2019; 24:e943-e952. [PMID: 30782978 DOI: 10.1634/theoncologist.2018-0643] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 01/09/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Although various phrases to communicate prognoses based on a certain concept have been proposed, no study has systematically investigated preferences of patients with cancer for actual phrases. We investigated whether phrases with a wider range and additional "hope for the best, and prepare for the worst" (hope/prepare) statement would be more preferable and explored variables associated with patients' preferences. MATERIALS AND METHODS In a cross-sectional survey, 412 outpatients with cancer self-assessed their preferences for 13 phrases conveying prognostic information (e.g., phrases with or without median, typical range, and/or best/worst cases, and those with or without a hope/prepare statement) on a 6-point scale (1 = not at all preferable; 6 = very preferable). We evaluated demographic data and the Coping Inventory for Stressful Situations and conducted multivariate regression analysis. RESULTS Regarding phrases with various ranges, the one including the median, typical range, and best/worst cases was more preferable (mean ± SD, 3.8 ± 1.3; 95% confidence interval [CI], 3.6-3.9) than the one with the median and typical range (3.4 ± 1.2; 3.3-3.6) or the one with only the median (3.2 ± 1.3; 3.1-3.3). Concerning the hope/prepare statement, the phrase including the median, typical range, uncertainty, and hope/prepare statement was more preferable (3.8 ± 1.4; 3.7-3.9) than the one without the statement (3.5 ± 1.2; 3.4-3.6). In multivariate analyses, task-oriented coping was significantly correlated with preferences for phrases with explicit information. CONCLUSION Overall, phrases with a wider range and the hope/prepare statement were preferable to those without them. When patients with cancer ask about prognoses, especially those with task-oriented coping, clinicians may provide explicit information with a wider range and the hope/prepare statement. IMPLICATIONS FOR PRACTICE Discussing prognoses with patients with advanced cancer is among the most important conversations for clinicians. In this cross-sectional survey to systematically investigate preferences of 412 patients with cancer for phrases conveying prognostic information, phrases with the median, typical range, and best/worst cases and those with the "hope for the best and prepare for the worst" (hope/prepare) statement were the most preferred. When patients with cancer ask about prognoses, clinicians may provide explicit information with a wider range and include the hope/prepare statement.
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Affiliation(s)
- Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan
- Division of Health Care Research, QOL Research Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Maiko Fujimori
- Division of Health Care Research, QOL Research Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
- Division of Cohort Consortium Research, Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center, Tokyo, Japan
| | - Tomohiro Nishi
- Kawasaki Comprehensive Care Center, Kawasaki Municipal Ida Hospital, Kawasaki, Japan
| | - Jun Hamano
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hiroyuki Otani
- Department of Palliative Care Team, and Palliative and Supportive Care, National Kyushu Cancer Center, Fukuoka, Japan
| | - Yu Uneno
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akira Oba
- Patient Support Center, Gunma Prefectural Cancer Center, Ota, Gunma, Japan
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Yosuke Uchitomi
- Division of Cohort Consortium Research, Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
- Innovation Center for Supportive, Palliative and Psychosocial Care, National Cancer Center, Tokyo, Japan
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67
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Thaete L, Hebert RS. Using business/law negotiation techniques in response to a ‘difficult’ family. PROGRESS IN PALLIATIVE CARE 2019. [DOI: 10.1080/09699260.2019.1591740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Lauren Thaete
- Department of Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Randy S. Hebert
- Department of Medicine, Allegheny Health Network, Pittsburgh, PA, USA
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68
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Franklin P, Arber A, Reed L, Ream E. Health and social care professionals' experiences of supporting parents and their dependent children during, and following, the death of a parent: A qualitative review and thematic synthesis. Palliat Med 2019; 33:49-65. [PMID: 30371147 DOI: 10.1177/0269216318803494] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND: Children need to be prepared for the death of a parent and supported afterwards. Parents seek support from health and social care professionals to prepare their children. Support is not always forthcoming. AIM: To systematically identify, analyse and synthesise literature reporting of the experiences of health and social care professionals when supporting parents and children during, and following, the death of a parent. DESIGN: A systematically constructed qualitative review and thematic synthesis. Registered on Prospero (CRD42017076345). DATA SOURCES: MEDLINE, CINAHL, Embase, PsycINFO, PsycARTICLES and PROSPERO, searched from January 1996 to July 2018 for qualitative studies in English, containing verbatim reporting of health and social care professionals' experiences of supporting parents and children during, and following, the death of a parent. Qualitative data were appraised using a modified Critical Appraisal Skills Programme qualitative appraisal checklist. RESULTS: The search yielded 15,758 articles. Of which, 15 met the inclusion criteria. A total of 13 included professionals' experiences of supporting parents and children before parental death. Two included experiences of supporting surviving parents and children afterwards. Three analytical themes identified as follows: (1) aspiring to deliver family-focussed care, (2) health and social care professionals' behaviours and emotions and (3) improving connections with parents and children. Connecting empathically with parents and children to prepare and support children entails significant emotional labour. Professionals seek to enhance their confidence to connect. CONCLUSION: Professionals struggle to connect empathically with parents and their children to prepare and to support children when a parent is dying and afterwards. Awareness of professionals' needs would enable provision of appropriate support for parents and children.
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Affiliation(s)
- Penny Franklin
- 1 School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Anne Arber
- 1 School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Liz Reed
- 2 Princess Alice Hospice, Esher, UK
| | - Emma Ream
- 1 School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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69
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Norton SA, Wittink MN, Duberstein PR, Prigerson HG, Stanek S, Epstein RM. Family caregiver descriptions of stopping chemotherapy and end-of-life transitions. Support Care Cancer 2018; 27:669-675. [PMID: 30056528 DOI: 10.1007/s00520-018-4365-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 07/18/2018] [Indexed: 11/21/2022]
Abstract
PURPOSE The purpose of this study was to describe family caregivers' perspectives of the final month of life of patients with advanced cancer, particularly whether and how chemotherapy was discontinued and the effect of clinical decision-making on family caregivers' perceptions of the patient's experience of care at the end of life (EOL). METHODS Qualitative descriptive design using semi-structured interviews collected from 92 family caregivers of patients with end-stage cancer enrolled in a randomized clinical trial. We used a phased approach to data analysis including open coding, focused coding, and within and across analyses. RESULTS We identified three patterns of transitions characterizing the shift away from active cancer treatment: (1) "We Pretty Much Knew," characterized by explicit discussions about EOL care, seemingly shared understanding about prognosis and seamless transitions from disease-oriented treatment to comfort-oriented care, (2) "Beating the Odds," characterized by explicit discussions about disease-directed treatment and EOL care options, but no shared understanding about prognosis and often chaotic transitions to EOL care, and (3) "Left to Die," characterized by no recall of EOL discussions with transitions to EOL occurring in crisis. CONCLUSIONS As communication and palliative care interventions continue to develop to improve care for patients with advanced cancer, it is imperative that we take into account the different patterns of transition and their unique patient and caregiver needs near the end of life. Our findings reveal considerable, and potentially unwarranted, variation in transitions from active treatment to death.
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Affiliation(s)
- S A Norton
- School of Nursing, University of Rochester, Rochester, NY, USA. .,Department of Medicine, Division of Palliative Care, University of Rochester, Rochester, NY, USA.
| | - M N Wittink
- Department of Family Medicine, University of Rochester, Rochester, NY, USA.,Department of Psychiatry, University of Rochester, Rochester, NY, USA
| | - P R Duberstein
- Department of Medicine, Division of Palliative Care, University of Rochester, Rochester, NY, USA.,Department of Family Medicine, University of Rochester, Rochester, NY, USA.,Department of Psychiatry, University of Rochester, Rochester, NY, USA
| | - H G Prigerson
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - S Stanek
- School of Nursing, University of Rochester, Rochester, NY, USA
| | - R M Epstein
- Department of Medicine, Division of Palliative Care, University of Rochester, Rochester, NY, USA.,Department of Family Medicine, University of Rochester, Rochester, NY, USA.,Department of Psychiatry, University of Rochester, Rochester, NY, USA.,Wilmot Cancer Center, University of Rochester, Rochester, NY, USA
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Girgis S, Smith A'B, Lambert S, Waller A, Girgis A. "It sort of hit me like a baseball bat between the eyes": a qualitative study of the psychosocial experiences of mesothelioma patients and carers. Support Care Cancer 2018; 27:631-638. [PMID: 30043265 DOI: 10.1007/s00520-018-4357-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/17/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Mesothelioma is an insidious disease with a generally poor prognosis even after invasive treatment. This qualitative study aimed to explore the experiences of patients suffering from mesothelioma and their carers and their perceptions of how their needs may be addressed. METHODS Eligible patients and carers were identified by a lung cancer care coordinator at each participating site, and invited to participate in one-on-one semi-structured telephone interviews (n = 5 patients, n = 3 carers), or in one of two focus groups (n = 3 patients, n = 3 carers). Discussions focusing on participants' experiences relating to physical, psychological, social, information and carer domains were audio-recorded, transcribed verbatim and thematically analysed. RESULTS The five major themes identified were (1) time of diagnosis is a particularly difficult period; (2) the timeliness, accuracy and balance of mesothelioma information is problematic; (3) coping strategies ranged from antagonism to acceptance; (4) the emotional and physical load of caring for the patient is significant and (5) carers need one-on-one support. CONCLUSION Mesothelioma patients and their carers face significant challenges, particularly around the time of diagnosis and in the physical, psychological and social/practical domains. There is a clear need for additional information, delivered in a timely and psychologically sensitive manner, as well as for practical and emotional support. Quantitative research may shed greater light on the prevalence and severity of challenges and needs reported by participants, and determine the usefulness of resources such as case workers and dyadic coping interventions in addressing these.
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Affiliation(s)
- Shenouda Girgis
- Centre for Oncology Education and Research Translation (CONCERT), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, 1871, Australia
| | - Allan 'Ben' Smith
- Centre for Oncology Education and Research Translation (CONCERT), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, 1871, Australia.
| | - Sylvie Lambert
- Centre for Oncology Education and Research Translation (CONCERT), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, 1871, Australia
- St. Mary's Research Centre, McGill University, Montreal, Canada
| | - Amy Waller
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Priority Research Centre for Health Behaviour (PRCHB), University of Newcastle, Newcastle, Australia
- Hunter Medical Research Institute, Newcastle, Australia
| | - Afaf Girgis
- Centre for Oncology Education and Research Translation (CONCERT), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, 1871, Australia
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Piers R, Albers G, Gilissen J, De Lepeleire J, Steyaert J, Van Mechelen W, Steeman E, Dillen L, Vanden Berghe P, Van den Block L. Advance care planning in dementia: recommendations for healthcare professionals. BMC Palliat Care 2018; 17:88. [PMID: 29933758 PMCID: PMC6014017 DOI: 10.1186/s12904-018-0332-2] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/10/2018] [Indexed: 01/08/2023] Open
Abstract
Background Advance care planning (ACP) is a continuous, dynamic process of reflection and dialogue between an individual, those close to them and their healthcare professionals, concerning the individual’s preferences and values concerning future treatment and care, including end-of-life care. Despite universal recognition of the importance of ACP for people with dementia, who gradually lose their ability to make informed decisions themselves, ACP still only happens infrequently, and evidence-based recommendations on when and how to perform this complex process are lacking. We aimed to develop evidence-based clinical recommendations to guide professionals across settings in the practical application of ACP in dementia care. Methods Following the Belgian Centre for Evidence-Based Medicine’s procedures, we 1) performed an extensive literature search to identify international guidelines, articles reporting heterogeneous study designs and grey literature, 2) developed recommendations based on the available evidence and expert opinion of the author group, and 3) performed a validation process using written feedback from experts, a survey for end users (healthcare professionals across settings), and two peer-review groups (with geriatricians and general practitioners). Results Based on 67 publications and validation from ten experts, 51 end users and two peer-review groups (24 participants) we developed 32 recommendations covering eight domains: initiation of ACP, evaluation of mental capacity, holding ACP conversations, the role and importance of those close to the person with dementia, ACP with people who find it difficult or impossible to communicate verbally, documentation of wishes and preferences, including information transfer, end-of-life decision-making, and preconditions for optimal implementation of ACP. Almost all recommendations received a grading representing low to very low-quality evidence. Conclusion No high-quality guidelines are available for ACP in dementia care. By combining evidence with expert and user opinions, we have defined a unique set of recommendations for ACP in people living with dementia. These recommendations form a valuable tool for educating healthcare professionals on how to perform ACP across settings.
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Affiliation(s)
- Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium.,End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Gwenda Albers
- Flanders Federation for Palliative Care, Vilvoorde, Belgium
| | - Joni Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Brussels, Belgium.
| | - Jan De Lepeleire
- Department of Public Health and Primary Care, ACHG, KU Leuven, Leuven, Belgium
| | - Jan Steyaert
- Department of Sociology, University of Antwerp, Antwerp, Belgium.,Flemish Expertise Centre on Dementia Care, Antwerp, Belgium
| | - Wouter Van Mechelen
- Department of Public Health and Primary Care, ACHG, KU Leuven, Leuven, Belgium
| | - Els Steeman
- Academic Centre for Nursing and Midwifery, KULeuven, Leuven, Belgium
| | - Let Dillen
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Lieve Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Brussels, Belgium.
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Mackenzie LJ, Carey ML, Suzuki E, Sanson-Fisher RW, Asada H, Ogura M, D’Este C, Yoshimura M, Toi M. Agreement between patients' and radiation oncologists' cancer diagnosis and prognosis perceptions: A cross sectional study in Japan. PLoS One 2018; 13:e0198437. [PMID: 29883453 PMCID: PMC5993258 DOI: 10.1371/journal.pone.0198437] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 05/18/2018] [Indexed: 12/01/2022] Open
Abstract
This study assessed agreement between radiation oncologist- and cancer patient-reported perceptions about cancer diagnosis, time since diagnosis, treatment purpose, and whether life expectancy had been discussed; and described preferences for prognosis discussions. Adult cancer patients receiving radiotherapy at a Japanese hospital were invited to complete a touchscreen tablet survey. Patient survey responses were linked and comparisons made with a survey completed by their radiation oncologist. Among 146 cancer patient-oncologist dyads, there was almost perfect agreement on cancer diagnosis (ĸ = 0.88, 95% CI: 0.82–0.94), substantial agreement on time since diagnosis (ĸ = 0.70, 95% CI: 0.57–0.83) and moderate agreement on whether treatment goal was curative or palliative (ĸ = 0.44, 95% CI: 0.28–0.57; all p’s < 0.0001). Agreement about whether a life expectancy discussion had occurred was less than expected by chance (κ = -0.06, p = 0.9). Radiation oncologists reported that they had spoken to over two thirds of patients about this, whilst less than one third of patients stated that this discussion had occurred with their radiation oncologist. Over half of the patients who had not discussed life expectancy wanted to. Patients had variable preferences for whether they (80%), their radiation oncologist (78%) or their partner/family (52%) should decide whether they discuss their life expectancy. Although patient self-reported information about diagnosis and time since diagnosis appears to be reasonably accurate (compared with clinician-reported information), limitations of self-reported data about prognostic discussions were highlighted by poor agreement between patient- and clinician-reported information about whether prognostic discussions have occurred. Additional support is needed to improve prognosis communication and understanding in radiation oncology settings.
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Affiliation(s)
- Lisa Jane Mackenzie
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Graduate School of Medicine, Kyoto University Hospital, Kyoto, Japan
- * E-mail:
| | - Mariko Leanne Carey
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Eiji Suzuki
- Breast Surgery, Kyoto University Hospital, Kyoto, Japan
| | | | - Hiromi Asada
- Department of Nursing, Kyoto University Hospital, Kyoto, Japan
| | - Masakazu Ogura
- Department of Radiation Oncology and Image Applied Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Catherine D’Este
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Acton, Australian Capital Territory, Australia
| | - Michio Yoshimura
- Department of Radiation Oncology and Image Applied Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Masakazu Toi
- Breast Surgery, Kyoto University Hospital, Kyoto, Japan
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Brisebois A, Ismond KP, Carbonneau M, Kowalczewski J, Tandon P. Advance care planning (ACP) for specialists managing cirrhosis: A focus on patient-centered care. Hepatology 2018; 67:2025-2040. [PMID: 29251778 DOI: 10.1002/hep.29731] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/28/2017] [Accepted: 12/11/2017] [Indexed: 01/07/2023]
Abstract
UNLABELLED Advance care planning (ACP) and goals of care designation (GCD) are being integrated into modern health care. In cirrhosis, uptake and adoption of these practices have been limited with physicians citing many perceived barriers and limitations. Recognizing the many tangible benefits of ACP and GCD processes in patients with life-limiting chronic diseases, the onus is on health practitioners to initiate and direct these conversations with their patients and surrogates. Drawing upon the literature and our experiences in palliative care and cirrhosis, we provide an actionable framework that can be readily implemented into a busy clinical setting by a practitioner. Conversation starters, visual aids, educational resources (for patients and practitioners), and videos of mock physician-patient scenarios are presented and discussed. Importantly, we have customized each of these tools to meet the unique health care needs of patients with cirrhosis. The inherent flexibility of our approach to ACP discussions and GCD can be further modified to accommodate practitioner preferences. CONCLUSION In our clinics, this assemblage of "best practice tools" has been well received by patients and surrogates enabling us to increase the number of outpatients with cirrhosis who have actively contributed to their GCD before acute health events and are supported by well-informed surrogates. (Hepatology 2018;67:2025-2040).
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Affiliation(s)
- Amanda Brisebois
- Division of General Internal Medicine, Department of Medicine and Division of Palliative Care, Department of Oncology, University of Alberta, Edmonton, AB, Canada.,PPRISM Non-Cancer Palliative Care Clinic, Edmonton, AB, Canada
| | - Kathleen P Ismond
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,CEGIIR, University of Alberta, Edmonton, AB, Canada
| | - Michelle Carbonneau
- University of Alberta Hospital, Edmonton, AB, Canada.,Cirrhosis Care Clinic, Edmonton, AB, Canada
| | | | - Puneeta Tandon
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,CEGIIR, University of Alberta, Edmonton, AB, Canada.,Cirrhosis Care Clinic, Edmonton, AB, Canada
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Collins A, McLachlan SA, Philip J. How should we talk about palliative care, death and dying? A qualitative study exploring perspectives from caregivers of people with advanced cancer. Palliat Med 2018; 32:861-869. [PMID: 29235421 DOI: 10.1177/0269216317746584] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Health professionals commonly underestimate caregiver needs for information about palliative care, death and dying and may feel poorly prepared to discuss these issues. Few studies have sought caregiver perspectives of these communication practices. AIM To explore caregiver perspectives on communication about death, dying and the introduction to palliative care, with a view towards a series of caregiver-informed recommendations for use in clinical practice. DESIGN Cross-sectional, prospective, exploratory qualitative design, involving narrative-style interviews and underpinned by an interpretative phenomenological framework. SETTING/PARTICIPANTS Purposively sampled, English-speaking, adult caregivers of people with advanced cancer ( n = 25) recruited from cancer services at a tertiary metropolitan hospital in Melbourne, Australia. RESULTS Caregivers reported wanting routinely available written resources about palliative care, supplemented by conversations that are ideally staged overtime. Education about the tasks of palliative care should be separated from referral process, allowing time for gradual adjustment, and re-visiting discussion to enable patients and families to take some control in the process of transition. Once death is imminent, carers wanted health professionals to clarify how much they want to know about the dying process; provide spoken acknowledgement when death is close; include the words 'death' and 'dying'; use direct language, avoiding euphemisms; and communicate about death with patient present. CONCLUSION This study is among the first to directly address caregiver perspectives of communication about death, dying and the introduction to palliative care. The recommendations derived from caregiver perspectives build upon existing guidelines and offer health professionals some preliminary considerations around how to undertake these important communication tasks in future.
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Affiliation(s)
- Anna Collins
- 1 Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia.,2 VCCC Palliative Medicine Research Group, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Sue-Anne McLachlan
- 1 Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia.,3 Medical Oncology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Jennifer Philip
- 1 Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia.,2 VCCC Palliative Medicine Research Group, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia.,4 Victorian Comprehensive Cancer Centre, Parkville, VIC, Australia
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Castellani C, Duff AJA, Bell SC, Heijerman HGM, Munck A, Ratjen F, Sermet-Gaudelus I, Southern KW, Barben J, Flume PA, Hodková P, Kashirskaya N, Kirszenbaum MN, Madge S, Oxley H, Plant B, Schwarzenberg SJ, Smyth AR, Taccetti G, Wagner TOF, Wolfe SP, Drevinek P. ECFS best practice guidelines: the 2018 revision. J Cyst Fibros 2018; 17:153-178. [PMID: 29506920 DOI: 10.1016/j.jcf.2018.02.006] [Citation(s) in RCA: 440] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/26/2018] [Accepted: 02/08/2018] [Indexed: 12/12/2022]
Abstract
Developments in managing CF continue to drive dramatic improvements in survival. As newborn screening rolls-out across Europe, CF centres are increasingly caring for cohorts of patients who have minimal lung disease on diagnosis. With the introduction of mutation-specific therapies and the prospect of truly personalised medicine, patients have the potential to enjoy good quality of life in adulthood with ever-increasing life expectancy. The landmark Standards of Care published in 2005 set out what high quality CF care is and how it can be delivered throughout Europe. This underwent a fundamental re-write in 2014, resulting in three documents; center framework, quality management and best practice guidelines. This document is a revision of the latter, updating standards for best practice in key aspects of CF care, in the context of a fast-moving and dynamic field. In continuing to give a broad overview of the standards expected for newborn screening, diagnosis, preventative treatment of lung disease, nutrition, complications, transplant/end of life care and psychological support, this consensus on best practice is expected to prove useful to clinical teams both in countries where CF care is developing and those with established CF centres. The document is an ECFS product and endorsed by the CF Network in ERN LUNG and CF Europe.
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Affiliation(s)
- Carlo Castellani
- Cystic Fibrosis Centre, Azienda Ospedaliera Universitaria Integrata Verona, Italy; Cystic Fibrosis Centre, Gaslini Institute, Genoa, Italy
| | - Alistair J A Duff
- Regional Paediatric CF Unit, Leeds General Infirmary Leeds, UK; Department of Clinical & Health Psychology, St James' University Hospital, Leeds, UK.
| | - Scott C Bell
- Adult Cystic Fibrosis Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Harry G M Heijerman
- Dept of Pulmonology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne Munck
- Hopital Robert Debré Assistante publique-Hôpitaux de Paris, Université Paris 7, Pediatric CF Centre, Paris, France
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada
| | - Isabelle Sermet-Gaudelus
- Service de Pneumologie et Allergologie Pédiatriques, Centre de Ressources et de Compétence de la Mucoviscidose, Institut Necker Enfants Malades/INSERM U1151 Hôpital Necker Enfants Malades, P, France
| | - Kevin W Southern
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Jurg Barben
- Ostschweizer Kinderspital Sankt Gallen, Claudiusstrasse 6, 9006 St. Gallen, Switzerland
| | - Patrick A Flume
- Division of Pulmonary and Critical Care, Medical University of South Carolina, USA
| | - Pavla Hodková
- Department of Clinical Psychology, University Hospital, Prague, Czech Republic
| | - Nataliya Kashirskaya
- Department of Genetic Epidemiology (Cystic Fibrosis Group), Federal State Budgetary Institution, Research Centre for Medical Genetics, Moscow, Russia
| | - Maya N Kirszenbaum
- Department of Pediatric Pulmunology, CRCM, Hôpital Necker-Enfants Malades, Paris, France
| | - Sue Madge
- Cystic Fibrosis Centre, Royal Brompton Hospital, London, UK
| | - Helen Oxley
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Barry Plant
- Cork Adult CF Centre, Cork University Hospital, University College, Cork, Republic of Ireland
| | - Sarah Jane Schwarzenberg
- Divison of Pediatric Gastroenterology Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology (COG), University of Nottingham, Nottingham, UK
| | - Giovanni Taccetti
- Cystic Fibrosis Centre, Department of Paediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | - Thomas O F Wagner
- Frankfurter Referenzzentrum für Seltene Erkrankungen (FRZSE), Universitätsklinikum Frankfurt am Main, Wolfgang von Goethe-Universität, Frankfurt am Main, Germany
| | - Susan P Wolfe
- Regional Paediatric CF Unit, The Leeds Children's Hospital, Leeds Teaching Hospitals, Belmont Grove, Leeds, UK
| | - Pavel Drevinek
- Department of Medical Microbiology, Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
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Collins A, McLachlan SA, Philip J. Communication about palliative care: A phenomenological study exploring patient views and responses to its discussion. Palliat Med 2018; 32:133-142. [PMID: 29130425 DOI: 10.1177/0269216317735247] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Communication about palliative care is a complex task frequently delayed until otherwise unavoidable. There is a need for discussion of palliative care to be viewed as a distinct communication task that is guided by empirical data. However, little is known of patient views and responses to these encounters. AIM To explore patient views surrounding communication about palliative care and their responses to its discussion. DESIGN Cross-sectional, prospective, exploratory qualitative design, involving narrative-style interviews and underpinned by an interpretative phenomenological framework. SETTING/PARTICIPANTS Purposively sampled, English-speaking, adult patients with advanced cancer ( n = 30) recruited from cancer services at a tertiary metropolitan hospital in Melbourne, Australia. RESULTS Three major themes evolved. (1) Death as unspeakable: death was expressed using only implicit, ambiguous or technical terms and perceived to be outside the parameters of medical interactions. (2) Palliative care as a euphemism for death: the term 'palliative care' was perceived to be used by health professionals as a tool to talk about dying and understood by patients as a euphemism for death. (3) Palliative care as unspeakable: 'palliative care' was personified by patients to mean not just death, but my death, in turn, also becoming unspeakable. CONCLUSION This study provides important new patient insights and responses to the discussion of palliative care. Results demonstrate that the task of discussing palliative care remains complex, difficult and limited by our language. Greater consistency, sensitivity and sophistication are required when talking about palliative care to patients who may benefit from this care.
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Affiliation(s)
- Anna Collins
- 1 VCCC Palliative Medicine Research Group, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia.,2 Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Sue-Anne McLachlan
- 2 Department of Medicine, University of Melbourne, Parkville, VIC, Australia.,3 The Department of Medical Oncology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Jennifer Philip
- 1 VCCC Palliative Medicine Research Group, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia.,2 Department of Medicine, University of Melbourne, Parkville, VIC, Australia
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Abstract
JUSTIFICATION The right to life has been accepted as one of the fundamental rights in our constitution. Resuscitation is a procedure performed for all patients suffering from cardiac or respiratory arrest irrespective of the clinical condition. There are no legal guidelines defining process to be adopted in situations where resuscitation is unlikely to be useful. There are no guidelines on withdrawal of care or end of life (EOL) decisions, accepted by the Government, judiciary, professionals, academicians or the community. Process A National Consultative meet was organized by Indian Medico-Legal and Ethics Association and the Medico-legal group of Indian Academy of Pediatrics (IAP) to formulate the guidelines on 'Do Not Resuscitate' (DNR), and 'End of Life Support'. The meeting was organized on 30th May, 2014 at Ram Manohar Lohia Hospital, New Delhi. The meeting involved professionals from legal and various medical fields as well as administrators, and members from Medical Council of India. OBJECTIVES To frame the guidelines related to EOL care issues and withdrawal or with-holding treatment in situations where outcome of continued treatment is expected to be poor in terms of ultimate survival or quality of life. RECOMMENDATIONS (i) DNR or end of life care should not be activated till consensus is achieved between treating team and the next of kin; (ii) Consensus within health care team (including nurses) needs to be achieved before discussion with family members; (iii) Discussion should involve the family members - next of kin and other persons who can influence decisions; (iv) If family members want to include their family physician or a prominent person from the community, it should be encouraged. Similarly if family members want a particular member of treating team, he/she should be included; (v) Treating doctors should have all the facts of the case including investigations available with them before discussion; (vi) Unit in-charge or treating doctor should be responsible for achieving consensus and should initiate the discussion; (vii) After presenting the facts of the cases, family members should be encouraged to ask questions and clear doubts (if any); (viii) At the end of discussion, a summary of the discussion should be prepared and signed by the next of kin and the unit in-charge or treating doctors; (ix) DNR orders should be reviewed in the event of unexpected improvement or on request of next of kin. Same should be documented; (x) DNR orders remain valid during transport.
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Chou WS, Hamel LM, Thai CL, Debono D, Chapman RA, Albrecht TL, Penner LA, Eggly S. Discussing prognosis and treatment goals with patients with advanced cancer: A qualitative analysis of oncologists' language. Health Expect 2017; 20:1073-1080. [PMID: 28261901 PMCID: PMC5600249 DOI: 10.1111/hex.12549] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The National Academy of Medicine recommends that cancer patients be knowledgeable of their prognosis to enable them to make informed treatment decisions, but research suggests few patients receive this information. OBJECTIVE This qualitative study describes oncologists' language during discussions of prognosis and treatment goals in clinical interactions with African American patients diagnosed with cancer. DESIGN We analysed transcripts from video recordings of clinical interactions between patients with Stage III or IV cancer (n=26) and their oncologists (n=9). In-depth discourse analysis was conducted to describe and interpret oncologists' communication behaviours and common linguistic features in the interactions. SETTING AND PARTICIPANTS Data were from a larger study of patient-provider communication between African Americans and oncologists at two cancer hospitals in Detroit. RESULTS Prognosis was discussed in 73.1% (n=19) of the interactions; treatment goals were discussed in 92.3% (n=24). However, analysis revealed that oncologists' description of prognosis was vague (e.g. "prognosis is a bit worse in your case") and rarely included a survival estimate. Oncologists often used ambiguous terminology, including euphemisms and jargon, and emphasized uncertainty (e.g. "lesions are suspicious for the disease"). Conversation about prognosis was frequently brief, moving quickly to the urgency and details of treatment. DISCUSSION This study demonstrates how oncologists' language may obscure discussion of prognosis and treatment goals. The identified behaviours may lead to missed opportunities in eliciting and discussing patients' knowledge about and preferences for their care. Patient-, provider- and system-oriented interventions are needed to improve clinical communication, especially among minority patients with advanced cancer.
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Affiliation(s)
| | - Lauren M. Hamel
- Wayne State University/Karmanos Cancer InstituteDetroitMIUSA
| | | | - David Debono
- Wayne State University/Karmanos Cancer InstituteDetroitMIUSA
| | | | | | - Louis A. Penner
- Wayne State University/Karmanos Cancer InstituteDetroitMIUSA
| | - Susan Eggly
- Wayne State University/Karmanos Cancer InstituteDetroitMIUSA
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79
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Henselmans I, Smets EMA, Han PKJ, de Haes HCJC, Laarhoven HWMV. How long do I have? Observational study on communication about life expectancy with advanced cancer patients. PATIENT EDUCATION AND COUNSELING 2017; 100:1820-1827. [PMID: 28511804 DOI: 10.1016/j.pec.2017.05.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/01/2017] [Accepted: 05/05/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To examine how communication about life expectancy is initiated in consultations about palliative chemotherapy, and what prognostic information is presented. METHODS Patients with advanced cancer (n=41) with a median life expectancy <1year and oncologists (n=6) and oncologists-in-training (n=7) meeting with them in consultations (n=62) to discuss palliative chemotherapy were included. Verbatim transcripts of audio-recorded consultations were analyzed using MAXqda10. RESULTS Life expectancy was addressed in 19 of 62 of the consultations. In all cases, patients took the initiative, most often through direct questions. Estimates were provided in 12 consultations in various formats: the likelihood of experiencing a significant event, point estimates or general time scales of "months to years", often with an emphasis on the "years". The indeterminacy of estimates was consistently stressed. Also their potential inadequacy was regularly addressed, often by describing beneficial prognostic predictors for the specific patient. Oncologists did not address the reliability or precision of estimates. CONCLUSION Oncologists did not initiate talk about life expectancy, they used different formats, emphasized the positive and stressed unpredictability, yet not ambiguity of estimates. PRACTICE IMPLICATIONS Prognostic communication should be part of the medical curriculum. Further research should address the effect of different formats of information provision.
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Affiliation(s)
- I Henselmans
- Academic Medical Center, Department of Medical Psychology, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam, The Netherlands.
| | - E M A Smets
- Academic Medical Center, Department of Medical Psychology, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - P K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME, USA; Tufts University Clinical and Translational Sciences Institute, Boston, MA, USA
| | - H C J C de Haes
- Academic Medical Center, Department of Medical Psychology, Amsterdam, The Netherlands
| | - H W M van Laarhoven
- Cancer Center Amsterdam, Amsterdam, The Netherlands; Academic Medical Center, Department of Medical Oncology, Amsterdam, The Netherlands
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Calabrese RK, Case AA. How Can We Improve the Collaborative Care Between the Primary Oncologist and the Palliative Care Specialist in Caring for Patients With Serious Illness? J Oncol Pract 2017; 13:601-605. [DOI: 10.1200/jop.2017.021253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Amy A. Case
- University at Buffalo and Roswell Park Cancer Institute, Buffalo, NY
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Rajasooriyar C, Kelly J, Sivakumar T, Navanesan G, Nadarasa S, Sriskandarajah MH, Sabesan S. Breaking Bad News in Ethnic Settings: Perspectives of Patients and Families in Northern Sri Lanka. J Glob Oncol 2017; 3:250-256. [PMID: 28717767 PMCID: PMC5493221 DOI: 10.1200/jgo.2016.005355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The discussion of a cancer diagnosis and prognosis often is difficult. This study explored the expectations of Tamil-speaking patients with cancer and their families with respect to receiving their cancer diagnosis in northern Sri Lanka. Methods This exploratory, descriptive, qualitative study used semistructured interviews. Results Thematic analysis identified two major themes: communication and information seeking. The findings illustrate a discrepancy between patient preference for direct disclosure of the diagnosis and that of families. Ninety-five percent of patients wanted medical staff to disclose their cancer diagnosis, whereas only 45% of family members believed that the diagnosis should be disclosed to the patient rather than to the family. Conclusion Although patients and their family members’ views and expectations of the disclosure of diagnosis and prognosis differ, a majority of patients want to be told directly about their diagnosis rather than to learn of it from a relative. The findings are similar to the literature on other ethnic groups from Sri Lanka and studies from English-speaking developed countries. Therefore, the main questions are how to educate families and physicians about the benefits of open disclosure to patients and how to change culture. Results of this study along with a previous study call for the development of strategies and guidelines to improve societal views, educate patients and families, and train health professionals in the area of breaking bad news and discussing prognosis in the Sri Lankan setting.
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Affiliation(s)
- Chrishanthi Rajasooriyar
- and , Jaffna Teaching Hospital; , Tellipalai Trail Cancer Hospital, Jaffna; and , National Hospital of Sri Lanka; , Teaching Hospital, Karapitiya, Sri Lanka; and , Townsville Hospital and Health Service; and , James Cook University; and , The Townsville Hospital, Townsville, Queensland, Australia
| | - Jenny Kelly
- and , Jaffna Teaching Hospital; , Tellipalai Trail Cancer Hospital, Jaffna; and , National Hospital of Sri Lanka; , Teaching Hospital, Karapitiya, Sri Lanka; and , Townsville Hospital and Health Service; and , James Cook University; and , The Townsville Hospital, Townsville, Queensland, Australia
| | - Thanikai Sivakumar
- and , Jaffna Teaching Hospital; , Tellipalai Trail Cancer Hospital, Jaffna; and , National Hospital of Sri Lanka; , Teaching Hospital, Karapitiya, Sri Lanka; and , Townsville Hospital and Health Service; and , James Cook University; and , The Townsville Hospital, Townsville, Queensland, Australia
| | - Gowcikan Navanesan
- and , Jaffna Teaching Hospital; , Tellipalai Trail Cancer Hospital, Jaffna; and , National Hospital of Sri Lanka; , Teaching Hospital, Karapitiya, Sri Lanka; and , Townsville Hospital and Health Service; and , James Cook University; and , The Townsville Hospital, Townsville, Queensland, Australia
| | - Shahini Nadarasa
- and , Jaffna Teaching Hospital; , Tellipalai Trail Cancer Hospital, Jaffna; and , National Hospital of Sri Lanka; , Teaching Hospital, Karapitiya, Sri Lanka; and , Townsville Hospital and Health Service; and , James Cook University; and , The Townsville Hospital, Townsville, Queensland, Australia
| | - Madona Hashanthy Sriskandarajah
- and , Jaffna Teaching Hospital; , Tellipalai Trail Cancer Hospital, Jaffna; and , National Hospital of Sri Lanka; , Teaching Hospital, Karapitiya, Sri Lanka; and , Townsville Hospital and Health Service; and , James Cook University; and , The Townsville Hospital, Townsville, Queensland, Australia
| | - Sabe Sabesan
- and , Jaffna Teaching Hospital; , Tellipalai Trail Cancer Hospital, Jaffna; and , National Hospital of Sri Lanka; , Teaching Hospital, Karapitiya, Sri Lanka; and , Townsville Hospital and Health Service; and , James Cook University; and , The Townsville Hospital, Townsville, Queensland, Australia
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Smith TA, Disler RT, Jenkins CR, Ingham JM, Davidson PM. Perspectives on advance care planning among patients recently requiring non-invasive ventilation for acute respiratory failure: A qualitative study using thematic analysis. Palliat Med 2017; 31:566-574. [PMID: 28440124 DOI: 10.1177/0269216316670286] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Patients requiring non-invasive ventilation for acute-on-chronic respiratory failure due to chronic obstructive pulmonary disease or heart failure exacerbations may have a poor prognosis underscoring the importance of advance care planning. AIM We aimed to describe attitudes to, and experiences of, discussing the future among patients recently treated with non-invasive ventilation. DESIGN Qualitative research using thematic analysis. SETTINGS AND PARTICIPANTS Tertiary teaching hospital. Patients with acute hypercapnic respiratory failure requiring non-invasive ventilation. RESULTS Individuals recently treated with non-invasive ventilation describe feeling the future is beyond their control and instead controlled by their illness. Participants often recognised their poor prognosis but avoided discussing some difficult topics. The majority preferred not to undergo cardiopulmonary resuscitation but most had not discussed this with healthcare professionals. When participants voiced concerns about their future health to family members, they were met with polarised responses. Some encountered willingness for further discussion, while others met deflection, deterring further conversation. An overarching narrative of 'Looking through my illness to an uncertain but concerning future' unites these themes. CONCLUSION This study suggests opportunities and barriers for advance care planning in individuals with chronic disease. Patients' understanding of their prognosis and their attitudes to cardiopulmonary resuscitation suggests an opportunity for advance care planning. Structuring discussions around patients' preferences for care during future exacerbations may foster a sense of control over the future despite illness. The diversity of familial responses to patients' concerns about their future health has implications for advance care planning. These findings have the potential to improve care for patients with respiratory failure and suggest an important ongoing research agenda.
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Affiliation(s)
- Tracy A Smith
- 1 St Vincent's Clinical School, Faculty of Medicine, UNSW Australia, Sydney, NSW, Australia.,2 Department of Respiratory & Sleep Medicine, Westmead Hospital, Wentworthville, NSW, Australia
| | - Rebecca T Disler
- 3 Sydney Nursing School, University of Sydney, Sydney, NSW, Australia.,4 ImPaCCT (Improving Palliative Care through Clinical Trials) NSW Palliative Care Collaborative Clinical Trials Group, Liverpool, NSW, Australia
| | - Christine R Jenkins
- 5 Faculty of Medicine, The University of Sydney, Sydney, NSW, Australia.,6 The George Institute, Sydney, NSW, Australia
| | - Jane M Ingham
- 1 St Vincent's Clinical School, Faculty of Medicine, UNSW Australia, Sydney, NSW, Australia.,7 St Vincent's Health Network, Sydney, NSW, Australia
| | - Patricia M Davidson
- 3 Sydney Nursing School, University of Sydney, Sydney, NSW, Australia.,8 Department of Acute and Chronic Care, Johns Hopkins University, Baltimore, MD, USA
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Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, Matlock DD, Rietjens JAC, Korfage IJ, Ritchie CS, Kutner JS, Teno JM, Thomas J, McMahan RD, Heyland DK. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. J Pain Symptom Manage 2017; 53:821-832.e1. [PMID: 28062339 PMCID: PMC5728651 DOI: 10.1016/j.jpainsymman.2016.12.331] [Citation(s) in RCA: 887] [Impact Index Per Article: 126.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/21/2016] [Accepted: 12/23/2016] [Indexed: 11/18/2022]
Abstract
CONTEXT Despite increasing interest in advance care planning (ACP) and previous ACP descriptions, a consensus definition does not yet exist to guide clinical, research, and policy initiatives. OBJECTIVE The aim of this study was to develop a consensus definition of ACP for adults. METHODS We convened a Delphi panel of multidisciplinary, international ACP experts consisting of 52 clinicians, researchers, and policy leaders from four countries and a patient/surrogate advisory committee. We conducted 10 rounds using a modified Delphi method and qualitatively analyzed panelists' input. Panelists identified several themes lacking consensus and iteratively discussed and developed a final consensus definition. RESULTS Panelists identified several tensions concerning ACP concepts such as whether the definition should focus on conversations vs. written advance directives; patients' values vs. treatment preferences; current shared decision making vs. future medical decisions; and who should be included in the process. The panel achieved a final consensus one-sentence definition and accompanying goals statement: "Advance care planning is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal of advance care planning is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness." The panel also described strategies to best support adults in ACP. CONCLUSIONS A multidisciplinary Delphi panel developed a consensus definition for ACP for adults that can be used to inform implementation and measurement of ACP clinical, research, and policy initiatives.
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Affiliation(s)
- Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA; San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.
| | - Hillary D Lum
- VA Eastern Colorado Geriatrics Research Education and Clinical Center (GRECC), Denver, Colorado, USA; Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - John J You
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Diane E Meier
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Steven Z Pantilat
- Palliative Care Program, Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Daniel D Matlock
- VA Eastern Colorado Geriatrics Research Education and Clinical Center (GRECC), Denver, Colorado, USA; Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Judith A C Rietjens
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Joan M Teno
- Division of Gerontology and Geriatrics, University of Washington, Seattle, Washington, USA
| | - Judy Thomas
- Coalition for Compassionate Care of California, Sacramento, California, USA
| | - Ryan D McMahan
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University; Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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Still Searching: A Meta-Synthesis of a Good Death from the Bereaved Family Member Perspective. Behav Sci (Basel) 2017; 7:bs7020025. [PMID: 28441339 PMCID: PMC5485455 DOI: 10.3390/bs7020025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 04/18/2017] [Accepted: 04/19/2017] [Indexed: 11/16/2022] Open
Abstract
The concept of a good death continues to receive attention in end-of-life (EOL) scholarship. We sought to continue this line of inquiry related to a good death by conducting a meta-synthesis of published qualitative research studies that examined a good death from the bereaved family member's perspective. Results of the meta-synthesis included 14 articles with 368 participants. Based on analysis, we present a conceptual model called The Opportunity Model for Presence during the EOL Process. The model is framed in socio-cultural factors, and major themes include EOL process engagement with categories of healthcare participants, communication and practical issues. The second theme, (dis)continuity of care, includes categories of place of care, knowledge of family member dying and moment of death. Both of these themes lead to perceptions of either a good or bad death, which influences the bereavement process. We argue the main contribution of the model is the ability to identify moments throughout the interaction where family members can be present to the EOL process. Recommendations for healthcare participants, including patients, family members and clinical care providers are offered to improve the quality of experience throughout the EOL process and limitations of the study are discussed.
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White B, Willmott L, Tilse C, Wilson J, Lawson D, Pearce A, Dunn J, Aitken JF, Feeney R, Jowett S. Community knowledge of law at the end of life: availability and accessibility of web-based resources. AUST HEALTH REV 2017; 42:266-271. [PMID: 28355526 DOI: 10.1071/ah16234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 02/01/2017] [Indexed: 11/23/2022]
Abstract
Objective The aim of the present study was to identify online resources community members may access to inform themselves about their legal duties and rights in end-of-life decision making. Methods Resource mapping identified online resources that members of the public in New South Wales, Victoria and Queensland are likely to identify, and assessed the ease or difficulty in locating them. Resources were then critically analysed for accessibility of language and format using the Patient Education Materials Assessment Tool (PEMAT). Results Identified resources differed considerably based on whether search terms identified by community members or experts were used. Most resources focused on advance directives, enduring powers of attorney and substitute decision making. Relatively few provided information about legal duties (e.g. powers and responsibilities of substitute decision makers) or resolving conflict with health practitioners. Accessibility (understandability and actionability) of resource content varied. Conclusions Although numerous resources on end-of-life law are available online, community members may not be able to identify relevant resources or find resource content accessible. What is known about the topic? Research on participation by patients in decision making about their treatment has focused primarily on medical rather than legal knowledge. What does this paper add? The present study investigated which online resources community members may access to inform themselves about the law on end-of-life decision making. The resources identified were analysed for ease of location and content accessibility. What are the implications for practitioners? Authors of online resources on end-of-life decision making should consider whether their resources can be: (1) identified by search terms used by the public; (2) understood by a general audience; and (3) readily used to promote reader action.
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Affiliation(s)
- Ben White
- Australian Centre for Health Law Research, Queensland University of Technology, GPO Box 2434, Brisbane, Qld 4001, Australia.
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, GPO Box 2434, Brisbane, Qld 4001, Australia.
| | - Cheryl Tilse
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, Qld 4072, Australia.
| | - Jill Wilson
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, Qld 4072, Australia.
| | - Deborah Lawson
- Cancer Council of Victoria, 100 Drummond Street, Carlton, Vic. 3053, Australia. Email
| | - Angela Pearce
- Cancer Council New South Wales, PO Box 572, Kings Cross, NSW 1340, Australia. Email
| | - Jeffrey Dunn
- Cancer Council Queensland, PO Box 201, Spring Hill, Qld 4004, Australia.
| | - Joanne F Aitken
- Cancer Council Queensland, PO Box 201, Spring Hill, Qld 4004, Australia.
| | - Rachel Feeney
- Australian Centre for Health Law Research, Queensland University of Technology, GPO Box 2434, Brisbane, Qld 4001, Australia.
| | - Stephanie Jowett
- Australian Centre for Health Law Research, Queensland University of Technology, GPO Box 2434, Brisbane, Qld 4001, Australia.
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Epstein RM, Duberstein PR, Fenton JJ, Fiscella K, Hoerger M, Tancredi DJ, Xing G, Gramling R, Mohile S, Franks P, Kaesberg P, Plumb S, Cipri CS, Street RL, Shields CG, Back AL, Butow P, Walczak A, Tattersall M, Venuti A, Sullivan P, Robinson M, Hoh B, Lewis L, Kravitz RL. Effect of a Patient-Centered Communication Intervention on Oncologist-Patient Communication, Quality of Life, and Health Care Utilization in Advanced Cancer: The VOICE Randomized Clinical Trial. JAMA Oncol 2017; 3:92-100. [PMID: 27612178 PMCID: PMC5832439 DOI: 10.1001/jamaoncol.2016.4373] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Observational studies demonstrate links between patient-centered communication, quality of life (QOL), and aggressive treatments in advanced cancer, yet few randomized clinical trials (RCTs) of communication interventions have been reported. OBJECTIVE To determine whether a combined intervention involving oncologists, patients with advanced cancer, and caregivers would promote patient-centered communication, and to estimate intervention effects on shared understanding, patient-physician relationships, QOL, and aggressive treatments in the last 30 days of life. DESIGN, SETTING, AND PARTICIPANTS Cluster RCT at community- and hospital-based cancer clinics in Western New York and Northern California; 38 medical oncologists (mean age 44.6 years; 11 (29%) female) and 265 community-dwelling adult patients with advanced nonhematologic cancer participated (mean age, 64.4 years, 146 [55.0%] female, 235 [89%] white; enrolled August 2012 to June 2014; followed for 3 years); 194 patients had participating caregivers. INTERVENTIONS Oncologists received individualized communication training using standardized patient instructors while patients received question prompt lists and individualized communication coaching to identify issues to address during an upcoming oncologist visit. Both interventions focused on engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information. Control participants received no training. MAIN OUTCOMES AND MEASURES The prespecified primary outcome was a composite measure of patient-centered communication coded from audio recordings of the first oncologist visit following patient coaching (intervention group) or enrollment (control). Secondary outcomes included the patient-physician relationship, shared understanding of prognosis, QOL, and aggressive treatments and hospice use in the last 30 days of life. RESULTS Data from 38 oncologists (19 randomized to intervention) and 265 patients (130 intervention) were analyzed. In fully adjusted models, the intervention resulted in clinically and statistically significant improvements in the primary physician-patient communication end point (adjusted intervention effect, 0.34; 95% CI, 0.06-0.62; P = .02). Differences in secondary outcomes were not statistically significant. CONCLUSIONS AND RELEVANCE A combined intervention that included oncologist communication training and coaching for patients with advanced cancer was effective in improving patient-centered communication but did not affect secondary outcomes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01485627.
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Affiliation(s)
- Ronald M Epstein
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York2Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York3Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York4James P Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Paul R Duberstein
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York2Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York3Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Joshua J Fenton
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento6UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento7Department of Family and Community Medicine, University of California, Davis, Sacramento
| | - Kevin Fiscella
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York2Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York8Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York9Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Michael Hoerger
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York10Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana11Tulane Cancer Center, Tulane University, New Orleans, Louisiana
| | - Daniel J Tancredi
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento12Department of Pediatrics, University of California, Davis, Sacramento
| | - Guibo Xing
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Robert Gramling
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York2Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York8Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York13School of Nursing, University of Rochester, Rochester, New York14Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Supriya Mohile
- James P Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York15Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Peter Franks
- Department of Family and Community Medicine, University of California, Davis, Sacramento
| | - Paul Kaesberg
- UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento16Department of Internal Medicine, University of California, Davis, Sacramento
| | - Sandy Plumb
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Camille S Cipri
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Richard L Street
- Department of Communication, Texas A & M University, College Station18Houston Center for Healthcare Innovation, Quality, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas19Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Cleveland G Shields
- Human Development and Family Studies Department, Purdue University, West Lafayette, Indiana21Purdue University Center for Cancer Research, Purdue University, West Lafayette, Indiana22Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, Indiana23Center on Poverty and Health Inequities, Purdue University, West Lafayette, Indiana24College of Health of Human Sciences, Purdue University, West Lafayette, Indiana
| | - Anthony L Back
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle26Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Phyllis Butow
- Centre for Medical Psychology and Evidence-based Decision-making, University of Sydney, Sydney, Australia28Psycho-oncology Co-operative Research Group, University of Sydney, Sydney, Australia
| | - Adam Walczak
- Centre for Medical Psychology and Evidence-based Decision-making, University of Sydney, Sydney, Australia29School of Psychology, University of Sydney, Sydney, Australia
| | - Martin Tattersall
- Centre for Medical Psychology and Evidence-based Decision-making, University of Sydney, Sydney, Australia30Sydney Medical School, University of Sydney, Sydney, Australia31Royal Prince Alfred Hospital, Sydney, Australia
| | - Alison Venuti
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Peter Sullivan
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Mark Robinson
- University of California, Davis School of Medicine, University of California, Davis, Sacramento
| | - Beth Hoh
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York2Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York34Department of Social Work, Strong Memorial Hospital, Rochester, New York
| | - Linda Lewis
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Richard L Kravitz
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento6UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento35Division of General Medicine, University of California, Davis, Sacramento
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Family discussions on life-sustaining interventions in neurocritical care. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:397-408. [PMID: 28187812 DOI: 10.1016/b978-0-444-63600-3.00022-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Approximately 20% of all deaths in the USA occur in the intensive care unit (ICU) and the majority of ICU deaths involves decision of de-escalation of life-sustaining interventions. Life-sustaining interventions may include intubation and mechanical ventilation, artificial nutrition and hydration, antibiotic treatment, brain surgery, or vasoactive support. Decision making about goals of care can be defined as an end-of-life communication and the decision-making process between a clinician and a patient (or a surrogate decision maker if the patient is incapable) in an institutional setting to establish a plan of care. This process includes deciding whether to use life-sustaining treatments. Therefore, family discussion is a critical element in the decision-making process throughout the patient's stay in the neurocritical care unit. A large part of care in the neurosciences intensive care unit is discussion of proportionality of care. This chapter provides a stepwise approach to hold these conferences and discusses ways to do it effectively.
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Bern-Klug M. Considering the CPR Decision Through the Lens of Prospect Theory in the Context of Advanced Chronic Illness. THE GERONTOLOGIST 2016; 57:61-67. [PMID: 28034893 DOI: 10.1093/geront/gnw141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 08/11/2016] [Indexed: 11/12/2022] Open
Abstract
It is common for people with advanced chronic illness to have many health care providers and many health care-related visits. It is also common, during those visits, to be asked whether attempts at cardiopulmonary resuscitation (CPR) are desired, in the event of cardiac arrest. Although the question is common, the implications of a "yes" or a "no" may not be well understood. Although CPR can be a life-saving procedure, it is not always in the patient's best interest. This article discusses experiences with CPR of 2 older women (and their adult children) during their last years of life, and uses concepts from prospect theory to make suggestions for changes in the way health care providers and patients approach advance care planning including the CPR decision.
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89
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Lewis E, Cardona-Morrell M, Ong KY, Trankle SA, Hillman K. Evidence still insufficient that advance care documentation leads to engagement of healthcare professionals in end-of-life discussions: A systematic review. Palliat Med 2016; 30:807-24. [PMID: 26951066 DOI: 10.1177/0269216316637239] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Administration of non-beneficial life-sustaining treatments in terminal elderly patients still occurs due to lack of knowledge of patient's wishes or delayed physician-family communications on preference. AIM To determine whether advance care documentation encourages healthcare professional's timely engagement in end-of-life discussions. DESIGN Systematic review of the English language articles published from January 2000 to April 2015. DATA SOURCES EMBASE, MEDLINE, EBM REVIEWS, PsycINFO, CINAHL and Cochrane Library and manual searches of reference lists. RESULTS A total of 24 eligible articles from 10 countries including 23,914 subjects met the inclusion criteria, mostly using qualitative or mixed methods, with the exception of two cohort studies. The influence of advance care documentation on initiation of end-of-life discussions was predominantly based on perceptions, attitudes, beliefs and personal experience rather than on standard replicable measures of effectiveness in triggering the discussion. While health professionals reported positive perceptions of the use of advance care documentations (18/24 studies), actual evidence of their engagement in end-of-life discussions or confidence gained from accessing previously formulated wishes in advance care documentations was not generally available. CONCLUSION Perceived effectiveness of advance care documentation in encouraging end-of-life discussions appears to be high but is mostly derived from low-level evidence studies. This may indicate a willingness and openness of patients, surrogates and staff to perceive advance directives as an instrument to improve communication, rather than actual evidence of timeliness or effectiveness from suitably designed studies. The assumption that advance care documentations will lead to higher physicians' confidence or engagement in communicating with patients/families could not be objectively demonstrated in this review.
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Affiliation(s)
- Ebony Lewis
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, NSW, Australia
| | - Magnolia Cardona-Morrell
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, NSW, Australia
| | - Kok Y Ong
- School of Medicine, Western Sydney University, Campbelltown NSW 2560, Australia
| | - Steven A Trankle
- School of Medicine, Western Sydney University, Campbelltown NSW 2560, Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, NSW, Australia Intensive Care Unit, Liverpool Hospital, Liverpool NSW 2170, Australia
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90
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Tong E, Deckert A, Gani N, Nissim R, Rydall A, Hales S, Rodin G, Lo C. The meaning of self-reported death anxiety in advanced cancer. Palliat Med 2016; 30:772-9. [PMID: 26857360 DOI: 10.1177/0269216316628780] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Death anxiety is important but understudied in palliative care. New self-report measurements have been developed, but their interpretation and clinical utility may not be evident. AIM To inform our understanding of death anxiety in patients with advanced cancer by exploring the relationship between this self-reported symptom and its clinical presentation. DESIGN Participants were part of a psychotherapy trial in advanced cancer. First therapy session transcripts were analyzed using interpretive description in patients reporting low, moderate, and high death anxiety on the Death and Dying Distress Scale (DADDS). SETTING/PARTICIPANTS A total of 16 participants (10 women and 6 men) with advanced or metastatic cancer were sampled from the Princess Margaret Cancer Centre, Toronto, Canada. Six participants reported low death anxiety scores (Death and Dying Distress Scale: 0-19), five moderate (Death and Dying Distress Scale: 20-50), and five high (Death and Dying Distress Scale: 51-75). RESULTS The low death anxiety group exhibited psychological readiness for death, or contrastingly, non-reflectiveness about death. The moderate group recognized the imminence of mortality, which impacted treatment decisions and future plans. Prior experience with death was discussed as raising the salience of mortality. The high group felt dominated by powerful emotions and could not make sense of their situation. Their distress was exacerbated by substantial relational concerns. CONCLUSION Self-reported death anxiety is affected by the awareness and ability to reflect on mortality. Death and Dying Distress Scale scores may facilitate exploration of this symptom as part of a clinical assessment and may serve to guide treatment approaches. Greater attention to death anxiety is consistent with and recommended by contemporary approaches to palliative care.
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Affiliation(s)
- Eryn Tong
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Amy Deckert
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Nina Gani
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Tuebingen, Germany
| | - Rinat Nissim
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Anne Rydall
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Sarah Hales
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Chris Lo
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada Department of Psychiatry, University of Toronto, Toronto, ON, Canada Department of Psychology, University of Guelph-Humber, Toronto, ON, Canada
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Abstract
Despite advances in the detection, pathological diagnosis and therapeutics of lung cancer, many patients still develop advanced, incurable and progressively fatal disease. As physicians, the duties to cure sometimes, relieve often and comfort always should be a constant reminder to us of the needs that must be met when caring for a patient with lung cancer. Four key areas of end-of-life care in advanced lung cancer begin with first recognizing 'when a patient is approaching the end of life'. The clinician should be able to recognize when the focus of care needs to shift from an aggressive life-sustaining approach to an approach that helps prepare and support a patient and family members through a period of progressive, inevitable decline. Once the needs are recognized, the second key area is appropriate communication, where the clinician should assist patients and family members in understanding where they are in the disease trajectory and what to expect. This involves developing rapport, breaking bad news, managing expectations and navigating care plans. Subsequently, the third key area is symptom management that focuses on the goals to first and foremost provide comfort and dignity. Symptoms that are common towards the end of life in lung cancer include pain, dyspnoea, delirium and respiratory secretions. Such symptoms need to be anticipated and addressed promptly with appropriate medications and explanations to the patient and family. Lastly, in order for physicians to provide quality end-of-life care, it is necessary to understand the ethical principles applied to end-of-life-care interventions. Misconceptions about euthanasia versus withholding or withdrawing life-sustaining treatments may lead to physician distress and inappropriate decision making.
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Affiliation(s)
- Richard B L Lim
- Department of Palliative Medicine, Hospital Selayang, Lebuhraya Selayang-Kepong, 68100 Batu Caves, Selangor Darul Ehsan, Malaysia
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92
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Han PK, Dieckmann NF, Holt C, Gutheil C, Peters E. Factors Affecting Physicians' Intentions to Communicate Personalized Prognostic Information to Cancer Patients at the End of Life: An Experimental Vignette Study. Med Decis Making 2016; 36:703-13. [PMID: 26985015 PMCID: PMC4930679 DOI: 10.1177/0272989x16638321] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 12/21/2015] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Paul K.J. Han
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME
- Tufts University Clinical and Translational Sciences Institute, Boston, MA
| | - Nathan F. Dieckmann
- School of Nursing & School of Medicine, Oregon Health & Science University, Portland, OR
- Decision Research, Eugene, OR
| | - Christina Holt
- Department of Family Medicine, Maine Medical Center, Portland, ME
| | - Caitlin Gutheil
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME
| | - Ellen Peters
- Department of Psychology, Ohio State University, Columbus, OH
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Shah K, Swinton M, You JJ. Barriers and facilitators for goals of care discussions between residents and hospitalised patients. Postgrad Med J 2016; 93:127-132. [PMID: 27450314 DOI: 10.1136/postgradmedj-2016-133951] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 05/05/2016] [Accepted: 07/03/2016] [Indexed: 11/04/2022]
Abstract
PURPOSE To observe how residents are engaging in goals of care discussions with patients and identify thematic patterns that inhibited (barriers) and promoted discussion (facilitators) about goals of care. DESIGN Admission encounters between residents and patients admitted to a tertiary care academic hospital were recorded and analysed using a qualitative descriptive method. Patients included in the study were individuals over the age of 65 being admitted to the internal medicine service. Residents were eligible if they were trainees in family medicine, emergency medicine, general surgery or internal medicine who were on call for the inpatient medicine rotation. RESULTS A total of 15 resident-patient encounters were recorded and analysed, of which 12 encounters included a goals of care discussion. Barriers to goals of care discussions were due to missed opportunities to clarify patient's preferences for life-sustaining treatment and missed opportunities to engage the patient in further discussion. Facilitators to goals of care discussions were use of simple language and exploration of patient's previous experiences with life-sustaining treatment. CONCLUSIONS Asking about patients' previous experiences with life support can be an effective strategy to gauge the patient's understanding and goals of care preferences. This knowledge can improve residents' skill in communicating with their patients about goals of care and inform future education initiatives.
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Affiliation(s)
- Kalpa Shah
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marilyn Swinton
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - John J You
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Sinclair C, Gates K, Evans S, Auret KA. Factors Influencing Australian General Practitioners' Clinical Decisions Regarding Advance Care Planning: A Factorial Survey. J Pain Symptom Manage 2016; 51:718-727.e2. [PMID: 26706628 DOI: 10.1016/j.jpainsymman.2015.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 11/22/2015] [Accepted: 11/27/2015] [Indexed: 10/22/2022]
Abstract
CONTEXT Primary care physicians are well placed to identify patients in need of advance care planning (ACP) and initiate ACP in advance of an acute situation. OBJECTIVES This study aimed to understand Australian general practitioner (GP) clinical decision making relating to a patient's "need for ACP" and the likelihood of initiating ACP. METHODS An experimental vignette study pseudorandomly manipulated factors thought to influence decision making regarding ACP. Patient-level factors included gender, age, type of disease, medical severity, openness to ACP, doctor-patient relationship, and family support. An accompanying demographic survey assessed health professional-level factors, including gender, years of experience, place of training, place of practice, caseload of patients with ACP, direct personal experience in ACP, and self-reported attitudes toward ACP. Seventy GPs were recruited, and each completed six unique vignettes, providing ratings of patient need for ACP, importance of initiating ACP in the coming months, and likelihood of initiating ACP at the next consultation. RESULTS Older patients, with malignant or cardiovascular disease, severe clinical presentations, good doctor-patient relationship, female gender, and poor family support were more likely to receive prompt ACP. Positive GP attitudes toward ACP were associated with greater likelihood of initiating ACP promptly. CONCLUSION Patients with presentations suggesting higher mortality risk were identified as being in need of ACP; however, the likelihood of initiating ACP was sensitive to GP attitudes and psychosocial aspects of the doctor-patient interaction. Training materials aimed at encouraging GP involvement in ACP should target attitudes toward ACP and communication skills, rather than focusing solely on prognostic risk.
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Affiliation(s)
- Craig Sinclair
- Rural Clinical School of Western Australia - Albany, Albany, Western Australia, Australia.
| | | | - Sharon Evans
- Rural Clinical School of Western Australia-Urban Centre, Perth, Western Australia, Australia
| | - Kirsten Anne Auret
- Rural Clinical School of Western Australia - Albany, Albany, Western Australia, Australia
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Aoun SM, Breen LJ, Howting D, Edis R, Oliver D, Henderson R, O’Connor M, Harris R, Birks C. Receiving the news of a diagnosis of motor neuron disease: What does it take to make it better? Amyotroph Lateral Scler Frontotemporal Degener 2015; 17:168-78. [DOI: 10.3109/21678421.2015.1111907] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | - Lauren J Breen
- School of Psychology and Speech Pathology Faculty of Health Sciences, Curtin University, Perth, Western Australia,
| | | | - Robert Edis
- Royal Perth Hospital, Shenton Park Campus, Shenton Park, Australia,
| | - David Oliver
- Wisdom Hospice and University of Kent, Rochester, UK,
| | | | - Margaret O’Connor
- Faculty of Health, Arts & Design, Swinburne University Melbourne, Victoria,
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Abstract
AbstractObjective:Motor neuron disease (MND) is an incurable progressive illness, characterized by incessant deterioration of neuromuscular function. Timely commencement of advance care planning (ACP) may enable patients to participate in future care choices. The present systematic review aimed to summarize what is known about the prevalence, content, patient/caregiver benefits, healthcare professional (HCP) awareness/support, and healthcare outcomes associated with ACP in the MND setting.Method:Quantitative and qualitative studies were identified through database searches and eligibility assessed by one author and verified by her coauthor. Data extraction and quality assessments against standardized criteria were completed by the two authors.Results:Of the 422 studies identified, 16 were included. The research methods generally lacked rigor. Advance directive (AD) prevalence varied considerably across studies. Disease progression was the strongest predictor of AD completion. ACP processes may clarify patients' wishes and promote communication. HCP attitudes or lack of awareness may limit ACP processes. Varying patient preferences may make flexible approaches and timing necessary.Significance of results:Important benefits may be associated with ACP in the context of a motor neuron disease (e.g., feelings of control/relief and refusal of unwanted treatments). However, further evidence is required to verify findings and identify optimal streamlined approaches (e.g., use of decision aids) consistent with patients' (and caregivers') needs over time.
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Hauser JM, Preodor M, Roman E, Jarvis DM, Emanuel L. The Evolution and Dissemination of the Education in Palliative and End-of-Life Care Program. J Palliat Med 2015; 18:765-70. [DOI: 10.1089/jpm.2014.0396] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Joshua M. Hauser
- Department of Medicine/Palliative Care, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Elisa Roman
- Buehler Center on Aging, Health & Society, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Derek M. Jarvis
- Buehler Center on Aging, Health & Society, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Linda Emanuel
- Buehler Center on Aging, Health & Society, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Umezawa S, Fujimori M, Matsushima E, Kinoshita H, Uchitomi Y. Preferences of advanced cancer patients for communication on anticancer treatment cessation and the transition to palliative care. Cancer 2015; 121:4240-9. [DOI: 10.1002/cncr.29635] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 05/27/2015] [Accepted: 05/27/2015] [Indexed: 12/15/2022]
Affiliation(s)
- Shino Umezawa
- Section of Liaison Psychiatry and Palliative Medicine, Division of Comprehensive Patient Care; Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences; Tokyo Japan
- Psycho-Oncology Division, Research Center for Innovative Oncology; National Cancer Center Hospital East; Chiba Japan
| | - Maiko Fujimori
- Psycho-Oncology Division, Research Center for Innovative Oncology; National Cancer Center Hospital East; Chiba Japan
- Center for Suicide Prevention, National Institute of Mental Health; National Center for Neurology and Psychiatry; Tokyo Japan
| | - Eisuke Matsushima
- Section of Liaison Psychiatry and Palliative Medicine, Division of Comprehensive Patient Care; Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences; Tokyo Japan
| | - Hiroya Kinoshita
- Psycho-Oncology Division, Research Center for Innovative Oncology; National Cancer Center Hospital East; Chiba Japan
- Department of Palliative Medicine; National Cancer Center Hospital East; Chiba Japan
| | - Yosuke Uchitomi
- Psycho-Oncology Division, Research Center for Innovative Oncology; National Cancer Center Hospital East; Chiba Japan
- Innovation Center for Supportive, Palliative and Psychosocial Care; National Cancer Center; Tokyo Japan
- Psycho-Oncology Division; National Cancer Center Hospital; Tokyo Japan
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