Paradoxes in advance care planning: the complex relationship of oncology patients, their physicians, and advance medical directives

[Experiences of family caregivers of patients with terminal cancer]

PURPOSE

This study done to identify the experiences of families caring for patients with terminal cancer. The question was, "What is the caregiving experience of a family who has a member with terminal cancer?"

METHODS

Grounded Theory was applied and in-depth interviews were done with 11 family members. Interviews were recorded with the interviewees' consent and were transcribed and analyzed. Participants' relationships to patients were 6 spouses, 4 daughters, and 1 mother. The ages of the participants were between 32 and 62, with an average of 47.5.

RESULTS

The study showed "enduring with bonds" as the main category and the main factor affecting this category was the "patients' diagnosis of terminal cancer." The caregiving experience was divided into four stages: shock, confusion, struggle, and acceptance. Mediating factors were relationship with the patient, intimacy with the patient, social support, communication, and trust. Conclusively, participants underwent internal maturity, and changes occurred in family and social and personal life.

CONCLUSION

The families took care of the patients with responsibility and love. The study results should help with the understanding of a family with a member with terminal cancer and should be used to develop nursing, mediating, and consulting programs for these caregivers.

Palliative oncology: identity, progress, and the path ahead

Palliative care is a rapidly growing subspecialty of medicine entailing expert and active assessment, evaluation and treatment of the physical, psychological, social and spiritual needs of patients and families with serious illnesses. It provides an added layer of support to the patient's regular medical care. As cancer is detected earlier and its treatments improve, palliative care is increasingly playing a vital role in the oncology population. Because of these advances in oncology, the role of palliative care services for such patients is actively evolving. Herein, we will highlight emerging paradigms in palliative care and attempt to delineate key education, research and policy areas that lie ahead for the field of palliative oncology. Despite the critical need for improving multi-faceted and multi-specialty symptom management and patient-physician communication, we will focus on the interface between palliative care and oncology specialists, a relationship that can lead to better overall patient care on all of these levels.

Palliative care and hematologic oncology: the promise of collaboration

Palliative medicine provides active evaluation and treatment of the physical, psychosocial and spiritual needs of patients and families with serious illnesses, regardless of curability or stage of illness. The hematologic malignancies comprise diverse clinical presentations, evolutions, treatment strategies and clinical and quality of life outcomes with dual potential for rapid clinical decline and ultimate improvement. While recent medical advances have led to cure, remission or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses and all are associated with significant symptom and quality of life burden for patients and families. The gravity of a diagnosis of a hematologic malignancy also weighs heavily on the medical team, who typically develop close and long-term relationships with their patients. Palliative care teams provide an additional layer of support to patients, family caregivers, and the primary medical team through close attention to symptoms and emotional, practical, and spiritual needs. Barriers to routine palliative care co-management in hematologic malignancies include persistent health professional confusion about the role of palliative care and its distinction from hospice; inadequate availability of palliative care provider capacity; and widespread lack of physician training in communicating about achievable goals of care with patients, family caregivers, and colleagues. We herein review the evidence of need for palliative care services in hematologic malignancy patients in the context of a growing body of evidence demonstrating the beneficial outcomes of such care when provided simultaneously with curative or life-prolonging treatment.

Religiosity and Death Attitudes and Engagement of Advance Care Planning Among Chronically Ill Older Adults

The aim of this study was to examine the association of religiosity and death attitudes with self-reported advance care planning (ACP) in chronically ill older adults. Survey data were collected in person for a sample of 157 chronically ill older adults drawn from primary care clinics in North Carolina. Logistic regression was used to examine associations of religiosity and death attitudes in the likelihood of engagement in three ACP outcomes: (a) ACP discussions with the doctor, (b) ACP discussions with family, and (c) the completion of a living will. Greater reported religiosity ( b = 1.67, p < .01) was significantly associated with reported ACP discussions with the doctor ( R2 = .29, model significance p < .01). Less fear of death was significantly associated ( b = −0.41, p < .01) with self-reported completion of a living will ( R2 = .21, model significance p < .01). Religiosity and fears of death should be considered in future ACP studies.

End-of-Life Care and Circumstances of Death in Patients Dying As a Result of Cancer in Belgium and the Netherlands: A Retrospective Comparative Study

Purpose

To examine and compare end-of-life care in patients with cancer dying in Belgium and the Netherlands.

Patients and Methods

A mortality follow-back study was undertaken in 2008 via representative nationwide sentinel networks of general practitioners (GPs) in Belgium and the Netherlands. By using similar standardized procedures, GPs reported on aspects of end-of-life care and the circumstances of nonsudden death of patients with cancer in their practice.

Results

Of the 422 reported patients with cancer, most resided at home during the last year of life (Belgium, 91%; the Netherlands, 95%). Death occurred at home in 34% (Belgium) and 61% (the Netherlands) and in the hospital in 29% (Belgium) and 19% (the Netherlands). In the last month of life, end-of-life issues were more often discussed in the Netherlands (88%) than in Belgium (68%). In both countries, physical problems were discussed most often (Belgium, 49%; the Netherlands, 78%) and spiritual issues least often (Belgium, 20%; the Netherlands, 32%). Certain end-of-life treatment preferences were known for 43% (Belgium) and 67% (the Netherlands) of patients. In the last week of life, treatment was most often focused on palliation (Belgium, 94%; the Netherlands, 91%). Physical distress was reported in 84% (Belgium) and 76% (the Netherlands) of patients and psychological distress in 59% and 36%. Most distressing was lack of energy (Belgium, 73%; the Netherlands, 71%) and lack of appetite (Belgium, 61%; the Netherlands, 53%). Two thirds of patients were bedridden (Belgium, 67%; the Netherlands, 69%).

Conclusion

Although place of death and communication about end-of-life issues differ substantially, a palliative treatment goal is adopted for the vast majority of patients in both countries. However, GPs reported that the majority of patients experienced symptom distress at the end of life, which suggests important challenges remain for improving end-of-life care.

Guiding patients facing decisions about "futile" chemotherapy

Ms. G is a 71-year-old woman with metastatic gastric adenocarcinoma recently diagnosed after an extensive surgical resection for a small bowel obstruction (SBO). She was admitted from the surgery clinic with intractable nausea and vomiting. An abdominal computerized tomographic (CT) scan revealed a partial SBO and peritoneal carcinomatosis. Given her recent surgery, the extent of her disease, and high likelihood of recurrent SBO, the surgical team decided that Ms. G was no longer a surgical candidate. When her symptoms did not improve with conservative measures, both oncology and palliative medicine were consulted to assist with symptom management and goals of care. The oncology team stated that Ms. G was still a chemotherapy candidate and suggested that she attend her new patient evaluation in oncology clinic the following week. The palliative medicine team then met with the patient to discuss management options and her preferences for care. The palliative care team explained ways to control her nausea and vomiting without using a nasogastric tube, and the patient agreed to transfer to their service for symptom management. The palliative team explained that her cancer was incurable but that chemotherapy options existed to help control her disease and possibly prolong her life. They also explained that the chemotherapy has side effects and that the patient would need to decide if she wanted to undergo treatment and accept potential side effects for the possibility of prolonging her life by weeks to months and improving her symptoms. As an alternative, she was told that she could focus solely on symptom control with medications and allow her disease to take its natural course. Ms. G was asked to think about how she wanted to spend the time she had left. Prior to discharge, as her symptoms improved, Ms. G was evaluated by another oncologist, who, after consulting the expert gastrointestinal cancer team, explained to her that the current chemotherapy options available for metastatic gastric cancer were rarely, if ever, successful at reversing malignant obstruction. With this information, the patient decided to be discharged home with hospice and spend time with her family. She died peacefully at her home approximately two weeks later.

[Knowledge and attitude regarding previous instructions for the patients of a public hospital of Madrid]

INTRODUCTION

The level of knowledge and attitudes of patients towards the previous instructions is a little known subject given that their introduction in the Community of Madrid (CM) is recent.

AIMS

To assess the level of knowledge and implementation of advance directives in patients admitted to an Internal Medicine Service of a public hospital in the CM, the attitudes of patients regarding these documents and their correlation with demographic variables.

PATIENTS AND METHODS

A cross-sectional study through structured survey of opinion, closed and voluntarily given to all patients admitted in the Internal Medicine Unit of the University Hospital Alcorcon Foundation on the dates May 20 and June 3, 2008 was carried out.

RESULTS

A total of 155 patients were included, the questions being answered by the patients per se by 57% and by members of theirs families in 42%. Mean age of the patients was 77 years, 50.9% were male and 86.45% were Catholic. Only 7 patients (4.5%) knew what the advance directives were and only one patient had done them. On learning of their existence, 49 patients (31.6%) would like to do the advance instructions. Of the respondents, 80.6% were in favor of having the advance directives document in their medical history and 72.9% do not believe that having these advance directives would change the attitude of their doctor.

CONCLUSIONS

Although the regulation of advance directives in the Community of Madrid has already been in force for 5 years, little is known about these documents and they are still in a period of diffusion.

Advance care planning in advanced cancer: can it be achieved? An exploratory randomized patient preference trial of a care planning discussion

OBJECTIVE

Little is known about the effectiveness of advance care planning in the United Kingdom, although policy documents recommend that it should be available to all those with life-limiting illness.

METHOD

An exploratory patient preference randomized controlled trial of advance care planning discussions with an independent mediator (maximum three sessions) was conducted in London outpatient oncology clinics and a nearby hospice. Seventy-seven patients (mean age 62 years, 39 male) with various forms of recurrent progressive cancer participated, and 68 (88%) completed follow-up at 8 weeks. Patients completed visual analogue scales assessing perceived ability to discuss end-of-life planning with healthcare professionals or family and friends (primary outcome), happiness with the level of communication, and satisfaction with care, as well as a standardized measure of anxiety and depression.

RESULTS

Thirty-eight patients (51%) showed preference for the intervention. Discussions with professionals or family and friends about the future increased in the intervention arms, whether randomized or preference, but happiness with communication was unchanged or worse, and satisfaction with services decreased. Trial participation did not cause significant anxiety or depression and attrition was low.

SIGNIFICANCE OF RESULTS

A randomized trial of advance care planning is possible. This study provides new evidence on its acceptability and effectiveness for patients with advanced cancer.

Ethical issues in palliative care

Ethical problems in medicine are common, especially when caring for patients at the end of life. However, many of these issues are not adequately identified in the outpatient setting. Primary care providers are in a unique and privileged position to identify ethical issues, prevent future conflicts, and help patients make medical decisions that are consistent with their individual values and preferences. This article describes some of the more common ethical issues faced by primary care physicians caring for patients with life-limiting illness.

Advance directives in an oncologic intensive care unit: a contemporary analysis of their frequency, type, and impact

BACKGROUND

Our objective was to provide a contemporary analysis of the prevalence, types, and impact of advance health care directives in critically ill cancer patients.

METHODS

We retrospectively reviewed all intensive care unit (ICU) admissions (January 1, 2006 to April 25, 2008) at an oncologic center and identified all patients who completed a living will (LW), or health care proxy (HCP), or neither prior to ICU admission. Demographics, clinical data, end-of-life (EOL) parameters and outcomes were compared among three groups: LWs, HCPs, and no LW or HCP.

RESULTS

Of 1,333 ICU admissions, 1,121 patients (84%) were included for analysis: 176 patients (15.7%) had LW, 534 (47.6%) had HCP and 411 (36.7%) had no LW or HCP. Patients with LW were significantly more likely to be older and white as compared to patients with HCP alone, or no LW or HCP. There were no significant demographic differences between patients with HCP or no LW or HCP. Patients with HCP alone, or no LW or HCP, were significantly more likely to have Medicaid than patients with LW. There were no differences noted in ICU care, EOL management, or outcomes among the three groups.

CONCLUSIONS

The prevalence of LWs in patients admitted to our oncologic ICU is low. More than half of the remaining patients had designated HCPs. Older age and white race were associated with the presence of LWs. However, the presence of LWs or HCPs did not influence ICU care, EOL management or outcomes at our institution.

A pilot trial of decision aids to give truthful prognostic and treatment information to chemotherapy patients with advanced cancer

Most cancer patients do not have an explicit discussion about prognosis and treatment despite documented adverse outcomes. Few decision aids have been developed to assist the difficult discussions of palliative management. We developed decision aids for people with advanced in curable breast, colorectal, lung, and hormone-refractory prostate cancers facing first-, second-, third-, and fourth-line chemotherapy. We recruited patients from our urban oncology clinic after gaining the permission of their treating oncologist. We measured knowledge of curability and treatment benefit before and after the intervention. Twenty-six of 27 (96%) patients completed the aids, with ameanage of 63, 56% female, 56% married, 56% African American, and 67% with a high school education or more. Most patients (14/27, 52%) thought a person with their advanced cancer could be cured, which was reduced (to 8/26, 31%, P = 0.15) after the decision aid. Nearly all overestimated the effect of palliative chemotherapy. No distress was noted, and hope did not change. The majority (20/27, 74%) found the information helpful to them, and almost all (25/27, 93%) wanted to share the information with their family and physicians. It is possible to give incurable patients their prognosis, treatment options, and options for improving end-of-life care without causing distress or lack of hope. Almost all find the information helpful and want to share it with doctors and family. Research is needed to test the findings in a larger sample and measure the outcomes of truthful information on quality of life, quality of care, and costs.