Communication between physicians and family caregivers about care at the end of life: when do discussions occur and what is said?

Communication in end-stage cancer: review of the literature and future research

Concerns have been raised about the quality of life and health care received by cancer patients at the end of life (EOL). Many patients die with pain and other distressing symptoms inadequately controlled, receiving burdensome, aggressive care that worsens quality of life and limits patient exposure to palliative care, such as hospice. Patient-physician communication is likely a very important determinate of EOL care. Discussions of EOL with physicians are associated with an increased likelihood of the following (1) acknowledgment of terminal illness, (2) preferences for comfort care over life extension, and (3) receipt of less intensive, life-prolonging and more palliative EOL care; while this appears to hold for White patients, it is less clear for Black, advanced cancer patients. These results highlight the importance of communication in determining EOL cancer care and suggest that communication disparities may contribute to Black-White differences in EOL care. We review the pertinent literature and discuss areas for future research.

Communication about cancer near the end of life

Cancer communication near the end of life has a growing evidence base, and requires clinicians to draw on a distinct set of communication skills. Patients with advanced and incurable cancers are dealing with the emotional impact of a life-limiting illness, treatment decisions that are complex and frequently involve consideration of clinical trials, and the challenges of sustaining hope while also having realistic goals. In this review, the authors sought to provide a guide to important evidence about communication for patients with advanced cancer regarding communication at diagnosis, discussing prognosis, decision making about palliative anticancer therapy and phase 1 trials, advance care planning, transitions in focus from anticancer to palliative care, and preparing patients and families for dying and death.

Pilot Testing of a Question Prompt Sheet to Encourage Family Caregivers of Cancer Patients and Physicians to Discuss End-of-life Issues

Family members of patients with advanced illness have many questions. Unfortunately, several barriers prevent caregivers from discussing their questions with the physicians caring for the patient. Although question prompt sheets can be helpful in overcoming barriers to communication, few have been developed for family caregivers. The goal of this study, therefore, was to develop and test the acceptability and feasibility of a short question prompt sheet designed to encourage discussions about end-of-life concerns in an outpatient palliative care clinic. Our results demonstrated that caregivers wanted to discuss a variety of questions, primarily questions about medications, symptoms, support services, and what to expect. All caregivers thought that the question prompt sheets was easy to understand and felt comfortable completing it in clinic and the majority reported that the question prompt sheets made it easier for them to ask questions.

Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment

CONTEXT

Talking about death can be difficult. Without evidence that end-of-life discussions improve patient outcomes, physicians must balance their desire to honor patient autonomy against a concern of inflicting psychological harm.

OBJECTIVE

To determine whether end-of-life discussions with physicians are associated with fewer aggressive interventions.

DESIGN, SETTING, AND PARTICIPANTS

A US multisite, prospective, longitudinal cohort study of patients with advanced cancer and their informal caregivers (n = 332 dyads), September 2002-February 2008. Patients were followed up from enrollment to death, a median of 4.4 months later. Bereaved caregivers' psychiatric illness and quality of life was assessed a median of 6.5 months later.

MAIN OUTCOME MEASURES

Aggressive medical care (eg, ventilation, resuscitation) and hospice in the final week of life. Secondary outcomes included patients' mental health and caregivers' bereavement adjustment.

RESULTS

One hundred twenty-three of 332 (37.0%) patients reported having end-of-life discussions before baseline. Such discussions were not associated with higher rates of major depressive disorder (8.3% vs 5.8%; adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 0.54-3.32), or more worry (mean McGill score, 6.5 vs 7.0; P = .19). After propensity-score weighted adjustment, end-of-life discussions were associated with lower rates of ventilation (1.6% vs 11.0%; adjusted OR, 0.26; 95% CI, 0.08-0.83), resuscitation (0.8% vs 6.7%; adjusted OR, 0.16; 95% CI, 0.03-0.80), ICU admission (4.1% vs 12.4%; adjusted OR, 0.35; 95% CI, 0.14-0.90), and earlier hospice enrollment (65.6% vs 44.5%; adjusted OR, 1.65;95% CI, 1.04-2.63). In adjusted analyses, more aggressive medical care was associated with worse patient quality of life (6.4 vs 4.6; F = 3.61, P = .01) and higher risk of major depressive disorder in bereaved caregivers (adjusted OR, 3.37; 95% CI, 1.12-10.13), whereas longer hospice stays were associated with better patient quality of life (mean score, 5.6 vs 6.9; F = 3.70, P = .01). Better patient quality of life was associated with better caregiver quality of life at follow-up (beta = .20; P = .001).

CONCLUSIONS

End-of-life discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient quality of life and worse bereavement adjustment.

Using the experiences of bereaved caregivers to inform patient- and caregiver-centered advance care planning

BACKGROUND

Traditional approaches to advance care planning (ACP) have many limitations; new approaches are being developed with the goal of improving end-of-life care.

OBJECTIVE

To understand how the end-of-life care experiences of older patients and their caregivers can inform the development of new approaches to ACP.

DESIGN

Qualitative cross-sectional study.

PARTICIPANTS

Caregivers of community-dwelling persons age > or = 60 years who died with advanced cancer, chronic obstructive pulmonary disease, or heart failure during follow-up in a longitudinal study.

APPROACH

In-depth interviews were conducted 6 months after the patient's death with 64 caregivers. Interviews began with open-ended questions to encourage the caregiver to tell the story of the patient's experiences at the end of life. Additional questions asked about how decisions were made, patient-caregiver, patient-clinician, and caregiver-clinician communication.

MAIN RESULTS

Although the experiences recounted by caregivers were highly individual, several common themes emerged from the interviews. These included the following: 1) the lack of availability of treatment options for certain patients, prompting patients and caregivers to consider broader end-of-life issues, 2) changes in preferences at the very end of an illness, 3) variability in patient and caregiver desire for and readiness to hear information about the patient's illness, and 4) difficulties with patient-caregiver communication.

DISCUSSION

The experiences of older patients at the end of life and their caregivers support a form of ACP that includes a broader set of issues than treatment decision-making alone, recognizes the dynamic nature of preferences, and focuses on addressing barriers to patient-caregiver communication.

Improving access to hospice care: informing the debate

The most frequently cited policy solution for improving access to hospice care for patients and families is to expand hospice eligibility criteria under the Medicare Hospice Benefit. However, the substantial implications of such a policy change have not been fully articulated or evaluated. This paper seeks to identify and describe the implications of expanding Medicare Hospice Benefit eligibility on the nature of hospice care, the cost of hospice care to the Medicare program, and the very structure of hospice and palliative care delivery in the United States. The growth in hospice has been dramatic and the central issue facing policymakers and the hospice industry is defining the appropriate target population for hospice care. As policymakers and the hospice industry discuss the future of hospice and potential changes to the Medicare Hospice Benefit, it is critical to clearly delineate the options--and the implications and challenges of each option--for improving access to hospice care for patients and families.

Disclosure of Incurable Illness to Spouses: Do They Want to Know? A Swedish Population-Based Follow-Up Study

Purpose

Awareness of the cancer patient's terminal state decreases the risk of psychological morbidity of the bereaved. We wanted to determine whether male spouses of cancer patients who died from their disease had received information that the illness was incurable and to determine their preferences of disclosure.

Participants and Methods

The study included 907 widowers whose wives had died of cancer. In an anonymous questionnaire, we asked whether the widower had received information that his wife's illness was incurable and about his attitudes towards receiving this information.

Results

Six hundred ninety-one widowers (76%) participated. Eighty percent of the widowers reported that they were told that the wife's cancer was incurable, and 21% reported that they had been informed within 1 week before the patient's death. Although 14% of the widowers did not think the next of kin should be told immediately when the patient's cancer is beyond cure, 39% of the men did not want the patient to be immediately informed. Furthermore, 71% of the men who were never informed about the incurable illness believed that the next of kin should receive that information immediately.

Conclusion

Although a large majority of men prefer an immediate disclosure about the incurable stage of their wife's illness, 41% of the husbands received this information during the last week of the patient's life or not at all. These findings indicate that there is room for improvement in the level of communication between health providers and the husbands of women with incurable cancer.

Death-talks: transformative learning for physicians

Conversations between physicians and their patients concerning terminal conditions are undoubtedly an uneasy process. These conversations are referred in this article as death-talks. Death-talks are social engagements among meaning-making human beings, and such encounters comprise complex grief dynamics as well as opportunities for personal insight. Towards preparing for and improving upon such sensitive and crucial talks, physicians must become growingly informed of their own existential standpoints in order to exude a more authentic presence. Transformative Learning is a theory of adult learning offering a rationale for physicians to exercise critically reflexive learning towards formulating a more meaningful medical and human care for those who are dying and their grieving relations.

Use of a palliative care order set to improve resident comfort with symptom management in palliative care

Although one-fourth of all medicare dollars are spent during the last year of life, symptom management for terminal hospitalized patients has continued to be inadequate. Quality end-of-life care is often overlooked, seldom taught and rarely measured within Internal Medicine Residency Programmes. We studied the effects of a palliative care order set and educational e-mail on resident comfort. Survey of residents showed that only 54% were comfortable across nine aspects of palliative care. Three months after release, 88% of residents were using the order set and 63% believed it increased their comfort with palliative care. Resident comfort managing palliative symptoms increased an average 10% (P = 0.02). First-year residents exposed to this order set increased in comfort from 40% to 65% (P < 0.0001), which significantly surpassed the 48% of second-year residents who reported being comfortable (P = 0.002). Introducing a palliative care order set improves resident comfort with symptom management in dying patients.

Palliative care for elderly patients with advanced cancer: a long-term intervention for end-of-life care

OBJECTIVE

This essay identifies elderly cancer patients as a population that experiences cancer-related health disparities at the end-of-life.

METHODS

While hospice and palliative care (PC) are care options for this population, it is argued that PC prior to hospice will yield numerous benefits for long-term end-of-life care.

RESULTS

It is theorized that PC prior to hospice will be beneficial in meeting the family's needs in a timely and adequate manner, improving quality of life, increasing caregiver satisfaction and communication, possibly delay institutionalization of the patient, and may ultimately impact bereavement.

CONCLUSION

Patients would be able to benefit from PC in an early stage of their disease, positively influencing older cancer patients and families.

PRACTICE IMPLICATIONS

Long-term assessment of the impact of PC prior to hospice is proposed as a promising direction of future research.

Exploration of communicative patterns of consultations in palliative cancer care

Building on the research conducted on institutional communication, and the analysis of actual communication taking place in clinical settings, this study describes and highlights features of palliative care consultations and focuses on the distribution of discursive space (i.e., share of words, lengths of turns), occurring topics and conversational frames. Six consultations between physicians, patients and significant others were videotaped and all participants took part in audio-taped interviews. The recordings were transcribed and analysed in regard to expectations of, the discursive space of, and topics addressed in the consultations. The distribution of the discursive space was unequal; the physicians had the greatest share of words and length of turns in all six consultations, and they mostly initiated discussion of medical issues connected to examinations and treatment, while only patients initiated the topic of the patient's future. During the consultations, institutional framing tended to dominate over client framing. There was found to be room for further study of the structure and content of palliative care consultations with emphasis on how the voice of the patient can manifest itself within the framework of the medical agenda of the consultation and its significance for palliative cancer team work.

The Maryland patient plan of care form: perceptions of physicians and social workers

OBJECTIVE

To assess nursing home physicians' and social workers' perceptions of the new Maryland Patient Plan of Care Form (PPOC).

DESIGN

Mailed survey.

SETTING

Nursing homes in Maryland.

PARTICIPANTS

Thirty-seven physicians and 60 social workers.

MEASUREMENTS

Views of physicians and social workers were assessed through quantitative questions about the use of the PPOC form and qualitative questions about barriers in completing the form and recommendations to improve the form.

RESULTS

The majority (79.2%) of physicians and social workers reported that completing the PPOC is somewhat of a major burden. An overwhelming majority (85.6%) reported that social workers are completing the form, while close to half of the physicians and a quarter of the social work respondents say that physicians are involved in completing the form. Moreover, significantly more social workers (63.3%) than physicians (36.7%) believe the form would be more useful as a physician's order (X(2) = 5.287; d f = 1; P = .021). Both physicians and social workers identify barriers to completing the form and offer recommendations to improve the form.

CONCLUSIONS

Despite legislation requiring physicians to sign the PPOC, it is not a physician's order, thus shifting the burden of completing the PPOC to social workers. We conclude that most physicians and social workers view the PPOC as burdensome and do not feel that it is useful, but whether it is having an effect on patient care preferences merits further investigation.

[Factors influencing the death of the elderly at home in an institution specializing home medical care--analysis of survey of the bereaved family]

AIM

To determine factors influencing on the death of the elderly at home in an institution specializing in-home medical care (home death rate: about 80%).

METHODS

This study was an anonymous mailed survey of bereaved families of patients (the caregivers) who died using the home medical care setting provided by an institution specializing in home medical care in Japan. We analyzed the relationship of demographics of the patients and the caregivers with such factors as the anxiety of the caregiver and eventual death at home, and that of such factors as perceived quality of home medical care by the caregiver, and satisfaction with home medical care, satisfaction with death bed nursing, regret for death bed nursing.

RESULTS

The most significant determinant factor associated with home death was that both patients and caregivers preferred death at home (OR=19.42). Determination coefficients (R(2)) in the multiple linear regression analysis of caregiver's satisfaction with home medical care, satisfaction with death bed nursing and regret for death bed nursing were as high as 0.68, 0.55 and 0.62, respectively. Significant influential factors were: peaceful death, psychological consistency of the caregiver, a good relationship with one's physician and fulfillment of the care service system.

CONCLUSIONS

Important components of home medical care and death bed nursing for the realization of death of the elderly at home are 1) peaceful death, 2) psychological consistency of caregivers, 3) a good relationship with one's physician, 4) fulfillment of the care service system.

Transitions to palliation: two solitudes or inevitable integration?

As options for systemic therapy for cancer continue to expand and median survival for many solid tumors lengthens, the divisions between active oncologic and palliative care continue to blur. Despite the well-recognized need to integrate palliative support for those with metastatic cancer, data on best practices facilitating the transition from active oncologic to active palliative care are lacking. Recent evidence outlining evolving issues surrounding this transition in care is reviewed, emphasizing the need for rigorous research efforts to define best practices and interventions.

Doctor-patient communication in primary care with an interpreter: physician perceptions of professional and family interpreters

OBJECTIVE

This paper explores physician perceptions of the ways professional and family interpreters affect their performance of doctor-communication tasks described in the Calgary-Cambridge Framework.

METHODS

Physicians' (19) encounters with patients (24) accompanied by an interpreter were videotaped. Stimulated recall was used to elicit each of the participants' perceptions of the clinical encounter. We analyzed transcriptions of the physician interviews using Atlas-ti software.

RESULTS

Physicians perceived all communication tasks to be more difficult using an interpreter than when one was not needed. Physicians perceived family interpreters to be less skilled translators than professional interpreters. Physicians expected professional interpreters to serve as culture brokers at least some of the time. Although only some family interpreters were also caregivers, physicians assumed that all of them fulfilled caregiver roles.

CONCLUSION

With professional interpreters, physicians follow communication rules they were taught. In contrast, physicians act as though these rules are not relevant with family interpreters who they treat as caregivers.

PRACTICE IMPLICATIONS

Guidelines to working with an interpreter should include directives on working with both professional and family interpreters, describing the similarities and differences with each type, and modifying the clinical encounter process to correspond to those attributes.

Hospice care: what services do patients and their families receive?

OBJECTIVE

To determine the degree to which patients and families enrolled with hospice received services across key categories of palliative care, the extent of hospice-level variability in services delivered, and changes over time in services delivered.

DATA SOURCE

Nationally representative sample of 9,409 discharged patients from 2,066 hospices in the National Home and Hospice Care Survey.

STUDY DESIGN

Observational, cross-sectional study conducted from 1992 to 2000. The primary outcome is the receipt of services across five key categories of palliative care: nursing care, physician care, medication management, psychosocial care, and caregiver support.

DATA COLLECTION

Data were obtained via interview with the hospice staff member most familiar with the patient's care, in conjunction with medical record review.

PRINCIPLE FINDINGS

In 2000, 22 percent of patients enrolled with hospice received services across five key categories of palliative care. There was marked variation across hospices in service delivery. One-third of hospices provided patients and families services in one or two of the five key categories of palliative care, whereas 14 percent of hospices provided services across five key categories of palliative care. In multivariable analysis, the odds of receiving any additional hospice service was significantly greater in later compared with earlier years (odds ratio=1.10, 95 percent confidence interval 1.01-1.20). Nevertheless, the percentages of patients in 2000 receiving medication management (59 percent), respite care (7 percent), and physician services (30 percent) remained low.

CONCLUSIONS

Hospice care for patients and families varies substantially across hospices. Whereas some hospices provide services across the key categories of palliative care, other hospices do not provide this breadth of services. Greater understanding of the causes of variation in service delivery as well as its impact on patient and family outcomes and satisfaction with end-of-life care is a critical subject for future research. Changes in Medicare's reimbursement policies may help hospices increase the range of services provided to patients and families.

Communication Strategies and Cultural Issues in the Delivery of Bad News

Good communication is a fundamental skill for all palliative care clinicians. Patients present with varied desires, beliefs, and cultural practices, and navigating these issues presents clinicians with unique challenges. This article provides an overview of the evidence for communication strategies in delivering bad news and discussing advance care planning. In addition, it reviews the literature regarding cultural aspects of care for terminally ill patients and their families and offers strategies for engaging them. Through good communication practices, clinicians can help to avoid conflict and understand patients' desires for end of life care.

Oncologists’ and specialist cancer nurses’ approaches to complementary and alternative medicine and their impact on patient action

High levels of use of complementary and alternative medicine (CAM) have been consistently reported amongst cancer patients over recent years. This is occurring in the context of an apparent increase in sources of information on therapeutic alternatives and a growth in the range of those claiming professional expertise in the field. To date there has been little research on patient experience of discussions about CAM with biomedical cancer specialists in this increasingly complex social environment. This paper addresses three issues: patient experience with cancer specialists; the significance of that experience for patient engagement with CAM; and the nature and significance of inter-professional dynamics. It draws on the results of a qualitative study with cancer patients in the UK. In-depth interviews with 80 purposively sampled patients, incorporating a range of disease types and stages, were conducted. Patients reported three main types of approach by oncologists: explicit or implicit negativity; supportive ambivalence; and, pragmatic acceptance. Crucially, patients' accounts suggest that the type of approach adopted influences (though does not determine) patient action. Specialist cancer nurses emerged as potentially powerful mediators between oncologists and patients. Despite the apparent potential for influence from multiple information sources and 'experts', on the basis of this study we would argue that oncologists remain crucial to patient engagement with CAM. However, this is not to argue that the influence is a simplistic one. Where patient and medical perspectives diverge, strategic alignment with specialist nurses may help patients make choices which conflict with perceived advice.

Bereavement services for family caregivers: how often used, why, and why not

BACKGROUND

Bereavement services are central to high-quality end-of-life care, however, little is known about how frequently and why such bereavement services are used and not used. We examined family caregiver reports about how often they used bereavement services, predictors of their use, and reported reasons for not using bereavement services.

METHODS

Prospective cohort study of family caregivers (n = 161) of patients with cancer enrolled with hospice between October 1999 and September 2001. We conducted bivariate and multivariable analyses to determine predictors of bereavement service use, adjusted for a broad range of factors including caregiving experiences, major depressive disorder (MDD), relationship with the deceased, and demographic factors. We used content analysis to summarize responses to open-ended questions concerning why individuals did not use bereavement services.

RESULTS

We found that approximately 30% of family caregivers used bereavement services in the year postloss, and the majority of these caregivers used services in the first 6 months postloss. Even among bereaved caregivers with MDD, less than half (47.6%) used bereavement services. Factors associated with using bereavement services included being a spouse caregiver, younger age, having MDD at study enrollment, witnessing highly distressing events pertaining to the patient's death, having assisted the patient with more Instrumental Activities of Daily Living (IADLs) prior to the patient's death, having greater availability of instrumental support for oneself, and physician communication with the caregiver about the patient's prognosis before the patient's death. The most common given reason for nonuse was the perception that bereavement services were not needed or would not help.

CONCLUSION

Addressing caregiver receptivity to bereavement services will be an important aspect of increasing appropriate use of such services. Future studies might examine specific interventions for reducing barriers and increasing receptivity to bereavement service use.