Complexities in prognostication in advanced cancer: "to help them live their lives the way they want to"

A new framework for understanding stress and disease: the developmental model of stress as applied to multiple sclerosis

This paper proposes a new model of stress that integrates earlier models and adds insights from developmental psychology. Previous models describe the behavioral and physical effects of stress events, but have not explained the translation of experiences into stress itself. The Developmental Model of Stress shows how psychosocial developmental challenges in childhood create persistent negative beliefs and behaviors that increase threat perception and maladaptive stress responses. These developmental challenges produce early psychological and physiological predispositions for increased stress responses over time. Ongoing stress leads to dysregulation of physical stress-response systems (allostatic load), which is associated with multiple diseases. High allostatic load provides the necessary preconditions for the diathesis-stress model, which says the addition of an acute stressor to a weakened or predisposed system can lead to disease development. The paper also documents the evolving measurement of stress to better understand the stress-disease relationship, helping to resolve conflicting results between studies. The Developmental Model of Stress was combined with clinician insight and patient reports to build an integrative framework for understanding the role of stress in the development and progression of multiple sclerosis (MS). It includes the first mapping of maladaptive beliefs and behaviors arising from developmental challenges that are common to people with MS. An initial comparison shows these may be distinct from those of people with other chronic diseases. These beliefs and behaviors form the predisposing factors and contribute to the triggering factors, which are the acute stressors triggering disease onset. These often took two forms, a prolonged incident experienced as feeling trapped or stuck, and threat of a breach in a relationship. The reinforcing factors add the stress of a chronic disease with a poor prognosis and seemingly random symptom fluctuation, still managed with the same beliefs and behaviors developed in childhood, increasing physiological dysregulation and symptom severity. A pilot study is described in which these three categories of stress factors in MS were explicitly addressed. This study noted clinically important improvements in physical and mental well-being, providing preliminary support for the Developmental Model. Future research might expand on the pilot using a more robust sample and design.

Can acutely ill patients predict their outcomes? A scoping review

INTRODUCTION

The full impact of an acute illness on subsequent health is seldom explicitly discussed with patients. Patients' estimates of their likely prognosis have been explored in chronic care settings and can contribute to the improvement of clinical outcomes and patient satisfaction. This scoping review aimed to identify studies of acutely ill patients' estimates of their outcomes and potential benefits for their care.

METHODS

A search was conducted in PubMed, Embase, Web of Science and Google Scholar, using terms related to prognostication and acute care. After removal of duplicates, all articles were assessed for relevance by six investigator pairs; disagreements were resolved by a third investigator. Risk of bias was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Our search identified 3265 articles, of which 10 were included. The methods of assessing self-prognostication were very heterogeneous. Patients seem to be able to predict their need for hospital admission in certain settings, but not their length of stay. The severity of their symptoms and the burden of their disease are often overestimated or underestimated by patients. Patients with severe health conditions and their relatives tend to be overoptimistic about the likely outcome.

CONCLUSION

The understanding of acutely ill patients of their likely outcomes and benefits of treatment has not been adequately studied and is a major knowledge gap. Limited published literature suggests patients may be able to predict their need for hospital admission. Illness perception may influence help-seeking behaviour, speed of recovery and subsequent quality of life. Knowledge of patients' self-prognosis may enhance communication between patients and their physicians, which improves patient-centred care.

Patients' perception of the benefits of palliative systemic therapy for advanced cancer

BACKGROUND

Patients with advanced cancer who misunderstand their prognosis and chance of cure tend to overestimate the likely benefits of palliative systemic therapy.

AIM

To determine patient perceptions of palliative systemic therapy benefits in advanced cancer.

METHODS

We surveyed 104 outpatients with advanced cancer receiving systemic anticancer therapy and their treating oncologists. Patients recorded their understanding of treatment impact on chance of cure and symptoms. Life expectancy was estimated by patients and oncologists. A visual analogue scale (0-10) was used to record how patients and oncologists valued quality of life (QOL) and length of life (LOL) (<4 QOL most important; 4-7 QOL and LOL equal; >7 LOL most important). Patient-oncologist discordance was defined as a ≥4-point difference.

RESULTS

The main reasons patients selected for receiving treatment were to live longer (54%) and cure their cancer (36%). Most patients reported treatment was very/somewhat likely to prolong life (84%) and improve symptoms (76%), whereas 20% reported treatment was very/somewhat likely to cure their cancer. 42% of patients selected a timeframe for life expectancy (choice of four timeframes between <1 year and ≥5 years); of these, 62% selected a longer timeframe than their oncologist. When making treatment decisions, 71% of patients (52% of oncologists) valued QOL and LOL equally. Patient-oncologist discordance was 21%, mostly because of oncologists valuing QOL more than their patients (70%).

CONCLUSION

At least 20% of patients receiving systemic therapy for advanced cancer reported an expectation of cure. Most patients and oncologists value QOL and LOL equally when making treatment decisions.

The role of family and culture in the disclosure of bad news: A multicentre cross-sectional study in Pakistan

Objectives

Disclosure of bad news is distressing for patients and family members. Our aim was to assess patients' perceptions and preferences regarding bad news in the health setting.

Methods

Cross-sectional, multi-centered study supported by an external grant in 15 Government and Private Hospitals across Pakistan. A sample size of 1673 patients and family members was used. Ethics permission/consent was taken from each participating hospital and participant. Responses were compared across provinces, gender, age, education and income.

Results

>80% patients preferred their relatives to know the diagnosis first and they wanted the news to be disclosed to them by doctors. Significant association between education level, income and preference for wanting to know the diagnosis was found. Reasons for wanting to know the diagnosis included treatment, prognosis and prevention options whereas reasons for not wanting to know included fear of emotions and God's will.

Conclusion

The majority of Pakistani patients want to be informed and want the family to know first. Preferences for disclosure vary across, age, education and income level.

Innovation

First countrywide study on this topic. Identifies need for culturally sensitive guidelines that include the family's role in disclosure of bad news.

Prognostic Discordance Among Parents and Physicians Caring for Infants with Neurologic Conditions

OBJECTIVE

To determine the frequency, degree, and nature of prognostic discordance between parents and physicians caring for infants with neurologic conditions.

STUDY DESIGN

In this observational cohort study, we enrolled parents and physicians caring for infants with neurologic conditions in advance of a family conference. Parent-physician dyads completed a postconference survey targeting expected neurologic outcomes across 3 domains (motor, speech, and cognition) using a 6-point scale. Prognostic discordance was defined as a difference of ≥2 response options and was considered moderate (difference of 2-3 response options) or high (difference of 4-5 response options). Responses were categorized as differences in belief and/or differences in understanding using an existing paradigm.

RESULTS

Forty parent-physician dyads of 28 infants completed surveys. Parent-physician discordance about prognosis occurred in ≥1 domain in the majority of dyads (n = 28/40, 70%). Discordance was generally moderate in degree (n = 23/28, 82%) and occurred with similar frequency across all domains. Of parent-physician dyads with discordance, the majority contained a difference in understanding in at least 1 domain (n = 25/28, 89%), while a minority contained a difference of belief (n = 6/28, 21%). When discordance was present, parents were typically more optimistic in their predictions compared with physicians (n = 25/28, 89%).

CONCLUSIONS

Differing perceptions about the prognosis of critically ill infants are common and due to differences in both understanding and belief. These findings can be used to develop targeted interventions to improve prognostic communication.

Responding to Parental Requests for Nondisclosure to Patients of Diagnostic and Prognostic Information in the Setting of Serious Disease

Learning that one's child is seriously ill can be devastating, requiring families to decide when and how to share information about diagnosis and prognosis with their child. In most cases, this disclosure is made thoughtfully and collaboratively with the medical team. Some parents, however, may be concerned that disclosure will take away their child's hope, cause emotional pain, or exceed the child's capacity for understanding. Faced with competing obligations of truth-telling to their patient and respect for parental wishes, pediatricians may be unsure how to proceed. This clinical report examines ethical duties and legal considerations, providing practical and culturally sensitive case-based guidance for clinicians to approach parental requests for nondisclosure of diagnostic or prognostic information.

Concordant palliative care delivery in advanced head and neck cancer

OBJECTIVES

To describe the palliative care consultation practices in an academic head and neck surgery practice.

METHODS

This is a retrospective review of a palliative care database and the health record for all palliative care consultations of patients suffering from advanced stage head and neck cancer within a 21-month period.

RESULTS

Ten head and neck cancer patients received palliative care consults while on the otolaryngology service. One consultation occurred preoperatively; nine occurred postoperatively, on a median of hospital day 9. At the time of referral, seven patients were in the ICU and three were on a surgical floor. Code status de-escalation occurred in six patients and psycho-socio-spiritual suffering was supported in all consultations. Nine patients died within six months, with a median post-consultation survival of 35 days. Of these, two died in an ICU, five were discharged to hospice, one to a SNF, and one to a LTACH.

CONCLUSION

Palliative care consultation in this advanced head and neck cancer cohort was commonly late, however, significant suffering was mitigated following most consults. Palliative care specialists are experts at eliciting patient values, determining acceptable tradeoffs and suffering limitations by employing a shared decision-making process that ends with a patient-centered value-congruent treatment recommendation. Oftentimes, this embraces curative-intent or palliative surgery, along with contingency plans for unacceptable value-incongruent postoperative outcomes. Enhanced awareness of the benefits of embracing concordant palliative care in advanced head and neck cancer patients may help overcome the significant barriers to involving palliative care experts earlier.

Quality Versus Quantity of Life: Beyond the Dichotomy

A restrictive and dichotomous question has become the primary approach in many goals of care discussions. Is the primary goal of care quantity of life through aggressive therapy or quality of life through comfort care and hospice? Even though many health care providers recognize that quality vs quantity of life (QvQ) is a false dichotomy, in practice QvQ underlies many goals of care discussions and can negatively impact patient care. This article offers strategies for assessing patients at the end of life, presenting a first-line conversation process that can support a range of treatment options as well as a diversity of dynamic patient values. Based on decades of experience in palliative care and a review of relevant literature, we recommend four practical questions to serve as values "vital signs," monitoring dynamic notions of quality of life and harmonizing patient values with treatment options.

Cancer palliative care referral: patients' and family caregivers' perspectives - a systematic review

BACKGROUND

Despite the evidence of palliative care benefits, referrals are infrequent and delayed. Patients and their caregivers are essential stakeholders in the referral process with valuable perspectives. This review systematically explored their perceived facilitators and barriers to palliative care referral.

METHODS

4 subject-specific databases (PubMed, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and EMBASE), 3 multidisciplinary databases (SCOPUS, Web of Science and Cochrane database) and 11 journals from 1 January 1990 to 31 May 2022 were searched; and scored for their methodological rigour using Hawker's tool. Findings were synthesised using Popay's Narrative Synthesis method and interpreted using decision-making theory.

RESULTS

4 themes were generated from 14 studies: (1) The timing of referral should be right and communication must be comprehensive. Delays in initiating serious illness conversations, prognostication, and decision-making hindered referral. In contrast, the presence of symptoms facilitated it. (2) Referral was equated to death, and as an inferior form of treatment, a rebranding might mitigate the stigma. (3) Referral made families feel emotional and devastated; explanation and team initiatives enabled the normalisation and positive coping. (4) Long-term holistic palliative care facilitated a positive care experience and a sense of reassurance and satisfaction, enabling a smooth transition from curative to comfort care. The late referral was associated with perceived inadequate symptom management, diminished quality of life and death and complicated bereavement issues.

CONCLUSION

Patients' and caregivers' predisposition to palliative care engagement was influenced by timely referral, comprehensive communication, perception and stigma about palliative care. Longitudinal association with the palliative care team mitigated negative perceptions and improved satisfaction and coping.

PROSPERO REGISTRATION NUMBER

CRD42018091481.

Fluorescence in situ hybridization detection of chromosome 7 and/or 17 polysomy as a prognostic marker for cholangiocarcinoma

Cholangiocarcinoma (CCA) is highly endemic in the Northeast Thailand. Recently, chromosome aberrations provided new insights into pathogenesis of CCA. Therefore, chromosome aberration might be used as a prognostic factor and therapeutic planning of this cancer. This aim of this study is to examine the correlation between an increase of chromosome 7 (C7) and/or 17 (C17) copy number variants (CNVs) with clinicopathological data and the overall survival time (OS) of CCA patients using fluorescence in situ hybridization (FISH) assays. C7 and C17 CNVs were examined using FISH form 157 formalin-fixed paraffin-embedded (FFPE) tissues of CCA patients from Khon Kaen, Thailand between 2011 and 2015. OS was visualized using Kaplan-Meier plot. Univariate and multivariate analyses were used to determine the ability of the clinicopathological parameters to predict OS. C17 > trisomy (odd ratio, 6.944, P < 0.001), C7/17 trisomy (odd ratio; 4.488, P = 0.019), and C7/17 > trisomy (odd ratio; 6.723, P < 0.001) were independently predictive factors for lymph node metastasis. Interestingly, an increase of C7, C17, and C7/17 CNVs in both trisomy and > trisomy was independently correlated with short median OS. An increased of C7 and/or 17 have a potential as a poor prognostic marker in CCA patients.

A Clinical Decision Aid to Support Personalized Treatment Selection for Patients with Clinical T1 Renal Masses: Results from a Multi-institutional Competing-risks Analysis

BACKGROUND

Personalized treatment for clinical T1 renal cortical masses (RCMs) should take into account competing risks related to tumor and patient characteristics.

OBJECTIVE

To develop treatment-specific prediction models for cancer-specific mortality (CSM), other-cause mortality (OCM), and 90-d Clavien grade ≥3 complications across radical nephrectomy (RN), partial nephrectomy (PN), thermal ablation (TA), and active surveillance (AS).

DESIGN, SETTING, AND PARTICIPANTS

Pretreatment clinical and radiological features were collected for consecutive adult patients treated with initial RN, PN, TA, or AS for RCMs at four high-volume referral centers (2000-2019).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Prediction models used competing-risks regression for CSM and OCM and logistic regression for 90-d Clavien grade ≥3 complications. Performance was assessed using bootstrap validation.

RESULTS AND LIMITATIONS

The cohort comprised 5300 patients treated with RN (n = 1277), PN (n = 2967), TA (n = 476), or AS (n = 580). Over median follow-up of 5.2 yr (interquartile range 2.5-8.7), there were 117 CSM, 607 OCM, and 198 complication events. The C index for the predictive models was 0.80 for CSM, 0.77 for OCM, and 0.64 for complications. Predictions from the fitted models are provided in an online calculator (https://small-renal-mass-risk-calculator.fredhutch.org). To illustrate, a hypothetical 74-yr-old male with a 4.5-cm RCM, body mass index of 32 kg/m², estimated glomerular filtration rate of 50 ml/min, Eastern Cooperative Oncology Group performance status of 3, and Charlson comorbidity index of 3 has predicted 5-yr CSM of 2.9-5.6% across treatments, but 5-yr OCM of 29% and risk of 90-d Clavien grade 3-5 complications of 1.9% for RN, 5.8% for PN, and 3.6% for TA. Limitations include selection bias, heterogeneity in practice across treatment sites and the study time period, and lack of control for surgeon/hospital volume.

CONCLUSIONS

We present a risk calculator incorporating pretreatment features to estimate treatment-specific competing risks of mortality and complications for use during shared decision-making and personalized treatment selection for RCMs.

PATIENT SUMMARY

We present a risk calculator that generates personalized estimates of the risks of death from cancer or other causes and of complications for surgical, ablation, and surveillance treatment options for patients with stage 1 kidney tumors.

Top Ten Tips Palliative Care Clinicians Should Know About Prognostication in Children

Pediatric palliative care (PPC) is different from palliative care (PC) for adults. However, conceptualizing PPC remains cumbersome due to the high heterogeneity of often rare diseases, the high diversity of disease trajectories, and the particular difficulty to predict the future of an individual, severely ill child. This article aims to provide an overview and critical reflection of different aspects of prognostication in children with PC needs. This includes different diseases from neurology to oncology, from the unborn baby to the young adult, new approaches in treatment, advance care planning, and, most important, communication with the affected child as well as parents.

Assessment of Changes in Symptoms Is Feasible and Prognostic in the Last Weeks of Life: An International Multicenter Cohort Study

Background: Symptoms are not typically part of established various prognostic factors and scoring systems but are among the most frequently assessed issues in patient care. Objectives: To evaluate that, changes in symptoms can provide additional useful prognostic information. Design: A secondary analysis of an international cohort study in Japan, Korea, and Taiwan. Setting/Subjects: Subjects were adult patients with advanced cancer (n = 2074) who were admitted to 37 palliative care units (PCUs) in 3 countries from January 2017 to September 2018. Measurements: Symptoms (dyspnea, fatigue, dry mouth, and drowsiness) were assessed at admission and one-week later. Dyspnea was assessed by the presence of resting and exertional dyspnea, whereas other symptoms were assessed using the Integrated Palliative care Outcome Scales (IPOS) (range 0-4). For analysis, we grouped patients by symptom change, as either Improved, Stable, or Worsened (by having at least a one increment decrease, no change, or at least a one increment increase, respectively). Results: Worsened groups had the shortest survival (median survival 15-21 days) compared with those with Improved (median survival 23-31 days) and Stable symptoms (median survival 27-29 days) across all four symptoms (dyspnea, fatigue, dry mouth, and drowsiness). Survival differences were statistically significantly different across all three groups for all symptoms (all p < 0.001). Interestingly, Improved symptoms were associated with similar survival compared with Stable groups, with no statistical differences. Conclusions: Worsened symptoms at one week after admission were useful predictors of survival for patients with advanced cancer in PCUs during the final weeks of life. Longitudinal assessments are needed to reflect passage of time as well as impact of treatments.

Ethical Considerations in Caring for Patients with Advanced Malignancy

Patients with advanced malignancy have decisions to make about next steps that are multifactorial and highly ramified. At each step, they, their loved ones, and their health care providers will attempt to make right decisions and avoid wrong ones. Beyond bare ethical principles, these patients face tensions between what they hope for, what is possible, and what those around them expect and advise. This article uses a case-based approach to explore the balance between prognostication and directive counsel; affective forecasting and decisional regret; hope and the therapeutic misconception; and issues of patient ownership and abandonment at the end of life.

Hope-Colored Glasses: Perceptions of Prognosis Among Pediatric Oncology Patients and Their Parents

PURPOSE

Cancer patients' belief about prognosis can heavily influence medical decision making and goals of care. It is known that parents of children with cancer tend to be optimistic regarding their child's prognosis; however, little is known about pediatric patients' prognostic beliefs, how physicians' prognostic communication is perceived, and how these perceptions are compared with actual prognoses.

PATIENTS AND METHODS

An original survey was administered to 100 pediatric oncology patients, age 10-18 years, and their parents from 2013 to 2015, at St Jude Children's Research Hospital. Patients were eligible for inclusion if they had an oncologic diagnosis, were between 1 month and 1 year from diagnosis, and were English speaking. Survey responses regarding perceived prognosis were compared with actual prognoses as determined from the medical record review and published literature. Analysis included descriptive statistics and association tests.

RESULTS

Nearly half of participants (patients = 48.9%, parents = 50.5%) displayed prognostic optimism as compared with the determined objective estimate of curative potential. The majority of both patients (78%) and parents (85%) reported belief in a very high chance of cure, although fewer reported that their physician communicated a very high chance for cure (patients = 57%, parents = 70%), and only 43% were determined to have a very high probability of cure. Significant differences were noted in prognostic optimism by cancer type (P < .0001); patients with solid tumor were more often optimistic (n = 25, 83.3% optimistic; n = 5, 16.7% accurate), and patients with lymphoma were most often accurate (n = 2, 8.7% optimistic; n = 21, 91.3% accurate).

CONCLUSION

Pediatric oncology patients and parents tend to be optimistic about their chance of cure, as compared to both perceived prognostic communication from physicians and objective estimated prognosis. Understanding the nature of prognostic optimism among patients with cancer and caregivers may empower clinicians to guide realistic decision making while supporting hope.

Development and validation of a risk stratification nomogram for predicting prognosis in bone metastatic breast cancer: A population-based study

ABSTRACT

Bone metastasis seriously affects the survival of breast cancer. Therefore, the study aimed to explore the independent prognostic factors in bone metastatic breast cancer (BMBC) and to construct a prognostic nomogram that can accurately predict the survival of BMBC and strictly divide the patients into different risk stratification.Four thousand three hundred seventy six patients with BMBC from the surveillance, epidemiology, and end results database in 2010 to 2015 were collected and randomly divided into training and validation cohort. Multivariate Cox regression identified the independent prognostic factors of BMBC. A nomogram for predicting cancer-specific survival (CSS) in BMBC was created using R software. The predictive performance of the nomogram was evaluated by plotting receiver operating characteristic (ROC) curves and calibration curves.Marital status, race, age, T stage, tumor grade, estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2, brain metastasis, liver metastasis, lung metastasis, chemotherapy, and breast surgery were identified as independent prognostic factors for CSS of BMBC. The area under the ROC curve at 1-, 3-, and 5-year of the nomogram were 0.775, 0.756, and 0.717 in the internal validation and 0.785, 0.737, and 0.735 in the external validation, respectively. Calibration curves further confirmed the unbiased prediction of the model. Kaplan-Meier analysis verified the excellent risk stratification of our model.The first prognostic nomogram for BMBC constructed in our study can accurately predict the survival of BMBC, which may provide a practical tool to help clinicians evaluate prognosis and stratify the prognostic risk for BMBC, thereby determining which patients should be given intensive treatment and optimizing individual treatment strategies for BMBC.

Health Information Preferences and Curability Beliefs Among Patients With Advanced Cancer

CONTEXT

Accurate prognostic understanding is associated with increased advance care planning, symptom control, and patient autonomy in oncology. The impact of prognostic understanding on patients' health information preferences (HIPs) and prognostic information preferences is unknown and has important implications for health care communication.

OBJECTIVES

The present study characterized the HIPs of patients with advanced cancer; examined differences in HIPs between patients with varying curability beliefs; and identified differences in the characteristics and psychological well-being of patients with varying curability beliefs.

METHODS

This cross-sectional study used a secondary data analysis of baseline data (prerandomization) for patients enrolled in a large randomized controlled psychotherapy trial. 206 participants were recruited from outpatient clinics at a single facility. Inclusion criteria included: 18 years and older; English speaking, Stage IV solid tumor cancer, and Distress Thermometer score of ≥4.

RESULTS

Most participants preferred as many details as possible about their diagnosis and treatment (69.4%; n = 143), and the likely outcome of their disease (72.3%; n = 149). Most participants accurately described their cancer as unlikely curable or incurable (62.6%; n = 129). There were no significant differences in HIPs based on level of prognostic understanding. Poorer prognostic understanding was associated with religiosity and better quality of life and existential well-being.

CONCLUSION

In the present study, prognostic understanding (i.e., curability beliefs) was not associated with HIPs. Therefore, oncology clinicians must individually and interatively evaluate patients' interest and preferences for receiving information. Future research should further clarify preferences for the framing and content of prognostic information from providers and improve the measurement of prognostic understanding to facilitate patient-centered end-of-life care.

Longitudinal prognostic communication needs of adolescents and young adults with cancer

BACKGROUND

Although the majority of adolescent and young adult (AYA) patients with cancer desire prognostic information, to the authors' knowledge little is known regarding how preferences for prognostic communication change over time.

METHODS

The current study was a longitudinal, prospective, questionnaire-based cohort study of 136 AYA patients with cancer who were aged 15 to 29 years and who were treated at a large academic cancer center. Previously published scales were administered at the time of diagnosis and at 4 months and 12 months after diagnosis.

RESULTS

The majority of patients reported that prognostic information was very/extremely important at the time of diagnosis (85%), at 4 months (96%; P = .002 compared with baseline), and at 12 months (81%; P = .02 compared with baseline). Few patients reported that prognostic knowledge was very/extremely upsetting at baseline (7%), at 4 months (9%; P = .44 compared with baseline), or at 12 months (11%; P = .27 compared with baseline). The majority of patients were satisfied with the amount of prognostic information received throughout the year after diagnosis (81%, 86%, and 81%, respectively, at the time of diagnosis, at 4 months, and at 12 months). This percentage did not change between the time of diagnosis and 4 months (P = .16) or between diagnosis and 12 months (P = 1.00). In multivariable analysis, satisfaction with prognostic information received was associated with patient report of high-quality communication (odds ratio, 2.67; 95% CI, 1.38-5.17) and having a >75% chance of cure (odds ratio, 2.39; 95% CI, 1.24-4.61) after adjustment for patient age category, race/ethnicity, and time point of administration.

CONCLUSIONS

The majority of AYA patients with cancer were satisfied with prognostic disclosure over time, but a sizeable minority wanted additional information. Desire for prognostic information increased over time. Clinicians should return to prognostic discussions over time to support AYA patients with cancer.

Pediatric Oncology Nurses' Experiences With Prognosis-Related Communication

OBJECTIVES

To examine nurses' experiences of prognosis-related communication (PRC) with parents of children with cancer.

SAMPLE & SETTING

Cross-sectional, correlational study in the pediatric oncology setting involving 316 members of the Association of Pediatric Hematology/Oncology Nurses.

METHODS & VARIABLES

Online survey regarding individual nurse factors, PRC, interprofessional collaboration, moral distress, and perceived quality of care.

RESULTS

Nurses strongly agreed that prognostic disclosure is critical for decision making, but they are challenged in determining their role. Nurses with more years of experience and training in PRC, those working in an outpatient setting, and those with higher levels of nurse-physician collaboration reported more positive experiences with PRC. Positive experiences with PRC and collaboration were significantly associated with higher nurse-perceived quality of care and reduced nurse moral distress.

IMPLICATIONS FOR NURSING

Nurses should work to be active participants in the process of PRC by collaborating with physician colleagues. When nurses sense that prognostic discussions have been absent or unclear, they should feel confident in approaching physician colleagues to ensure parent understanding and satisfaction with communication.

The complexity of physicians' understanding and management of prognostic uncertainty in neonatal hypoxic-ischemic encephalopathy

OBJECTIVE

Prognosis of Hypoxic-Ischemic Encephalopathy (HIE) remains challenging and uncertain. This paper investigates how physicians understand and address the ethical challenges of prognostic uncertainty in the case of neonatal HIE, contextualized within the social science literature.

STUDY DESIGN

Semi-structured interviews were conducted with 12 Canadian neurologists and neonatologists, addressing their perspectives and clinical experiences concerning neonatal HIE prognostication. Interviews were analyzed using thematic content analysis.

RESULTS

Participants unanimously recognized uncertainty in their prognostication. They identified several sources contributing to uncertainty in HIE prognostication, including etiology and underlying pathophysiologic mechanisms, statistical limitations, variable clinical data, the dynamic process of neurodevelopment, or the impact of hypothermia treatment. Unlike in some other literature, some physicians in this study talked about ways to render uncertainty explicit rather than hide it.

CONCLUSION

Results from this study support the call for recognition of the ubiquitous uncertainty surrounding this act in medical education and training.

Korean Physicians' Perspectives on Prognostication in Palliative Care: A Qualitative Study

BACKGROUND

Prognostication is an essential component of palliative care for patients with advanced cancer but also poses challenges. Little is known about physicians' perspectives on prognostication and prognostic tools used in palliative care practice in Eastern countries.

OBJECTIVES

To explore Korean physicians' perspectives and experiences with prognostication in their palliative care practices.

METHODS

Semi-structured interviews were conducted in Korea in 11 palliative care physicians. A constant comparative and grounded theory approach was used to derive themes from interview transcripts.

RESULTS

Participants on average had 6.4 (SD = 4.5, range 0.5-15) years of hospice and palliative care experience. We identified 4 main themes about prognostication: (1) the importance of prognostication (to help patients and their families prepare for death, to determine the appropriate time of transition to hospice care, to facilitate appropriate decision making, and to facilitate communication with patients and their families); (2) difficulties of prognostication (discomfort estimating the exact date of death); (3) basis of prognostication (clinical prediction of survival as well as prognostic scores); and (4) areas for further research (need for a simpler scoring system or parameters to predict survival with greater certainty).

CONCLUSION

Palliative care physicians in Korea reported similar perceptions about the role and challenges inherent in prognostication compared to clinicians in Western cultures. However, they emphasize the need to predict final days to keep families with dying patients, reflecting family-centered aspects of Asian culture. They reported frustrations with inaccurate prognostication schemas and called for the development of simpler, more accurate predictors as a focus of future research.

The Survival time of Terminal Cancer Patients: Prediction Based on Clinical Parameters and Simple Prognostic Scores

Aim: By examining clinical parameters associated with survival time and analyzing patients’ survival times using prognostic scores, this study aimed to provide helpful information related to the treatment of terminal cancer patients. Methods: We retrospectively reviewed the medical records of 415 inpatients who died in the hospices of two hospitals from March 2009 to August 2011 then analyzed differences in survival times and relative risk for clinical parameters and prognostic scores. Results: There were 15 parameters associated with survival time. Performance decline was the most influential factor. The optimal scores for predicting four-week survival were over 4.5 on the Palliative Prognostic Index (PPI), over 10 on the Palliative Prognostic (PaP) Score, and 30 or under on the Palliative Performance Scale (PPS). Conclusion: Performance decline is a major factor affecting survival time. The PaP is the most useful tool for predicting four-week survival, with an optimal value of over 10.

Evaluation of physicians' skills in breaking bad news to cancer patients

Background:

Delivering bad news to patients is one of the most difficult tasks of physicians that play a big role in the process of treatment and cooperation of patients. The objective of this study is to evaluate the ability and skills of physicians in delivery bad news to cancer patients.

Methods:

This study is a cross-sectional study performed on 70 specialist physicians in two hospitals of Mashhad in 2016. Data were collected by Persian questionnaire of SPIKES included 16 questions and were analyzed by SPSS software.

Results:

In this study, among the questionnaire items, the most prevalent item was not giving the bad news by phone (100%) and the least prevalent item was putting the hand on the shoulder (24.3%). This study showed that 81.4% of doctors agreed on giving the bad news in private, 72.9% agreed on giving relative hope to patients and 67.1% agreed on evaluating patients knowledge of his/her disease when giving bad news.

Conclusion:

The results of this study show that the ability of physicians in giving bad news is not enough in some aspects. Therefore, holding educational courses during physicians’ education and after graduation are recommended to increase patients’ trust and decreasing worries and inconvenience of physicians in difficult situations of delivering bad news.

Communication of prognosis in head and neck cancer patients; a descriptive qualitative analysis

OBJECTIVES

In shared decision making it is important to adequately, timely and actively involve patients in treatment decisions. Sharing prognostic information can be of key importance. This study describes whether and how prognostic information on life expectancy is included during communication on diagnosis and treatment plans between physicians and head and neck (H&N) oncologic patients in different phases of disease.

METHODS

A descriptive, qualitative study was performed of n = 23 audiotaped physician-patient conversations in which both palliative and curative treatment options were discussed and questions on prognosis were expected. Verbatim transcribed consultations were systematically analyzed. A distinction was made between prognostic information that was provided (a) quantitatively: by giving numerical probability estimates, such as percentages or years or (b) qualitatively: through the use of words such as 'most likely' or 'highly improbable'.

RESULTS

In all consultations, H&N surgeons provided some prognostic information. In 5.9% of the provided prognostic information, a quantitative method was used. In 94.1% prognostic information was provided qualitatively, using six identified approaches. H&N surgeons possibly affect patients' perception of prognostic content with two identified communication styles: directive (more physician-centered) and affective (more patient-centered).

CONCLUSION

This study is first in providing examples of how H&N surgeons communicate with their patients regarding prognosis in all stages of disease. They often exclude specific prognostic information. The study outcomes can be used as a first step in developing a guideline for sharing prognostic information in H&N oncologic patients, in order enable the process of shared decision making.

Communication About Prognosis With Adolescent and Young Adult Patients With Cancer: Information Needs, Prognostic Awareness, and Outcomes of Disclosure

Purpose

Communication about prognosis affects decisions patients and family members make about cancer care, and most patients say they want to know about their chances of cure. We sought to evaluate experiences with prognosis communication among adolescents and young adults (AYAs) with cancer.

Patients and Methods

We surveyed 203 AYAs with cancer age 15 to 29 years (response rate, 74%) treated at Dana-Farber Cancer Institute and their oncologists. Patients were approached within 6 weeks of diagnosis and asked to report on their prognosis communication preferences and experiences, their beliefs about likelihood of cure, and psychosocial outcomes of communication, such as trust (using an item from the Trust in Physician Scale), peace of mind (using select items from the Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being Scale), and anxiety and depression (using the Hospital Anxiety and Depression Scale). Oncologists were asked to report the patient’s likelihood of cure.

Results

Most patients (83%, 167 of 203 patients) considered prognostic information to be extremely or very important. Patients who reported having received more extensive prognostic disclosure had higher odds of trust in the oncologist (odds ratio [OR], 1.30; 95% CI, 1.01 to 1.67; P = .05), peace of mind (OR, 2.13; 95% CI, 1.29 to 3.51; P = .002), and hope related to physician communication (OR, 1.27; 95% CI, 1.01 to 1.59; P = .04), after adjusting for patient sex, age, race or ethnicity, prognosis, and diagnosis. Disclosure was also associated with lower distress related to knowing about prognosis (OR, 0.65; 95% CI, 0.44 to 0.95; P = .03). However, a majority of patients (62%) reported prognostic estimates that exceeded those reported by physicians (McNemar P < .001).

Conclusion

Most AYAs with cancer value receiving prognostic information, which is positively associated with aspects of well-being. However, most overestimate chances of cure relative to oncologists, highlighting the importance of efforts to improve communication with this young population.

A prospective observational study to assess clinical decision-making, prognosis, quality of life and satisfaction with care in patients with relapsed/refractory multiple myeloma: the CLARITY study protocol

BACKGROUND

Treatment decision-making in patients with relapsed/refractory multiple myeloma (RRMM) is challenging for a number of reasons including, the heterogeneity of disease at relapse and the number of possible therapeutic approaches. This study broadly aims to generate new evidence-based data to facilitate clinical decision-making in RRMM patients. The primary objective is to investigate the prognostic value of patient self-reported fatigue severity for overall survival.

METHODS

This multicenter prospective observational study will consecutively enroll 312 patients with multiple myeloma who have received at least 1 prior line of therapy and are considered as RRMM according to the International Myeloma Working Group (IMWG) criteria. Eligible RRMM participants will be adults (≥ 18 years old) patients and will be enrolled irrespective of comorbidities and performance status. At the time of study inclusion, data to calculate the frailty score are to be available. Patients will be followed up for 30 months and patient-reported outcome (PRO) assessment is planned at baseline and thereafter at 3, 6, 12, and 24 months. The following PRO validated questionnaires will be used: the European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), the EORTC QLQ-MY20 and the EORTC QLQ-INFO25. Satisfaction with care and preference for involvement in treatment decisions will also be evaluated. Clinical, laboratory and treatment related information will be prospectively collected in conjunction with pre scheduled PRO assessments. Cox regression analyses will be used to assess the prognostic value of baseline fatigue severity (EORTC QLQ-C30) and other patient-reported health-related quality of life parameters.

DISCUSSION

Clinical decision-making in RRMM is a challenge and outcome prediction is also an important aspect to enhance personalized treatment planning. Given the paucity of PRO data in this population, this prospective observational study aims to provide novel information that may facilitate patients' management in routine practice.

TRIAL REGISTRATION

This trial is registered as identifier NCT03190525 .

Quality of life predicts overall survival in women with platinum-resistant ovarian cancer: an AURELIA substudy

Background

Women with platinum-resistant ovarian cancer are a heterogeneous group whose median overall survival is 12 months. We hypothesized that their quality of life (QoL) scores would be prognostic.

Patients and methods

Data from AURELIA (n = 326), a randomized trial of chemotherapy with or without bevacizumab, were used to identify baseline QoL domains [EORTC (European Organisation for Research and Treatment of Cancer) QLQ-C30 and OV28] that were significantly associated with overall survival in multivariable Cox regression analyses. Patients were classified as having good, medium, or poor risk. Cutpoints were validated in an independent dataset, CARTAXHY (n = 136). Multivariable analyses of significant QoL domains on survival were adjusted for clinicopathological prognostic factors. The additional QoL information was assessed using C statistic.

Results

In AURELIA, all domains, except cognitive function, predicted overall survival in univariable analyses. Physical function (P < 0.001) and abdominal/gastrointestinal symptom (P < 0.001) scores remained significant in multivariable models. In high (score <67), medium (67-93), and low (>93) risk categories for physical function, median overall survival was 11.0, 14.7, and 19.3 months, respectively (P < 0.001). In CARTAXHY, median overall survival was 7.9, 16.2, and 23.9 months (P < 0.001), respectively. For high- (>44), medium- (13-44), and low- (<13) risk categories for abdominal/gastrointestinal symptoms, median overall survival was 11.9, 14.3, and 19.7 months in AURELIA (P < 0.001) and 10.5, 19.6, and 24.1 months in CARTAXHY (P = 0.02). Physical function (P = 0.02) and abdominal/gastrointestinal symptoms (P = 0.03) remained independent prognostic factors after adjustment for clinicopathological factors. The C statistic of the full model was 0.71. For QoL factors alone, patient factors alone and disease factors alone, the C statistics were 0.61, 0.61, and 0.67 respectively.

Conclusions

Physical function and abdominal/gastrointestinal symptom scores improved predictions of overall survival over clinicopathological factors alone in platinum-resistant ovarian cancer. This additional prognostic information could improve trial stratification, patient-doctor communication about prognosis, and clinical decision-making.

Clinical trial registration

NCT00976911.

The NEAT Predictive Model for Survival in Patients with Advanced Cancer

PURPOSE

We previously developed a model to more accurately predict life expectancy for stage IV cancer patients referred to radiation oncology. The goals of this study are to validate this model and to compare competing published models.

Materials and Methods

From May 2012 to March 2015, 280 consecutive patientswith stage IV cancerwere prospectively evaluated by a single radiation oncologist. Patients were separated into training, validation and combined sets. TheNEAT model evaluated number of active tumors ("N"), Eastern Cooperative Oncology Group performance status ("E"), albumin ("A") and primary tumor site ("T"). The Odette Cancer Center model validated performance status, bone only metastases and primary tumor site. The Harvard TEACHH model investigated primary tumor type, performance status, age, prior chemotherapy courses, liver metastases, and hospitalization within 3 months. Cox multivariable analyses and logisticalregressionwere utilized to compare model performance.

RESULTS

Number of active tumors, performance status, albumin, primary tumor site, prior hospitalizationwithin the last 3 months, and liver metastases predicted overall survival on uinvariate and multivariable analysis (p < 0.05 for all). The NEAT model separated patients into four prognostic groups with median survivals of 24.9, 14.8, 4.0, and 1.2 months, respectively (p < 0.001). The NEAT model had a C-index of 0.76 with a Nagelkerke's R2 of 0.54 suggesting good discrimination, calibration and total performance compared to competing prognostic models.

CONCLUSION

The NEAT model warrants further investigation as a clinically useful approach to predict survival in patients with stage IV cancer.

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

Highlights

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

The Impact of Teaching Prognostication at the End of Life: A Pre-Post Interventional Study

BACKGROUND

Providing accurate and valid prognostic information significantly influences end-of-life care. Disclosing a poor prognosis can be among the most difficult of physician responsibilities, thus having appropriate knowledge during training is crucial for appropriate prognostication.

OBJECTIVE

To provide internal medicine (IM) house staff with a pre- and posteducational survey to determine their ability to accurately prognosticate 5 common end-stage diseases.

DESIGN

We conducted a pre- and posteducational intervention survey-based study. A preintervention survey was administered to IM postgraduate year 1 (PGY-1) and PGY-2-4 house staff. The survey consisted of case scenarios for 5 common end-stage diseases, containing 1 question on comfort level and 2 on prognostication (totaling 10 points). A 30-minute educational intervention was presented immediately after the initial survey. The same survey was readministered 4 weeks thereafter. An identical survey was administered once to palliative care faculty.

RESULTS

Forty house staff completed pre- and posteducational surveys. Eight palliative care faculty completed the survey. No difference was found between all house staff pre- and postscores (mean 2.70 [1.45] vs 2.78 [1.59], P = .141). There was no significant difference between PGY-1 and PGY-2-4 pretest scores (mean 2.63 [1.71] vs 2.81 [1.42], P = .72). The PGY-2-4 posttest score was significantly greater than PGY-1 posttest score (3.38 [1.58] vs 2.38 [1.58], P = .05). Total house staff posttest score was significantly lower than gold standard palliative care faculty (mean 4.71 [1.98] vs 2.78 [1.59], P = .006).

CONCLUSIONS

Our pre-post intervention survey-based study demonstrates no significant increases in all house staff scores. The PGY-2-4 postintervention scores improved significantly. We speculate the optimal time for prognostication education may be after the PGY-1 year when house staff have had sufficient exposure to common conditions.

Strengthening primary health care teams with palliative care leaders: protocol for a cluster randomized clinical trial

Background

The objective of the Balearic Islands Palliative Care (PC) Program is to improve the quality of PC through a shared model consisting of primary health care professionals, home-based PC teams, and PC units in hospitals. According to the World Health Organization (WHO), patients with advanced cancer and other terminal diseases benefit from early identification and proactive PC. We will evaluate the effectiveness of an intervention in which a PC leader is established in the primary health care center, and assess the effect of this intervention on the early identification of patients in need of PC, the efficient use of health care services, and direct health care costs.

Methods

Design: A two-arm cluster randomized clinical trial of 30 Primary Health Care Centers (PHCC) in Mallorca (Spain), in which each center was randomized to an intervention arm or a usual care arm. We expect that the number of patients identified as suitable for PC (including non-oncological PC) is at least 5% greater in the intervention arm.

Sample size: A total of 4640 deceased patients. Outcomes will be assessed by a blinded external review of the electronic records.

Interventions: General practitioners (GPs) and nurse leaders in PC for each PHCC will be appointed. These leaders will help promote PC training of colleagues, improve symptom management and psychological support of patients, and evaluate the complexity of individual cases so that these cases receive assistance from PC home-based teams.

Measurements: Early identification (>90 days before death), evaluation of case complexity, level of case complexity (with referral to a home-based PC team), use and cost of hospital and primary care services, and quality of life during the last month of life (≥2 emergency room visits, ≥2 hospital admissions, ≥14 days of hospitalization).

Discusion

PC leaders in primary care teams will improve the early identification of patients eligible for PC. This initiative could improve the quality of end-of-life care and utilization of hospital resources.

Trial registration

ISRCTN Registry identifier: ISRCTN92479122. Retrospectively registered on 28 February 2017.

Nurses' Perceptions of Diagnosis and Prognosis-Related Communication: An Integrative Review

BACKGROUND

Disclosure of diagnostic and prognostic information has become the standard in the United States and increasingly around the world. Disclosure is generally identified as the responsibility of the physician. However, nurses are active participants in the process both intentionally and inadvertently. If not included in initial discussions regarding diagnosis and prognosis, the nurse may find it challenging to openly support the patient and family.

OBJECTIVE

The aim of this study is to synthesize published literature regarding nurses' perceptions and experiences with diagnosis and prognosis-related communication.

METHODS

The Whittemore and Knafl method guided the integrative review process. Electronic databases including Cumulative Index to Nursing and Allied Health Literature, Health Sciences in ProQuest, PubMed, and Web of Science were used to review the literature from 2000 to 2015. Constant comparison methods were used to analyze the data and develop themes.

RESULTS

Thirty articles met all of the inclusion criteria and were included in this review. Several themes emerged from the data, including the nurse's role in the process of diagnosis and prognosis-related communication, barriers and difficulties related to communication, and positive and negative outcomes.

CONCLUSIONS

Nurses play an integral role in the process of diagnostic and prognostic disclosure. Further exploration of both physician and patient perceptions of the nurse's role are needed. Interprofessional training regarding diagnosis and prognosis-related communication is essential to promote collaboration and better empower nurses in this process.

IMPLICATIONS FOR PRACTICE

Nurses should aim to purposefully partner with physician colleagues to plan and participate in diagnostic and prognostic discussions. Nurses should identify opportunities to improve their knowledge, understanding, and comfort with challenging conversations.

End-of-Life Care in the Treatment of Heart Failure in Older Adults

Heart failure presents unique challenges to the clinician who desires to provide excellent and humane care near the end of life. Accurate prediction of mortality in the individual patient is complicated by a chronic disease that is punctuated by recurrent acute episodes and sudden death. Health care providers continue to have difficulty communicating effectively with terminally ill patients and their caregivers regarding end-of-life care preferences, all of which needs to occur earlier rather than later. This article also discusses various means of providing palliative care, and specific issues regarding device therapy, cardiopulmonary resuscitation, and palliative sedation with concurrent discussion of the ethical ramifications and pitfalls of each.

Nocebo effects in clinical studies: hints for pain therapy

INTRODUCTION

Nocebo-induced algesic responses occurring within clinical contexts present a challenge for health care practitioners working in the field of pain medicine.

OBJECTIVES

Following the recent research on algesic nocebo effects, the scope of this review is to develop ethically acceptable strategies to help avoid, or at least reduce, nocebo responses within clinical settings.

METHODS

We reviewed relevant clinical studies that depict how patient-practitioner interactions may contribute to the reduction of nocebo responses.

RESULTS

A strong algesic nocebo effect may adversely impact a patient's condition by causing decreases in both the efficacy and effectiveness of interventions, as well as by promoting treatment nonadherence and discontinuation. These effects may be triggered through multiple channels and can lead to significant alterations in a patient's perception of pain, consequently producing a weakening of the specific positive effects of pharmacological, psychological, or physical pain-management interventions.

CONCLUSION

To minimize nocebo effects in clinical settings, we identified and discussed five contextual aspects relevant to the treatment of patients with chronic pain: (1) negative patient-clinician communication and interaction during treatment; (2) emotional burden of patients during treatment with analgesic medication; (3) negative information provided via informational leaflets; (4) cued and contextual conditioning nocebo effects; and (5) patient's lack of positive information. Through an understanding of these elements, many preventive and ethically acceptable clinical actions can be taken to improve multidisciplinary pain treatment outcomes.

First Counseling Revealing the Diagnosis of Childhood Cancer: Parent Preferences From an Indian Perspective

BACKGROUND

The first counseling or the exchange between the physician and the parent(s) of children with cancer is of vital importance as it sets the tone for the rest of the treatment. The goal of our study was to find out the preferences among parents of Indian children with cancer regarding communication and breaking of bad news when fully informed about the diagnosis.

MATERIALS AND METHODS

A sample of 60 parents who had been counseled within 3 months from diagnosis were interviewed with a prepared questionnaire directed at eliciting their experiences with the physicians who broke the bad news to them and also suggestions to improve the exchange.

RESULTS

Sixty parents of children diagnosed with cancer participated in the study. All parents agreed on the importance of first counseling and asked for a second round of counseling to reinforce concepts learned during the first counseling. An overall 83% of parents wanted a comparison with another child having the same diagnosis, 57% wanted immediate or extended family to be present, and 92% did not want support staff to be present during counseling. In all, 68% of parents did not want to reveal the diagnosis to the child, 77% wanted as much information about the disease as possible, including estimated cost of treatment, and 90% wanted access to other information services and information about other centers where treatment was available.

CONCLUSIONS

Parents have preferences about the ways in which information is presented to them during the first counseling. Knowing these preferences will help physicians to better their ability to interact with parents in the future during first counseling and help them decide a culturally appropriate course of action.

The Ethics of Palliative Sedation as a Therapy of Last Resort

Many patients nearing the end of life reach a point at which the goals of care change from an emphasis on prolonging life and optimizing function to maximizing the quality of remaining life, and palliative care becomes a priority. For some patients, however, even high-quality aggressive palliative care fails to provide relief. For patients suffering from severe pain, dyspnea, vomiting, or other symptoms that prove refractory to treatment, there is a consensus that palliative sedation is an appropriate intervention of last resort. In this report, the National Ethics Committee, Veterans Health Administration examines what is meant by palliative sedation, explores ethical concerns about the practice, reviews the emerging professional consensus regarding the use of palliative sedation for managing severe, refractory symptoms at the end of life, and offers specific recommendations for institutional policy.

Rethinking autonomy: decision making between patient and surgeon in advanced illnesses

Patients with advanced illness such as advanced stage cancer presenting with the need for possible surgical intervention can be some of the most challenging cases for a surgeon. Often there are multiple factors influencing the decisions made. For patients they are facing not just the effects of the disease on their body, but the stark realization that the disease will also limit their life. Not only are these factors a consideration when patients are making decisions, but also the desire to make the decision that is best for themselves, the autonomous decision. Also included in this process for the patient facing the possible need for an intervention is the surgeon. While patient autonomy remains one of the main principles within medicine, guiding treatment decisions, there is also the surgeon's autonomy to be considered. Surgeons determine if there is even a possible intervention to be offered to patients, a decision making process that respects surgeons' autonomous choices and includes elements of paternalism as surgeons utilize their expertise to make decisions. Included in the treatment decisions that are made and the care of the patient is the impact patients' outcomes have on the surgeon, the inherent drive to be the best for the patient and desire for good outcomes for the patient. While both the patient's and surgeon's autonomy are a dynamic interface influencing decision making, the main goal for the patient facing a palliative procedure is that of making treatment decisions based on the concept of shared decision making, always giving primary consideration to the patient's goals and values. Lastly, regardless of the decision made, it is the responsibility of surgeons to their patients to be a source of support through this challenging time.

Identifying the potential long-term survivors among breast cancer patients with distant metastasis

BACKGROUND

We aimed to develop a prediction model to identify long-term survivors after developing distant metastasis from breast cancer.

PATIENTS AND METHODS

From the institution's database, we collected data of 547 patients who developed distant metastasis during their follow-ups. We developed a model that predicts the post-metastasis overall survival (PMOS) based on the clinicopathologic factors of the primary tumors and the characteristics of the distant metastasis. For validation, the survival data of 254 patients from four independent institutions were used.

RESULTS

The median duration of the PMOS was 31.0 months. The characteristics of the initial primary tumor, such as tumor stage, hormone receptor status, and Ki-67 expression level, and the characteristics of the distant metastasis presentation including the duration of disease-free interval, the site of metastasis, and the presence of metastasis-related symptoms were independent prognostic factors determining the PMOS. The association between tumor stage and the PMOS was only seen in tumors with early relapses. The PMOS score, which was developed based on the above six factors, successfully identified patients with superior survival after metastasis. The median PMOS for patients with a PMOS score of <2 and for patients with a PMOS score of >5 were 71.0 and 12 months, respectively. The clinical significance of the PMOS score was further validated using independent multicenter datasets.

CONCLUSIONS

We have developed a novel prediction model that can classify breast cancer patients with distant metastasis according to their survival after metastasis. Our model can be a valuable tool to identify long-term survivors who can be potential candidates for more intensive multidisciplinary approaches. Furthermore, our model can provide a more reliable survival information for both physicians and patients during their informed decision-making process.

Design of, and enrollment in, the palliative care communication research initiative: a direct-observation cohort study

BACKGROUND

Understanding the characteristics of communication that foster patient-centered outcomes amid serious illness are essential for the science of palliative care. However, epidemiological cohort studies that directly observe clinical conversations can be challenging to conduct in the natural setting. We describe the successful enrollment, observation and data collection methods of the ongoing Palliative Care Communication Research Initiative (PCCRI).

METHODS

The PCCRI is a multi-site cohort study of naturally occurring inpatient palliative care consultations. The 6-month cohort data includes directly observed and audio-recorded palliative care consultations (up to first 3 visits); patient/proxy/clinician self-report questionnaires both before and the day after consultation; post-consultation in-depth interviews; and medical/administrative records.

RESULTS

One hundred fourteen patients or their proxies enrolled in PCCRI during Enrollment Year One (of Three). Seventy percent of eligible patients/proxies were invited to hear about a communication research study (188/269); 60% of them ultimately enrolled in the PCCRI (114/188), resulting in a 42% sampling proportion (114/269 eligible). All PC clinicians at study sites were invited to participate; all 45 participated.

CONCLUSIONS

Epidemiologic study of patient-family-clinician communication in palliative care settings is feasible and acceptable to patients, proxies and clinicians. We detail the successful PCCRI methods for enrollment, direct observation and data collection for this complex "field" environment.

Parental hope for children with advanced cancer

BACKGROUND

Previous work suggests that parents of children with cancer can remain hopeful despite receiving prognostic information, but we know little about what hope means to such parents, or the extent to which parents can feel hopeful even while facing the child's impending death.

METHODS

We audiotaped conversations between clinicians and parents of 32 children with relapsed or refractory cancer, and then interviewed parents about their hopes and expectations for their child.

RESULTS

Parent statements about prognosis in interviews mirrored those made by clinicians during discussions about the child's diagnosis with refractory or relapsed cancer. Clinicians used language referring to hope during these conversations but did not ask parents directly about their hopes. Parents expressed a range of hopes for their children, from hopes related to cure or treatment response, to quality of life, normalcy, and love and relationships for the child. For most parents, expectations about prognosis were not aligned with their hopes for the child; for example, many parents hoped for a cure and also reported that they did not believe cure was possible. Many parents were able to acknowledge this incongruence.

CONCLUSIONS

Parents accurately conveyed the reality of their child's serious condition in the setting of advanced cancer, and yet maintained hope. Hopes were not limited to hope for cure/treatment response. Clinicians should be encouraged to engage in direct conversations about hope with parents as a means to elicit realistic hopes that can help to focus the most meaningful plans for the child and family.

Clinical Predictors of Survival for Patients with Stage IV Cancer Referred to Radiation Oncology

BACKGROUND

There is an urgent need for a robust, clinically useful predictive model for survival in a heterogeneous group of patients with metastatic cancer referred to radiation oncology.

METHODS

From May 2012 to August 2013, 143 consecutive patients with stage IV cancer were prospectively evaluated by a single radiation oncologist. We retrospectively analyzed the effect of 29 patient, laboratory and tumor-related prognostic factors on overall survival using univariate analysis. Variables that were statistically significant on univariate analysis were entered into a multivariable Cox regression to identify independent predictors of overall survival.

RESULTS

The median overall survival was 5.5 months. Four prognostic factors significantly predicted survival on multivariable analysis including ECOG performance status (0-1 vs. 2 vs. 3-4), number of active tumors (1 to 5 vs. ≥ 6), albumin levels (≥ 3.4 vs. 2.4 to 3.3 vs. < 2.4 and primary tumor site (Breast, Kidney or Prostate vs. Other). Risk group stratification was performed by assigning points for adverse prognostic factors resulting in very low, low, intermediate and high risk groups. The median survival was > 31.4 months for very low risk patients compared to 14.5 months for low risk, 4.1 months for intermediate risk and 1.2 months for high risk (p < 0.001).

CONCLUSIONS

These data suggest that a model that considers performance status, extent of disease, primary tumor site and serum albumin represents a simple model to accurately predict survival for patients with stage IV cancer who are potential candidates for radiation therapy.

End of life/palliative care/ethics

Palliative and end-of-life care, once the purview of oncologists and intensivists, has also become the responsibility of the emergency physician. As our population ages and medical technology enables increased longevity, it is essential that all medical professionals know how to help patients negotiate the balance between quantity and quality of life. Emergency physicians have the opportunity to educate patients and their loved ones on how to best accomplish their goals of care while also enhancing quality of life through treatment of symptoms. The emergency physician must be aware of the ethical and medico-legal parameters that govern decision making.

Phase angle for prognostication of survival in patients with advanced cancer: preliminary findings

BACKGROUND

Accurate survival prediction is essential for decision-making in cancer therapies and care planning. Objective physiologic measures may improve the accuracy of prognostication. In this prospective study, the authors determined the association of phase angle, handgrip strength, and maximal inspiratory pressure with overall survival in patients with advanced cancer.

METHODS

Hospitalized patients with advanced cancer who were seen by palliative care specialists for consultation were enrolled. Information regarding phase angle, handgrip strength, maximal inspiratory pressure, and known prognostic factors including the Palliative Prognostic Score, Palliative Prognostic Index, serum albumin, and body composition was collected. Univariate and multivariate survival analysis were performed, and the correlation between phase angle and other prognostic variables was examined.

RESULTS

A total of 222 patients were enrolled. The average age of the patients was 55 years (range, 22 years-79 years); 59% of the patients were female, with a mean Karnofsky performance status of 55 and a median overall survival of 106 days (95% confidence interval [95% CI], 71 days-128 days). The median survival for patients with phase angle 2 to 2.9°, 3 to 3.9°, 4 to 4.9°, 5 to 5.9° and ≥ 6° was 35 days, 54 days, 112 days, 134 days, and 220 days, respectively (P = .001). On multivariate analysis, phase angle (hazards ratio [HR], 0.86-per degree increase; 95% CI, 0.74-0.99 increase [P = .04]), Palliative Prognostic Score (HR, 1.07; 95% CI, 1.02-1.13 [P = .008]), serum albumin (HR, 0.67; 95% CI, 0.50-0.91 [P = .009]), and fat-free mass (HR, 0.98; 95% CI, 0.96-0.99 [P = .02]) were found to be significantly associated with survival. Phase angle was found to be only weakly (γ < 0.4) associated with other prognostic variables.

CONCLUSIONS

Phase angle was found to be a novel predictor of poor survival, independent of established prognostic factors, in the advanced cancer setting. This objective and noninvasive tool may be useful for bedside prognostication.

Can oncologists predict survival for patients with progressive disease after standard chemotherapies?

BACKGROUND

Prediction of prognosis is important for patients so that they can make the most of the rest of their lives. Oncologists could predict survival, but the accuracy of such predictions is unclear.

METHODS

In this observational prospective cohort study, 14 oncologists treating 9 major adult solid malignancies were asked to complete questionnaires predicting survival based on performance status, oral intake, and other clinical factors when patients experienced progressive disease after standard chemotherapies. Clinically predicted survival (cps) was calculated by the oncologists from the date of progressive disease to the predicted date of death. Actual survival (as) was compared with cps using Kaplan-Meier survival curves, and factors affecting inaccurate prediction were determined by logistic regression analysis. The prediction of survival time was considered accurate when the cps/as ratio was between 0.67 and 1.33.

RESULTS

The study cohort consisted of 75 patients. Median cps was 120 days (interquartile range: 60-180 days), and median as was 121 days (interquartile range: 40-234 days). The participating oncologists accurately predicted as within a 33% range 36% of the time; the survival time was overestimated 36% of time and underestimated 28% of the time. The factors affecting the accuracy of the survival estimate were the experience of the oncologist, patient age, and information given about the palliative care unit.

CONCLUSIONS

Prediction of cps was accurate for just slightly more than one third of all patients in this study. Additional investigation of putative prognostic factors with a larger sample size is warranted.

Communicating about prognosis: ethical responsibilities of pediatricians and parents

Clinicians are sometimes reluctant to discuss prognosis with parents of children with life-threatening illness, usually because they worry about the emotional impact of this information. However, parents often want this prognostic information because it underpins informed decision-making, especially near the end of life. In addition, despite understandable clinician concerns about its emotional impact, prognostic disclosure can actually support hope and peace of mind among parents struggling to live with a child's illness. Children, too, may need to understand what is ahead to manage uncertainty and make plans for the ways their remaining life will be lived. In this article, we describe the ethical issues involved in disclosure of prognostic information to parents and children with life-threatening illness and offer practical guidance for these conversations.

Predicting cancer prognosis using interactive online tools: a systematic review and implications for cancer care providers

Cancer prognosis is of keen interest for patients with cancer, their caregivers, and providers. Prognostic tools have been developed to guide patient-physician communication and decision-making. Given the proliferation of prognostic tools, it is timely to review existing online cancer prognostic tools and discuss implications for their use in clinical settings. Using a systematic approach, we searched the Internet, Medline, and consulted with experts to identify existing online prognostic tools. Each was reviewed for content and format. Twenty-two prognostic tools addressing 89 different cancers were identified. Tools primarily focused on prostate (n = 11), colorectal (n = 10), breast (n = 8), and melanoma (n = 6), although at least one tool was identified for most malignancies. The input variables for the tools included cancer characteristics (n = 22), patient characteristics (n = 18), and comorbidities (n = 9). Effect of therapy on prognosis was included in 15 tools. The most common predicted outcome was cancer-specific survival/mortality (n = 17). Only a few tools (n = 4) suggested patients as potential target users. A comprehensive repository of online prognostic tools was created to understand the state-of-the-art in prognostic tool availability and characteristics. Use of these tools may support communication and understanding about cancer prognosis. Dissemination, testing, refinement of existing, and development of new tools under different conditions are needed.