Patients' willingness to participate in symptom-related and disease-modifying research: results of a research screening initiative in a palliative care clinic

Dyadic coping mediates the effects of attachment on quality of life among couples facing ovarian cancer

Cancer is an interpersonal stressor affecting both patient and spouse. To examine the pathways that insecure adult attachment can impact health outcomes by way of dyadic processes, this cross-sectional study used the actor-partner interdependence mediation model to examine whether common dyadic coping (CDC) mediated the associations between attachment and quality of life (QOL). Couples (N = 106) facing ovarian cancer were recruited from a comprehensive cancer center and completed self-report questionnaires. Results indicated that worse social and functional QOL were associated with both one's own and one's partner's greater insecure attachment, by way of one's own use of less CDC. Unexpectedly, greater CDC reported by one's partner was associated with one's own lower functional QOL. Although CDC has beneficial effects on QOL, CDC may also be experienced as draining. Effects of adult attachment on dyadic coping are a significant contributor to subjective health outcomes among couples facing ovarian cancer.

Palliative care needs of heart failure patients in China: putting people first

PURPOSE OF REVIEW

Recognizing the rising prevalence of heart failure in China, patients with heart failure have substantial palliative needs. This review highlights recent evidence on the epidemic of heart failure, identifies needs and potential benefit of palliative care in heart failure, and sets future strategic policy and research directions in China.

RECENT FINDINGS

Epidemiological studies demonstrate the prevalence of heart failure among women is higher than men in China and increases substantially with age. However, few studies have addressed the palliative needs of Chinese heart failure patients. The main themes from this review include: Healthcare providers should be culturally sensitive whenever assessing symptoms and needs. Locally validated, brief outcome measures are called for to identify symptoms and needs of Chinese heart failure patients. Palliative care should be better integrated into the management of heart failure through increased training for healthcare providers, policy development, financial support, and cultural acceptance of palliative care.

SUMMARY

Large-scale epidemiological studies are urgently needed to assess the current situation of heart failure in China, alongside interventional studies to drive the development of innovative palliative care services to address the needs of Chinese heart failure patients.

How Accurately Do Consecutive Cohort Audits Predict Phase III Multisite Clinical Trial Recruitment in Palliative Care?

CONTEXT

Audits have been proposed for estimating possible recruitment rates to randomized controlled trials (RCTs), but few studies have compared audit data with subsequent recruitment rates.

OBJECTIVES

To compare the accuracy of estimates of potential recruitment from a retrospective consecutive cohort audit of actual participating sites and recruitment to four Phase III multisite clinical RCTs.

METHODS

The proportion of potentially eligible study participants estimated from an inpatient chart review of people with life-limiting illnesses referred to six Australian specialist palliative care services was compared with recruitment data extracted from study prescreening information from three sites that participated fully in four Palliative Care Clinical Studies Collaborative RCTs. The predominant reasons for ineligibility in the audit and RCTs were analyzed.

RESULTS

The audit overestimated the proportion of people referred to the palliative care services who could participate in the RCTs (pain 17.7% vs. 1.2%, delirium 5.8% vs. 0.6%, anorexia 5.1% vs. 0.8%, and bowel obstruction 2.8% vs. 0.5%). Approximately 2% of the referral base was potentially eligible for these effectiveness studies. Ineligibility for general criteria (language, cognition, and geographic proximity) varied between studies, whereas the reasons for exclusion were similar between the audit and pain and anorexia studies but not for delirium or bowel obstruction.

CONCLUSION

The retrospective consecutive case note audit in participating sites did not predict realistic recruitment rates, mostly underestimating the impact of study-specific inclusion criteria. These findings have implications for the applicability of the results of RCTs. Prospective pilot studies are more likely to predict actual recruitment.

Improving the evidence base in palliative care to inform practice and policy: thinking outside the box

The adoption of evidence-based hierarchies and research methods from other disciplines may not completely translate to complex palliative care settings. The heterogeneity of the palliative care population, complexity of clinical presentations, and fluctuating health states present significant research challenges. The aim of this narrative review was to explore the debate about the use of current evidence-based approaches for conducting research, such as randomized controlled trials and other study designs, in palliative care, and more specifically to (1) describe key myths about palliative care research; (2) highlight substantive challenges of conducting palliative care research, using case illustrations; and (3) propose specific strategies to address some of these challenges. Myths about research in palliative care revolve around evidence hierarchies, sample heterogeneity, random assignment, participant burden, and measurement issues. Challenges arise because of the complex physical, psychological, existential, and spiritual problems faced by patients, families, and service providers. These challenges can be organized according to six general domains: patient, system/organization, context/setting, study design, research team, and ethics. A number of approaches for dealing with challenges in conducting research fall into five separate domains: study design, sampling, conceptual, statistical, and measures and outcomes. Although randomized controlled trials have their place whenever possible, alternative designs may offer more feasible research protocols that can be successfully implemented in palliative care. Therefore, this article highlights "outside the box" approaches that would benefit both clinicians and researchers in the palliative care field. Ultimately, the selection of research designs is dependent on a clearly articulated research question, which drives the research process.

Ethical conduct of palliative care research: enhancing communication between investigators and institutional review boards

Palliative care has faced moral and ethical challenges when conducting research involving human subjects. There are currently no resources to guide institutional review boards (IRBs) in applying standard ethical principles and terms-in a specific way-to palliative care research. Using as a case study a recently completed multisite palliative care clinical trial, this article provides guidance and recommendations for both IRBs and palliative care investigators to facilitate communication and attain the goal of conducting ethical palliative care research and protecting study participants while advancing the science. Beyond identifying current challenges faced by palliative care researchers and IRBs reviewing palliative care research, this article suggests steps that the palliative care research community can take to establish a scientifically sound, stable, productive, and well-functioning relationship between palliative care investigators and the ethical bodies that oversee their work.

Ethical challenges and solutions regarding delirium studies in palliative care

CONTEXT

Delirium occurs commonly in settings of palliative care (PC), in which patient vulnerability in the unique context of end-of-life care and delirium-associated impairment of decision-making capacity may together present many ethical challenges.

OBJECTIVES

Based on deliberations at the Studies to Understand Delirium in Palliative Care Settings (SUNDIPS) meeting and an associated literature review, this article discusses ethical issues central to the conduct of research on delirious PC patients.

METHODS

Together with an analysis of the ethical deliberations at the SUNDIPS meeting, we conducted a narrative literature review by key words searching of relevant databases and a subsequent hand search of initially identified articles. We also reviewed statements of relevance to delirium research in major national and international ethics guidelines.

RESULTS

Key issues identified include the inclusion of PC patients in delirium research, capacity determination, and the mandate to respect patient autonomy and ensure maintenance of patient dignity. Proposed solutions include designing informed consent statements that are clear, concise, and free of complex phraseology; use of concise, yet accurate, capacity assessment instruments with a minimally burdensome schedule; and use of PC friendly consent models, such as facilitated, deferred, experienced, advance, and proxy models.

CONCLUSION

Delirium research in PC patients must meet the common standards for such research in any setting. Certain features unique to PC establish a need for extra diligence in meeting these standards and the employment of assessments, consent procedures, and patient-family interactions that are clearly grounded on the tenets of PC.

Recruitment strategies and rates of a multi-site behavioral intervention for adolescents and young adults with cancer

INTRODUCTION

To provide an overview of factors related to recruitment of adolescents and young adults (AYA) into research and recruitment rates and reasons for refusal from a multicenter study entitled "Stories and Music for Adolescent/Young Adult Resilience during Transplant" (SMART).

METHODS

A randomized clinical trial study design was used. The settings included 9 hospitals. The sample included AYAs (aged 11-24 years) who were undergoing a stem cell transplant. Several instruments were used to measure symptom distress, coping, resilience, and quality of life in AYA with cancer.

RESULTS

A total of 113 AYA were recruited (50%) for this study. Strategies were refined as the study continued to address challenges related to recruitment. We provide a description of recruitment strategies and an evaluation of our planning, implementing, and monitoring of recruitment rates for the SMART study.

DISCUSSION

When designing a study, careful consideration must be given to factors influencing recruitment as well as special considerations for unique populations. Dissemination of strategies specific to unique populations will be helpful to the design of future research studies.

Development and validation of a modified version of the Edmonton Symptom Assessment Scale in a Flemish palliative care population

Palliative cancer patients are faced with multiple symptoms that threaten their quality of life. To manage these symptoms, a reliable and valid way of registration is crucial. In this study, the Edmonton Symptom Assessment Scale (ESAS) has been translated, modified, and tested on content, face, criterion, construct validity, and internal consistency for patients admitted to Flemish palliative care units. These aspects are tested in a descriptive, comparative, longitudinal study based on 3 convenience samples. The first consisted of 8 palliative care experts. The second sample checked the face validity and consisted of 4 patients, 5 family members, and 5 nurses. The last sample involved 23 patients admitted to 3 Flemish palliative care units. Heedful of the "new-wave" vision on validity, the translated and altered ESAS seemed a suitable instrument for the symptom assessment of patients with cancer admitted to a palliative care unit.

Methodological challenges in conducting a multi-site randomized clinical trial of massage therapy in hospice

Researchers conducting multi-site studies of interventions for end-of-life symptom management face significant challenges with respect to obtaining an adequate sample and training and retaining on-site study teams. The purpose of this paper is to describe the strategies and responses to these challenges in a multi-site randomized clinical trial (RCT) of the efficacy of massage therapy for decreasing pain among patients with advanced cancer in palliative care/hospice settings. Over a period of 36 months, we enrolled 380 participants across 15 sites; 27% of whom withdrew prior to study completion (less than the anticipated 30% rate). We saw an average of 68% turnover amongst study staff. Three key qualities characterized successful on-site study teams: (1) organizational commitment; (2) strong leadership from on-site study coordinators; and (3) effective lines of communication between the on-site study coordinators and both their teams and the university-based research team. Issues of recruitment, retention and training should be accounted for in hospice-based research study design and budgeting.

Sampling in population-based cancer caregivers research

BACKGROUND

Awareness that cancer impacts not only the person with the disease but also the family has increased, yet existing data provide limited information, primarily because of reliance on small geographically restricted samples. The current study used population-based sampling to develop a formula to compute the probability of survivors completing a survivor survey and nominating their family caregivers.

METHODS

Eleven SEER/NPCR state cancer registries participated in the American Cancer Society Study of Cancer Survivors survey, providing information about the survivors, including their age, race/ethnicity, gender, type of cancer, and stage of cancer. A total of 19,294 cancer survivors met the inclusion criteria (>/=18 years old and diagnosed with one of the 10 common cancers).

RESULTS

Approximately 30% of survivors identified from state cancer registries completed the survivor survey, of whom 42% nominated a caregiver. Logistic regression analysis revealed that middle-aged, female, or non-black survivors and survivors diagnosed with breast or ovarian cancer were more likely to complete the survey and nominate a caregiver, whereas survivors with bladder or lung cancer and survivors with advanced-stage cancer were less likely to complete the survey and nominate a caregiver.

CONCLUSIONS

Using the formula based on the logistic regression analysis results, a number of certain groups of survivors to be recruited from state registry can be calculated in order to have a present number of caregivers to contact for participation into a caregiver study. This is practical and valuable information, which fosters research that uses state cancer registries and increases the generalizability of findings to multiple types of cancer and different stages of cancer.

Challenges to and lessons learned from conducting palliative care research

In response to a 2005 solicitation from the U.S. National Institutes of Health, 16 investigators received funding to test interventions that would reduce the barriers that prevent cancer patients from receiving adequate and appropriate symptom management therapies. Since the awards have been issued, the investigators have met two times and have identified a number of challenges to implementing their respective studies. A survey was conducted that focused on their experiences with hiring and retaining study personnel, gaining Institutional Review Board approval, incurring unexpected costs, challenges to accruing participants, and a listing of standard measures used in the study. The survey was completed online by the Principal Investigator for each project in late 2006 and the initial results were confirmed one year later by resending the initial survey and by a follow-up telephone call. All but one Principal Investigator completed the survey. Obtaining Institutional Review Board approval, hiring and recruiting research personnel, establishing subcontracts, and accruing research subjects were the primary challenges experienced by the investigators. This palliative care solicitation achieved more than its original intent of stimulating research in overcoming barriers to delivering cancer symptom management, palliative care and end-of-life care. From a survey on the challenges and issues that emerged from their projects, grantees were able to identify specific hurdles and their unique solutions that may help other investigators as they plan their program of research.

"I will do it if it will help others:" motivations among patients taking part in qualitative studies in palliative care

The aim of this study was to explore patients' and carers' preferences and expectations regarding their contribution to research in palliative care through the use of qualitative interviews. Data were collected in the context of two studies exploring the experiences of care of palliative care patients and carers. Both studies recorded the recruitment process, numbers of patients or carers accepting and declining, and the circumstances of interviews. Participants were asked about their motivation to participate in research. The data were analyzed by labeling patients' reflections on their motivations for participating in these studies and identifying themes. Analysis of the recruitment process revealed differential patterns in decline and acceptance of interviews by patients with different conditions and across settings. Among cancer patients, 21/51 declined; the proportion with other conditions that declined was small, and was 0/10 for patients with motor neuron disease. Motivation to participate in the studies was related to (1) altruism, (2) gratitude and concerns about care, (3) the need to have somebody to talk to, and (4) the need for information or access to services. Palliative care patients and carers were capable of deciding whether to participate in interviews and negotiating how they wanted this to happen. This strengthens the argument for patients' autonomy in deciding whether to participate in research. Patients and carers have different motivations for participation, reflecting the heterogeneity of the palliative care population. This suggests a need for ethics committees to reconsider their views and widen their perspectives on the involvement of palliative care patients and carers in research.

A systematic review highlights threats to validity in studies of barriers to cancer trial participation

OBJECTIVE

To investigate the barriers, modifiers, and benefits involved in participating in randomized controlled trials of cancer therapies as perceived by health care providers and patients.

STUDY DESIGN AND SETTING

We conducted a systematic review of the literature to identify published and unpublished studies in any language using electronic databases searched from 1996 to 2004, contact with experts, and reference lists. All study designs were acceptable provided relevant data were reported. Two reviewers were involved in the selection of studies, data extraction, and quality assessment processes. Studies were combined in a narrative synthesis.

RESULTS

Fifty-six studies met the inclusion criteria and represented the perspective of the patient or the health care provider or both. Although a range of barriers to trial participation were identified, a number of threats to the internal and external validity of the included studies limited interpretation of the evidence.

CONCLUSION

The limitations within the evidence base do not permit a clear interpretation of the barriers, moderators, and benefits involved in participation in cancer trials. We recommend that trialists prospectively identify the issues relevant to a particular trial using the current research as a starting point. We report checklists to guide this process.

Ethical issues in research to improve the management of malignant bowel obstruction: challenges and recommendations

Research to improve the care of patients with malignant bowel obstruction (MBO) is urgently needed. In particular, there is an urgent need for high-quality descriptive research, including prospective cohort studies, as well as randomized controlled trials to define optimal management strategies. However, investigators and clinicians face numerous barriers in conducting high-quality research in this patient population. These barriers include lack of funding, difficulties in identifying eligible patients, and a variety of practical and methodological challenges of designing these studies. In addition, there are a variety of ethical challenges that arise in the design and conduct of studies of MBO and particularly in the conduct of clinical trials. In this article, we address four categories of ethical issues: study design, recruitment, informed consent, and Institutional Review Board review. For each, we outline salient issues and suggest recommendations for enhancing the ethics of MBO studies, including interventional trials.

Psychosocial registry for persons with cancer: a method of facilitating quality of life and symptom research

Research focused on the psychosocial aspects of the experience of persons with cancer and their family caregivers is hampered by the methodological challenges inherent in quality of life research. A data registry offers a potential solution to many of these problems in providing a large, comprehensive database, using standardized instruments. We report here our preliminary experience with establishing a Psychosocial Registry designed to advance research in the psychological, social, and spiritual aspects of quality of life of newly diagnosed cancer patients and their family caregivers. The first six months of enrollment demonstrated that the majority of newly diagnosed patients approached for consent (68%) and their primary family caregiver (92%) were willing to participate in the registry; of these, 80% also agreed to be contacted in the future for additional studies. Face-to-face interview was the preferred method of data collection. Our preliminary experience suggests that continuation of the registry with the current modest level of resources would generate a sample of approximately 1000 patients in three years. The long-range goal is to establish a national psychosocial data registry that will enroll patients at diagnosis and follow them through the entire cancer experience, including end of life or survivorship.

Band versus bypass: randomization and patients' choices and perceptions

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are becoming increasingly popular; however, little is understood about patients' motivational factors and reasons for choosing a particular procedure. This investigation explored patient choices and perceptions concerning LRYGB and LAGB.

METHODS

A survey was given to 120 consecutive patients who had undergone LRYGB or LAGB 3-24 months earlier. The survey was designed to ascertain why patients chose banding or bypass, and how they rated their surgical outcome.

RESULTS

A total of 101 patients responded (84%): 22 had undergone LAGB, 79 LRYGB. The top reason for choosing LRYGB was greater expectation of weight loss, whereas LAGB was chosen for its lower risk. Overall, 21% (18/84) of the patients were willing to be involved in a prospective randomized study of bariatric procedure choice. Six of 19 (32%) patients who underwent LAGB, but only 12 of the 65 (18%) who underwent LRYGB stated that they would be willing to accept randomization between the operations.

CONCLUSIONS

Patients expressed varied reasons for choosing their procedure, most related to weight loss or safety profiles. Patients undergoing LAGB would have predicted similar results with either procedure, whereas those undergoing LRYGB showed a trend toward greater overall satisfaction with their operations (p = 0.06) and would have predicted an inferior outcome with the other procedure. Although the overall percentage of patients willing to be randomized is not high, a busy bariatric practice could recruit sufficient numbers of willing patients to undergo a prospective randomized trial of LRYGB and LAGB.

Monitoring child and parent refusals to enrol in clinical research protocols

AIMS

The aim of this paper is to report the rates and reasons for refusal given by 817 eligible participants from 10 completed and ongoing nursing and behavioural medicine studies in paediatric oncology from 1994 to 2004.

BACKGROUND

Eligible participants have the right to accept or decline participation in research studies. Information about rates of refusal and reasons for refusal could be useful in determining participant-perceived burden related to study participation, in accurately estimating the time needed to accrue an adequate number of participants to achieve the study aims, and in interpreting study findings from certain groups of participants.

METHODS

A 13-item survey form about study characteristics was completed prospectively for each study included in this report; categories of reasons for refusal were inductively identified and defined using a semantic content analytic technique.

RESULTS

The overall rate of refusal was 23.6% (range: 6.7-46.7%). The studies that involved blood sampling or end-of-life decision-making had the highest refusal rates and an instrumentation study had the lowest. Eligible male participants had consistently higher rates of refusal than did females across the 10 studies. Nine categories of refusal were inductively identified, with the most commonly reported reason being the burden of the research methods.

CONCLUSION

A careful informed consent process will still result in some refusals. The refusal rates reported here can be used to help future researchers more accurately estimate accrual periods for studies involving blood sampling or investigating sensitive topics in paediatric oncology.

Ethical Considerations in End-of-Life Care and Research

The goal of good palliative care is to relieve suffering and to improve quality of life. However, it is clear that access to palliative care is inconsistent. At least in part, these deficiencies exist because of a lack of solid evidence on which to base clinical decisions. Therefore, there is an urgent need for research that can define the standard of care and can increase access to quality care. This paper discusses six ethical aspects of end-of-life research that investigators and clinicians should consider in designing and conducting palliative care research. These include: (1) whether a study is research or quality improvement; (2) the study's potential benefits to future patients; (3) the study's potential benefits to subjects; (4) the study's risks to subjects; (5) subjects' decision-making capacity; and (6) the voluntariness of subjects' choices to participate in research.

Recruiting for research in hospice: feasibility of a research screening protocol

BACKGROUND

The growth of palliative care research has been limited by challenges of slow recruitment and underenrollment. One potential solution to this problem is the use of screening questions embedded in clinical data collection, which identify patients who are interested in participating in research and who can then be approached directly. The goal of this study was to evaluate the feasibility of this strategy for identifying hospice patients who are interested in research participation.

DESIGN

Cross-sectional survey. SETTING/ SUBJECTS: Patients and their families who had enrolled in one of two community-based hospice programs.

MEASUREMENTS

Three screening questions (for survey-based research, clinical trials and family- focused research) were integrated into the intake process of two community-based hospice organizations.

RESULTS

Of the 214 patients who were able to respond, 54% indicated willingness to be approached about survey-based research, 40% were willing to be approached for clinical trials and 65% were willing to be approached for family-focused research.

CONCLUSIONS

These results suggest that screening questions may be useful in identifying hospice patients who are willing to be recruited for research. Further study is needed to define the likelihood that these patients will consent and whether these screening questions introduce selection bias in the recruitment process.