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Tarbi EC, Blanch-Hartigan D, van Vliet LM, Gramling R, Tulsky JA, Sanders JJ. Toward a basic science of communication in serious illness. PATIENT EDUCATION AND COUNSELING 2022; 105:1963-1969. [PMID: 35410737 DOI: 10.1016/j.pec.2022.03.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/09/2022] [Accepted: 03/24/2022] [Indexed: 06/14/2023]
Abstract
High-quality communication can mitigate suffering during serious illness. Innovations in theory and technology present the opportunity to advance serious illness communication research, moving beyond inquiry that links broad communication constructs to health outcomes toward operationalizing and understanding the impact of discrete communication functions on human experience. Given the high stakes of communication during serious illness, we see a critical need to develop a basic science approach to serious illness communication research. Such an approach seeks to link "what actually happens during a conversation" - the lexical and non-lexical communication content elements, as well as contextual factors - with the emotional and cognitive experiences of patients, caregivers, and clinicians. This paper defines and justifies a basic science approach to serious illness communication research and outlines investigative and methodological opportunities in this area. A systematic understanding of the building blocks of serious illness communication can help identify evidence-informed communication strategies that promote positive patient outcomes, shape more targeted communication skills training for clinicians, and lead to more tailored and meaningful serious illness care.
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Affiliation(s)
- Elise C Tarbi
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Boston, USA.
| | | | | | - Robert Gramling
- University of Vermont. Department of Family Medicine, Burlington, USA.
| | - James A Tulsky
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Boston, USA; Brigham and Women's Hospital, Division of Palliative Medicine, Department of Medicine, Boston, USA.
| | - Justin J Sanders
- McGill University, Division of Palliative Care, Department of Family Medicine, Montreal, Canada.
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2
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Gramling CJ, Durieux BN, Clarfeld LA, Javed A, Matt JE, Manukyan V, Braddish T, Wong A, Wills J, Hirsch L, Straton J, Cheney N, Eppstein MJ, Rizzo DM, Gramling R. Epidemiology of Connectional Silence in specialist serious illness conversations. PATIENT EDUCATION AND COUNSELING 2022; 105:2005-2011. [PMID: 34799186 DOI: 10.1016/j.pec.2021.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 06/13/2023]
Abstract
CONTEXT Human connection can reduce suffering and facilitate meaningful decision-making amid the often terrifying experience of hospitalization for advanced cancer. Some conversational pauses indicate human connection, but we know little about their prevalence, distribution or association with outcomes. PURPOSE To describe the epidemiology of Connectional Silence during serious illness conversations in advanced cancer. METHODS We audio-recorded 226 inpatient palliative care consultations at two academic centers. We identified pauses lasting 2+ seconds and distinguished Connectional Silences from other pauses, sub-categorized as either Invitational (ICS) or Emotional (ECS). We identified treatment decisional status pre-consultation from medical records and post-consultation via clinicians. Patients self-reported quality-of-life before and one day after consultation. RESULTS Among all 6769 two-second silences, we observed 328 (4.8%) ECS and 240 (3.5%) ICS. ECS prevalence was associated with decisions favoring fewer disease-focused treatments (ORadj: 2.12; 95% CI: 1.12, 4.06). Earlier conversational ECS was associated with improved quality-of-life (p = 0.01). ICS prevalence was associated with clinicians' prognosis expectations. CONCLUSIONS Connectional Silences during specialist serious illness conversations are associated with decision-making and improved patient quality-of-life. Further work is necessary to evaluate potential causal relationships. PRACTICE IMPLICATIONS Pauses offer important opportunities to advance the science of human connection in serious illness decision-making.
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Affiliation(s)
| | | | | | - Ali Javed
- Department of Computer Science, University of Vermont, Burlington, VT, USA
| | - Jeremy E Matt
- Complex Systems & Data Science, University of Vermont, Burlington, VT, USA
| | | | - Tess Braddish
- Department of Family Medicine, University of Vermont, Burlington, VT, USA
| | - Ann Wong
- University of Vermont, Burlington, VT, USA
| | | | | | | | - Nicholas Cheney
- Department of Computer Science, University of Vermont, Burlington, VT, USA
| | | | - Donna M Rizzo
- Department of Civil Engineering, University of Vermont, Burlington, VT, USA
| | - Robert Gramling
- Department of Family Medicine, University of Vermont, Burlington, VT, USA.
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3
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Cripe LD, Vater LB, Lilly JA, Larimer A, Hoffmann ML, Frankel RM. Goals of care communication and higher-value care for patients with advanced-stage cancer: A systematic review of the evidence. PATIENT EDUCATION AND COUNSELING 2022; 105:1138-1151. [PMID: 34489147 DOI: 10.1016/j.pec.2021.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/23/2021] [Accepted: 08/20/2021] [Indexed: 06/13/2023]
Abstract
CONTEXT Goals-of-care communication (GOCC) is recommended to increase the value of cancer care near the end of life (EOL). OBJECTIVES Conduct a systematic review of the evidence that GOCC is associated with higher-value care. METHODS We searched PubMed, Scopus, Ovid MEDLINE, EMBASE, EMB Reviews, CINAHL, and PsycInfo from inception to July 2019. We analyzed the population,design, and results and the authors' definitions of GOCC. Risk of bias was assessed. RESULTS Thirty-two articles were selected. Ten articles reported results from 8 interventions; 17 characterized participants' perspectives; and 5 were retrospective The topics, behaviors, timing, and anticipated outcomes of GOCC varied significantly and were indistinguishable from practices such as advance care planning. GOCC typically focused on treatment outcomes rather than patients' goals. Four of 5 interventions increased evidence of GOCC after clinician training. Only one reported improved patient outcomes. CONCLUSION No consensus exists about what GOCC entails. There is limited evidence that GOCC increases the value of EOL care. PRACTICE IMPLICATIONS Future studies should focus on how to engage patients in conversations about their personal goals and integrate their goals into care planning. Clinicians can encourage GOCC by explaining how patients' goals influence decisions especially as treatment options become limited.
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Affiliation(s)
- Larry D Cripe
- Indiana University School of Medicine, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Simon Cancer Center, 473 Barnhill Drive, Indianapolis, IN 46202, USA.
| | - Laura B Vater
- Indiana University School of Medicine, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Simon Cancer Center, 473 Barnhill Drive, Indianapolis, IN 46202, USA.
| | - Jason A Lilly
- Indiana University Health, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Medical Library, 473 Barnhill Drive, Indianapolis, IN 46202, USA.
| | - Angeline Larimer
- Indiana University Purdue University at Indianapolis (IUPUI), 473 Barnhill Drive, Indianapolis, IN 46202, USA.
| | - Mary Lynn Hoffmann
- Indiana University School of Medicine, 473 Barnhill Drive, Indianapolis, IN 46202, USA.
| | - Richard M Frankel
- Indiana University School of Medicine, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Simon Cancer Center, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Regenstrief Institute, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Purdue University at Indianapolis (IUPUI), 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Health, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Medical Library, 473 Barnhill Drive, Indianapolis, IN 46202, USA.
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4
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Juhrmann ML, Vandersman P, Butow PN, Clayton JM. Paramedics delivering palliative and end-of-life care in community-based settings: A systematic integrative review with thematic synthesis. Palliat Med 2022; 36:405-421. [PMID: 34852696 PMCID: PMC8972966 DOI: 10.1177/02692163211059342] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a growing demand for community palliative care and home-based deaths worldwide. However, gaps remain in this service provision, particularly after-hours. Paramedicine may help to bridge that gap and avoid unwanted hospital admissions, but a systematic overview of paramedics' potential role in palliative and end-of-life care is lacking. AIM To review and synthesise the empirical evidence regarding paramedics delivering palliative and end-of-life care in community-based settings. DESIGN A systematic integrative review with a thematic synthesis was undertaken in accordance with Whittemore and Knafl's methodology. Prospero: CRD4202119851. DATA SOURCES MEDLINE, CINAHL, PsycINFO and Scopus databases were searched in August 2020 for primary research articles published in English, with no date limits applied. Articles were screened and reviewed independently by two researchers, and quality appraisal was conducted following the Mixed-Methods Appraisal Tool (2018). RESULTS The search retrieved 5985 articles; 23 articles satisfied eligibility criteria, consisting of mixed-methods (n = 5), qualitative (n = 7), quantitative descriptive (n = 8) and quantitative non-randomised studies (n = 3). Through data analysis, three key themes were identified: (1) Broadening the traditional role, (2) Understanding patient wishes and (3) Supporting families. CONCLUSIONS Paramedics are a highly skilled workforce capable of helping to deliver palliative and end-of-life care to people in their homes and reducing avoidable hospital admissions, particularly for palliative emergencies. Future research should focus on investigating the efficacy of palliative care clinical practice guideline implementation for paramedics, understanding other healthcare professionals' perspectives, and undertaking health economic evaluations of targeted interventions.
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Affiliation(s)
- Madeleine L Juhrmann
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,HammondCare Centre for Learning and Research in Palliative Care, Greenwich Hospital, Greenwich, NSW, Australia
| | - Priyanka Vandersman
- Research Centre for Palliative Care, Death and Dying, Flinders University of South Australia, Adelaide, SA, Australia
| | - Phyllis N Butow
- Psycho-oncology Co-operative Research Group and Centre for Medical Psychology and Evidence-based Decision-making, University of Sydney, Sydney, NSW, Australia
| | - Josephine M Clayton
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,HammondCare Centre for Learning and Research in Palliative Care, Greenwich Hospital, Greenwich, NSW, Australia
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Ekberg S, Parry R, Land V, Ekberg K, Pino M, Antaki C, Jenkins L, Whittaker B. Communicating with patients and families about illness progression and end of life: a review of studies using direct observation of clinical practice. BMC Palliat Care 2021; 20:186. [PMID: 34876096 PMCID: PMC8651503 DOI: 10.1186/s12904-021-00876-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is growing recognition that a diverse range of healthcare professionals need competence in palliative approaches to care. Effective communication is a core component of such practice. This article informs evidence-based communication about illness progression and end of life through a rapid review of studies that directly observe how experienced clinicians manage such discussions. METHODS The current rapid review updates findings of a 2014 systematic review, focussing more specifically on evidence related to illness progression and end-of-life conversations. Literature searches were conducted in nine bibliographic databases. Studies using conversation analysis or discourse analysis to examine recordings of actual conversations about illness progression or end of life were eligible for inclusion in the review. An aggregative approach was used to synthesise the findings of included studies. RESULTS Following screening, 26 sources were deemed to meet eligibility criteria. Synthesis of study findings identified the structure and functioning of ten communication practices used in discussions about illness progression and end-of-life. CONCLUSION The ten practices identified underpin five evidence-based recommendations for communicating with patients or family members about illness progression and end of life.
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Affiliation(s)
- Stuart Ekberg
- School of Psychology & Counselling, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Queensland, 4059, Australia.,Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ruth Parry
- School of Social Sciences and Humanities, Loughborough University, Brockington Building, Epinal Way, Margaret Keay Road, Loughborough, LE11 3TU, UK.
| | - Victoria Land
- School of Social Sciences and Humanities, Loughborough University, Brockington Building, Epinal Way, Margaret Keay Road, Loughborough, LE11 3TU, UK
| | - Katie Ekberg
- School of Early Childhood & Inclusive Education, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Queensland, 4059, Australia.,School of Health & Rehabilitation Sciences, University of Queensland, St Lucia, Queensland, 4072, Australia
| | - Marco Pino
- School of Social Sciences and Humanities, Loughborough University, Brockington Building, Epinal Way, Margaret Keay Road, Loughborough, LE11 3TU, UK
| | - Charles Antaki
- School of Social Sciences and Humanities, Loughborough University, Brockington Building, Epinal Way, Margaret Keay Road, Loughborough, LE11 3TU, UK
| | - Laura Jenkins
- School of Social Sciences and Humanities, Loughborough University, Brockington Building, Epinal Way, Margaret Keay Road, Loughborough, LE11 3TU, UK
| | - Becky Whittaker
- School of Social Sciences and Humanities, Loughborough University, Brockington Building, Epinal Way, Margaret Keay Road, Loughborough, LE11 3TU, UK
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Tarbi EC, Gramling R, Bradway C, Broden EG, Meghani SH. "I Had a Lot More Planned": The Existential Dimensions of Prognosis Communication with Adults with Advanced Cancer. J Palliat Med 2021; 24:1443-1454. [PMID: 33534644 DOI: 10.1089/jpm.2020.0696] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Communication about prognosis is a key ingredient of effective palliative care. When patients with advanced cancer develop increased prognostic understanding, there is potential for existential distress to occur. However, the existential dimensions of prognosis communication are underexplored. Objective: To describe the existential dimensions of prognosis communication in naturally-occurring palliative care conversations. Methods: This study was an explanatory sequential mixed methods design. We analyzed a random subset of patients from the Palliative Care Communication Research Initiative (PCCRI) parent study (n = 34, contributing to 45 palliative care conversations). Data were based on audio-recorded and transcribed inpatient palliative care conversations between adults with advanced cancer, their families, and palliative care clinicians. We stratified the study sample by levels of prognosis communication, and qualitatively examined patterns of existential communication, comparing the intensity, frequency, and content, within and across levels. Results: Existential communication was more common, and of stronger intensity, within conversations with higher levels of prognosis communication. Conversations with more prognosis communication appeared to exhibit a shift toward the existential and away from the more physical nature of the serious illness experience. Conclusion: Existential and prognosis communication are intimately linked within palliative care conversations. Results highlight the multiplicity and mutuality of concerns that arise when contemplating mortality, drawing attention to areas of palliative care communication that warrant future research.
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Affiliation(s)
- Elise C Tarbi
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Robert Gramling
- Department of Family Medicine, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Christine Bradway
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Elizabeth G Broden
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Salimah H Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Ross L, Danforth CM, Eppstein MJ, Clarfeld LA, Durieux BN, Gramling CJ, Hirsch L, Rizzo DM, Gramling R. Story Arcs in Serious Illness: Natural Language Processing features of Palliative Care Conversations. PATIENT EDUCATION AND COUNSELING 2020; 103:826-832. [PMID: 31831305 DOI: 10.1016/j.pec.2019.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/17/2019] [Accepted: 11/19/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Serious illness conversations are complex clinical narratives that remain poorly understood. Natural Language Processing (NLP) offers new approaches for identifying hidden patterns within the lexicon of stories that may reveal insights about the taxonomy of serious illness conversations. METHODS We analyzed verbatim transcripts from 354 consultations involving 231 patients and 45 palliative care clinicians from the Palliative Care Communication Research Initiative. We stratified each conversation into deciles of "narrative time" based on word counts. We used standard NLP analyses to examine the frequency and distribution of words and phrases indicating temporal reference, illness terminology, sentiment and modal verbs (indicating possibility/desirability). RESULTS Temporal references shifted steadily from talking about the past to talking about the future over deciles of narrative time. Conversations progressed incrementally from "sadder" to "happier" lexicon; reduction in illness terminology accounted substantially for this pattern. We observed the following sequence in peak frequency over narrative time: symptom terms, treatment terms, prognosis terms and modal verbs indicating possibility. CONCLUSIONS NLP methods can identify narrative arcs in serious illness conversations. PRACTICE IMPLICATIONS Fully automating NLP methods will allow for efficient, large scale and real time measurement of serious illness conversations for research, education and system re-design.
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Affiliation(s)
| | | | | | | | | | | | | | - Donna M Rizzo
- Department of Civil Engineering, University of Vermont, Burlington, VT, USA
| | - Robert Gramling
- Department of Family Medicine, University of Vermont, Burlington, VT, USA.
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8
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Mapes MV, DePergola PA, McGee WT. Patient-Centered Care and Autonomy: Shared Decision-Making in Practice and a Suggestion for Practical Application in the Critically Ill. J Intensive Care Med 2019; 35:1352-1355. [PMID: 31451000 DOI: 10.1177/0885066619870458] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Decision-making for the hospitalized dying and critically ill is often characterized by an understanding of autonomy that leads to clinical care and outcomes that are antithetical to patients' preferences around suffering and quality of life. A better understanding of autonomy will facilitate the ultimate goal of a patient-centered approach and ensure compassionate, high-quality care that respects our patients' values. We reviewed the medical literature and our experiences through the ethics service, palliative care service, and critical care service of a large community teaching hospital. The cumulative experience of a senior intensivist was filtered through the lens of a medical ethicist and the palliative care team. The practical application of patient-centered care was discerned from these interactions. We determined that a clearer understanding of patient-centeredness would improve the experience and outcomes of care for our patients as well as our adherence to ethical practice. The practical applications of autonomy and patient-centered care were evaluated by the authors through clinical interactions on the wards to ascertain problems in understanding their meaning. Clarification of autonomy and patient-centeredness is provided using specific examples to enhance understanding and application of these principles in patient-centered care.
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Affiliation(s)
- Marianna V Mapes
- 6637Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Clinical Ethics, Baystate Health, Springfield, MA, USA
| | - Peter A DePergola
- Department of Clinical Ethics, Baystate Health, Springfield, MA, USA
| | - William T McGee
- Critical Care Division, 21645Baystate Medical Center, Springfield, MA, USA
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Ingersoll LT, Alexander SC, Priest J, Ladwig S, Anderson W, Fiscella K, Epstein RM, Norton SA, Gramling R. Racial/ethnic differences in prognosis communication during initial inpatient palliative care consultations among people with advanced cancer. PATIENT EDUCATION AND COUNSELING 2019; 102:1098-1103. [PMID: 30642715 DOI: 10.1016/j.pec.2019.01.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/12/2018] [Accepted: 01/02/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE We examined whether conversations involving Black or Latino patients with advanced cancer differ in the presence or characteristics of prognosis communication. METHODS We audio-recorded initial consultations between 54 palliative care clinicians and 231 hospitalized people with advanced cancer. We coded for the presence and characteristics of prognosis communication. We examined whether the presence or characteristics of prognosis communication differed by patients' self-reported race/ethnicity. RESULTS In 231 consultations, 75.7% contained prognosis communication. Prognosis communication was less than half as likely to occur during conversations with Black or Latino patients (N = 48) compared to others. Among consultations in which prognosis was addressed, those involving Black or Latino patients were more than 8 times less likely to contain optimistically cued prognoses compared to others. CONCLUSION Prognosis communication occurred less frequently for Black and Latino patients and included fewer optimistic cues than conversations with other patients. More work is needed to better understand these observed patterns of prognosis communication that vary by race and ethnicity. PRACTICE IMPLICATIONS Growing evidence supports prognosis communication being important for end-of-life decision-making and disproportionately rare among non-White populations. Therefore, our findings identify a potentially salient target for clinical interventions that are focused on ameliorating disparities in end-of-life care.
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Affiliation(s)
- Luke T Ingersoll
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America.
| | - Stewart C Alexander
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Jeff Priest
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Susan Ladwig
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Wendy Anderson
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Kevin Fiscella
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Ronald M Epstein
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Sally A Norton
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Robert Gramling
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
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10
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Scheunemann LP, Ernecoff NC, Buddadhumaruk P, Carson SS, Hough CL, Curtis JR, Anderson WG, Steingrub J, Lo B, Matthay M, Arnold RM, White DB. Clinician-Family Communication About Patients' Values and Preferences in Intensive Care Units. JAMA Intern Med 2019; 179:676-684. [PMID: 30933293 PMCID: PMC6503570 DOI: 10.1001/jamainternmed.2019.0027] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Little is known about whether clinicians and surrogate decision makers follow recommended strategies for shared decision making by incorporating intensive care unit (ICU) patients' values and preferences into treatment decisions. OBJECTIVES To determine how often clinicians and surrogates exchange information about patients' previously expressed values and preferences and deliberate and plan treatment based on these factors during conferences about prognosis and goals of care for incapacitated ICU patients. DESIGN, SETTING, AND PARTICIPANTS A secondary analysis of a prospective, multicenter cohort study of audiorecorded clinician-family conferences between surrogates and clinicians of 249 incapacitated, critically ill adults was conducted. The study was performed between October 8, 2009, and October 23, 2012. Data analysis was performed between July 2, 2014, and April 20, 2015. Patient eligibility criteria included lack of decision-making capacity, a diagnosis of acute respiratory distress syndrome, and predicted in-hospital mortality of 50% or more. In addition to the patients, 451 surrogates and 144 clinicians at 13 ICUs at 6 US academic and community medical centers were included. MAIN OUTCOMES AND MEASURES Two coders analyzed transcripts of audiorecorded conversations for statements in which clinicians and surrogates exchanged information about patients' treatment preferences and health-related values and applied them in deliberation and treatment planning. RESULTS Of the 249 patients, 134 (54.9%) were men; mean (SD) age was 58.2 (16.5) years. Among the 244 conferences that addressed a decision about goals of care, 63 (25.8%; 95% CI, 20.3%-31.3%) contained no information exchange or deliberation about patients' values and preferences. Clinicians and surrogates exchanged information about patients' values and preferences in 167 (68.4%) (95% CI, 62.6%-74.3%) of the conferences and specifically deliberated about how the patients' values applied to the decision in 108 (44.3%; 95% CI, 38.0%-50.5%). Important end-of-life considerations, such as physical, cognitive, and social functioning or spirituality were each discussed in 87 (35.7%) or less of the conferences; surrogates provided a substituted judgment in 33 (13.5%); and clinicians made treatment recommendations based on patients' values and preferences in 20 conferences (8.2%). CONCLUSIONS AND RELEVANCE Most clinician-family conferences about prognosis and goals of care for critically ill patients appear to lack important elements of communication about values and preferences, with robust deliberation being particularly deficient. Interventions may be needed to better prepare surrogates for these conversations and improve clinicians' communication skills for eliciting and incorporating patients' values and preferences into treatment decisions.
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Affiliation(s)
- Leslie P Scheunemann
- Division of Geriatric Medicine and Gerontology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Natalie C Ernecoff
- Department of Health Policy and Management, University of North Carolina at Chapel Hill
| | - Praewpannarai Buddadhumaruk
- Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shannon S Carson
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill
| | - Catherine L Hough
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Wendy G Anderson
- Palliative Care Program, University of California, San Francisco Medical Center, San Francisco.,Division of Hospital Medicine, University of California, San Francisco School of Medicine, San Francisco.,Department of Physiological Nursing, University of California, San Francisco School of Nursing, San Francisco
| | - Jay Steingrub
- Division of Pulmonary and Critical Care Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Bernard Lo
- The Greenwall Foundation, New York, New York
| | - Michael Matthay
- Departments of Medicine and Anesthesia and Perioperative Care, University of California, San Francisco
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania.,Palliative and Supportive Institute, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania
| | - Douglas B White
- Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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11
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Common Neurologic Problems: Impact on Patient Welfare, Caregiver Burden and Veterinarian Wellbeing. Vet Clin North Am Small Anim Pract 2019; 49:463-476. [PMID: 30846382 DOI: 10.1016/j.cvsm.2019.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Most neurologic diseases are incurable. Palliative care is vital in the treatment of companion animals with serious or chronic neurologic disease. A Neuropalliative Care Core Skill Set includes multifaceted communication competencies and symptom management. Because some of the most common clinical signs of neurologic disease are also associated with stress of caregiving, veterinarians should understand their clients' unique potential for caregiver burden. Acknowledging caregiver burden in their clients, means that veterinarians treating patients with neurologic disease must be proactive in building their own resilience to the occupational stress inherent in treating their patients and supporting their patients' caregivers.
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12
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Gramling R, Gajary-Coots E, Cimino J, Fiscella K, Epstein R, Ladwig S, Anderson W, Alexander SC, Han PK, Gramling D, Norton SA. Palliative Care Clinician Overestimation of Survival in Advanced Cancer: Disparities and Association With End-of-Life Care. J Pain Symptom Manage 2019; 57:233-240. [PMID: 30391655 DOI: 10.1016/j.jpainsymman.2018.10.510] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/24/2018] [Accepted: 10/25/2018] [Indexed: 10/27/2022]
Abstract
CONTEXT Clinicians frequently overestimate survival time in serious illness. OBJECTIVE The objective of this study was to understand the frequency of overestimation in palliative care (PC) and the relation with end-of-life (EOL) treatment. METHODS This is a multisite cohort study of 230 hospitalized patients with advanced cancer who consulted with PC between 2013 and 2016. We asked the consulting PC clinician to make their "best guess" about the patients' "most likely survival time, assuming that their illnesses are allowed to take their natural course" (<24 hours; 24 hours to less than two weeks; two weeks to less than three months; three months to less than six months; six months or longer). We followed patients for up to six month for mortality and EOL treatment utilization. Patients completed a brief interviewer-facilitated questionnaire at study enrollment. RESULTS Median survival was 37 days (interquartile range: 12 days, 97 days) and 186/230 (81%) died during the follow-up period. Forty-one percent of clinicians' predictions were accurate. Among inaccurate prognoses, 85% were overestimates. Among those who died, overestimates were substantially associated with less hospice use (ORadj: 0.40; 95% CI: 0.16-0.99) and later hospice enrollment (within 72 hours of death ORadj: 0.33; 95% CI: 0.15-0.74). PC clinicians were substantially more likely to overestimate survival for patients who identified as Black or Latino compared to others (ORadj: 3.89; 95% CI: 1.64-9.22). EOL treatment preferences did not explain either of these findings. CONCLUSION Overestimation is common in PC, associated with lower hospice use and a potentially mutable source of racial/ethnic disparity in EOL care.
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Pino M, Parry R. How and when do patients request life-expectancy estimates? Evidence from hospice medical consultations and insights for practice. PATIENT EDUCATION AND COUNSELING 2019; 102:223-237. [PMID: 29685640 DOI: 10.1016/j.pec.2018.03.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 03/02/2018] [Accepted: 03/28/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To break new ground by directly examining how patients seek life-expectancy estimates, and how doctors support them in doing so. METHODS Conversation analytic examination of 10 recorded UK hospice consultations involving 3 palliative specialists. RESULTS Life-expectancy estimate episodes frequently begin after a doctor has given a patient an opportunity to shape the consultation agenda. Rather than posing direct questions, patients cautiously display their interest in receiving an estimate using statements. These often contain preparatory information about: what they already know about their prognosis, their perspective on it, and readiness to hear more. When patients do not provide this information, doctors invite it before giving an estimate. Patients' companions also contribute to this preparatory work. CONCLUSION Doctors, patients, and companions collaboratively work to prepare a conversational environment wherein emotional states and uncertainties have been addressed prior to delivery of the actual estimate. This helps manage both possible emotional distress, and prognostic uncertainty entailed in seeking and delivering estimates. PRACTICE IMPLICATIONS Clinicians should be mindful that rather than overtly requesting estimates, patients may seek them more cautiously. Before delivering estimates, doctors can support patients to articulate their existing understanding and perspective regarding prognosis, and their readiness to hear more.
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Affiliation(s)
- Marco Pino
- Department of Social Sciences, Loughborough University, Brockington Building, Margaret Keay Rd, Loughborough, Leicestershire, LE11 3TU, UK.
| | - Ruth Parry
- Department of Social Sciences, Loughborough University, Brockington Building, Margaret Keay Rd, Loughborough, Leicestershire, LE11 3TU, UK.
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Gramling R, Ingersoll LT, Anderson W, Priest J, Berns S, Cheung K, Norton SA, Alexander SC. End-of-Life Preferences, Length-of-Life Conversations, and Hospice Enrollment in Palliative Care: A Direct Observation Cohort Study among People with Advanced Cancer. J Palliat Med 2018; 22:152-156. [PMID: 30526222 DOI: 10.1089/jpm.2018.0476] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
CONTEXT Prognosis communication is one hypothesized mechanism by which effective palliative care (PC) promotes preference-concordant treatment near end of life (EOL), but little is known about this relationship. METHODS This is a multisite cohort study of 231 hospitalized patients with advanced cancer who consulted with PC. We audio-recorded the initial consultation with the PC team and coded conversations for all statements regarding expectations for how long the patient will live. We refer to these statements as length-of-life talk. We followed patients for up to six months to determine EOL treatment utilization, including hospice enrollment. Patients completed a brief interviewer-facilitated questionnaire at study enrollment. RESULTS Forty-four percent (101/231) of observed conversations contained at least one statement about expectations for length of life, and 60% of patients (139/231) enrolled in hospice during the six months following these conversations. The association between length-of-life talk and hospice enrollment was strong among those (155/231) who endorsed treatment preferences favoring comfort over longevity in the last weeks to months of life (odds ratio [OR]adj = 2.98; 95% confidence interval [CI] = 1.34-6.65) and weak/absent among others (69/231; ORadj = 0.70; 95% CI = 0.16-3.04). CONCLUSIONS Talking about expectations for remaining length of life during PC consultations is associated with six-month hospice enrollment among people with advanced cancer who endorse preferences for EOL treatment that favor comfort over longevity.
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Affiliation(s)
- Robert Gramling
- 1 Department of Family Medicine, Division of Palliative Medicine, University of Vermont Medical Center, Burlington, Vermont
| | - Luke T Ingersoll
- 2 Department of Consumer Science, Purdue University, West Lafayette, Indiana
| | - Wendy Anderson
- 3 Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Jeff Priest
- 4 Medical Biostatistics Unit, University of Vermont, Burlington, Vermont
| | - Stephen Berns
- 5 Department of Family Medicine, University of Vermont, Burlington, Vermont
| | - Katharine Cheung
- 6 Department of Medicine, University of Vermont, Burlington, Vermont
| | - Sally A Norton
- 7 School of Nursing, University of Rochester, Rochester, New York
| | - Stewart C Alexander
- 2 Department of Consumer Science, Purdue University, West Lafayette, Indiana
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Ingersoll LT, Saeed F, Ladwig S, Norton SA, Anderson W, Alexander SC, Gramling R. Feeling Heard and Understood in the Hospital Environment: Benchmarking Communication Quality Among Patients With Advanced Cancer Before and After Palliative Care Consultation. J Pain Symptom Manage 2018; 56:239-244. [PMID: 29729348 DOI: 10.1016/j.jpainsymman.2018.04.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/23/2018] [Accepted: 04/24/2018] [Indexed: 12/25/2022]
Abstract
CONTEXT Maximizing value in palliative care requires continued development and standardization of communication quality indicators. OBJECTIVES To describe the basic epidemiology of a newly adopted patient-centered communication quality indicator for hospitalized palliative care patients with advanced cancer. METHODS Cross-sectional analysis of 207 advanced cancer patients who received palliative care consultation at two medical centers in the U.S. Participants completed the Heard & Understood quality indicator immediately before and the day after the initial palliative care consultation: Over the past two days ["24 hours" for the post-consultation version], how much have you felt heard and understood by the doctors, nurses, and hospital staff?-completely/quite a bit/moderately/slightly/not at all. We categorized completely as indicating ideal quality. RESULTS Approximately one-third indicated ideal Heard & Understood quality before palliative care consultation. Age, financial security, emotional distress, preferences for comfort-longevity tradeoffs at the end of life, and prognosis expectations were associated with preconsultation quality. Among those with less-than-ideal quality at baseline, 56% rated feeling more Heard & Understood the day after palliative care consultation. The greatest prepost improvement was among people who had unformed end-of-life treatment preferences or who reported having no idea about their prognosis at baseline. CONCLUSION Most patients felt incompletely heard and understood at the time of referral to palliative care consultation, and more than half of the patients improved after consultation. Feeling heard and understood is an important quality indicator sensitive to interventions to improve care and key variations in the patient experience.
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Affiliation(s)
- Luke T Ingersoll
- Department of Consumer Science, Purdue University, West Lafayette, Indiana.
| | - Fahad Saeed
- Division of Nephrology, Department of Medicine, University of Rochester, Rochester, New York
| | - Susan Ladwig
- Public Health Sciences, University of Rochester, Rochester, New York, USA
| | - Sally A Norton
- Department of Medicine, University of Rochester, Rochester, New York
| | - Wendy Anderson
- Department of Medicine, University of California San Francisco, San Francisco, California
| | | | - Robert Gramling
- Division of Palliative Medicine, Department of Family Medicine, University of Vermont, Burlington, Vermont
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Gramling R, Stanek S, Han PK, Duberstein P, Quill TE, Temel JS, Alexander SC, Anderson WG, Ladwig S, Norton SA. Distress Due to Prognostic Uncertainty in Palliative Care: Frequency, Distribution, and Outcomes among Hospitalized Patients with Advanced Cancer. J Palliat Med 2018; 21:315-321. [DOI: 10.1089/jpm.2017.0285] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Robert Gramling
- Division of Palliative Medicine, Department of Family Medicine, University of Vermont Medical Center, Burlington, Vermont
| | - Susan Stanek
- School of Nursing, University of Rochester, Rochester, New York
| | - Paul K.J. Han
- Maine Medical Center Research Institute, Scarborough, Maine
| | - Paul Duberstein
- Department of Psychiatry, University of Rochester, Rochester, New York
| | - Tim E. Quill
- School of Nursing, University of Rochester, Rochester, New York
| | - Jennifer S. Temel
- Department of Medicine, Harvard University, Cambridge, Massachusetts
| | - Stewart C. Alexander
- Department of Consumer Science, Department of Medicine, Purdue University, West Lafayette, Indiana
| | | | - Susan Ladwig
- Division of Palliative Care, University of Rochester, Rochester, New York
| | - Sally A. Norton
- School of Nursing, University of Rochester, Rochester, New York
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Carrasco JM, García M, Navas A, Olza I, Gómez-Baceiredo B, Pujol F, Garralda E, Centeno C. What does the media say about palliative care? A descriptive study of news coverage in written media in Spain. PLoS One 2017; 12:e0184806. [PMID: 28968433 PMCID: PMC5624582 DOI: 10.1371/journal.pone.0184806] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 08/31/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The goal of palliative care (PC) is to improve the quality of life of terminal stage patients and their families. The subject frequently appears in the mass-media and this helps create a socially accepted identity. The aim of this study is to describe and analyse PC related news items appeared in the Spanish written media. METHODOLOGY A descriptive cross-sectional study was designed. Considering diffusion, scope and the range in editorial policy criteria, four printed newspapers (PN) were selected, together with four exclusively digital media sources (DM). Through Mynews, a newspaper content depository, and the search tool for each DM website, articles published between 2009 and 2014 which included the terms "palliative care" and "palliative medicine" were sought. A questionnaire was created to characterise each article identified and a descriptive analysis was undertaken. RESULTS A total of 627 articles were identified, of which 359 (57%) were published in PN (42% in the printed editions -PE- 16% in their online editions -OE-) and 268 (43%) in DM. In general, they appeared mainly in sections concerning Health (23%), Culture and Society (18%) and General/Home News (15%). In PE, just 2% were found in the Health section and nearly 70% in Culture and Society and General/Home News. Most of the articles were informative in nature and contained socio-political messages (90%). Statements by PC professionals were found in 35% of the articles and by politicians in 32%. The most frequent content was related to facing end of life (74%) and patient quality of life (70%). CONCLUSIONS The Spanish written media reflects the socio-political interest aroused by PC. Nevertheless, messages circulating about PC do not describe professional practice, or the contribution of the same for patients. Content more in line with the clinical practice might help contribute to the development of this new area of medicine.
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Affiliation(s)
- José Miguel Carrasco
- ATLANTES Research Program, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | | | - Alejandro Navas
- Public Communication Department, School of Communication, University of Navarra, Pamplona, Spain
| | - Inés Olza
- GRADUN, Institute for Culture and Society, University of Navarra, Pamplona, Spain
| | - Beatriz Gómez-Baceiredo
- Journalism Projects Department, School of Communication, University of Navarra, Pamplona, Spain
| | - Francesc Pujol
- Department of Economics, School of Economics and Business Administration, University of Navarra, Pamplona, Spain
| | - Eduardo Garralda
- ATLANTES Research Program, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Carlos Centeno
- ATLANTES Research Program, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
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Smith TA, Disler RT, Jenkins CR, Ingham JM, Davidson PM. Perspectives on advance care planning among patients recently requiring non-invasive ventilation for acute respiratory failure: A qualitative study using thematic analysis. Palliat Med 2017; 31:566-574. [PMID: 28440124 DOI: 10.1177/0269216316670286] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Patients requiring non-invasive ventilation for acute-on-chronic respiratory failure due to chronic obstructive pulmonary disease or heart failure exacerbations may have a poor prognosis underscoring the importance of advance care planning. AIM We aimed to describe attitudes to, and experiences of, discussing the future among patients recently treated with non-invasive ventilation. DESIGN Qualitative research using thematic analysis. SETTINGS AND PARTICIPANTS Tertiary teaching hospital. Patients with acute hypercapnic respiratory failure requiring non-invasive ventilation. RESULTS Individuals recently treated with non-invasive ventilation describe feeling the future is beyond their control and instead controlled by their illness. Participants often recognised their poor prognosis but avoided discussing some difficult topics. The majority preferred not to undergo cardiopulmonary resuscitation but most had not discussed this with healthcare professionals. When participants voiced concerns about their future health to family members, they were met with polarised responses. Some encountered willingness for further discussion, while others met deflection, deterring further conversation. An overarching narrative of 'Looking through my illness to an uncertain but concerning future' unites these themes. CONCLUSION This study suggests opportunities and barriers for advance care planning in individuals with chronic disease. Patients' understanding of their prognosis and their attitudes to cardiopulmonary resuscitation suggests an opportunity for advance care planning. Structuring discussions around patients' preferences for care during future exacerbations may foster a sense of control over the future despite illness. The diversity of familial responses to patients' concerns about their future health has implications for advance care planning. These findings have the potential to improve care for patients with respiratory failure and suggest an important ongoing research agenda.
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Affiliation(s)
- Tracy A Smith
- 1 St Vincent's Clinical School, Faculty of Medicine, UNSW Australia, Sydney, NSW, Australia.,2 Department of Respiratory & Sleep Medicine, Westmead Hospital, Wentworthville, NSW, Australia
| | - Rebecca T Disler
- 3 Sydney Nursing School, University of Sydney, Sydney, NSW, Australia.,4 ImPaCCT (Improving Palliative Care through Clinical Trials) NSW Palliative Care Collaborative Clinical Trials Group, Liverpool, NSW, Australia
| | - Christine R Jenkins
- 5 Faculty of Medicine, The University of Sydney, Sydney, NSW, Australia.,6 The George Institute, Sydney, NSW, Australia
| | - Jane M Ingham
- 1 St Vincent's Clinical School, Faculty of Medicine, UNSW Australia, Sydney, NSW, Australia.,7 St Vincent's Health Network, Sydney, NSW, Australia
| | - Patricia M Davidson
- 3 Sydney Nursing School, University of Sydney, Sydney, NSW, Australia.,8 Department of Acute and Chronic Care, Johns Hopkins University, Baltimore, MD, USA
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McIlfatrick S, Connolly M, Collins R, Murphy T, Johnston B, Larkin P. Evaluating a dignity care intervention for palliative care in the community setting: community nurses’ perspectives. J Clin Nurs 2017; 26:4300-4312. [DOI: 10.1111/jocn.13757] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Sonja McIlfatrick
- Institute of Nursing and Health Research; Ulster University; Newtownabbey UK
- All Ireland Institute of Hospice and Palliative Care; Dublin Ireland
| | - Michael Connolly
- School of Nursing, Midwifery & Health Sciences Centre; University College Dublin; Dublin Ireland
| | - Rita Collins
- All Ireland Institute of Hospice and Palliative Care; c/o Our Lady's Hospice & Care Services; Dublin Ireland
| | - Tara Murphy
- All Ireland Institute of Hospice and Palliative Care; c/o Our Lady's Hospice & Care Services; Dublin Ireland
| | - Bridget Johnston
- School of Medicine, Dentistry and Nursing; University of Glasgow; Glasgow UK
| | - Philip Larkin
- School of Nursing, Midwifery & Health Sciences Centre; University College Dublin; Dublin Ireland
- Education and Research; Our Lady's Hospice & Care Services; Dublin Ireland
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20
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Gramling R, Fiscella K, Xing G, Hoerger M, Duberstein P, Plumb S, Mohile S, Fenton JJ, Tancredi DJ, Kravitz RL, Epstein RM. Determinants of Patient-Oncologist Prognostic Discordance in Advanced Cancer. JAMA Oncol 2017; 2:1421-1426. [PMID: 27415765 DOI: 10.1001/jamaoncol.2016.1861] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Patients with advanced cancer often report expectations for survival that differ from their oncologists' expectations. Whether patients know that their survival expectations differ from those of their oncologists remains unknown. This distinction is important because knowingly expressing differences of opinion is important for shared decision making, whereas patients not knowing that their understanding differs from that of their treating physician is a potential marker of inadequate communication. Objective To describe the prevalence, distribution, and proportion of prognostic discordance that is due to patients' knowingly vs unknowingly expressing an opinion that differs from that of their oncologist. Design, Setting, and Participants Cross-sectional study conducted at academic and community oncology practices in Rochester, New York, and Sacramento, California. The sample comprises 236 patients with advanced cancer and their 38 oncologists who participated in a randomized trial of an intervention to improve clinical communication. Participants were enrolled from August 2012 to June 2014 and followed up until October 2015. Main Outcomes and Measures We ascertained discordance by comparing patient and oncologist ratings of 2-year survival probability. For discordant pairs, we determined whether patients knew that their opinions differed from those of their oncologists by asking the patients to report how they believed their oncologists rated their 2-year survival. Results Among the 236 patients (mean [SD] age, 64.5 [11.4] years; 54% female), 161 patient-oncologist survival prognosis ratings (68%; 95% CI, 62%-75%) were discordant. Discordance was substantially more common among nonwhite patients compared with white patients (95% [95% CI, 86%-100%] vs 65% [95% CI, 58%-73%], respectively; P = .03). Among 161 discordant patients, 144 (89%) did not know that their opinions differed from that of their oncologists and nearly all of them (155 of 161 [96%]) were more optimistic than their oncologists. Conclusions and Relevance In this study, patient-oncologist discordance about survival prognosis was common and patients rarely knew that their opinions differed from those of their oncologists.
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Affiliation(s)
- Robert Gramling
- School of Nursing, University of Rochester, Rochester, New York2Division of Palliative Medicine, University of Vermont, Burlington3Department of Family Medicine, University of Vermont, Burlington4Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York5Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York6Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York7Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Kevin Fiscella
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York5Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York6Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York8Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Guibo Xing
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Michael Hoerger
- Department of Psychology, Tulane University, New Orleans, Louisiana11Tulane Cancer Center, Tulane University, New Orleans, Louisiana12Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Paul Duberstein
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York6Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York12Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Sandy Plumb
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Supriya Mohile
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York14James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Joshua J Fenton
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento15Department of Family and Community Medicine, University of California, Davis, Sacramento16UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento
| | - Daniel J Tancredi
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento17Department of Pediatrics, University of California, Davis, Sacramento
| | - Richard L Kravitz
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento16UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento18Division of General Medicine, University of California, Davis, Sacramento
| | - Ronald M Epstein
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York6Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York7Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York12Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York14James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York
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Abstract
AIM To report an analysis and clarification of the concept of goals of care. BACKGROUND Goals of care have been used by healthcare providers since 1978, but no operationalized, consensual definition exists. DESIGN Norris's method of concept clarification was used to create an operational definition, conceptual model and testable hypotheses of goals of care from the healthcare provider's perspective. DATA SOURCES Data came from current research reports, interviews with experts and web sites of professional organizations. Research reports were published between 2003-2013. METHODS Antecedents, definitions and consequences were systematized and organized into coherent and more abstract groups to define goals of care. A conceptual model and testable hypotheses were created from this process. RESULTS Goals of care are desired health expectations that are formulated through the thoughtful interaction between a human being seeking medical care and the healthcare team in the healthcare system and are appropriate, agreed on, documented and communicated. CONCLUSIONS Development of clear goals of care can increase patient satisfaction and quality of care while decreasing costs, hospital length of stay and hospital readmission. Goals of care are dynamic and should be reassessed regularly. How and when goals of care transition from implicit to explicit should be explored further, and what prompts this transition. Nurses, physicians and healthcare providers need education on how to best fill their roles in the development of goals of care.
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Affiliation(s)
- Susan Stanek
- University of Rochester School of Nursing, New York, USA
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Wittenberg E, Ferrell B, Goldsmith J, Buller H, Neiman T. Nurse Communication About Goals of Care. J Adv Pract Oncol 2016; 7:146-154. [PMID: 28090365 PMCID: PMC5226308 DOI: 10.6004/jadpro.2016.7.2.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Conversations about goals of care with the patient and family are a critical component of advanced practice in oncology. However, there are often inadequate team structures, training, or resources available to assist advanced practitioners in initiating these conversations. We conducted a study to assess nurses’ perceived role and communication tasks in such conversations about goals of care. In a cross-sectional survey of 109 nurses attending a comprehensive 2-day end-of-life nursing education course, nurses were asked to describe how they would participate in a "goals of care" meeting in three different scenarios. They were also asked what changes they desired in their clinical settings. Nurses overwhelmingly described that their primary task and communication role was to assess patient/family understanding. Nurses referenced their team members and team support with the least frequency across scenarios. Team roles, structure, and process were reported as areas in greatest need of change in patient/family goals of care meetings. These findings demonstrate that lack of preparation to function as a team is a barrier for nurses in communicating about goals of care, and there is a demand to move such conversations upstream in oncology care.
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Affiliation(s)
- Elaine Wittenberg
- City of Hope National Medical Center, Division of Nursing Research and Education, Duarte, California
| | - Betty Ferrell
- City of Hope National Medical Center, Division of Nursing Research and Education, Duarte, California
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Gramling R, Sanders M, Ladwig S, Norton SA, Epstein R, Alexander SC. Goal Communication in Palliative Care Decision-Making Consultations. J Pain Symptom Manage 2015; 50:701-6. [PMID: 26025274 DOI: 10.1016/j.jpainsymman.2015.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/09/2015] [Accepted: 05/21/2015] [Indexed: 11/23/2022]
Abstract
CONTEXT Palliative care (PC) promotes patient-centered outcomes, but the mechanisms underlying these effects remain poorly understood. Identifying, clarifying, and prioritizing patients' goals are conceptually fundamental to the process of patient-centeredness and are the main reasons for PC referral. However, very little is empirically known about the content or process of goal expression in the natural setting of PC. OBJECTIVES To describe the frequency, types, and determinants of goal expression in PC consultations. METHODS This was a cross-sectional direct observational study of 72 audiorecorded PC consultations with hospitalized patients (and families) referred for PC goals of care clarification or end-of-life decision making. We coded digital audio files using reliable methods and linked conversation codes to clinical record and brief clinician interview data. RESULTS Goal expressions occurred frequently in PC consultations and addressed both length-of-life and quality-of-life domains. The presence of existential suffering in the conversation was associated with substantially more expressions and types of goals. CONCLUSION Goal communication is common in PC decision-making settings and strongly influenced by existential suffering.
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Affiliation(s)
| | | | - Susan Ladwig
- University of Rochester, Rochester, New York, USA
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24
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Gramling R, Gajary-Coots E, Stanek S, Dougoud N, Pyke H, Thomas M, Cimino J, Sanders M, Alexander SC, Epstein R, Fiscella K, Gramling D, Ladwig S, Anderson W, Pantilat S, Norton SA. Design of, and enrollment in, the palliative care communication research initiative: a direct-observation cohort study. BMC Palliat Care 2015; 14:40. [PMID: 26286538 PMCID: PMC4544824 DOI: 10.1186/s12904-015-0037-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 08/11/2015] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Robert Gramling
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Elizabeth Gajary-Coots
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Susan Stanek
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY, 14642, USA.
| | - Nathalie Dougoud
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY, 14642, USA.
| | - Heather Pyke
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY, 14642, USA.
| | - Marie Thomas
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Jenica Cimino
- Division of Hospital Medicine and Palliative Care Program, University of California, Clinical Sciences Building Suite C-126, 521 Parnassus Ave, Box 0131, San Francisco, CA, 94143-0131, USA.
| | - Mechelle Sanders
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Stewart C Alexander
- Purdue University, Matthews Hall, 812 West State Street, West Lafayette, IN, 47907-2060, USA.
| | - Ronald Epstein
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Kevin Fiscella
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - David Gramling
- University of Arizona, 301 Learning Services Building, 1512 East First St., Tucson, AZ, 85721, USA.
| | - Susan Ladwig
- Palliative Care Program, University of Rochester Medical Center, 601 Elmwood Avenue, Box 687, Rochester, NY, 14642, USA.
| | - Wendy Anderson
- Division of Hospital Medicine and Palliative Care Program, University of California, Clinical Sciences Building Suite C-126, 521 Parnassus Ave, Box 0131, San Francisco, CA, 94143-0131, USA.
| | - Stephen Pantilat
- Division of Hospital Medicine and Palliative Care Program, University of California, Clinical Sciences Building Suite C-126, 521 Parnassus Ave, Box 0131, San Francisco, CA, 94143-0131, USA.
| | - Sally A Norton
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY, 14642, USA.
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Tierney DK, Passaglia J, Jenkins P. Palliative care of hematopoietic cell transplant recipients and families. Semin Oncol Nurs 2015; 30:253-61. [PMID: 25361877 DOI: 10.1016/j.soncn.2014.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To provide support for the early integration of palliative care into the care of hematopoietic cell transplant (HCT) recipients and families with the goal of improving care. DATA SOURCES Journal articles and on-line databases. CONCLUSION Early integration of palliative care for HCT recipients at high risk for complex symptom clusters, non-relapse mortality, or relapse offers an opportunity to clarify goals of care, advanced care planning, and improving the quality of care for both recipients and families. IMPLICATIONS FOR NURSING PRACTICE The palliative care service can support the HCT nurse in providing complex care to HCT recipients who are faced with significant side effects, toxicities, and complications of transplant.
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How clinicians discuss critically ill patients' preferences and values with surrogates: an empirical analysis. Crit Care Med 2015; 43:757-64. [PMID: 25565458 DOI: 10.1097/ccm.0000000000000772] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Although shared decision making requires clinicians to discuss the patient's values and preferences, little is known about the extent to which this occurs with surrogates in ICUs. We sought to assess whether and how clinicians talk with surrogates about incapacitated patients' preferences and values. DESIGN Prospective, cross-sectional study. SETTING Five ICUs of two hospitals. SUBJECTS Fifty-four physicians and 159 surrogates for 71 patients. INTERVENTIONS We audio-recorded 71 conferences in which clinicians and surrogates discussed life-sustaining treatment decisions for an incapacitated patient near the end of life. Two coders independently coded each instance in which clinicians or surrogates discussed the patient's previously expressed treatment preferences or values. They subcoded for values that are commonly important to patients near the end of life. They also coded treatment recommendations by clinicians that incorporated the patient's preferences or values. MEASUREMENTS AND MAIN RESULTS In 30% of conferences, there was no discussion about the patient's previously expressed preferences or values. In 37%, clinicians and surrogates discussed both the patient's treatment preferences and values. In the remaining 33%, clinicians and surrogates discussed either the patient's treatment preferences or values, but not both. In more than 88% of conferences, there was no conversation about the patient's values regarding autonomy and independence, emotional well-being and relationships, physical function, cognitive function, or spirituality. On average, 3.8% (SD, 4.3; range, 0-16%) of words spoken pertained to patient preferences or values. CONCLUSIONS In roughly a third of ICU family conferences for patients at high risk of death, neither clinicians nor surrogates discussed patients' preferences or values about end-of-life decision making. In less than 12% of conferences did participants address values of high importance to most patients, such as cognitive and physical function. Interventions are needed to ensure patients' values and preferences are elicited and integrated into end-of-life decisions in ICUs.
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Abstract
Research has validated the desire of patients and families for ongoing prognostic information; however, few conversations occur before patients reach the advanced stages of their disease trajectory. Physician hesitance and delay in discussing unfavorable prognoses deny patients and families optimal time to prepare for critical decision making. Advanced practice registered nurses can play a crucial, complementary role with the critical care interdisciplinary team to implement strategies to improve communication about prognosis and end of life with patients and families. Clinicians should discuss deterioration in disease-specific characteristics and changes (decline) in functional status. Functional status can serve as an accurate guide for forecasting prognosis, particularly in patients with heart failure, stroke, chronic lung disease, and end-stage renal disease. This article provides an overview of effective intensive care unit prognostic systems and discusses barriers and opportunities for nurses to use evidence-based knowledge related to disease trajectory and prognosis to improve communication and the quality of palliative and end-of-life care for patients.
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Affiliation(s)
- Peggy Kalowes
- Peggy Kalowes is Director, Nursing Research, Innovation and Evidence Based Practice, Long Beach Memorial, Miller Children’s and Women’s Hospital, 2801 Atlantic Ave, Long Beach, CA 90806
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Parry R, Land V, Seymour J. How to communicate with patients about future illness progression and end of life: a systematic review. BMJ Support Palliat Care 2014; 4:331-41. [PMID: 25344494 PMCID: PMC4251180 DOI: 10.1136/bmjspcare-2014-000649] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Conversation and discourse analytic research has yielded important evidence about skills needed for effective, sensitive communication with patients about illness progression and end of life. Objectives To:
▸ Locate and synthesise observational evidence about how people communicate about sensitive future matters; ▸ Inform practice and policy on how to provide opportunities for talk about these matters; ▸ Identify evidence gaps. Design Systematic review of conversation/discourse analytic studies of recorded interactions in English, using a bespoke appraisal approach and aggregative synthesis. Results 19 publications met the inclusion criteria. We summarised findings in terms of eight practices: ‘fishing questions’—open questions seeking patients’ perspectives (5/19); indirect references to difficult topics (6/19); linking to what a patient has already said—or noticeably not said (7/19); hypothetical questions (12/19); framing difficult matters as universal or general (4/19); conveying sensitivity via means other than words, for example, hesitancy, touch (4/19); encouraging further talk using means other than words, for example, long silences (2/19); and steering talk from difficult/negative to more optimistic aspects (3/19). Conclusions Practices vary in how strongly they encourage patients to engage in talk about matters such as illness progression and dying. Fishing questions and indirect talk make it particularly easy to avoid engaging—this may be appropriate in some circumstances. Hypothetical questions are more effective in encouraging on-topic talk, as is linking questions to patients’ cues. Shifting towards more ‘optimistic’ aspects helps maintain hope but closes off further talk about difficulties: practitioners may want to delay doing so. There are substantial gaps in evidence.
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Affiliation(s)
- Ruth Parry
- Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care, School of Health Sciences, University of Nottingham, B Floor Queen's Medical Centre, Nottingham, UK
| | - Victoria Land
- Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care, School of Health Sciences, University of Nottingham, B Floor Queen's Medical Centre, Nottingham, UK
| | - Jane Seymour
- Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care, School of Health Sciences, University of Nottingham, B Floor Queen's Medical Centre, Nottingham, UK
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