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Svendsen SJ, Grov EK, Staats K. Patients' experiences with shared decision-making in home-based palliative care - navigation through major life decisions. BMC Palliat Care 2024; 23:101. [PMID: 38627710 PMCID: PMC11022472 DOI: 10.1186/s12904-024-01434-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/12/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND This study addresses the issue of shared decision-making (SDM) in a Norwegian home-based palliative care setting. The significance of patient involvement in SDM is widely acknowledged, and many patients want to participate in decisions about care and treatment. Yet, it remains a need for more knowledge regarding the initiators and approaches of SDM in the context of home-based palliative care, particularly from the patients' perspective. The aim of this study is to understand patients' experiences and preferences for SDM in home-based palliative care, seeking to enhance the quality of care and direct the planning of healthcare services. METHODS We used a qualitative explorative design. A hermeneutic approach was employed, and data was collected through in-dept interviews with 13 patients. RESULTS The study uncovered an overarching theme of "Navigating to reach own decisions," comprising three sub-themes: "To be trapped in life without decisions to act on"; "To surrender to others and let others deal with decisions"; "To continue to be oneself without focusing on disease and decision-making". CONCLUSIONS The findings underscore the need for flexible, person-centered approaches in SDM, tailored to the fluctuating health literacy and changing preferences of patients in palliative care settings. Our study contributes to the understanding of SDM in palliative care by highlighting how patients navigate the balance between autonomy and reliance on HCPs. Future research should explore how healthcare systems, including HCPs' roles in the system, can adapt to the patients' dynamic needs, to ensuring that SDM will remain a supportive and empowering process for patients at all stages of their disease.
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Affiliation(s)
- Sandra Jahr Svendsen
- Lillestrøm Municipality, Lillestrøm, Norway.
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Kjeller, Norway.
| | - Ellen Karine Grov
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Pilestredet, Norway
| | - Katrine Staats
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Kjeller, Norway
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Wang SJ, Hu WY, Chang YC. Question prompt list intervention for patients with advanced cancer: a systematic review and meta-analysis. Support Care Cancer 2024; 32:231. [PMID: 38492095 DOI: 10.1007/s00520-024-08432-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 03/09/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Enhanced communication in end-of-life care (EOL) improves preparation and treatment decisions for patients with advanced cancer, affecting their quality of life at the end of life. Question prompt list (QPL) has been shown to enhance physician-patient communication in patients with cancer, but there is a lack of systematic review and meta-analysis for those with advanced cancer. Enhanced communication in end-of-life care improves preparation and treatment decisions for patients with advanced cancer, affecting their quality of life at the end of life. OBJECTIVE To review the effectiveness of QPL intervention on physician-patient communication and health outcomes during consultation in patients with advanced cancer. METHODS CINAHL, Embase, Scopus, and PsycINFO databases were undertaken using inclusion criteria for relevant articles up to August 2021. Pooled standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated using random-effects models. We used the Cochrane risk-of-bias assessment tool and modified Jadad scale to assess the quality of the studies. RESULTS Seven RCTs with 1059 participants were included, of which six studies were eligible for the meta-analysis. The pooled meta-analysis results indicated that QPL in patients with advanced cancer had a significant positive effect on the total number of questions asked (SMD, 0.73; 95% CI, 0.28 to 1.18; I2 = 83%) and on the patients' expectations for the future (SMD, 0.67; 95% CI, 0.08 to 1.25; I2 = 88%). There were no significant improvements in health-related outcomes such as end of life, anxiety, and quality of life. CONCLUSIONS Using QPL in advanced cancer consultations boosts patient questions which helps communication but not health-related indicators. Optimal results depend on full reading, but timing varies. Future research should examine the relationship between communication and health outcomes, including patient/physician behavior and social context.
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Affiliation(s)
- Shu-Jung Wang
- Nursing Department, Ren Ai Hospital, New Taipei City, Taiwan
| | - Wen-Yu Hu
- School of Nursing, College of Medicine, National Taiwan University, Taipei City, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei City, Taiwan
| | - Yun-Chen Chang
- School of Nursing and Graduate Institute of Nursing, China Medical University, Beitun District, , 406, Taichung, Taiwan.
- Nursing Department, China Medical University Hospital, Taichung, Taiwan.
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3
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Yeo HY, Wong JHY, Chan SJ, Latu ATF, Han CH, Anwar M, Marra CA. Exploring the Important Determinants Shaping Treatment Preferences: Qualitative Insights into Breast Cancer Patient Experiences and Perspectives in New Zealand. Patient Prefer Adherence 2023; 17:3525-3537. [PMID: 38148974 PMCID: PMC10750490 DOI: 10.2147/ppa.s443217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/19/2023] [Indexed: 12/28/2023] Open
Abstract
Purpose Despite the importance of acknowledging patient preferences in treatment decision-making, little is known about the treatment preferences and the factors underlying those preferences of breast cancer patients. This study aims explore patient experience and perspective regarding treatment preferences and identify the important determinants that shape these preferences in the context of New Zealand. Patients and Methods Semi-structured online interviews comprised of six focus group discussions and five individual interviews were performed with 26 breast cancer patients. The interviews were recorded, transcribed, and analyzed using the reflexive thematic analysis approach. Results Four main themes were derived: (1) positive treatment outcomes; (2) the negative impact of treatment-related side effects on quality of life; (3) treatment accessibility, availability, and timeliness; (4) cost of treatment. Patients revealed a strong preference towards treatments that yield longer survival, achieve remission, and prevent cancer recurrence. Additionally, patients favored treatments with minimal side effects that had minimal impact on their quality of life. There was a notable preference for treatments that were easily accessible and available in a timely manner. However, patients faced challenging decisions in balancing the costs of treatments with their benefits, leading to a consistent preference for treatments supported by government funding or medical insurance to alleviate financial burdens. Conclusion Our study reveals that breast cancer patients in New Zealand have different perceptions and preferences regarding cancer treatment. Patients frequently find themselves making trade-offs among various attributes of a treatment, aligning these decisions with their personal values and beliefs. By considering these preferences and trade-offs in future studies that measure patient preferences, healthcare professionals can enhance their support for patients in making informed choices that align with their values and priorities. Additionally, healthcare policymakers can develop patient-centered policies that cater to the unique needs and preferences of breast cancer patients.
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Affiliation(s)
- Hui Yee Yeo
- School of Pharmacy, University of Otago, Dunedin, New Zealand
- Clinical Research Center, Hospital Seberang Jaya, Seberang Jaya, Penang, Malaysia
| | | | - Suz Jack Chan
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | | | - Catherine H Han
- Auckland Oncology, Auckland, New Zealand
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Mudassir Anwar
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Carlo A Marra
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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4
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Salvadé H, Stiefel F, Bourquin C. "You'll need to settle your affairs": How the subject of death is approached by oncologists and advanced cancer patients in follow-up consultations. Palliat Support Care 2022:1-9. [PMID: 36354030 DOI: 10.1017/s147895152200147x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This qualitative study aimed to investigate communication about death in consultations with patients undergoing chemotherapy with no curative intent. Specifically, we examined (i) how the topic of death was approached, who raised it, in what way, and which responses were elicited, (ii) how the topic unfolded during consultations, and (iii) whether interaction patterns or distinguishing ways of communicating can be identified. METHODS The data consisted of 134 audio-recorded follow-up consultations. A framework of sensitizing concepts was developed, and interaction patterns were looked for when death was discussed. RESULTS The subject of death and dying was most often initiated by patients, and they raised it in various ways. In most consultations, direct talk about death was initiated only once. We identified 4 interaction patterns. The most frequent consists of indirect references to death by patients, followed by a direct mention of the death of a loved one, and a statement of the oncologists aiming to skip the subject. SIGNIFICANCE OF RESULTS Patients and oncologists have multiple ways of raising, pursuing, addressing and evacuating the subject of death. Being attentive and recognizing these ways and associated interaction patterns can help oncologists to think and elaborate on this topic and to facilitate discussions.
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Affiliation(s)
- Hélène Salvadé
- Psychiatric Liaison Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Friedrich Stiefel
- Psychiatric Liaison Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Céline Bourquin
- Psychiatric Liaison Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Barlet MH, Barks MC, Ubel PA, Davis JK, Pollak KI, Kaye EC, Weinfurt KP, Lemmon ME. Characterizing the Language Used to Discuss Death in Family Meetings for Critically Ill Infants. JAMA Netw Open 2022; 5:e2233722. [PMID: 36197666 PMCID: PMC9535532 DOI: 10.1001/jamanetworkopen.2022.33722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/09/2022] [Indexed: 12/03/2022] Open
Abstract
Importance Communication during conversations about death is critical; however, little is known about the language clinicians and families use to discuss death. Objective To characterize (1) the way death is discussed in family meetings between parents of critically ill infants and the clinical team and (2) how discussion of death differs between clinicians and family members. Design, Setting, and Participants This longitudinal qualitative study took place at a single academic hospital in the southeast US. Patients were enrolled from September 2018 to September 2020, and infants were followed up longitudinally throughout their hospitalization. Participants included families of infants with neurologic conditions who were hospitalized in the intensive care unit and had a planned family meeting to discuss neurologic prognosis or starting, not starting, or discontinuing life-sustaining treatment. Family meetings were recorded, transcribed, and deidentified before being screened for discussion of death. Main Outcomes and Measures The main outcome was the language used to reference death during family meetings between parents and clinicians. Conventional content analysis was used to analyze data. Results A total of 68 family meetings involving 36 parents of 24 infants were screened; 33 family meetings (49%) involving 20 parents (56%) and 13 infants (54%) included discussion of death. Most parents involved in discussion of death identified as the infant's mother (13 [65%]) and as Black (12 [60%]). Death was referenced 406 times throughout the family meetings (275 times by clinicians and 131 times by family members); the words die, death, dying, or stillborn were used 5% of the time by clinicians (13 of 275 references) and 15% of the time by family members (19 of 131 references). Four types of euphemisms used in place of die, death, dying, or stillborn were identified: (1) survival framing (eg, not live), (2) colloquialisms (eg, pass away), (3) medical jargon, including obscure technical terms (eg, code event) or talking around death with physiologic terms (eg, irrecoverable heart rate drop), and (4) pronouns without an antecedent (eg, it). The most common type of euphemism used by clinicians was medical jargon (118 of 275 references [43%]). The most common type of euphemism used by family members was colloquialism (44 of 131 references [34%]). Conclusions and Relevance In this qualitative study, the words die, death, dying, or stillborn were rarely used to refer to death in family meetings with clinicians. Families most often used colloquialisms to reference death, and clinicians most often used medical jargon. Future work should evaluate the effects of euphemisms on mutual understanding, shared decision-making, and clinician-family relationships.
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Affiliation(s)
| | - Mary C. Barks
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Peter A. Ubel
- Duke University School of Medicine, Durham, North Carolina
- Fuqua School of Business, Duke University, Durham, North Carolina
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - J. Kelly Davis
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Kathryn I. Pollak
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Erica C. Kaye
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Monica E. Lemmon
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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6
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van der Velden NCA, van Laarhoven HWM, Burgers SA, Hendriks LEL, de Vos FYFL, Dingemans AMC, Jansen J, van Haarst JMW, Dits J, Smets EM, Henselmans I. Characteristics of patients with advanced cancer preferring not to know prognosis: a multicenter survey study. BMC Cancer 2022; 22:941. [PMID: 36050628 PMCID: PMC9434918 DOI: 10.1186/s12885-022-09911-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/14/2022] [Indexed: 12/14/2022] Open
Abstract
Background For some patients with advanced cancer not knowing prognosis is essential. Yet, in an era of informed decision-making, the potential protective function of unawareness is easily overlooked. We aimed to investigate 1) the proportion of advanced cancer patients preferring not to know prognosis; 2) the reasons underlying patients’ prognostic information preference; 3) the characteristics associated with patients’ prognostic information preference; and 4) the concordance between physicians’ perceived and patients’ actual prognostic information preference. Methods This is a cross-sectional study with structured surveys (PROSPECT). Medical and thoracic oncologists included patients (n = 524), from seven Dutch hospitals, with metastatic/inoperable cancer and an expected median overall survival of ≤ 12 months. For analysis, descriptive statistics and logistic regression models were used. Results Twenty-five to 31% of patients preferred not to know a general life expectancy estimate or the 5/2/1-year mortality risk. Compared to patients preferring to know prognosis, patients preferring unawareness more often reported optimism, avoidance and inability to comprehend information as reasons for wanting limited information; and less often reported expectations of others, anxiety, autonomy and a sense of control as reasons for wanting complete information. Females (p < .05), patients receiving a further line of systemic treatment (p < .01) and patients with strong fighting spirit (p < .001) were more likely to prefer not to know prognosis. Concordance between physicians’ perceived and patients’ actual prognostic information preference was poor (kappa = 0.07). Conclusions We encourage physicians to explore patients’ prognostic information preferences and the underlying reasons explicitly, enabling individually tailored communication. Future studies may investigate changes in patients’ prognostic information preferences over time and examine the impact of prognostic disclosure on patients who prefer unawareness. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09911-8.
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Affiliation(s)
- Naomi C A van der Velden
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Sjaak A Burgers
- Department of Thoracic Oncology, Netherlands Cancer Institute, Antoni Van Leeuwenhoek Ziekenhuis, Amsterdam, The Netherlands
| | - Lizza E L Hendriks
- Department of Pulmonary Diseases, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Filip Y F L de Vos
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anne-Marie C Dingemans
- Department of Pulmonary Diseases, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joost Jansen
- Department of Pulmonary Diseases, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan-Maarten W van Haarst
- Department of Respiratory Medicine and Department of Surgery, Tergooi Ziekenhuis, Hilversum, The Netherlands
| | - Joyce Dits
- Department of Pulmonology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Ellen Ma Smets
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Inge Henselmans
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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7
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Petrillo LA, Shimer SE, Zhou AZ, Sommer RK, Feldman JE, Hsu KE, Greer JA, Traeger LN, Temel JS. Prognostic communication about lung cancer in the precision oncology era: A multiple-perspective qualitative study. Cancer 2022; 128:3120-3128. [PMID: 35731234 DOI: 10.1002/cncr.34369] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/31/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although most patients with cancer prefer to know their prognosis, prognostic communication between oncologists and patients is often insufficient. Targeted therapies for lung cancer improve survival yet are not curative and produce variable responses. This study sought to describe how oncologists communicate about prognosis with patients receiving targeted therapies for lung cancer. METHODS This qualitative study included 39 patients with advanced lung cancer with targetable mutations, 14 caregivers, and 10 oncologists. Semistructured interviews with patients and caregivers and focus groups or interviews with oncologists were conducted to explore their experiences with prognostic communication. One oncology follow-up visit was audio-recorded per patient. A framework approach was used to analyze interview transcripts, and a content analysis of patient-oncologist dialogue was conducted. Themes were identified within each source and then integrated across sources to create a multidimensional description of prognostic communication. RESULTS Six themes in prognostic communication were identified: Patients with targetable mutations develop a distinct identity in the lung cancer community that affects their information-seeking and self-advocacy; oncologists set high expectations for targeted therapy; the uncertain availability of new therapies complicates prognostic discussions; patients and caregivers have variable information preferences; patients raise questions about progression by asking about physical symptoms or scan results; and patients' expectations of targeted therapy influence their medical decision-making. CONCLUSIONS Optimistic patient-oncologist communication shapes the expectations of patients receiving targeted therapy for lung cancer and affects their decision-making. Further research and clinical guidance are needed to help oncologists to communicate uncertain outcomes effectively.
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Affiliation(s)
- Laura A Petrillo
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sophia E Shimer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ashley Z Zhou
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert K Sommer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Kelly E Hsu
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lara N Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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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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Janett-Pellegri C, Eychmüller AS. 'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication? PRAXIS 2021; 110:914-924. [PMID: 34814721 DOI: 10.1024/1661-8157/a003785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Uncertainty, fear to harm the patient, discomfort handling the discussion and lack of time are the most cited barriers to prognostic disclosure. Physicians can be reassured that patients desire the truth about prognosis and can manage the discussion without harm, including the uncertainty of the information, if approached in a sensitive manner. Conversational guides could provide support in preparing such difficult conversations. Communicating 'with realism and hope' is possible, and anxiety is normal for both patients and clinicians during prognostic disclosure. As a clinician pointed out: 'I had asked a mentor once if it ever got easier. - No. But you get better at it.'
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Affiliation(s)
- Camilla Janett-Pellegri
- Service de Médicine Interne, Hôpital Cantonal Fribourg, Fribourg
- Universitäres Zentrum für Palliative Care, Inselspital, Universitätsspital Bern, Bern
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10
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van der Velden NCA, van der Kleij MBA, Lehmann V, Smets EMA, Stouthard JML, Henselmans I, Hillen MA. Communication about Prognosis during Patient-Initiated Second Opinion Consultations in Advanced Cancer Care: An Observational Qualitative Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115694. [PMID: 34073341 PMCID: PMC8199300 DOI: 10.3390/ijerph18115694] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 11/16/2022]
Abstract
Prognostic communication is essential for patients with advanced cancer to enable informed medical decision-making and end-of-life planning. Discussing prognosis is challenging, and might be especially complex for oncologists conducting a second opinion (SO). Survival data are often lacking, and consulting oncologists need to consider previously conveyed information and patients’ relationship with the referring oncologist. We qualitatively investigated how advanced cancer patients and consulting oncologists discuss prognosis during audio-recorded SO consultations (N = 60), including prognostic information received from the referring oncologist. Our results show that patients regularly expressed implicit cues to discuss prognosis or posed explicit questions tentatively. Consulting oncologists were mostly unresponsive to patients’ cues and cautious to prognosticate. They also seemed cautious when patients brought up the referring oncologist. Consulting oncologists checked which prognostic information patients had received from the referring oncologist, before estimating prognosis. They agreed with the first opinion or rectified discrepancies carefully. Altogether, this study exposes missed opportunities for open prognostic discussions in SOs. Consulting oncologists could explicitly explore patients’ information preferences and perceptions of prognosis. If desired, they can provide tailored, independent information to optimise patients’ prognostic awareness and informed medical decision-making. They may additionally support patients in dealing with prognosis and the uncertainties associated with it.
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Affiliation(s)
- N. C. A. van der Velden
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
- Correspondence:
| | - M. B. A. van der Kleij
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
| | - V. Lehmann
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - E. M. A. Smets
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - J. M. L. Stouthard
- Department of Medical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands;
| | - I. Henselmans
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - M. A. Hillen
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
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11
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Enzinger AC, Uno H, McCleary N, Frank E, Sanoff H, Van Loon K, Matin K, Bullock A, Cronin C, Bagley J, Schrag D. The Effect of Disclosing Life Expectancy Information on Patients' Prognostic Understanding: Secondary Outcomes From a Multicenter Randomized Trial of a Palliative Chemotherapy Educational Intervention. J Pain Symptom Manage 2021; 61:1-11.e3. [PMID: 32777456 PMCID: PMC7769864 DOI: 10.1016/j.jpainsymman.2020.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/21/2020] [Accepted: 07/25/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT Many advanced patients with cancer have unrealistic prognostic expectations. OBJECTIVES We tested whether offering life expectancy (LE) statistics within palliative chemotherapy (PC) education promotes realistic expectations. METHODS In this multicenter trial, patients with advanced colorectal and pancreatic cancers initiating first or second line PC were randomized to usual care versus a PC educational tool with optional LE information. Surveys at two weeks and three months assessed patients' review of the LE module and their reactions; at three months, patients estimated their LE and reported occurrence of prognosis and end-of-life (EOL) discussions. Wilcoxon tests and proportional odds models evaluated between-arm differences in LE self-estimates, and how realistic those estimates were (based on cancer type and line of treatment). RESULTS From 2015 to 2017, 92 patients were randomized to the intervention and 94 to usual care. At baseline most patients (80.9%) wanted "a lot" or "as much information as possible" about the impact of chemotherapy on LE. Among patients randomized to the intervention, 52.0% reviewed the LE module by two weeks and 66.7% by three months-of whom 88.2% reported the information was important, 31.4% reported it was upsetting, and 3.9% regretted reviewing it. Overall, patients' LE self-estimates were very optimistic; 71.4% of patients with colorectal cancer estimated greater than five years; 50% pancreatic patients estimated greater than two years. The intervention had no effect on the length or realism of patients' LE self-estimates, or on the occurrence of prognostic or EOL discussions. CONCLUSIONS Offering LE information within a PC educational intervention had no effect on patients' prognostic expectations.
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Affiliation(s)
- Andrea C Enzinger
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA; Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA.
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Nadine McCleary
- Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Elizabeth Frank
- Susan F. Smith Center for Women's Cancers, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Hanna Sanoff
- Division of Medical Oncology, University of North Carolina Lineberger Cancer Center, Chapel Hill, North Carolina, USA
| | - Katherine Van Loon
- Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Khalid Matin
- Division of Medical Oncology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Andrea Bullock
- Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christine Cronin
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Janet Bagley
- Department of Nursing, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Deborah Schrag
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA; Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
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12
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van Kleef J, van den Boorn H, Verhoeven R, Vanschoenbeek K, Abu-Hanna A, Zwinderman A, Sprangers M, van Oijen M, De Schutter H, van Laarhoven H. External Validation of the Dutch SOURCE Survival Prediction Model in Belgian Metastatic Oesophageal and Gastric Cancer Patients. Cancers (Basel) 2020; 12:E834. [PMID: 32244310 PMCID: PMC7225946 DOI: 10.3390/cancers12040834] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 12/17/2022] Open
Abstract
The SOURCE prediction model predicts individualised survival conditional on various treatments for patients with metastatic oesophageal or gastric cancer. The aim of this study was to validate SOURCE in an external cohort from the Belgian Cancer Registry. Data of Belgian patients diagnosed with metastatic disease between 2004 and 2014 were extracted (n = 4097). Model calibration and discrimination (c-indices) were determined. A total of 2514 patients with oesophageal cancer and 1583 patients with gastric cancer with a median survival of 7.7 and 5.4 months, respectively, were included. The oesophageal cancer model showed poor calibration (intercept: 0.30, slope: 0.42) with an absolute mean prediction error of 14.6%. The mean difference between predicted and observed survival was -2.6%. The concordance index (c-index) of the oesophageal model was 0.64. The gastric cancer model showed good calibration (intercept: 0.02, slope: 0.91) with an absolute mean prediction error of 2.5%. The mean difference between predicted and observed survival was 2.0%. The c-index of the gastric cancer model was 0.66. The SOURCE gastric cancer model was well calibrated and had a similar performance in the Belgian cohort compared with the Dutch internal validation. However, the oesophageal cancer model had not. Our findings underscore the importance of evaluating the performance of prediction models in other populations.
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Affiliation(s)
- J.J. van Kleef
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Department of Medical Oncology, 1105 AZ Amsterdam, The Netherlands; (J.J.v.K.); (H.G.v.d.B.); (M.G.H.v.O.)
| | - H.G. van den Boorn
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Department of Medical Oncology, 1105 AZ Amsterdam, The Netherlands; (J.J.v.K.); (H.G.v.d.B.); (M.G.H.v.O.)
| | - R.H.A. Verhoeven
- Department of Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), 3511 DT Utrecht, The Netherlands;
| | - K. Vanschoenbeek
- Belgian Cancer Registry, 1210 Brussels, Belgium; (K.V.); (H.D.S.)
| | - A. Abu-Hanna
- Department of Medical Informatics, Amsterdam University Medical Centers, University of Amsterdam, 1105 AZ, Amsterdam, The Netherlands;
| | - A.H. Zwinderman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
| | - M.A.G. Sprangers
- Department of Medical Psychology, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, 1105 AZ Amsterdam, The Netherlands;
| | - M.G.H. van Oijen
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Department of Medical Oncology, 1105 AZ Amsterdam, The Netherlands; (J.J.v.K.); (H.G.v.d.B.); (M.G.H.v.O.)
| | - H. De Schutter
- Belgian Cancer Registry, 1210 Brussels, Belgium; (K.V.); (H.D.S.)
| | - H.W.M. van Laarhoven
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Department of Medical Oncology, 1105 AZ Amsterdam, The Netherlands; (J.J.v.K.); (H.G.v.d.B.); (M.G.H.v.O.)
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13
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Ginter AC. "The day you lose your hope is the day you start to die": Quality of life measured by young women with metastatic breast cancer. J Psychosoc Oncol 2020; 38:418-434. [PMID: 32067600 DOI: 10.1080/07347332.2020.1715523] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose/Objectives: The number of young women with metastatic breast cancer (MBC) is growing in the United States. The intersection of age and cancer stage presents unique challenges for this population. However, there is little extant research on the concerns and perspectives of young women with MBC. The purpose of this study is to understand how young women describe their lived experiences following their diagnoses of MBC.Design: A cross-sectional qualitative study with a life course theoretical framework was employed.Sample/Participants: Purposive sampling yielded nine participants who took part in semi-structured interviews. Phenomenology informed understanding of the lived experience of young women with MBC.Findings: The findings describe how young women with MBC measure quality of life, via themes of facing off-time diagnoses, strategizing disclosure, relying on mindfulness and spirituality, contemplating the future, and differentiating surviving from truly living.Conclusion: The notion of short-term or long-term decision-making is clouded by a metastatic prognosis.Implications for Psychosocial Providers: These findings present new information about the needs of young women with MBC, with potentially transferable implications for young adults with other forms of metastatic cancer.
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Affiliation(s)
- Amanda C Ginter
- Department of Family Studies and Community Development, Towson University, Towson, MD, USA
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14
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Back AL. Patient-Clinician Communication Issues in Palliative Care for Patients With Advanced Cancer. J Clin Oncol 2020; 38:866-876. [PMID: 32023153 DOI: 10.1200/jco.19.00128] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The delivery of palliative care to patients with advanced cancer and their families, whether done by oncology clinicians or palliative care clinicians, requires patient-centered communication. Excellent communication can introduce patients and families to palliative care in a nonthreatening way, build patient trust, enable symptom control, strengthen coping, and guide decision making. This review covers deficiencies in the current state of communication, patient preferences for communication about palliative care topics, best practices for communication, and the roles of education and system intervention. Communication is a two-way, relational process that is influenced by context, culture, words, and gestures, and it is one of the most important ways that clinicians influence the quality of medical care that patients and their families receive.
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15
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Zayts O, Shipman H, Fung JL, Liu AP, Kwok S, Tsai AC, Yung T, Chung BH. The different facets of “culture” in genetic counseling: A situated analysis of genetic counseling in Hong Kong. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2019; 181:187-195. [DOI: 10.1002/ajmg.c.31699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/21/2019] [Accepted: 03/29/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Olga Zayts
- School of English, Faculty of ArtsThe University of Hong Kong Hong Kong, SAR China
| | - Hannah Shipman
- School of English, Faculty of ArtsThe University of Hong Kong Hong Kong, SAR China
| | - Jasmine L.‐F. Fung
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of MedicineThe University of Hong Kong Hong Kong, SAR China
| | - Anthony P.‐Y. Liu
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of MedicineThe University of Hong Kong Hong Kong, SAR China
| | - Sit‐Yee Kwok
- Department of Paediatric CardiologyQueen Mary Hospital, Hong Kong Hong Kong, SAR China
| | - Anne C.‐H. Tsai
- Department of Pediatrics, The Children's HospitalUniversity of Colorado School of Medicine Aurora Colorado
| | - Tak‐Cheung Yung
- Department of Paediatric CardiologyQueen Mary Hospital, Hong Kong Hong Kong, SAR China
| | - Brian H.‐Y. Chung
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of MedicineThe University of Hong Kong Hong Kong, SAR China
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Collins A, McLachlan SA, Philip J. How should we talk about palliative care, death and dying? A qualitative study exploring perspectives from caregivers of people with advanced cancer. Palliat Med 2018; 32:861-869. [PMID: 29235421 DOI: 10.1177/0269216317746584] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Health professionals commonly underestimate caregiver needs for information about palliative care, death and dying and may feel poorly prepared to discuss these issues. Few studies have sought caregiver perspectives of these communication practices. AIM To explore caregiver perspectives on communication about death, dying and the introduction to palliative care, with a view towards a series of caregiver-informed recommendations for use in clinical practice. DESIGN Cross-sectional, prospective, exploratory qualitative design, involving narrative-style interviews and underpinned by an interpretative phenomenological framework. SETTING/PARTICIPANTS Purposively sampled, English-speaking, adult caregivers of people with advanced cancer ( n = 25) recruited from cancer services at a tertiary metropolitan hospital in Melbourne, Australia. RESULTS Caregivers reported wanting routinely available written resources about palliative care, supplemented by conversations that are ideally staged overtime. Education about the tasks of palliative care should be separated from referral process, allowing time for gradual adjustment, and re-visiting discussion to enable patients and families to take some control in the process of transition. Once death is imminent, carers wanted health professionals to clarify how much they want to know about the dying process; provide spoken acknowledgement when death is close; include the words 'death' and 'dying'; use direct language, avoiding euphemisms; and communicate about death with patient present. CONCLUSION This study is among the first to directly address caregiver perspectives of communication about death, dying and the introduction to palliative care. The recommendations derived from caregiver perspectives build upon existing guidelines and offer health professionals some preliminary considerations around how to undertake these important communication tasks in future.
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Affiliation(s)
- Anna Collins
- 1 Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia.,2 VCCC Palliative Medicine Research Group, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Sue-Anne McLachlan
- 1 Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia.,3 Medical Oncology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Jennifer Philip
- 1 Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia.,2 VCCC Palliative Medicine Research Group, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia.,4 Victorian Comprehensive Cancer Centre, Parkville, VIC, Australia
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17
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Henselmans I, Smets EMA, de Haes JCJM, Dijkgraaf MGW, de Vos FY, van Laarhoven HWM. A randomized controlled trial of a skills training for oncologists and a communication aid for patients to stimulate shared decision making about palliative systemic treatment (CHOICE): study protocol. BMC Cancer 2018; 18:55. [PMID: 29310605 PMCID: PMC5759304 DOI: 10.1186/s12885-017-3838-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 11/23/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Systemic treatment for advanced cancer offers uncertain and sometimes little benefit while the burden can be high. Hence, treatment decisions require Shared Decision Making (SDM). The CHOICE trial examines the separate and combined effect of oncologist training and a patient communication aid on SDM in consultations about palliative systemic treatment. METHODS A RCT design with four parallel arms will be adopted. Patients with metastatic or irresectable cancer with a median life expectancy <12 months who meet with a medical oncologist to discuss the start or continuation of palliative systemic treatment are eligible. A total of 24 oncologists (in training) and 192 patients will be recruited. The oncologist training consists of a reader, two group sessions (3.5 h; including modelling videos and role play), a booster feedback session (1 h) and a consultation room tool. The patient communication aid consists of a home-sent question prompt list and a value clarification exercise to prepare patients for SDM in the consultation. The control condition consists of care as usual. The primary outcome is observed SDM in audio-recorded consultations. Secondary outcomes include patient and oncologist evaluation of communication and decision-making, the decision made, quality of life, potential adverse outcomes such as anxiety and hopelessness, and consultation duration. Patients fill out questionnaires at baseline (T0), before (T1) and after the consultation (T2) and at 3 and 6 months (T3 and T4). All oncologists participate in two standardized patient assessments (before-after training) prior to the start of patient inclusion. They will fill out a questionnaire before and after these assessments, as well as after each of the recorded consultations in clinical practice. DISCUSSION The CHOICE trial will enable evidence-based choices regarding the investment in SDM interventions targeting either oncologists, patients or both in the advanced cancer setting. The trial takes into account the immediate effect of the interventions on observed communication, but also on more distal and potential adverse patient outcomes. Also, the trial provides evidence regarding the assumption that SDM about palliative cancer treatment results in less aggressive treatment and more quality of life in the final period of life. TRIAL REGISTRATION Netherlands Trial Registry number NTR5489 (prospective; 15 Sep 2015).
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Affiliation(s)
- I. Henselmans
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, the Netherlands
| | - E. M. A. Smets
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, the Netherlands
| | - J. C. J. M. de Haes
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, the Netherlands
| | - M. G. W. Dijkgraaf
- Clinical Research Unit, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - F. Y. de Vos
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H. W. M. van Laarhoven
- Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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18
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Collins A, McLachlan SA, Philip J. Communication about palliative care: A phenomenological study exploring patient views and responses to its discussion. Palliat Med 2018; 32:133-142. [PMID: 29130425 DOI: 10.1177/0269216317735247] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Communication about palliative care is a complex task frequently delayed until otherwise unavoidable. There is a need for discussion of palliative care to be viewed as a distinct communication task that is guided by empirical data. However, little is known of patient views and responses to these encounters. AIM To explore patient views surrounding communication about palliative care and their responses to its discussion. DESIGN Cross-sectional, prospective, exploratory qualitative design, involving narrative-style interviews and underpinned by an interpretative phenomenological framework. SETTING/PARTICIPANTS Purposively sampled, English-speaking, adult patients with advanced cancer ( n = 30) recruited from cancer services at a tertiary metropolitan hospital in Melbourne, Australia. RESULTS Three major themes evolved. (1) Death as unspeakable: death was expressed using only implicit, ambiguous or technical terms and perceived to be outside the parameters of medical interactions. (2) Palliative care as a euphemism for death: the term 'palliative care' was perceived to be used by health professionals as a tool to talk about dying and understood by patients as a euphemism for death. (3) Palliative care as unspeakable: 'palliative care' was personified by patients to mean not just death, but my death, in turn, also becoming unspeakable. CONCLUSION This study provides important new patient insights and responses to the discussion of palliative care. Results demonstrate that the task of discussing palliative care remains complex, difficult and limited by our language. Greater consistency, sensitivity and sophistication are required when talking about palliative care to patients who may benefit from this care.
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Affiliation(s)
- Anna Collins
- 1 VCCC Palliative Medicine Research Group, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia.,2 Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Sue-Anne McLachlan
- 2 Department of Medicine, University of Melbourne, Parkville, VIC, Australia.,3 The Department of Medical Oncology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Jennifer Philip
- 1 VCCC Palliative Medicine Research Group, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia.,2 Department of Medicine, University of Melbourne, Parkville, VIC, Australia
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19
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Henselmans I, Smets EMA, Han PKJ, de Haes HCJC, Laarhoven HWMV. How long do I have? Observational study on communication about life expectancy with advanced cancer patients. PATIENT EDUCATION AND COUNSELING 2017; 100:1820-1827. [PMID: 28511804 DOI: 10.1016/j.pec.2017.05.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/01/2017] [Accepted: 05/05/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To examine how communication about life expectancy is initiated in consultations about palliative chemotherapy, and what prognostic information is presented. METHODS Patients with advanced cancer (n=41) with a median life expectancy <1year and oncologists (n=6) and oncologists-in-training (n=7) meeting with them in consultations (n=62) to discuss palliative chemotherapy were included. Verbatim transcripts of audio-recorded consultations were analyzed using MAXqda10. RESULTS Life expectancy was addressed in 19 of 62 of the consultations. In all cases, patients took the initiative, most often through direct questions. Estimates were provided in 12 consultations in various formats: the likelihood of experiencing a significant event, point estimates or general time scales of "months to years", often with an emphasis on the "years". The indeterminacy of estimates was consistently stressed. Also their potential inadequacy was regularly addressed, often by describing beneficial prognostic predictors for the specific patient. Oncologists did not address the reliability or precision of estimates. CONCLUSION Oncologists did not initiate talk about life expectancy, they used different formats, emphasized the positive and stressed unpredictability, yet not ambiguity of estimates. PRACTICE IMPLICATIONS Prognostic communication should be part of the medical curriculum. Further research should address the effect of different formats of information provision.
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Affiliation(s)
- I Henselmans
- Academic Medical Center, Department of Medical Psychology, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam, The Netherlands.
| | - E M A Smets
- Academic Medical Center, Department of Medical Psychology, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - P K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME, USA; Tufts University Clinical and Translational Sciences Institute, Boston, MA, USA
| | - H C J C de Haes
- Academic Medical Center, Department of Medical Psychology, Amsterdam, The Netherlands
| | - H W M van Laarhoven
- Cancer Center Amsterdam, Amsterdam, The Netherlands; Academic Medical Center, Department of Medical Oncology, Amsterdam, The Netherlands
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20
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Oikonomidou D, Anagnostopoulos F, Dimitrakaki C, Ploumpidis D, Stylianidis S, Tountas Y. Doctors' Perceptions and Practices of Breaking Bad News: A Qualitative Study From Greece. HEALTH COMMUNICATION 2017; 32:657-666. [PMID: 27367603 DOI: 10.1080/10410236.2016.1167991] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
There is limited information about doctors' communication behaviors and their salient beliefs with regard to bad news disclosure in Greece. In this qualitative study we investigated the self-reported practices of doctors on breaking bad news, their perceptions about the factors affecting the delivery of such news, and their beliefs about the most appropriate disclosure manner. A focus group discussion and individual interviews were conducted. Twenty-five resident and specialist doctors from primary health care and hospital settings participated. We analyzed the collected data with content analysis techniques. Participants were found to acknowledge the importance of appropriate and effective delivery of bad news; however, none of them reported the implementation of empirically informed communication practices. They described communication patterns mainly formed by their work experience and often guided by the patient's family requests. Doctor, patient, and family characteristics and organizational features and resources were reported to affect the delivery of bad news. Participants perceived the most appropriate disclosure manner as an individualized approach to each patient's unique needs. They suggested an interdisciplinary, collaborative management of the delivery process and the establishment of formal supportive services. These findings may provide useful information for the development of tailored, empirically informed curriculum interventions and educational programs in order to address several barriers to communication. Sociocultural characteristics that influence the disclosure practice, as well as physicians' perceptions that are consistent with the optimal information delivery, should be taken into account. System-level strategies that focus on the development of patient-centered communication also need to be prioritized.
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Affiliation(s)
- Despoina Oikonomidou
- a Department of Hygiene, Epidemiology and Medical Statistics , University of Athens Medical School
| | | | - Christine Dimitrakaki
- a Department of Hygiene, Epidemiology and Medical Statistics , University of Athens Medical School
| | - Dimitrios Ploumpidis
- c First Department of Psychiatry, Eginition Hospital , University of Athens Medical School
| | | | - Yannis Tountas
- a Department of Hygiene, Epidemiology and Medical Statistics , University of Athens Medical School
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Gemmiti M, Hamed S, Wildhaber J, Pharisa C, Klumb PL. Pediatric Consultations: Negative-Word Use and Parent Satisfaction. J Pediatr Psychol 2017; 42:1165-1174. [DOI: 10.1093/jpepsy/jsx061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 02/19/2017] [Indexed: 12/30/2022] Open
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Ekberg S, Danby S, Herbert A, Bradford NK, Yates P. Affording opportunities to discuss deterioration in paediatric palliative care consultations: a conversation analytic study. BMJ Support Palliat Care 2017; 10:e13. [DOI: 10.1136/bmjspcare-2016-001130] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 12/12/2016] [Accepted: 01/19/2017] [Indexed: 11/03/2022]
Abstract
ObjectiveDiscussing the potential deterioration of a child who has a life-limiting condition has recognised benefits for future care, but can be challenging in a clinical context where uncertain illness trajectories are common. Existing research is restricted to indirect forms of evidence such as self-report data from clinicians and families. This study directly explores how discussions about deterioration are managed within actual paediatric palliative care consultations.Methods9 consultations were video recorded in an Australian paediatric palliative care service. Each consultation involved the same paediatric palliative care specialist. Conversation analysis was used to identify and explore recurrent ways in which discussions about deterioration came to be realised.FindingsThe study identified two communicative practices used by a paediatric palliative care specialist that afforded opportunities to discuss deterioration: (1) soliciting the family's agenda for the consultation; (2) initiating and maintaining topics where discussing deterioration is a relevant possibility. Across these different practices, a common feature was indirect initiation of discussions about deterioration. This approach made such discussions possible, but without mandating or even suggesting that such discussion must occur.ConclusionsThese communicative practices balance the benefit of discussing deterioration against a recognised importance of allowing discussions to be directed by a child's family. This was achieved by creating opportunities for discussing deterioration, without making such discussions necessary.
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Flynn S, Hulbert-Williams NJ, Hulbert-Williams L, Bramwell R. “You don't know what's wrong with you”: an exploration of cancer-related experiences in people with an intellectual disability. Psychooncology 2016; 25:1198-1205. [DOI: 10.1002/pon.4211] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 06/16/2016] [Accepted: 07/05/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Samantha Flynn
- Chester Research Unit for the Psychology of Health, Department of Psychology; University of Chester; Chester Cheshire UK
| | - Nicholas J. Hulbert-Williams
- Chester Research Unit for the Psychology of Health, Department of Psychology; University of Chester; Chester Cheshire UK
| | - Lee Hulbert-Williams
- Chester Research Unit for the Psychology of Health, Department of Psychology; University of Chester; Chester Cheshire UK
| | - Ros Bramwell
- Chester Research Unit for the Psychology of Health, Department of Psychology; University of Chester; Chester Cheshire UK
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Zafar W, Hafeez H, Jamshed A, Shah MA, Quader A, Yusuf MA. Preferences regarding disclosure of prognosis and end-of-life care: A survey of cancer patients with advanced disease in a lower-middle-income country. Palliat Med 2016; 30:661-73. [PMID: 26769733 DOI: 10.1177/0269216315625810] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cancer patients' preferences regarding disclosure of prognosis and end-of-life care remain under-reported from low- and middle-income countries where cancer poses an increasing demand on scarce healthcare resources. A better knowledge of these preferences can help in achievement of shared treatment goals. AIM To survey preferences of adult cancer patients regarding disclosure of prognosis and end-of-life care DESIGN A multidimensional questionnaire was developed to survey consecutively sampled patients. A fifth of the participants completed a repeat survey 3 months later. SETTING/PARTICIPANTS Adult patients at a specialist cancer center in Pakistan. RESULTS In total, 520 patients were surveyed initially (participation rate 98.6%) and 100 completed the repeat survey. Three in five respondents wanted a healthcare provider to give them detailed information about their prognosis and life expectancy. Those who wanted information withheld were significantly more likely to be female, to have a lower socioeconomic status, or to have lung cancer. Only two in five patients agreed that they wanted to die at home and more than 90% wanted all possible care till end-of-life. Yet, a little over half also agreed that they did not wish to be placed on a ventilator. In rank ordering preferences about end-of-life, respondents ranked "religious wellbeing" as the highest and "avoiding inappropriate prolongation of dying" as the lowest of six options. CONCLUSION A majority of adult cancer patients surveyed in this study wanted a truthful disclosure about their disease prognosis and expressed a preference for hospital-based care at end-of-life. Healthcare providers should find ways to tailor prognostic information to patients' expressed information needs.
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Affiliation(s)
- Waleed Zafar
- Department of Cancer Registry and Clinical Data Management, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan
| | - Haroon Hafeez
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan
| | - Arif Jamshed
- Department of Radiation Oncology, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan
| | - Mazhar Ali Shah
- Department of Radiation Oncology, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan
| | - Ainul Quader
- Department of Cancer Registry and Clinical Data Management, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan
| | - M Aasim Yusuf
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan
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Hardy JR, Douglas CM. Pining for the fjords(1). Intern Med J 2016; 46:651-2. [PMID: 27257147 DOI: 10.1111/imj.13105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 04/06/2016] [Indexed: 11/30/2022]
Affiliation(s)
- J R Hardy
- Department of Palliative and Supportive Care, Mater Health Services.,Mater Research-University of Queensland, Queensland, Australia
| | - C M Douglas
- Palliative and Supportive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Rodenbach RA, Rodenbach KE, Tejani MA, Epstein RM. Relationships between personal attitudes about death and communication with terminally ill patients: How oncology clinicians grapple with mortality. PATIENT EDUCATION AND COUNSELING 2016; 99:356-363. [PMID: 26519993 PMCID: PMC5955702 DOI: 10.1016/j.pec.2015.10.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 10/01/2015] [Accepted: 10/12/2015] [Indexed: 05/02/2023]
Abstract
OBJECTIVE Clinician discomfort with death may affect care of patients but has not been well-studied. This study explores oncology clinicians' attitudes surrounding their own death and how these attitudes both affect and are affected by their care of dying patients and their communication with them. METHODS Qualitative interviews with physicians (n=25), nurse practitioners (n=7), and physician assistants (n=1) in medical or hematologic oncology clinical practices about communication styles, care of terminally ill patients, and personal perspectives about mortality. RESULTS Clinicians described three communication styles used with patients about death and dying: direct, indirect, or selectively direct. Most reported an acceptance of their mortality that was "conditional," meaning that that they could not fully know how they would respond if actually terminally ill. For many clinicians, caring for dying patients affected their outlook on life and death, and their own perspectives on life and death affected their approach to caring for dying patients. CONCLUSION An awareness of personal mortality may help clinicians to discuss death more openly with patients and to provide better care. PRACTICE IMPLICATIONS Efforts to promote self-awareness and communication training are key to facilitating clear communication with and compassionate care of terminally ill patients.
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Affiliation(s)
- Rachel A Rodenbach
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14642, USA.
| | - Kyle E Rodenbach
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14642, USA
| | - Mohamedtaki A Tejani
- Department of Medicine, Hematology/Oncology, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642, USA
| | - Ronald M Epstein
- Department of Family Medicine, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, USA
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Samimi Ardestani SM, Faridhosseini F, Shirkhani F, Karamad A, Farid L, Fayyazi Bordbar MR, Motlagh A. Do Cancer Patients Prefer to Know the Diagnosis? A Descriptive Study Among Iranian Patients. IRANIAN JOURNAL OF PSYCHIATRY AND BEHAVIORAL SCIENCES 2015; 9:e1792. [PMID: 26834800 PMCID: PMC4733304 DOI: 10.17795/ijpbs-1792] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 04/17/2015] [Accepted: 05/04/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are important differences regarding cancer disclosure in various geographical populations (Europeans, Western Asia, Eastern Asia), depending on multiple sociocultural factors, and therefore, there is no standard protocol on this issue, especially in Iran. OBJECTIVES To evaluate the amount of information that Iranian patients have and their preference for the disclosure of the cancer diagnosis. PATIENTS AND METHODS In this cross sectional descriptive research, patients admitted in the oncology departments of 3 referral medical centers, Imam Hussein, Shohada-e-Tajrish and Modarres, in Tehran, from March 2007 to April 2008, were questioned about their awareness and knowledge regarding their diagnosis. Two different structured questionnaires were designed for the people who know and who didn't know their diagnosis. For the former, the survey concerned their psychological reactions to their situations, whether they would prefer to know about their diagnosis and by whom they are preferred to be informed .For the latter, the questionnaire included their preference whether to know the diagnosis and their current emotional state. Descriptive statistics and chi square test was applied to analyze gathering Data, using SPSS version 14. RESULTS 60.3% of the patients knew their diagnosis. Among the subjects who did not know their diagnosis, 88% preferred to be more informed about their diagnosis and 68% had some psychological reaction to their situations. Among the subjects who knew their diagnosis, 92.1 % preferred to know their diagnosis, 73.6% preferred to be informed directly by their physicians. Following the diagnostic disclosure, 81.5% reported that they had felt nervous, anxious and worried. CONCLUSIONS The majority of Iranian patients with malignancy want to know the truth and they prefer to be informed directly by their doctors.
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Affiliation(s)
| | - Farhad Faridhosseini
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Fatemeh Shirkhani
- Behavioral Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Ardeshir Karamad
- Behavioral Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Layla Farid
- School of Pharmacy, Southern Illinois University, Edwardsville, USA
| | | | - Ali Motlagh
- Radiation Oncology Department, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran; Cancer Research Center, Shahid Beheshti University of Medical Sciences Tehran, IR Iran
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A qualitative study of women's experiences of healthcare, treatment and support for metastatic breast cancer. Breast 2015; 24:242-7. [PMID: 25753212 DOI: 10.1016/j.breast.2015.02.025] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 02/13/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The purpose of this qualitative research was to identify the healthcare, information and support needs of women living with metastatic breast cancer. MATERIALS AND METHODS Semi-structured qualitative interviews were conducted with 18 women. Women were asked about their experiences of living with metastatic breast cancer and their information and support needs. RESULTS Women valued relationships with their healthcare professionals, particularly their oncologists. They wanted more attention paid to side-effects of ongoing treatments, which had a negative impact on their health. While oncologists were a primary source of information, women also drew on other sources. There were mixed findings about the value of support groups, with women preferring to seek alternative sources of social support. CONCLUSION A diagnosis of metastatic breast cancer brings heightened reliance on healthcare professionals to respond to women's needs in a way that is different to that required with a diagnosis of early breast cancer.
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Bélanger E, Rodríguez C, Groleau D, Légaré F, Macdonald ME, Marchand R. Initiating decision-making conversations in palliative care: an ethnographic discourse analysis. BMC Palliat Care 2014; 13:63. [PMID: 25859161 PMCID: PMC4391144 DOI: 10.1186/1472-684x-13-63] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 12/17/2014] [Indexed: 11/25/2022] Open
Abstract
Background Conversations about end-of-life care remain challenging for health care providers. The tendency to delay conversations about care options represents a barrier that impedes the ability of terminally-ill patients to participate in decision-making. Family physicians with a palliative care practice are often responsible for discussing end-of-life care preferences with patients, yet there is a paucity of research directly observing these interactions. In this study, we sought to explore how patients and family physicians initiated decision-making conversations in the context of a community hospital-based palliative care service. Methods This qualitative study combined discourse analysis with ethnographic methods. The field research lasted one year, and data were generated through participant observation and audio-recordings of consultations. A total of 101 consultations were observed longitudinally between 18 patients, 6 family physicians and 2 pivot nurses. Data analysis consisted in exploring the different types of discourses initiating decision-making conversations and how these discourses were affected by the organizational context in which they took place. Results The organization of care had an impact on decision-making conversations. The timing and origin of referrals to palliative care shaped whether patients were still able to participate in decision-making, and the decisions that remained to be made. The type of decisions to be made also shaped how conversations were initiated. Family physicians introduced decision-making conversations about issues needing immediate attention, such as symptom management, by directly addressing or eliciting patients’ complaints. When decisions involved discussing impending death, decision-making conversations were initiated either indirectly, by prompting the patients to express their understanding of the disease and its progression, or directly, by providing a justification for broaching a difficult topic. Conclusions Decision-making conversations and the initiation thereof were framed by the organization of care and the referral process prior to initial encounters. While symptom management was taken for granted as part of health care professionals’ expected role, engaging in decisions regarding preparation for death implicitly remained under patients’ control. This work makes important clinical contributions by exposing the rhetorical function of family physicians’ discourse when introducing palliative care decisions.
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Affiliation(s)
- Emmanuelle Bélanger
- Department of Social and Preventive Medicine, Université de Montréal, 7101 Parc Avenue, Montreal, H3N 1X9 Quebec Canada ; Department of Family Medicine, McGill University, Montreal, Canada
| | - Charo Rodríguez
- Department of Family Medicine, McGill University, Montreal, Canada
| | | | - France Légaré
- Department of Emergency and Family Medicine, Université Laval, Quebec City, Canada
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Hoff L, Hermerén G. Identifying Challenges to Communicating with Patients about Their Imminent Death. THE JOURNAL OF CLINICAL ETHICS 2014. [DOI: 10.1086/jce201425405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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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: 75] [Impact Index Per Article: 7.5] [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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Brandes K, Butow PN, Tattersall MHN, Clayton JM, Davidson PM, Young J, Epstein RM, Walczak A. Advanced cancer patients' and caregivers' use of a Question Prompt List. PATIENT EDUCATION AND COUNSELING 2014; 97:30-37. [PMID: 25023487 DOI: 10.1016/j.pec.2014.06.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 05/13/2014] [Accepted: 06/19/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE The objective of this study was to provide insight into how advanced cancer patients and their caregivers use a Question Prompt List (QPL) during a consultation and for preparation for future consultations. METHODS Audiotaped consultations and follow-up phone calls of 28 advanced cancer patients were coded and content analyzed. Questions asked and concerns expressed in consultations were coded for initiator, content, inclusion in the QPL and exact wording. Patients' reported and future use of the QPL were coded from the phone calls. RESULTS The majority of patients reported that they used the QPL. Questions asked by patients and caregivers predominately coincided with questions from the prognosis section of the QPL. Questions were rarely asked literally from the QPL, instead questions were tailored to patients' own circumstances. CONCLUSION QPLs are useful to stimulate discussion on prognosis among advanced cancer patients and caregivers. Patients tailored questions from the QPL to their own circumstances which may suggest high involvement and engagement. The development of more specific tailored communication interventions for advanced cancer patients is warranted. PRACTICE IMPLICATIONS Implementation of QPLs in the advanced cancer setting may be beneficial for patients, caregivers and healthcare providers to facilitate discussion of topics such as prognosis.
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Affiliation(s)
- Kim Brandes
- Amsterdam School of Communication Research (ASCoR), University of Amsterdam, Amsterdam, The Netherlands; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, University of Sydney, Sydney, Australia.
| | - Phyllis N Butow
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, University of Sydney, Sydney, Australia
| | - Martin H N Tattersall
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, University of Sydney, Sydney, Australia
| | - Josephine M Clayton
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, University of Sydney, Sydney, Australia; Hammond Care Palliative and Supportive Care Service, Greenwich Hospital, Sydney, Australia
| | - Patricia M Davidson
- Cardiovascular and Chronic Care Centre, University of Technology, Sydney, Australia
| | - Jane Young
- School of Public Health, University of Sydney, Sydney, Australia
| | - Ronald M Epstein
- Department of Family Medicine, University of Rochester Medical Centre, USA
| | - Adam Walczak
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, University of Sydney, Sydney, Australia
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Bakitas M, Lyons KD, Hegel MT, Ahles T. Oncologists' perspectives on concurrent palliative care in a National Cancer Institute-designated comprehensive cancer center. Palliat Support Care 2013; 11:415-23. [PMID: 23040412 PMCID: PMC3797174 DOI: 10.1017/s1478951512000673] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The purpose of this study was to understand oncology clinicians' perspectives about the care of advanced cancer patients following the completion of the ENABLE II (Educate, Nurture, Advise, Before Life Ends) randomized clinical trial (RCT) of a concurrent oncology palliative care model. METHOD This was a qualitative interview study of 35 oncology clinicians about their approach to patients with advanced cancer and the effect of the ENABLE II RCT. RESULTS Oncologists believed that integrating palliative care at the time of an advanced cancer diagnosis enhanced patient care and complemented their practice. Self-assessment of their practice with advanced cancer patients comprised four themes: (1) treating the whole patient, (2) focusing on quality versus quantity of life, (3) “some patients just want to fight,” and (4) helping with transitions; timing is everything. Five themes comprised oncologists' views on the complementary role of palliative care: (1) “refer early and often,” (2) referral challenges: “Palliative” equals “hospice”; “Heme patients are different,” (3) palliative care as consultants or co-managers, (4) palliative care “shares the load,” and (5) ENABLE II facilitated palliative care integration. SIGNIFICANCE OF RESULTS Oncologists described the RCT as holistic and complementary, and as a significant factor in adopting concurrent care as a standard of care.
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Affiliation(s)
- Marie Bakitas
- Department of Anesthesiology, Section of Palliative Medicine, Geisel School of Medicine, Hanover, NH
- Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | | | - Mark T. Hegel
- Department of Psychiatry, Geisel School of Medicine, Hanover, NH
| | - Tim Ahles
- Department of Psychiatry, Memorial Sloan-Kettering Cancer Center, NY
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Mackenzie LJ, Carey ML, Paul CL, Sanson-Fisher RW, D'Este CA. Do we get it right? Radiation oncology outpatients' perceptions of the patient centredness of life expectancy disclosure. Psychooncology 2013; 22:2720-8. [PMID: 23801643 DOI: 10.1002/pon.3337] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Revised: 03/26/2013] [Accepted: 05/20/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVE A patient-centred approach to discussing life expectancy with cancer patients is recommended in Western countries. However, this approach to eliciting and meeting patient preferences can be challenging for clinicians. The aims of this study were the following: (i) to examine cancer patients' preferences for life expectancy disclosure; and (ii) to explore agreement between cancer patients' preferences for, and perceived experiences of, life expectancy disclosure. METHODS Cancer patients undergoing radiotherapy treatment in metropolitan Australia completed a cross-sectional touchscreen computer survey including optional questions about their life expectancy disclosure preferences and experiences. RESULTS Of the 208 respondents, 178 (86%) indicated that they would prefer their clinician to ask them before discussing life expectancy, and 30 (14%) indicated that they would prefer others (i.e. clinicians, family) to decide whether they were given life expectancy information. Of the 175 respondents who were classified as having a self- determined or other-determined disclosure experience, 105 (60%) reported an experience of life expectancy disclosure that was in accordance with their preferences. Cohen's κ was -0.04 (95% CI, -0.17, 0.08), indicating very poor agreement between patients' preferences for and perceived experiences of life expectancy disclosure (p = 0.74). CONCLUSIONS In light of patient-centred prognosis disclosure guidelines, our findings of a majority preference for, and experience of, a self-determined approach to life expectancy disclosure amongst radiation oncology patients are encouraging. However, poor agreement between preferences and experiences highlights that additional effort from clinicians is required in order to achieve a truly patient-centred approach to life expectancy disclosure.
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Affiliation(s)
- Lisa J Mackenzie
- Priority Research Centre for Health Behaviour, School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Callaghan, New South Wales, Australia; Hunter Medical Research Institute, Newcastle, Australia
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Salmon P, Young B. The validity of education and guidance for clinical communication in cancer care: evidence-based practice will depend on practice-based evidence. PATIENT EDUCATION AND COUNSELING 2013; 90:193-9. [PMID: 22632737 DOI: 10.1016/j.pec.2012.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 04/03/2012] [Accepted: 04/13/2012] [Indexed: 05/12/2023]
Abstract
OBJECTIVE The validity of clinical communication skills education and guidance for cancer care is sometimes portrayed as self-evident. This view needs re-examination in light of critiques of the concept of communication skills. METHODS We critically examine principles that steer communication teaching and guidance in cancer care and draw on research that can inform the next generation of development in this field. RESULTS Unlike other areas of clinical skills, communication is highly contested. Any instance of communication is open to multiple interpretations; expert principles of communication are imprecise and often contradictory. The concept of communication skills will constrain development, because of its implication that universal, expert-defined components of communication are the building blocks of clinical relationships. Research on communication in practice indicates insights that could enrich future education and guidance. CONCLUSIONS Communication experts have more to learn from practitioners and patients than is commonly appreciated. Inductive, qualitative research should incorporate patient and practitioner perspectives as well as observations of communication. PRACTICE IMPLICATIONS Solutions to communication dilemmas might be found in detailed study of communication in practice, rather than in current expert principles. Incorporating such evidence will help to ensure the continued authority of communication curricula and guidance as evidence-based and patient-centred.
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Affiliation(s)
- Peter Salmon
- Division of Clinical Psychology, University of Liverpool, Liverpool, UK.
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Thorne SE, Stajduhar KI. Patient perceptions of communications on the threshold of cancer survivorship: implications for provider responses. J Cancer Surviv 2012; 6:229-37. [DOI: 10.1007/s11764-012-0216-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 02/16/2012] [Indexed: 12/31/2022]
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Salmon P, Hill J, Ward J, Gravenhorst K, Eden T, Young B. Faith and protection: the construction of hope by parents of children with leukemia and their oncologists. Oncologist 2012; 17:398-404. [PMID: 22371382 DOI: 10.1634/theoncologist.2011-0308] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Oncologists are criticized for fostering unrealistic hope in patients and families, but criticisms reflect a perspective that is oversimplified and "expert" guidance that is ambiguous or impractical. Our aim was to understand how pediatric oncologists manage parents' hope in practice and to evaluate how they address parents' needs. METHODS Participants were 53 parents and 12 oncologists whom they consulted across six U.K. centers. We audio recorded consultations approximately 1-2, 6, and 12 months after diagnosis. Parents were interviewed after each consultation to elicit their perspectives on the consultation and clinical relationship. Transcripts of consultations and interviews were analyzed qualitatively. RESULTS Parents needed hope in order to function effectively in the face of despair, and all wanted the oncologists to help them be hopeful. Most parents focused hope on the short term. They therefore needed oncologists to be authoritative in taking responsibility for the child's long-term survival while cushioning parents from information about longer-term uncertainties and being positive in providing information about short-term progress. A few parents who could not fully trust their oncologist were unable to hope. CONCLUSION Oncologists' pivotal role in sustaining hope was one that parents gave them. Most parents' "faith" in the oncologist allowed them to set aside, rather than deny, their fears about survival while investing their hopes in short-term milestones. Oncologists' behavior generally matched parents' needs, contradicting common criticisms of oncologists. Nevertheless, oncologists need to identify and address the difficulty that some parents have in fully trusting the oncologist and, consequently, being hopeful.
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Affiliation(s)
- Peter Salmon
- Division of Clinical Psychology, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool L69 3GB, UK.
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Graugaard PK, Rogg L, Eide H, Uhlig T, Loge JH. Ways of providing the patient with a prognosis: a terminology of employed strategies based on qualitative data. PATIENT EDUCATION AND COUNSELING 2011; 83:80-86. [PMID: 20570463 DOI: 10.1016/j.pec.2010.04.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Revised: 04/04/2010] [Accepted: 04/22/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To identify, denote, and structure strategies applied by physicians and patients when communicating information about prognosis. METHODS A descriptive qualitative study based on audiotaped physician-patient encounters between 23 haematologists and rheumatologists, and 89 patients in Oslo. Classification of identified prognostic sequences was based on consensus. RESULTS Physicians seldom initiated communication with patients explicitly to find out their overall preferences for prognostic information (metacommunication). Instead, they used sounding and implicit strategies such as invitations, implicatures, and non-specific information that might result in further disclosure of information if requested by the patients. In order to balance the obligation to promote hope and provide (true) information, they used strategies such as bad news/good news spirals, authentications, safeguardings, and softenings. Identified strategies applied by the patients to adjust the physician-initiated prognostic information to their needs were requests for specification, requests for optimism, and emotional warnings. PRACTICE IMPLICATIONS The study presents an empirically derived terminology so that clinicians and educators involved in medical communication can increase their awareness of prognostic communication. Based on qualitative data obtained from communication excerpts, we suggest that individual clinicians and researchers evaluate the possible benefits of more frequent use of metacommunication and explicit prognostic information.
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Fine E, Reid MC, Shengelia R, Adelman RD. Directly observed patient-physician discussions in palliative and end-of-life care: a systematic review of the literature. J Palliat Med 2010; 13:595-603. [PMID: 20491550 DOI: 10.1089/jpm.2009.0388] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To review studies that used direct observation (i.e., videotaping or audiotaping) methods in palliative/end-of-life care communication research. DESIGN Descriptive thematic analysis. SETTING Multinational studies were conducted in both the outpatient and inpatient setting. MEASUREMENTS Extensive bibliographic searches (January 1, 1998 to July 31, 2009) of English-language literature involving physician-patient (or physician-family) interactions were conducted and augmented by reviews of reference listings. Three investigators independently abstracted key information from each article. RESULTS Of the 20 retained articles, most enrolled young-old participants (mean age, 60 years) who were white and had a cancer diagnosis. Patient/family participation rates ranged from 68% to 89% demonstrating feasibility of this approach when studying palliative/end-of-life care communication issues. Four common themes were identified: (1) physicians focus on medical/technical and avoid emotional/quality of life issues; (2) sensitive topics are perceived by physicians to take longer to discuss and often do take longer to discuss; (3) physicians dominate discussions; and (4) patient/family satisfaction is associated with supportive physician behaviors. CONCLUSIONS This study demonstrates that direct observation methods can be feasibly used when studying physician-patient/physician-family communication in palliative/end-of-life care, but few investigations have utilized this approach. This article highlights areas that need improvement, including physicians' ability to address patient/family emotional issues and provide what patients and families find most satisfying (participation and support). A particular focus on older patients and patients with end-stage or late-stage chronic (noncancer) illness, the adaptation/application of existing communication measurement tools to capture palliative care communication issues, and development of corresponding outcome measures to assess impact is now needed.
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Affiliation(s)
- Elizabeth Fine
- Department of Geriatrics, Center for Geriatrics, University Hospitals, Case Medical Center, Cleveland, Ohio 44106, USA.
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Quinn GP, Vadaparampil ST, King L, Miree CA, Wilson C, Raj O, Watson J, Lopez A, Albrecht TL. Impact of physicians' personal discomfort and patient prognosis on discussion of fertility preservation with young cancer patients. PATIENT EDUCATION AND COUNSELING 2009; 77:338-43. [PMID: 19796912 DOI: 10.1016/j.pec.2009.09.007] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Revised: 09/02/2009] [Accepted: 09/09/2009] [Indexed: 05/22/2023]
Abstract
OBJECTIVE This study sought to determine if physician's personal discomfort with the topic of FP and a patient's prognosis would have an impact on the likelihood of discussing FP with cancer patients. METHODS Data from larger studies of qualitative semi-structured interviews with pediatric and adult oncologists were analyzed using grounded theory and crystallizing immersion method to examine the themes of "personal comfort" and "patient prognosis" in relation to discussion. RESULTS Results showed that, across both physician types, the majority of respondents' personal comfort with the topic of FP was related to the likelihood of discussion. Personal discomfort manifested as: (a) lack of knowledge; (b) language/cultural barriers; (c) perception that subject of FP adds more stress to situation; (d) general uncertainty about success of FP methods. Data also indicate physicians do not feel discussions are appropriate for patients with poor prognosis. CONCLUSION Despite the ASCO guidelines suggesting physicians should discuss FP with all patients, the majority of physicians are not following these guidelines. PRACTICE IMPLICATIONS Improved training on recognition of such biases and communication strategies may improve the quality and frequency of such discussions. Involving the entire healthcare team in discussions may alleviate the need for physicians to have sole responsibility.
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Affiliation(s)
- Gwendolyn P Quinn
- Moffitt Cancer Center, 12902 Magnolia Drive, MRC-CANCONT, Tampa, FL 33612, USA.
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Del Vento A, Bavelas J, Healing S, MacLean G, Kirk P. An experimental investigation of the dilemma of delivering bad news. PATIENT EDUCATION AND COUNSELING 2009; 77:443-449. [PMID: 19819095 DOI: 10.1016/j.pec.2009.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 09/09/2009] [Accepted: 09/11/2009] [Indexed: 05/28/2023]
Abstract
OBJECTIVE This randomly controlled experiment tested a theory of how experienced physicians solve the dilemma of communicating bad news by using implicit language. METHODS 8 physicians delivered both bad and good news to 16 analogue patients. Microanalysis of their news delivery reliably identified departures from explicit language. RESULTS As predicted, the physicians used implicit language at a significantly higher rate when delivering bad news than good news. For bad news, they tended to use alternative terms for the diagnosis, to qualify their evaluation, to underemphasize certainty, and to subtly separate the patient from the disease. The evidence both within and after the interview indicated that recipients still understood the bad news. CONCLUSION (1) The skilful use of implicit language is a solution to the dilemma of honest but not harsh communication of bad news. (2) Experimental methods can complement surveys and qualitative studies for investigating bad news delivery by providing a theoretical foundation and controlled conditions. PRACTICE IMPLICATIONS Physicians can deliver bad news honestly without being blunt by skilfully incorporating implicit language. The theory, data, and examples presented here provide insights into the nature and functions of implicit language, from which students and practitioners can develop their individual styles.
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Lee SY, Hung CL, Lee JH, Shih SC, Weng YL, Chang WH, Ho YH, Huang WC, Lai YL. Attaining Good End-of-Life Care in Intensive Care Units in Taiwan—The Dilemma And the Strategy. INT J GERONTOL 2009. [DOI: 10.1016/s1873-9598(09)70017-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Chaturvedi SK, Loiselle CG, Chandra PS. Communication with relatives and collusion in palliative care: a cross-cultural perspective. Indian J Palliat Care 2009; 15:2-9. [PMID: 20606848 PMCID: PMC2886207 DOI: 10.4103/0973-1075.53485] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Handling collusion among patients and family members is one of the biggest challenges that palliative care professionals face across cultures. Communication with patients and relatives can be complex particularly in filial cultures where families play an important role in illness management and treatment decision-making. Collusion comes in different forms and intensity and is often not absolute. Some illness-related issues may be discussed with the patient, whereas others are left unspoken. Particularly in palliative care, the transition from curative to palliative treatment and discussion of death and dying are often topics involving collusion. Communication patterns may also be influenced by age, gender, age, and family role. This paper outlines different types of collusion and how collusion manifests in Indian and Western cultures. In addition, promising avenues for future research are presented.
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Affiliation(s)
- Santosh K. Chaturvedi
- Department of Psychiatry, Professor & Head, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Carmen G. Loiselle
- Department of McGill University Oncology Nursing, Associate Professor, McGill School of Nursing, CIHR PORT Program Leader, Montreal, Quebec, Canada
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Rodriguez KL, Gambino FJ, Butow PN, Hagerty RG, Arnold RM. 'It's going to shorten your life': framing of oncologist-patient communication about prognosis. Psychooncology 2008; 17:219-25. [PMID: 17575562 DOI: 10.1002/pon.1223] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In this qualitative study, we used grounded theory techniques to analyze transcripts of 29 first-time encounters between oncologists and patients referred to them with previously diagnosed, incurable cancer. We found that 23 (79%) of the transcripts included 166 examples of prognostic talk. The language used ranged from general to personal, with 25% of statements mentioning no patients (e.g., 'the tumor will usually come back'), 13% mentioning patients other than the current patient (e.g., 'some patients with tumor response will be around for 2-5 years'), 11% mentioning the current patient in the context of others (e.g., 'on average, people like you live a couple of years'), and 51% directly focusing on the patient (e.g., 'this thing's going to kill you eventually'). More statements pertained to treatment-related prognosis than to disease-related prognosis (67 versus 33%). While 31% of statements focused on negative outcomes (loss framing), the remainder either focused on positive outcomes (gain framing) or discussed a combination of positive and negative outcomes (mixed framing). When discussions focused on negative outcomes, general and indirect language was commonly used, perhaps to buffer the patient from news of the poor prognosis.
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Affiliation(s)
- Keri L Rodriguez
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240-1000, USA.
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Don't leave me alone! Inter-professional documentation relating to the effects of time spent in the communication of information to lung cancer patients regarding their status. Eur J Oncol Nurs 2008; 12:393-7. [PMID: 18502175 DOI: 10.1016/j.ejon.2008.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Revised: 02/05/2008] [Accepted: 02/16/2008] [Indexed: 11/22/2022]
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Patient-oncologist communication in advanced cancer: predictors of patient perception of prognosis. Support Care Cancer 2008; 16:1049-57. [PMID: 18196288 DOI: 10.1007/s00520-007-0372-2] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Accepted: 12/06/2007] [Indexed: 10/22/2022]
Abstract
GOALS OF WORK Advanced cancer patients' perceptions of prognosis, which are often overly optimistic compared to oncologist estimates, influence treatment preferences. The predictors of patients' perceptions and the effect of oncologist communication on patient understanding are unclear. This study was designed to identify the communication factors that influence patient-oncologist concordance about chance of cure. MATERIALS AND METHODS We analyzed audiorecorded encounters between 51 oncologists and 141 advanced cancer patients with good (n = 69) or poor (n = 72) concordance about chance of cure. Encounters were coded for communication factors that might influence oncologist-patient concordance, including oncologist statements of optimism and pessimism. MAIN RESULTS Oncologists made more statements of optimism (mean = 3.3 per encounter) than statements of pessimism (mean = 1.2 per encounter). When oncologists made at least one statement of pessimism, patients were more likely to agree with their oncologist's estimated chance of cure (OR = 2.59, 95%CI = 1.31-5.12). Statements of optimism and uncertainty were not associated with an increased likelihood that patients would agree or disagree with their oncologists about chance of cure. CONCLUSIONS Communication of pessimistic information to patients with advanced cancer increases the likelihood that patients will report concordant prognostic estimates. Communication of optimistic information does not have any direct effect. The best communication strategy to maximize patient knowledge for informed decision making while remaining sensitive to patients' emotional needs may be to emphasize optimistic aspects of prognosis while also consciously and clearly communicating pessimistic aspects of prognosis.
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