Assessment of palliative care cancer patients' most important concerns

Tools for guiding interventions to address patient-perceived multidimensional unmet healthcare needs in palliative care: systematic literature review

CONTEXT

The unmet needs of patients with advanced disease are indicative of the patient centredness of healthcare. By tracking unmet needs in clinical practice, palliative interventions are aligned with patient priorities, and clinicians receive support in intervention delivery decisions for patients with overlapping, complex needs.

OBJECTIVE

Identify tools used in everyday clinical practice for the purpose of identifying and addressing unmet healthcare needs for patients with advanced disease.

METHODS

We conducted PubMed and Cumulative Index of Nursing and Allied Health Literature searches to include studies published between 1 January 2008 and 21 April 2020. Three concepts were used in constructing a search statement: (1) patient need, (2) validated instrument and (3) clinical practice. 2313 citations were reviewed according to predefined eligibility, exclusion and inclusion criteria. Data were collected from 17 tools in order to understand how instruments assess unmet need, who is involved in tool completion, the psychometric validation conducted, the tool's relationship to delivering defined palliative interventions, and the number of palliative care domains covered.

RESULTS

The majority of the 17 tools assessed unmet healthcare needs and had been validated. However, most did not link directly to clinical intervention, nor did they facilitate interaction between clinicians and patients to ensure a patient-reported view of unmet needs. Half of the tools reviewed covered ≤3 dimensions of palliative care. Of the 17 tools evaluated, 4 were compared in depth, but all were determined to be insufficient for the specific clinical applications sought in this research.

CONCLUSION

A new, validated tool is needed to track unmet healthcare needs and guide interventions for patients with advanced disease.

Nutrition in palliative care: issues, perceptions and opportunities to improve care for patients

Dietary advice, the provision of timely nutritional support and the alleviation of diet-related issues, should be an essential component of a holistic approach to palliative and end-of-life care, adjusted to account for the stage in the patient's journey, including prognosis. With an ageing population and increasing numbers of people living with not just one life-limiting disease but several, the dietary management of these patients is becoming more complex. This article considers the issues patients and families experience, how nurses can play a key role in identifying and alleviating nutrition- and diet-related issues in palliative care, including the use of tools to screen, assess and guide nutrition conversations and interventions. The content of the article is mostly drawn from the literature relating to palliative cancer care, knowledge derived from stakeholder engagement, clinical observations in a dietetic role in a hospice setting and qualitative research on the role of diet in palliative care as perceived by patients, carers, and health professionals.

A prospective, randomized trial of patient-reported outcome measures to drive management decisions in hematology and oncology

Background

Clinicians have limited time during patient encounters which can result in patients' concerns not being addressed. This study's objective was to test whether an electronic patient-reported outcome quality of life tool (PROQOL) in which patients identify their primary concern during clinic visits improves cancer patient quality of life (QOL).

Patients and methods

This single center non-blinded prospective clinical trial randomized patients (2:1) to PROQOL versus usual care (UC). Two patient cohorts were enrolled: those with hematologic malignancies (multiple myeloma [MM] or light chain amyloidosis [AL]) and solid tumors (head and neck [H/N] or gynecologic [GYN] malignancies). Primary endpoint was patient-reported QOL at 12 months measured by a single-item Linear Analog Self-Assessment. Value to patients and impact on clinician workflow was measured using a "was it worth it" survey. The study was powered to detect a 0.5 standard deviation difference between groups.

Results

Overall 383 patients were enrolled, 171 with MM, 62 AL, 113 GYN, and 37 H/N between July 2016 and April 2018, with 12-month follow-up. There were 171 (44.6%) male patients and median age was 62 years (range 31-87). The most often selected concern was physical health (30.9%), and second was cancer diagnosis and treatment (29.1%). Mean QOL was 7.12 for PROQOL and 6.98 for UC (0-10 scale) at 12 months, with no between-group difference overall (p = 0.56) or within hematologic or solid tumor cohorts, respectively. Among patients, 74% thought the PROQOL tool was worthwhile, 86% would choose PROQOL again, and 81% would recommend it to others. Among clinicians, 95% responded that PROQOL was worthwhile and did not think that PROQOL negatively impacted their workflow.

Conclusions

Although we did not demonstrate a QOL difference between PROQOL and UC groups; the PROQOL tool held considerable value in identifying patients' main concerns over time and was worthwhile for patients and clinicians.

Prostate cancer survivor capacity to engage in survivorship self-management: a comparison of perceptions between oncology specialists, primary care, and survivors

PURPOSE

The rapidly increasing number of prostate cancer survivors in tandem with a forthcoming shortage of oncology specialists in our health system poses a barrier to ensuring that high-quality survivorship care is available to support this population. As such, there is a need to consider ways to optimize survivorship care, while taking health system constraints into account. The purpose of this study is to explore the perceptions of survivorship self-management between oncology specialists, primary care providers (PCPs), and survivors themselves.

METHODS

A single cross-sectional survey, relating to how prostate cancer survivorship care could be improved, was administered to each group.

RESULTS

Two hundred forty-three participants (N = 206 survivors, N = 10 oncology specialists, N = 27 PCPs) completed the study survey. Most PCPs (90%) and oncology specialists (84%) perceived that an opportunity for prostate cancer survivors to have an expanded role in their care would be beneficial. Nearly half (49%) of survivors reported that it would be beneficial to have an expanded role in their survivorship care with only 11% indicating that it would not be beneficial at all.

CONCLUSIONS

Barriers to developing this model involve limited oncology specialist time to execute survivorship plans, limited communication between oncology specialists and PCPs, and a lack of primary care and survivor education targeted specifically to prostate cancer survivorship.

Care plus study: a multi-site implementation of early palliative care in routine practice to improve health outcomes and reduce hospital admissions for people with advanced cancer: a study protocol

Background

Current international consensus is that ‘early’ referral to palliative care services improves cancer patient and family carer outcomes. In practice, however, these referrals are not routine. An approach which directly addresses identified barriers to early integration of palliative care is required. This protocol details a trial of a standardized model of early palliative care (Care Plus) introduced at key defined, disease-specific times or transition points in the illness for people with cancer. Introduced as a ‘whole of system’ practice change for identified advanced cancers, the key outcomes of interest are population health service use change.

The aims of the study are to examine the effect of Care Plus implementation on (1) acute hospitalisation days in the last 3 months of life; (2) timeliness of access to palliative care; (3) quality and (4) costs of end of life care; and (5) the acceptability of services for people with advanced cancer.

Methods

Multi-site stepped wedge implementation trial testing usual care (control) versus Care Plus (practice change). The design stipulates ‘control’ periods when usual care is observed, and the process of implementing Care Plus which includes phases of planning, engagement, practice change and evaluation. During the practice change phase, all patients with targeted advanced cancers reaching the transition point will, by default, receive Care Plus.

Health service utilization and unit costs before and after implementation will be collated from hospital records, and state and national health service administrative datasets. Qualitative data from patients, consumers and clinicians before and after practice change will be gathered through interviews and focus groups.

Discussion

The study outcomes will detail the impact and acceptability of the standardized integration of palliative care as a practice change, including recommendations for ongoing sustainability and broader implementation.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN 12619001703190. Registered 04 December 2019.

Referral criteria to palliative care for patients with respiratory disease: a systematic review

BACKGROUND

Advanced non-malignant respiratory diseases are associated with significant patient morbidity, yet access to palliative care occurs late, if at all.

AIM

To examine referral criteria for palliative care among patients with advanced non-malignant respiratory disease, with a view to developing a standardised set of referral criteria.

DESIGN

Systematic review of all studies reporting on referral criteria to palliative care in advanced non-malignant respiratory disease, with a focus on chronic obstructive pulmonary disease and interstitial lung disease.

DATA SOURCES

A systematic review conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses guideline was undertaken using electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed).

RESULTS

Searches yielded 2052 unique titles, which were screened for eligibility resulting in 62 studies addressing referral criteria to palliative care in advanced non-malignant respiratory disease. Of 18 categories put forward for referral to palliative care, the most commonly discussed factors were hospital use (69% of papers), indicators of poor respiratory status (47%), physical and emotional symptoms (37%), functional decline (29%), need for advanced respiratory therapies (27%), and disease progression (26%).

CONCLUSION

Clinicians consider referral to specialist palliative care for a wide range of disease- and needs-based criteria. Our findings highlight the need to standardise palliative care access by developing consensus referral criteria for patients with advanced non-malignant respiratory illnesses.

Survey of palliative care providers' needs, perceived roles, and ethical concerns about addressing cancer family history at the end of life

OBJECTIVE

Palliative care providers may face questions from patients and relatives regarding the heritability of cancers. Implications of such discussions for providers have been little explored. This study aimed to gather palliative care providers' views on their main needs, roles, and ethical concerns regarding cancer family history discussions.

METHOD

The palliative care providers who participated in the 2015 and 2017 annual meetings of the Quebec Palliative Care Association were approached to complete a web-based questionnaire. Study participants answered the questionnaire between November 2016 and July 2017. They were asked to identify the most facilitating factor for cancer family history discussions, as well as their most important knowledge needs, potential role, and ethical concerns. Descriptive analyses were conducted.

RESULTS

Ninety-four palliative care providers answered the questionnaire. Access to specialized resources to obtain information and protocols or guidelines were considered the most facilitating factors for cancer family history discussions by 32% and 20% of providers, respectively. Knowledge of hereditary cancers was the most relevant educational need for 53%. Thirty-eight per cent considered essential to be informed about their rights and duties regarding cancer family history discussions. Being attentive to patients' concerns and referring families to appropriate resources were identified as the most relevant roles for palliative care providers by 47% and 34% of respondents, respectively. Fifty-eight per cent agreed that cancer family history discussions should be initiated only if beneficial to family members.

SIGNIFICANCE OF RESULTS

Education on hereditary cancers made consensus among palliative care providers as the most important knowledge need regarding discussing cancer family history at the end of life. Nonetheless, other less commonly expressed needs, including access to genetics specialists, protocols, or guidelines, and awareness of provider rights and duties concerning such discussions, deserve attention. Answering providers' needs might help optimize cancer predisposition management in palliative care.

Self-management of patients with advanced cancer: A systematic review of experiences and attitudes

BACKGROUND

Patients with advanced cancer are increasingly expected to self-manage. Thus far, this topic has received little systematic attention.

AIM

To summarise studies describing self-management strategies of patients with advanced cancer and associated experiences and personal characteristics. Also, to summarise attitudes of relatives and healthcare professionals towards patient self-management.

DESIGN

A systematic review including non-experimental quantitative and qualitative studies. Data were analysed using critical interpretive synthesis. Included studies were appraised on methodological quality and quality of reporting.

DATA SOURCES

MEDLINE, Embase, Cochrane Central, PsycINFO, CINAHL, Web of Science and Google Scholar (until 11 June 2019).

RESULTS

Of 1742 identified articles, 31 moderate-quality articles describing 8 quantitative and 23 qualitative studies were included. Patients with advanced cancer used self-management strategies in seven domains: medicine and pharmacology, lifestyle, mental health, social support, knowledge and information, navigation and coordination and medical decision-making (29 articles). Strategies were highly individual, sometimes ambivalent and dependent on social interactions. Older patients and patients with more depressive symptoms and lower levels of physical functioning, education and self-efficacy might have more difficulties with certain self-management strategies (six articles). Healthcare professionals perceived self-management as desirable and achievable if based on sufficient skills and knowledge and solid patient-professional partnerships (three articles).

CONCLUSION

Self-management of patients with advanced cancer is highly personal and multifaceted. Strategies may be substitutional, additional or even conflicting compared to care provided by healthcare professionals. Self-management support can benefit from an individualised approach embedded in solid partnerships with relatives and healthcare professionals.

Rehabilitation in palliative care: a qualitative study of team professionals

OBJECTIVES

There has been a recent drive to embed rehabilitation within palliative care. The concept of rehabilitative palliative care has been advocated to help patients preserve function and independence, through greater patient enablement and self-management. Such an approach requires engagement from all members of the palliative care team. There is a lack of understanding of such viewpoints. The objective of this research was to explore hospice-based palliative care professionals' understanding and perceptions of rehabilitation.

METHODS

Qualitative semi-structured interviews were conducted. Eighteen hospice-based healthcare professionals were recruited from a hospice in central Scotland. Interviews were audio-recorded, transcribed and thematically analysed.

RESULTS

Overall, participants clearly articulated the underlying values and benefits of rehabilitative palliative care. Emphasis was placed on ensuring that rehabilitation was appropriately tailored to each individual patient. There was more ambiguity regarding the pragmatic implementation of rehabilitative palliative care, with a number of barriers and facilitators identified.

CONCLUSIONS

The findings suggest that hospice-based palliative care professionals would be receptive to further implementation of rehabilitative palliative care. A lack of conceptual clarity among palliative care professionals may be a barrier to the effective implementation of rehabilitative palliative care. At an organisational level, this would require clarification of the approach, and additional training involving all members of the multidisciplinary team.

[HeiMeKOM (Heidelberg Milestones Communication): development of an interprofessional intervention for improvement of communication in patients with limited prognosis]

BACKGROUND

The care for patients with advanced disease and limited prognosis and their relatives is complex and characterized by insufficient communication and lack of coordination and continuity.

AIM

Development of an interprofessional, practice-guided concept of longitudinally structured communication with the goal of fostering communication, improving quality of life and facilitating early integration of palliative care.

METHODS

Multi-level process starting from a draft with discussion and approval within the multiprofessional team and correlation with interviews with patients and relatives. Preparation of a comprehensive concept with review of the literature, problem analysis, theoretical foundation, goal setting and intervention components. Discussion of suitability for daily use, adaptation and further development of the concept.

RESULTS AND CONCLUSIONS

Concept with the following components: interprofessional communication training, structured conversations at defined moments in a tandem of physician and nurse with patient and relative, follow-up conversations conducted by the nurse, and respective instruments (conversation protocol, question prompt list, memory cards). Only iterative discussion with and the approval of patients, relatives and the multiprofessional team and their approval will put the concept into practice.

Self-efficacy for coping: utility of the Cancer behavior inventory (Italian) for use in palliative care

Background

Newer models of palliative and supportive cancer care view the person as an active agent in managing physical and psychosocial challenges. Therefore, personal efficacy is an integral part of this model. Due to the lack of instruments in Italian to assess coping self-efficacy, the present study included the translation and validation of the Italian version of the Cancer Behavior Inventory–Brief (CBI-B/I) and an initial analysis of the utility of self-efficacy for coping in an Italian sample of palliative care patients.

Methods

216 advanced cancer patients who attended palliative care clinics were enrolled. The CBI-B/I was administered along with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), the Mini Mental Adjustment to Cancer Scale (Mini-MAC), the Cancer Concerns Checklist (CCL), and the Hospital Anxiety and Depression Scale (HADS). The Eastern Cooperative Oncology Group Performance Status (ECOG-PS) ratings of functional capacity were completed by physicians.

Results

Factor analysis confirmed that the structure of the CBI-B/I was consistent with the English version. Internal consistency reliability and significant correlations with the EORTC QLQ-C30, Mini-MAC, and HADS supported the concurrent validity of the CBI-B/I. Differences in CBI-B/I scores for high versus low levels of the CCL and ECOG-PS supported the clinical utility of the CBI-B/I.

Conclusions

The CBI-B/I has strong psychometric properties and represents an important addition to newer model of palliative and supportive care. In order to improve clinical practice, the CBI-B/I could be useful in identifying specific self-efficacy goals for coping in structured psychosocial interventions.

Combined exercise and nutritional rehabilitation in outpatients with incurable cancer: a systematic review

PURPOSE

The optimal components for rehabilitation in patients with incurable cancer are unclear. However, principles of exercise and nutrition-based interventions used in cancer cachexia may be applied usefully to this population of cancer patients. This systematic review examines current evidence for rehabilitation combining exercise and nutritional support in patients with incurable cancer.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched. Eligible studies included patients with incurable cancer and rehabilitation programmes combining exercise and nutritional interventions. Studies of cancer survivors, curative treatments, reviews, case note reviews, protocols and abstracts were excluded. Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were applied to patient-important outcomes.

RESULTS

Of the 2424 search results, 67 abstracts were reviewed and 24 full texts examined. Eight studies (n = 685) were included comprising two randomised control trials, three prospective, one exploratory and two secondary analyses. All examined multi-modal outpatient programmes. GRADE analysis revealed moderate evidence (B) for improvements in depression and physical endurance, low-quality evidence (C) for quality of life and fatigue and very low-quality evidence (D) for overall function and nutritional status.

CONCLUSION

There are limited data for multi-modal rehabilitation programmes combining exercise and nutritional interventions in patients with incurable cancer. However, studies to date report improvements in multiple domains, most notably physical endurance and depression scores. This supports the concept that multi-modal rehabilitation incorporating principles of cachexia management may be appropriate for the wider group of patients with incurable cancer. Further, high-quality studies are needed to define the optimal approach and outcome measures.

Feeling Heard and Understood in the Hospital Environment: Benchmarking Communication Quality Among Patients With Advanced Cancer Before and After Palliative Care Consultation

CONTEXT

Maximizing value in palliative care requires continued development and standardization of communication quality indicators.

OBJECTIVES

To describe the basic epidemiology of a newly adopted patient-centered communication quality indicator for hospitalized palliative care patients with advanced cancer.

METHODS

Cross-sectional analysis of 207 advanced cancer patients who received palliative care consultation at two medical centers in the U.S. Participants completed the Heard & Understood quality indicator immediately before and the day after the initial palliative care consultation: Over the past two days ["24 hours" for the post-consultation version], how much have you felt heard and understood by the doctors, nurses, and hospital staff?-completely/quite a bit/moderately/slightly/not at all. We categorized completely as indicating ideal quality.

RESULTS

Approximately one-third indicated ideal Heard & Understood quality before palliative care consultation. Age, financial security, emotional distress, preferences for comfort-longevity tradeoffs at the end of life, and prognosis expectations were associated with preconsultation quality. Among those with less-than-ideal quality at baseline, 56% rated feeling more Heard & Understood the day after palliative care consultation. The greatest prepost improvement was among people who had unformed end-of-life treatment preferences or who reported having no idea about their prognosis at baseline.

CONCLUSION

Most patients felt incompletely heard and understood at the time of referral to palliative care consultation, and more than half of the patients improved after consultation. Feeling heard and understood is an important quality indicator sensitive to interventions to improve care and key variations in the patient experience.

Challenges in supporting lay carers of patients at the end of life: results from focus group discussions with primary healthcare providers

Background

Family caregivers (FCGs) of patients at the end of life (EoL) cared for at home receive support from professional and non-professional care providers. Healthcare providers in general practice play an important role as they coordinate care and establish contacts between the parties concerned. To identify potential intervention targets, this study deals with the challenges healthcare providers in general practice face in EoL care situations including patients, caregivers and networks.

Methods

Focus group discussions with general practice teams in Germany were conducted to identify barriers to and enablers of an optimal support for family caregivers. Focus group discussions were analysed using content analysis.

Results

Nineteen providers from 11 general practices took part in 4 focus group discussions. Participants identified challenges in communication with patients, caregivers and within the professional network. Communication with patients and caregivers focused on non-verbal messages, communicating at an appropriate time and perceiving patient and caregiver as a unit of care. Practice teams perceive themselves as an important part of the healthcare network, but also report difficulties in communication and cooperation with other healthcare providers.

Conclusion

Healthcare providers in general practice identified relational challenges in daily primary palliative care with potential implications for EoL care. Communication and collaboration with patients, caregivers and among healthcare providers give opportunities for improving palliative care with a focus on the patient-caregiver dyad. It is insufficient to demand a (professional) support network; existing structures need to be recognized and included into the care.

Assessment of palliative care needs of patients/families living with cancer in a developing country

PURPOSE

The study seeks to assess the care needs of oncology in-patients and clinic attendees or families in two tertiary health institutions.

METHODS

This was a descriptive study which utilised a quantitative survey questionnaire of all cancer patients diagnosed between January 2014 and September 2016 (n = 547) with the return rate (n = 455) representing 82%. The questionnaire explored assessment of palliative care need. These instruments were used, because patients with cancer and their families are reluctant to talk about the disease. Using a questionnaire was therefore the best means of obtaining their full participation. The data were analysed using descriptive statistics to identify the highest need of patients with cancer patients. The study was approved by the two participating hospitals and the Human and Social Sciences Research Ethics of University of KwaZulu-Natal.

FINDINGS

The study found that most common needs of patients were information on possibilities of treatment and side effects (92.8%), diagnosis (91.6%), testing (91.1%) and physical symptoms (90.9%). There were also other needs, such as psychological, spiritual and financial needs, related to factors causing distress to patients and their families following diagnosis of cancer.

CONCLUSIONS

This article focused on needs as expressed by patients and families and offers a useful guide to develop a model for integration of palliative care activities. The findings reveal that patients who are undergoing follow-up care and cancer treatment or investigation are clearly concerned about receiving information on a range of cancer issues. We therefore conclude that patients are able to deal with the disease more effectively when hospitals set up a palliative care team or unit to carry out proper assessment of patients living with cancer.

Top ten concerns burdening people with cancer: Perceptions of patients with cancer and the nurses caring for them

PURPOSE

We examined the concerns that nurses perceive patients to have, whether these are congruent with patients' concerns and whether they vary according to cancer site. We also examined Distress Thermometer scores according to cancer site.

METHOD

A cross-sectional survey design: (i) secondary analysis of an existing Holistic Needs Assessment (HNA) and Distress Thermometer (DT) dataset was used, (ii) a survey of specialist nurse teams to identify their perceptions of patient concerns. Data collected between January 2015 and June 2016 from the HNA database from one NHS Trust in England (n = 1233 patients). Specialist nurse teams for breast, colorectal, gynaecology, skin and urology cancers identified the concerns that they perceived their patients would report.

RESULTS

The HNA showed high internal consistency (Cronbach's alpha 0.86). Across the five cancer sites, nurses identified between 3 and 6 of the top ten concerns (TTC) expressed by patients, with wide variation across cancer sites. Nine of the TTC were significantly associated (p < 0.05) with a specific cancer site. The breast and gynaecological cancer groups both recorded significantly higher median Distress Thermometer scores than the urology, skin and colorectal cancer groups (Kruskall-Wallis χ² (4, n = 1228) 186.695, p=<.01).

CONCLUSIONS

One of the aims of the eHNA is to enable service delivery appropriate to patient needs. Our findings suggest that this will only be achieved if eHNA is examined, and services developed, by individual cancer site. The misconception of patient needs by specialist nurses underscores the importance of review of information provided by patients during consultations.

A longitudinal communication approach in advanced lung cancer: A qualitative study of patients', relatives' and staff's perspectives

Communication and the care of patients with advanced cancer are a dynamic, interactive and challenging process, often characterised in every day practice by discontinuity and lack of coordination. The objective of this study was to explore the patients' and family-caregivers' needs and preferences regarding communication, quality of life and care over the trajectory of disease. The second aim was to assess health professionals' views on a longitudinally structured, forward-thinking communication approach based on defined milestones. A qualitative approach was chosen incorporating semi-structured interviews with nine patients with metastatic lung cancer and nine relatives, and focus groups with 15 healthcare providers from different professions involved in the care of these patients. Patients and relatives described a situation of shock and coping deficits with moments of insufficient communication and lack of continuity in care. Healthcare providers reported the strong need for improvement in communication within the team and between patients and professionals and welcomed the implementation of a longitudinal communication approach. Requirements for the implementation of a longitudinal communication approach include specific communication training with focus on the process that patients and relatives are involved in. Team-building measures and the necessary flexibility to respect individuality in life should be incorporated.

Lack of Patient-Clinician Concordance in Cancer Patients: Its Relation With Patient Variables

CONTEXT

Patients with cancer are bothered by its diagnosis, treatment, and associated uncertainty. Lack of concordance (LOC) of patients' reporting of their symptoms and quality of life (QOL) with that of their clinicians has been observed in cancer care. However, information regarding the reporting of patients' bother due to aspects of cancer experience and their clinicians' assessment is lacking.

OBJECTIVES

The objective was to describe cancer patients' bother due to aspects of their disease experience and explore the concordance (LOC) or a lack thereof between patients' and clinicians' reporting of patients' bother and factors associated with it.

METHODS

Data from a prospective study of cancer patients' symptoms were analyzed. LOC was defined as any discrepancy between patient-clinician pairs in reporting patients' bother due to disease, cancer treatment, comorbidity, and side effects of symptom management. The relation of LOC to patients' QOL and distress was also explored.

RESULTS

Of the 2597 patients analyzed, a perfect concordance was observed in 37%-42%. Clinicians underestimated the severity of bother in 62%-76% of discordant cases. LOC was significantly associated with patient-reported distress and poor QOL. Referral for symptom management was associated with the clinician's rating of patients' bother, and LOC was associated with likelihood of poor compliance with recommendations for symptom management.

CONCLUSION

Majority of clinicians tended to underestimate cancer patients' bother, and this was associated with poor QOL of cancer patients and their distress. Future studies should examine the LOC and its correlates to confirm the results of this study.

A Qualitative Analysis of a Healthcare Professional's Understanding and Approach to Management of Spiritual Distress in an Acute Care Setting

OBJECTIVE

The goal of this study was to explore healthcare professionals' (HCPs') perception of their role in provision of spiritual care, in addition to attempting to identify a simple question(s) to help identify spiritual distress.

BACKGROUND

Spirituality is well recognized as important to whole-person care, particularly in those with terminal illnesses. Understanding the role of front-line providers in the identification and management of spiritual distress, however, remains challenging.

METHODS

Twenty-one HCPs (eight physicians, seven nurses, six social workers) underwent qualitative semi-structured interviews exploring an understanding of spirituality/spiritual distress. HCPs were drawn from inpatient and outpatient settings in a tertiary care facility, and all had experience with patients with terminal illnesses. Interviews were subsequently coded and analyzed for dominant themes.

RESULTS

Essentially all participants spoke of the high importance of spirituality and spiritual care, particularly for those facing end of life. However, the majority of HCPs had difficulty in formulating definitions/descriptions of spiritual care and spiritual distress, in marked contradistinction to the importance they ascribed to this aspect of holistic care. Almost universally provision of spiritual care was seen as critical, yet in the domain of chaplaincy/dedicated spiritual care providers. Reasons frequently cited for HCP's reluctance to provide such care themselves included time available, lack of training and expertise, and the sense that others could do a better job.

DISCUSSION

Despite spirituality being highlighted as important to care, few HCPs felt able to provide this, raising questions around how such care can be encouraged and developed in busy acute care settings.

Validation of the electronic Holistic Needs Assessment

Macmillan Cancer Support UK have developed an electronic Holistic Needs Assessment (eHNA) to: (1) help people living with cancer express all their needs, (2) help those helping them better target support. eHNA consists of 48 items each ranked from zero (no problem) to 10. There has been no psychometric analysis of this tool and so its validity and reliability are untested. The aim of this study was to evaluate the psychometric properties of the eHNA by examining its construct validity. Objectives were to (a) test whether the eHNA measured holistic concerns and (b) analyse the factor structure of the eHNA. Objectives were achieved through a secondary analysis of 5421 responses to eHNA using concurrent application of Rasch analysis and principal component analysis. All the items bar one fit with the Rasch rating model and were equivalently important to people. Differential item functioning was evident according to whether people were described as curative or not. A 12-factor solution explained 46 % variance. Of this the emotional/spiritual factor explained the most variance accounting for 15 %. The eHNA was internally consistent and conceptually coherent with the construct of holistic needs assessment. Clinical focus is best directed to the individual items highlighted by the patient except where patients check too many problems for the clinician to accurately prioritise. In these cases only, the emotional/spiritual factor may help identify appropriate clinical action. Strengths and weaknesses of the analyses are discussed, particularly in relation to ‘at risk’ subsamples such as those classified as non-curative.

Evaluating a new methodology for providing individualized feedback in healthcare on quality of life and its importance, using the WHOQOL-BREF in a community population

PURPOSE

We conducted an evaluation to find out how a novel quality of life (QoL) intervention containing guided individualized feedback was appraised. The importance of QoL was matched with QoL assessment for each subjective dimension, using graphical feedback. We examined whether this information was acceptable, feasible and valued beyond the clinical context, among the community.

METHODS

Using a mixed-methods cross-sectional design, the intervention was piloted with 129 participants from communities and registered in primary care. WHOQOL-BREF and WHOQOL Importance scores were graphically matched by dimension. Results were inspected and interpreted with directed guidance to identify good and poor QoL. We report the post-intervention evaluation of feedback, including qualitative themes. Follow-up interviews among those expecting feedback to be helpful explored potential self-management and healthcare uses.

RESULTS

After feedback, 65 % reported changes in thoughts and perceptions of QoL, often describing insights as self-affirming. Goals or expectations changed for 34 %, and motivation to change was reported. Over 50 % evaluated the feedback as helpful in the short term or for the future. Follow-up interviews endorsed the value of the feedback and its usefulness in sharing with a healthcare professional (92 %), suggesting it would facilitate professionals' understandings of patients and enable health advice to be targeted.

CONCLUSIONS

The benefits of using this novel feedback can be extended to the general population, as directed guidance aids interpretation, thereby saving health service costs. This complex pilot intervention needs testing in a blinded fully randomized controlled trial. Beyond independent self-management, graphs could be used during clinical decision-making.

Using guided individualised feedback to review self-reported quality of life in health and its importance

This pilot study investigated the effects of providing guided, individualised feedback on subjective quality of life (QoL), using results from the multidimensional WHOQOL-BREF profile. Participants (n = 129; 85 chronically ill) were recruited in the community, and primary care. They were randomised to receive written or verbal guidance on interpreting a new graphical summary profile, which simultaneously presented (a) their individual self-ratings of QoL and (b) the importance attributed to each QoL dimension. Before and after feedback, participants completed health status, subjective QoL, QoL Importance, goal-oriented QoL and mood measures. Receiving individualised feedback was associated with increased psychological QoL, with modest effect size. No effects were found for physical, social or environmental QoL or QoL importance, health status, mood or goal-oriented QoL. There were no differences between modes of delivering guidance, indicating equal effectiveness. Chronic illness participants reported poorer QoL, moved more slowly towards their QoL goals, and had larger differences between core QoL and QoL Importance than healthy participants. Guided individualised empirical feedback about QoL judgements could be used to promote psychological well-being. Although professional interpretation of feedback is unnecessary, if shared, patients' profiled WHOQOL information could support self-monitoring, self-management and clinical decision-making.

Emotional distress and compassionate responses in palliative care decision-making consultations

BACKGROUND

Seriously ill hospitalized patients and their loved ones are frequently faced with complex treatment decisions laden with expressions of emotional distress during palliative care (PC) consultations. Little is known about these emotional expressions or the compassionate responses providers make and how common these are in PC decision-making conversations.

OBJECTIVES

To describe the types and frequency of emotional distress that patients and loved ones express and how providers respond to these emotions during PC decision-making consultations with seriously ill hospitalized patients.

METHODS

We used a quantitative descriptive approach to analyze 71 audio-recorded inpatient PC decision-making consultations for emotional distress and clinicians' responses to those emotions using reliable and established methods.

RESULTS

A total of 69% of conversations contained at least one expression of emotional distress. The per-conversation frequency of expressions of emotional distress ranged from 1 to 10. Anxiety/fear were the most frequently encountered emotions (48.4%) followed by sadness (35.5%) and anger/frustration (16.1%). More than half of the emotions related to the patient's feelings (53.6%) and 41.9% were related to the loved ones' own emotions. The majority of emotions were moderate in intensity (65.8%) followed by strong (20.7%) and mild (13.5%). Clinicians responded to a majority of emotions with a compassionate response (75.7%) followed by those with medical content (21.9%) and very few were ignored (1.3%).

CONCLUSIONS

Expressions of emotional distress are common during PC consultations and are usually met with compassionate responses by the clinician.

Understanding quality-of-life while living with late-stage lung cancer: an exploratory study

U.S. Veterans have a higher prevalence of advanced lung cancer and poorer survival outcomes compared to the general population; yet, no studies exist which specifically explore the psychosocial and existential quality-of-life (QOL) of late-stage lung cancer among this population. This article presents the perspectives of older veterans (N = 12) living with late-stage lung cancer who were receiving chemotherapy, routine hospice care, or both concurrently. Based on individual interviews, themes associated with loss of functionality, close relationships, and communicative acts contributed to veterans' perceptions of diminished or enhanced QOL while living with advanced disease. An overarching theme, loss of the person I know myself to be, suggests that personhood is an important concept to consider in QOL assessment. While findings suggest that the experiences of older Veterans with late-stage lung cancer are similar to other populations of lung cancer patients, and persons with incurable cancer in general, further research regarding the influence of veteran identity at end-of-life is warranted. Further research is needed which explores the influence of a whole person approach to QOL during life-limiting illness and end-of-life decision-making, particularly while receiving late-stage cancer-directed therapy.

Effects of Anma massage therapy (Japanese massage) for gynecological cancer survivors: study protocol for a randomized controlled trial

BACKGROUND

Cancer patients and survivors regularly feel anxious about cancer recurrence or death, even after the conclusion of medical treatment, and they are often highly physiologically and psychologically stressed. Massage therapy is one of the most widely used complementary and alternative therapies used in the hope of alleviating such stress and physical and psychological complaints and to improve health-related quality of life. This randomized phase III, two-armed, parallel group, clinical trial was designed after obtaining positive findings in a preliminary study. The primary objective is to verify the effects of continuous Japanese massage therapy, referred to as Anma therapy, for cancer survivors. The secondary objective is to confirm the immediate effects of a single Anma massage session for cancer survivors.

METHODS/DESIGN

Sixty cancer survivors older than 20 years of age who have had histologically confirmed uterine cervical, endometrial, ovarian, fallopian tube or peritoneal cancer in the past, but with no recurrence for more than 3 years since receiving standard medical treatment, are being recruited by gynecologists in medical facilities. In the coordinating office, they are randomly allocated to two groups (n = 30 each): an Anma massage group receiving a 40-min Anma massage session once weekly over a 2-month intervention period (total of eight Anma massage sessions) and a control group being followed by medical doctors and receiving no Anma massage sessions. The primary end point is the severity of physical subjective symptoms that cancer survivors report in daily life, assessed using a Visual Analogue Scale. Secondary end points are urine and saliva analyses, psychological condition and health-related quality-of-life scores as determined on the basis of a self-report questionnaire.

DISCUSSION

Using the evidence-based findings of this trial, medical professionals should be able to explain the benefits conferred by Anma massage to cancer survivors and provide higher-quality information to better inform patients regarding their decisions about whether to receive such therapy.

TRIAL REGISTRATION

This trial is registered with the UMIN Clinical Trials Registry as UMIN000009097.

Concordance: a concept analysis

AIM

To report an analysis of the concept of concordance.

BACKGROUND

Adherence-based medicines interventions are known to be of limited success. Concordance appears to offer an alternative approach consistent with person-centred approaches to decision-making. However, the application of the principle of concordance appears inconsistent. This article considers the extent to which any of this confusion may be a function of the different usage of the term concordance in the disciplines of nursing, general medicine, psychiatry and pharmacy.

DESIGN

Rodger's evolutionary method of concept analysis.

DATA SOURCES

CINAHL, Medline, PsychINFO, Cochrane library, Psychology and Behavioural Sciences Collection were searched for publications between 2000 and 2012 with combinations of key words including concord*, adherence, compliance, medic*, psychiatr*, pharm*, nurs*.

REVIEW METHODS

Rodgers' evolutionary analytic method was used to identify and explore the concept of concordance across healthcare disciplines. A representative sample of papers was identified from the source disciplines. Over 500 papers were identified. Exclusion criteria limited the final sample to 60 papers in total, entailing 15 per discipline. Each discipline's papers were analysed for references, antecedents, consequences, attributes and surrogates separately. The team then worked together to cross-check these interpretations.

RESULTS

There was minimal agreement between the disciplines suggesting each discipline practised a different conceptualization of concordance. The main point of agreement was that better research is required to articulate the scope and value of partnership working.

CONCLUSION

The results clarified a distinct and currently missing research agenda.

The Patient Concerns Inventory: A Tool to Uncover Unmet Needs in a Cancer Outpatient Clinic

The Patient Concerns Inventory (PCI) is a holistic, patient reported tool that aids in identifying concerns and issues. it is a 55-item checklist of issues that may be grouped into categories of general function, specific head and neck function, emotional-psychological and others, which include finances, treatment related matters and social care. The PCI also gives patients an opportunity to identify from a list of 15 multidisciplinary team (MDT) members whom they would like to see or be referred on to.

Applying sociodramatic methods in teaching transition to palliative care

We introduce the technique of sociodrama, describe its key components, and illustrate how this simulation method was applied in a workshop format to address the challenge of discussing transition to palliative care. We describe how warm-up exercises prepared 15 learners who provide direct clinical care to patients with cancer for a dramatic portrayal of this dilemma. We then show how small-group brainstorming led to the creation of a challenging scenario wherein highly optimistic family members of a 20-year-old young man with terminal acute lymphocytic leukemia responded to information about the lack of further anticancer treatment with anger and blame toward the staff. We illustrate how the facilitators, using sociodramatic techniques of doubling and role reversal, helped learners to understand and articulate the hidden feelings of fear and loss behind the family's emotional reactions. By modeling effective communication skills, the facilitators demonstrated how key communication skills, such as empathic responses to anger and blame and using "wish" statements, could transform the conversation from one of conflict to one of problem solving with the family. We also describe how we set up practice dyads to give the learners an opportunity to try out new skills with each other. An evaluation of the workshop and similar workshops we conducted is presented.

Quality of life in patients with muscle invasive and non-muscle invasive bladder cancer

PURPOSE

Compared to the literature on other malignancies, data on quality of life (QoL) in bladder cancer are sparse. This study sought answers to the following questions: In what QoL domains do patients with bladder cancer differ from the general population? Do patients with radical cystectomy differ in QoL compared to those who received conservative treatment? Do patients with neobladder generally have better QoL compared to patients with other diversion methods?

METHODS

At the beginning of inpatient rehabilitation, N = 823 patients with bladder cancer were assessed. Data of a representative community sample (N = 2037) were used for comparison. The questionnaire EORTC QLQ-C30 was used to measure QoL. Multivariate linear regression models were computed to investigate differences between groups.

RESULTS

Patients with both non-muscle invasive and muscle invasive bladder cancer reported significantly more problems and worse functioning than the general population. Radiotherapy is associated with clinically relevant more pain, dyspnoea, constipation, appetite loss and decreased social functioning while chemotherapy is associated more with dyspnoea. Cystectomy patients reported more fatigue, appetite loss and decreased role functioning. Male patients ≥70 years with conduit experienced more sleep and emotional problems. These effects of urinary diversion were not observed in women and younger patients.

CONCLUSIONS

Patients with bladder cancer experience various QoL concerns at the beginning of inpatient rehabilitation. These problems can partly be explained by the type of treatment the patients receive. Type of urinary diversion is relevant for QoL in subgroups of patients.

Validation of the Symptom and Problem Checklist of the German Hospice and Palliative Care Evaluation (HOPE)

CONTEXT

The German Hospice and Palliative Care Evaluation (HOPE) is a national, long-term quality assurance project. Every year, German hospice and palliative care institutions document a core data set for their patients for a period of three months.

OBJECTIVES

To validate the multidimensional symptom and problem checklist (HOPE-SP-CL) of the core data set and report details on reliability and validity.

METHODS

Data from yearly evaluation periods between 2002 and 2009 were used to calculate construct and convergent validity, internal consistency, test-retest reliability, and documentation discipline and acceptance of the core documentation system.

RESULTS

The HOPE-SP-CL includes items on physical, nursing, psychological, and social symptoms and problems. Factor analysis extracted four low to moderately intercorrelating factors with eigenvalues greater than 1.0 explaining 56% of the total variance. Discriminant validity of the HOPE-SP-CL showed good properties in detecting patient groups with different symptom intensities and overall symptom burden using the Eastern Cooperative Oncology Group performance status and primary cancer diagnosis as external validation criteria. The global sum score of the HOPE-SP-CL correlated most closely with the Palliative Outcome Scale staff version (r=0.750). Internal consistencies ranged between α=0.768-0.801 at three different times of assessment. Test-retest coefficients showed moderate to high correlations at one-week intervals.

CONCLUSION

Analyses of reliability and validity of the HOPE-SP-CL showed satisfactory to good psychometric properties; therefore, the HOPE-SP-CL can be recommended for standard implementation in German hospice and palliative care institutions.

Palliative care needs of patients with cancer living in the community

PURPOSE

With improved effectiveness of early detection and treatment, many patients with cancer are now living with advanced disease and associated symptoms. As cancer becomes a chronic illness, adequate attention to patients' symptoms and psychosocial needs in the community setting requires positioning of palliative care alongside cancer care. This article describes the current palliative care needs of a population of community-dwelling patients with advanced cancer who are not yet ready for transition to hospice.

METHODS

This secondary analysis used quality-monitoring data collected in three community-based palliative care organizations. Analyses focused on people with cancer-related diagnoses who were receiving palliative care during 2008 to 2011.

RESULTS

The analytic data set included 4,980 people, 10% of whom had cancer. Median age was 71 years. Forty-eight percent had been hospitalized at least once in the 6 months before palliative care referral. Forty-nine percent had a Palliative Performance Score (PPS) of 40% to 60%; 40% had PPS ≤ 30%. Although 81% had an estimated prognosis of ≤ 6 months, 58% were expected to live weeks to months. Thirty-three percent had no identified healthcare surrogate; 59% had no do-not-resuscitate order despite declining functional status and limited prognosis. Ninety-five percent reported ≥ 1 symptom, and 67% reported ≥ 3 symptoms; a substantial proportion did not receive treatment for symptoms.

CONCLUSIONS

Patients referred to community-based palliative care experience multiple often-severe symptoms that have been insufficiently addressed. They tend to have declining performance status. Earlier palliative care intervention could improve outcomes but will require delivery models that better coordinate inpatient/outpatient oncology and community-based palliative care.

Using the 12-item General Health Questionnaire to screen psychological distress from survivorship to end-of-life care: dimensionality and item quality

OBJECTIVES

This study aimed (i) to determine the factor structure of the 12-item General Health Questionnaire (GHQ-12) across the cancer trajectory represented by samples from three cancer care settings and (ii) to appraise the item misfit and differential item functioning (DIF) of the GHQ-12.

DATA AND METHODS

Data were from cancer outpatient (n = 200), general community (n = 364) and palliative care (n = 150) settings. The factor structure was tested using exploratory factor analysis followed by confirmatory factor analysis. The factors were assessed for correlation using Spearman's ρ. The analyses were run separately for standard GHQ, Likert, modified Likert and chronic GHQ scoring and for the individual cancer settings. The best scoring method within the cancer setting was determined by Akaike's information criterion (AIC). Item misfit (mean square, MNSQ; standardised z-score, ZSTD) and DIF were assessed using the Rasch model.

RESULTS

The best scoring method was the chronic GHQ for the cancer outpatient (AIC = -45.8), modified Likert for the general community (AIC = 9.6) and standard GHQ for the palliative care (AIC = -43.0). The GHQ-12 displayed a correlated two-factor structure ('social dysfunction' and 'distress'); Spearman ρ values were 0.69, 0.82 and 0.88 in the cancer outpatient, the general community and the palliative care, respectively. One item in the palliative care indicated misfit (MNSQ = 1.62, ZSTD = 3.0). Five items in the cancer outpatient showed DIF by gender and age. Two items in the palliative care showed DIF by gender.

CONCLUSIONS

The GHQ-12 was more problematic (less clear factor structure and evidence of item bias) for newly diagnosed patients, less problematic for patients approaching end-of-life and satisfactory for patients between those times.