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Luck G, Eggenberger TL, Bautista A, Peters D, Mellman RT, Keller KB, Jacomino M. Fearing Pain at the End of Life: A Review of Advance Directives. Am J Hosp Palliat Care 2024; 41:824-830. [PMID: 37491203 DOI: 10.1177/10499091231190063] [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] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Patients, caregivers, and healthcare professionals often describe a "good death" as a pain-free process. However, many patients experience pain during their last weeks of life. Advance directives (ADs) are legally binding documents that allow individuals to express their wishes for end-of-life care which should include management of their pain. METHODS An interprofessional team conducted a comprehensive analysis of ADs from all 50 states and the District of Columbia to assess the inclusion of language that reflects patients' wishes for pain relief at the end of life. RESULTS Thirty-seven (73%) of the 51 entities examined reflected the prototypical directive, containing explicit instructions for withholding or withdrawing interventions that may prolong suffering rather than options for treating pain. Of these, 12 (24%) did not include the word "pain". Only 14 states (27%) provided clear guidance for managing pain. Unexpectantly, researchers found that 13 (25%) addressed the common fears of patients, caregivers, and healthcare teams when using opioids to relieve suffering, such as addiction, sedation, appetite, or respiratory suppression, and hastening death. CONCLUSION The majority of ADs reviewed lacked clear and comprehensive measures for addressing pain relief. This deficiency may contribute to the undertreatment of pain and amplify the anxiety felt by patients, families, and healthcare providers when making end-of-life decisions. The results highlight the need for improvements in ADs to help ensure that patients' wishes regarding pain management are adequately addressed, documented and respected.
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Affiliation(s)
- George Luck
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | | | - Adriana Bautista
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Darian Peters
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Ross T Mellman
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Kathryn B Keller
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL, USA
| | - Mario Jacomino
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
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Bergers JH, Wessels-Wynia H, Seute T, Janssens A, van Delden JJ. Getting to Know Your Patient: Content Analysis of Patients' Answers to a Questionnaire for Promoting Person-Centered Care. J Particip Med 2024; 16:e48573. [PMID: 38437017 PMCID: PMC10949129 DOI: 10.2196/48573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 11/08/2023] [Accepted: 01/03/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Person-centered care (PCC) encourages patients to actively participate in health care, thus facilitating care that fits the life of the patient. Therefore, health care professionals (HCPs) need to know the patient. As part of a broad policy for improving PCC, a digital questionnaire ("We would like to know you") consisting of 5 questions has previously been developed to help HCPs to get to know the patient with the help of patient and staff involvement. OBJECTIVE The purpose of this study was to provide insight into the content and aims of the questionnaire to understand its potential and usability. METHODS We conducted a qualitative, retrospective content analysis of patients' answers using NVivo Pro (QSR International). The questionnaire was used in the outpatient neuro-oncology department of a Dutch academic hospital. RESULTS Of 374 invited patients, 78 (20.9%) completed the questionnaire. We selected a sample of 42 (54%) of the 78 patients. Patients used a median of 16 (IQR 7-27) words per question, and most answers were easily interpretable. When asked about important activities, social activities, sports, or maintaining a normal life were most frequently mentioned. Patients wrote about fear of the disease, its possible influence on life, or fear of the future in general. Patients wanted HCPs to know about their care and communication preferences or shared personal information. They formulated expectations about effective treatment, communication, and the care process. CONCLUSIONS The questionnaire seems usable because patients provide interpretable answers that take little time to read, which HCPs can use to personalize care. Our study shows the potential of the questionnaire to help deliver PCC.
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Affiliation(s)
- Juno Hk Bergers
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Hester Wessels-Wynia
- Marketing and Communication, Concern Staff, University Medical Center Utrecht, Utrecht, Netherlands
| | - Tatjana Seute
- Department of Neuro-oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Astrid Janssens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Johannes Jm van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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Lin CP, Chiang CH, Sheu SJ. Using the Kipling method to explore the contextual factors of decision-making during advance care planning for older cancer patients, their family, and health-care professionals: A qualitative secondary analysis. Palliat Support Care 2023:1-7. [PMID: 37859416 DOI: 10.1017/s1478951523001256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
OBJECTIVES Advance care planning (ACP) interventions are supposed to affect patients' autonomy and family health-care outcomes positively. However, the clinical benefits of ACP actualization and associated contextual factors merit questioning. Therefore, this study explores the critical contextual and procedural factors related to ACP decision-making based on the actual situation of older patients with cancer encountering end-of-life care in Taiwan. METHODS This retrospective qualitative secondary analysis used the Kipling method (5W1H) to explore further the critical contextual and procedural factors related to ACP decision-making processes. We applied thematic analysis and dual coding for 35 narratives, including 10 patients with cancer, 10 family caregivers, and 15 health-care staff, derived from a preliminary qualitative study regarding palliative care decision-making among patients with advanced cancer, their families, and health-care staff. RESULTS We identified 6 domains detailing the contextual factors for ACP decision-making: (1) WHO (decision makers); (2) WHAT (discussion content); (3) WHEN (care plan for which disease stage); (4) WHERE (patient's situational location); (5) WHY (reasons underpinning the decisions); and (6) HOW (the way to form the decisions). SIGNIFICANCE OF RESULTS Using the Kipling method to elaborate the contextual factors for ACP decision-making among older patients with cancer strengthens the understanding of complicated end-of-life care decision-making procedure. This study also demonstrates the dynamic and cultural complexity and the various factors considered during end-of-life care and future ACP discussion.
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Affiliation(s)
- Cheng-Pei Lin
- Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, King's College London, London, UK
| | - Chia-Hsuan Chiang
- Department of Nursing, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shuh-Jen Sheu
- Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Cohen MG, Althouse AD, Arnold RM, White D, Chu E, Rosenzweig M, Smith KJ, Schenker Y. Primary Palliative Care Improves Uptake of Advance Care Planning Among Patients With Advanced Cancers. J Natl Compr Canc Netw 2023; 21:383-390. [PMID: 37015338 PMCID: PMC10477933 DOI: 10.6004/jnccn.2023.7002] [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: 11/14/2022] [Accepted: 01/06/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Palliative care specialists are experts in conducting advance care planning (ACP) but are a limited resource. Oncology nurses often have special relationships with their patients and thus may be poised to provide primary palliative care. We sought to determine the impact of a nurse-led primary palliative care intervention on ACP uptake among patients with advanced cancer. METHODS We performed a secondary analysis of a cluster randomized controlled trial examining the impact of nurse-based primary palliative care. In the parent trial, patients with advanced cancer received either monthly primary palliative care visits with trained nurses within their cancer center or standard care. Nurses in the intervention arm received special training in ACP. ACP uptake was assessed at enrollment and 3 months later evaluating (1) whether an end-of-life conversation (EOLC) occurred with one's oncologist, and (2) completion of an advance directive (AD). Multivariable logistic regression tested differences in ACP uptake by treatment arm adjusted for age, religious importance, education, time with current oncologist, and performance status. RESULTS Of 672 patients enrolled, 182/336 (54%) patients in the intervention arm and 196/336 (58%) in the standard care arm lacked an EOLC at baseline and completed the 3-month assessment. Of those, 82/182 (45.1%) patients in the intervention arm and 29/196 (14.8%) in the standard care arm reported having an EOLC at 3 months (adjusted odds ratio, 5.28; 95% CI, 3.10-8.97; P<.001). Similarly, 111/336 (33%) patients in the intervention arm and 105/336 (31%) in the standard care arm lacked an AD at baseline and completed the 3-month assessment. Of those, 48/111 (43.2%) patients in the intervention arm and 19/105 (18.1%) in the standard care arm completed an AD over the study period (adjusted odds ratio, 3.68; 95% CI, 1.89-7.16; P<.001). CONCLUSIONS Nurse-led primary palliative care increased ACP uptake among patients with advanced cancer. Training oncology nurses embedded within community cancer centers to provide primary palliative care may help improve ACP access.
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Affiliation(s)
- Michael G. Cohen
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Andrew D. Althouse
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Section of Palliative Care and Medical Ethics, Palliative Research Center and Division of General Internal Medicine, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania
| | - Douglas White
- Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edward Chu
- Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, New York
| | | | - Kenneth J. Smith
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Palliative Research Center and Division of General Internal Medicine, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania
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Michael N, Symons X, Mendz GL, Kissane D. Vulnerability and Resilience: Phenomenological Analysis of Cancer Patients Value Directives. J Pain Symptom Manage 2022; 64:438-448. [PMID: 35932954 DOI: 10.1016/j.jpainsymman.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/22/2022] [Accepted: 07/27/2022] [Indexed: 12/24/2022]
Abstract
CONTEXT Personal values are individual conceptions of the desirable appraisals and actions that guide our attitudes and behaviour. Advance care planning (ACP) now emphasises the consideration of personal life goals and values expressed as a Values Directive (VD) to guide discussions concerning medical treatment. OBJECTIVE To investigate the diversity of values, experiences and adaptations expressed in cancer patients VDs. METHODS Contents of the VDs of ACPs of cancer patients who participated in a randomised control trial comparing a video intervention showing values communication between cancer patient-caregivers with usual care were analysed. Qualitative phenomenological content analysis was used to understand how participants made meaning of their lived experiences. RESULTS Forty-two participants completed an ACP (37.2% response rate), with 97.6% of these completing a VD (57.1% female, mean age 72 years, 30.1% gastrointestinal cancer). Participants described diverse adjustments to frailty and adaptive coping with deteriorating functionality. Emotional and financial concerns were eased through experiencing benevolence and trust established through family and friendship bonds and reciprocation of care. Death anxiety and ambivalence were expressed concurrently with the experiential acceptance of dying. Secular and sacred rituals featured as an affirmation of their faith or beliefs. CONCLUSION Cancer patients seek to make meaning of their experiences, concurrently posturing vulnerability and resilience, despite conflicting emotions and experiences. Given that the choices people make as they approach dying relate to their most deeply held values, ACP conversations should explore how patients draw from their values and life goals to optimise their adaptations to illness.
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Affiliation(s)
- Natasha Michael
- Supportive, Psychosocial and Palliative Care Research Department (N.M., D.K.), Cabrini Health, VIC Australia; School of Medicine (N.M., G.L.M., D.K.), University of Notre Dame Australia Darlinghurst, NSW, Australia; Faculty of Medicine (N.M., D.K.), Nursing and Health Sciences, Monash University, VIC, Australia.
| | - Xavier Symons
- Plunkett Centre for Ethics (X.S.), St Vincent's Hospital, NSW, Australia; Institute of Ethics and Society (X.S.), University of Notre Dame, Australia, NSW, Australia
| | - George L Mendz
- School of Medicine (N.M., G.L.M., D.K.), University of Notre Dame Australia Darlinghurst, NSW, Australia
| | - David Kissane
- Supportive, Psychosocial and Palliative Care Research Department (N.M., D.K.), Cabrini Health, VIC Australia; School of Medicine (N.M., G.L.M., D.K.), University of Notre Dame Australia Darlinghurst, NSW, Australia; Faculty of Medicine (N.M., D.K.), Nursing and Health Sciences, Monash University, VIC, Australia; Sacred Heart Health Service (D.K.), St. Vincent's Hospital, Sydney, NSW, Australia
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Kodba‐Čeh H, Lunder U, Bulli F, Caswell G, van Delden JJM, Kars MC, Korfage IJ, Miccinesi G, Rietjens JAC, Seymour J, Toccafondi A, Zwakman M, Pollock K. How can advance care planning support hope in patients with advanced cancer and their families: A qualitative study as part of the international ACTION trial. Eur J Cancer Care (Engl) 2022; 31:e13719. [PMID: 36168108 PMCID: PMC9787960 DOI: 10.1111/ecc.13719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Clinicians' fears of taking away patients' hope is one of the barriers to advance care planning (ACP). Research on how ACP supports hope is scarce. We have taken up the challenge to specify ways in which ACP conversations may potentially support hope. METHODS In an international qualitative study, we explored ACP experiences of patients with advanced cancer and their personal representatives (PRs) within the cluster-randomised control ACTION trial. Using deductive analysis of data obtained in interviews following the ACP conversations, this substudy reports on a theme of hope. A latent thematic analysis was performed on segments of text relevant to answer the research question. RESULTS Twenty patients with advanced cancer and 17 PRs from Italy, the Netherlands, Slovenia, and the United Kingdom were participating in post-ACP interviews. Three themes reflecting elements that provide grounds for hope were constructed. ACP potentially supports hope by being (I) a meaningful activity that embraces uncertainties and difficulties; (II) an action towards an aware and empowered position; (III) an act of mutual care anchored in commitments. CONCLUSION Our findings on various potentially hope supporting elements of ACP conversations provide a constructive way of thinking about hope in relation to ACP that could inform practice.
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Affiliation(s)
- Hana Kodba‐Čeh
- University Clinic of Respiratory and Allergic Diseases GolnikGolnikSlovenia
- Faculty of Arts, Department of PsychologyUniversity of LjubljanaLjubljanaSlovenia
| | - Urška Lunder
- University Clinic of Respiratory and Allergic Diseases GolnikGolnikSlovenia
| | - Francesco Bulli
- Clinical Epidemiology UnitOncological network research and prevention Institute‐ISPROSienaItaly
| | - Glenys Caswell
- School of Health SciencesUniversity of NottinghamNottinghamUK
| | - Johannes J. M. van Delden
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Marijke C. Kars
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Ida J. Korfage
- Department of Public HealthErasmus MC, Erasmus University Medical CenterRotterdamThe Netherlands
| | - Guido Miccinesi
- Clinical Epidemiology UnitOncological network research and prevention Institute‐ISPROSienaItaly
| | - Judith A. C. Rietjens
- Department of Public HealthErasmus MC, Erasmus University Medical CenterRotterdamThe Netherlands
| | - Jane Seymour
- Division of Nursing and Midwifery, Health Sciences SchoolUniversity of SheffieldSheffieldUK
| | - Alessandro Toccafondi
- Clinical Epidemiology UnitOncological network research and prevention Institute‐ISPROSienaItaly
| | - Marieke Zwakman
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
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Koenig JFL, Asendorf T, Simon A, Bleckmann A, Truemper L, Wulf G, Overbeck TR. "SpezPat"- common advance directives versus disease-centred advance directives: a randomised controlled pilot study on the impact on physicians' understanding of non-small cell lung cancer patients' end-of-life decisions. BMC Palliat Care 2022; 21:167. [PMID: 36167565 PMCID: PMC9516789 DOI: 10.1186/s12904-022-01057-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 09/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The advance directive represents patients' health care choices and fosters patients' autonomy. Nevertheless, understanding patients' wishes based on the information provided in advance directives remains a challenge for health care providers. Based on the ethical premises of positive obligation to autonomy, an advanced directive that is disease-centred and details potential problems and complications of the disease should help health care providers correctly understand patients' wishes. To test this hypothesis, a pilot-study was conducted to investigate whether physicians could make the correct end-of-life decision for their patients when patients used a disease-centred advance directive compared to a common advance directive. MATERIAL AND METHODS: A randomised, controlled, prospective pilot study was designed that included patients with non-small cell lung cancer (NSCLC) stage VI from the Department of Haematology and Medical Oncology, University Medical Centre, Goettingen. Patients were randomised into intervention and control groups. The control group received a common advance directive, and the intervention group received a disease-centred advance directive. Both groups filled out their advance directives and returned them. Subsequently, patients were asked to complete nine medical scenarios with different treatment decisions. For each scenario the patients had to decide whether they wanted to receive treatment on a 5-point Likert scale. Four physicians were given the same scenarios and asked to decide on the treatment according to the patients' wishes as stated in their advance directives. The answers by patients and physicians were then compared to establish whether physicians had made the correct assumptions. RESULTS Recruitment was stopped prior to reaching anticipated sample target. 15 patients with stage IV NSCLC completed the study, 9 patients were randomised into the control group and 6 patients in the intervention group. A total of 135 decisions were evaluated. The concordance between physicians' and patients' answers, was 0.83 (95%-CI 0.71-0.91) in the intervention group, compared to 0.60 (95%-CI 0.48-0.70) in the control group, and the difference between the two groups was statistically significant (p = 0.005). CONCLUSION This pilot study shows that disease-centred advance directives help physicians understand their NSCLC patients' wishes more precisely and make treatment choices according to these wishes. TRIAL REGISTRATION The study is registered at the German Clinical Trial Register (no. DRKS00017580, registration date 27/08/2019).
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Affiliation(s)
- Julia Felicitas Leni Koenig
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany.
| | - Thomas Asendorf
- Department of Medical Statistics, University Medical Centre, Von-Siebold-Str. 3, Goettingen, Germany
| | - Alfred Simon
- Academy of Ethics in Medicine, Robert-Koch-Str. 40, Goettingen, Germany
| | - Annalen Bleckmann
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany.,Department of Medicine A; Hematology, Oncology and Pneumology, University Hospital Muenster; Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Lorenz Truemper
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany
| | - Gerald Wulf
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany
| | - Tobias R Overbeck
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany
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Prospective Randomized Study of Advance Directives in Allogeneic Hematopoietic Cell Transplantation Recipients. Transplant Cell Ther 2021; 27:615.e1-615.e7. [PMID: 33836311 DOI: 10.1016/j.jtct.2021.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/19/2021] [Accepted: 03/29/2021] [Indexed: 11/20/2022]
Abstract
Patients undergoing allogeneic hematopoietic cell transplantation (HCT) are at risk for high morbidity and mortality. Advance directives (AD) allow patients to express wishes regarding their care at the end of life, but these are not completed in the majority of patients undergoing HCT, with only 44% of deceased allogeneic HCT recipients at this institution completing an AD in the past decade. Increasing the AD completion rate can improve the quality of care for allogeneic HCT recipients. Our objective was to evaluate whether an alternative AD instrument can increase AD completion rate and patient satisfaction. We conducted a prospective, randomized controlled study of the traditional California AD versus a novel Letter AD, the Stanford What Matters Most Letter, in adult allogeneic HCT recipients. Patients age ≥18 years undergoing first allogeneic HCT at Stanford University were eligible. Prior to HCT conditioning, enrolled patients were assigned at random to complete either the traditional AD or the Letter AD. The primary endpoint was AD completion. The chi-square test was used to compare the AD completion rate between arms. The Wilcoxon rank-sum test was used to compare uncertainty, satisfaction with decision making, and satisfaction with the AD. Of the 212 patients who were eligible, 126 (59.4%) were enrolled and randomized. The mean age was 53.7 years, 57 (45.2%) were female, and 74 (58.7%) were non-Hispanic white. The overall AD completion rate was 71.4% and did not differ between the traditional and Letter AD arms (70.3% versus 72.6%; P = .78). Of those who completed the Letter AD, 66.7%, 42.2%, and 46.7% of patients wished to die gently/naturally, at home, and/or with hospice, respectively. In the traditional AD arm, 60.0% wished to not prolong life if recovery was unlikely. Opinion surveys did not find differences in levels of satisfaction between the traditional AD and Letter AD. Completion rates of AD on this study were high (71.4%) compared with historically reported completion rates and did not significantly differ based on AD version.
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Duijn JM, Zweers D, Kars MC, de Graeff A, Teunissen SCCM. Anxiety in Hospice Inpatients With Advanced Cancer, From the Perspective of Their Informal Caregivers: A Qualitative Study. J Hosp Palliat Nurs 2021; 23:155-161. [PMID: 33633096 PMCID: PMC7919700 DOI: 10.1097/njh.0000000000000729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Anxiety is a common symptom in patients with advanced cancer. Early recognition of anxiety is difficult, especially when the physical condition of patients declines and patients are not able to verbally express about their concerns. Under these circumstances, informal caregivers may be a valuable source of information. The aim of this study was to explore anxiety in hospice inpatients with advanced cancer from the perspective of their informal caregivers. Fourteen informal caregivers were interviewed; 64% were women and the median age was 55 years. Informal caregivers assessed patients' anxiety as moderate to severe and identified a negative impact of anxiety on physical, psychological, social, and spiritual dimensions of the patients' lives. They indicated a variety of expressions of anxiety and mentioned physical and mental deterioration as an important source of anxiety. Informal caregivers recognized patients' needs as having a safe environment, presence of people around, and a sense of control over the situation. Although the patients' perspective is the gold standard, informal caregivers can be a valuable source of information in identifying anxiety and providing personalized support. Therefore, informal caregivers should be more involved in the care for anxious patients to improve early recognition of anxiety and to ameliorate anxiety management for this vulnerable patient population.
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Korfage IJ, Carreras G, Arnfeldt Christensen CM, Billekens P, Bramley L, Briggs L, Bulli F, Caswell G, Červ B, van Delden JJM, Deliens L, Dunleavy L, Eecloo K, Gorini G, Groenvold M, Hammes B, Ingravallo F, Jabbarian LJ, Kars MC, Kodba-Čeh H, Lunder U, Miccinesi G, Mimić A, Ozbič P, Payne SA, Polinder S, Pollock K, Preston NJ, Seymour J, Simonič A, Thit Johnsen A, Toccafondi A, Verkissen MN, Wilcock A, Zwakman M, van der Heide A, Rietjens JAC. Advance care planning in patients with advanced cancer: A 6-country, cluster-randomised clinical trial. PLoS Med 2020; 17:e1003422. [PMID: 33186365 PMCID: PMC7665676 DOI: 10.1371/journal.pmed.1003422] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 10/19/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) supports individuals to define, discuss, and record goals and preferences for future medical treatment and care. Despite being internationally recommended, randomised clinical trials of ACP in patients with advanced cancer are scarce. METHODS AND FINDINGS To test the implementation of ACP in patients with advanced cancer, we conducted a cluster-randomised trial in 23 hospitals across Belgium, Denmark, Italy, Netherlands, Slovenia, and United Kingdom in 2015-2018. Patients with advanced lung (stage III/IV) or colorectal (stage IV) cancer, WHO performance status 0-3, and at least 3 months life expectancy were eligible. The ACTION Respecting Choices ACP intervention as offered to patients in the intervention arm included scripted ACP conversations between patients, family members, and certified facilitators; standardised leaflets; and standardised advance directives. Control patients received care as usual. Main outcome measures were quality of life (operationalised as European Organisation for Research and Treatment of Cancer [EORTC] emotional functioning) and symptoms. Secondary outcomes were coping, patient satisfaction, shared decision-making, patient involvement in decision-making, inclusion of advance directives (ADs) in hospital files, and use of hospital care. In all, 1,117 patients were included (442 intervention; 675 control), and 809 (72%) completed the 12-week questionnaire. Patients' age ranged from 18 to 91 years, with a mean of 66; 39% were female. The mean number of ACP conversations per patient was 1.3. Fidelity was 86%. Sixteen percent of patients found ACP conversations distressing. Mean change in patients' quality of life did not differ between intervention and control groups (T-score -1.8 versus -0.8, p = 0.59), nor did changes in symptoms, coping, patient satisfaction, and shared decision-making. Specialist palliative care (37% versus 27%, p = 0.002) and AD inclusion in hospital files (10% versus 3%, p < 0.001) were more likely in the intervention group. A key limitation of the study is that recruitment rates were lower in intervention than in control hospitals. CONCLUSIONS Our results show that quality of life effects were not different between patients who had ACP conversations and those who received usual care. The increased use of specialist palliative care and AD inclusion in hospital files of intervention patients is meaningful and requires further study. Our findings suggest that alternative approaches to support patient-centred end-of-life care in this population are needed. TRIAL REGISTRATION ISRCTN registry ISRCTN63110516.
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Affiliation(s)
- Ida J. Korfage
- Department of Public Health, Erasmus MC, Rotterdam, Netherlands
- * E-mail:
| | - Giulia Carreras
- Clinical Epidemiology, Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Caroline M. Arnfeldt Christensen
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Palliative Medicine, Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Louise Bramley
- Institute of Nursing and Midwifery Care Excellence, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Linda Briggs
- Respecting Choices, C-TAC Innovations, Oregon, Wisconsin, United States of America
| | - Francesco Bulli
- Clinical Epidemiology, Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Glenys Caswell
- School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Branka Červ
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Lesley Dunleavy
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | - Kim Eecloo
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Giuseppe Gorini
- Clinical Epidemiology, Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Mogens Groenvold
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Palliative Medicine, Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | - Bud Hammes
- Respecting Choices, C-TAC Innovations, Oregon, Wisconsin, United States of America
| | - Francesca Ingravallo
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | | | - Marijke C. Kars
- Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht, Netherlands
| | - Hana Kodba-Čeh
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Urska Lunder
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Guido Miccinesi
- Clinical Epidemiology, Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Alenka Mimić
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Polona Ozbič
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Sheila A. Payne
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | | | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Nancy J. Preston
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | - Jane Seymour
- Health Sciences School, University of Sheffield, Sheffield, United Kingdom
| | - Anja Simonič
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Anna Thit Johnsen
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Palliative Medicine, Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | - Alessandro Toccafondi
- Clinical Epidemiology, Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Mariëtte N. Verkissen
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Andrew Wilcock
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Marieke Zwakman
- Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht, Netherlands
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