Let us talk about death: gender effects in cancer patients' preferences for end-of-life discussions

Telemedicine-based serious illness conversations, healthcare utilization, and end of life care among patients with advanced lung cancer

PURPOSE

Little is known about serious illness conversations (SIC) conducted during telemedicine visits and their impact on end-of-life (EOL) outcomes for patients with advanced cancer.

PATIENTS AND METHODS

We conducted a retrospective analysis telemedicine visits for patients with metastatic lung cancer conducted during the first surge of the COVID-19 pandemic (October 3, 2020-October 6, 2020). We used natural language processing (NLP) to characterize documentation of SIC domains (ie, goals of care [GOC], limitation of life-sustaining treatment [LLST], prognostic awareness [PA], palliative care [PC], and hospice). We used unadjusted logistic regression to evaluate factors associated with SIC documentation and the relationship between SIC documentation and EOL outcomes.

RESULTS

The study included 634 telemedicine visits across 360 patients. Documentation of at least one SIC domain was present in 188 (29.7%) visits with GOC and PA being the most discussed domains. Family presence (odds ratio [OR], 1.66; P = .004), progressive or newly diagnosed disease (OR, 5.42; P < .000), age ≥ 70 (OR, 1.80; P = .009), and male sex (OR, 2.23; P < .000) were associated with a greater likelihood of discussing ≥ 1 SIC domain. Of the 61 patients who died within 12 months of the study period, having ≥ 1 SIC domain discussed was associated with a lower likelihood of hospitalization in the last 30 days of life (OR, 0.27; P = .020).

CONCLUSION

In this study of telehealth visits, we identified important factors associated with an increased likelihood of having documentation of an SIC and demonstrated that SIC documentation correlated with lower likelihood of hospitalization at EOL.

Qualitative analysis of expressions used in the end-of-life discussions and their associated factors

OBJECTIVES

Discussing end-of-life (EOL) issues with patients remains challenging for health professionals. Physicians may use various expressions, including euphemistic ones, when disclosing the prognosis to their patients to reduce their psychological impact. However, the actual expressions of EOL disclosure in clinical practice are unclear. This study aims to investigate the expressions used in EOL disclosures and explore their associated factors.

METHODS

A retrospective chart review was conducted enrolling all the patients who died in a university-affiliated hospital. Expressions used in the EOL disclosure were qualitatively analyzed. The patients' participation rate and length from the discussion to death were investigated.

RESULTS

EOL disclosures were observed in 341 of 358 patients. The expressions used by the physicians were categorized into 4 groups; Group 1: Clear presentation of life expectancy (n = 106; 31.1%), Group 2: Euphemistic presentation of life expectancy (n = 24; 7.0%), Group 3: Presentation of risk of sudden death (n = 147; 43.1%), Group 4: No mention on life expectancy (n = 64; 18.8%). The proportion of male patients was higher in Group 2 (79%) and lower in Group 4 (56%). Patients with cancer accounted for approximately 70% of Groups 1 and 4, but only approximately 30% of Group 3. The patient participation rate was highest in Group4 (84.4%), followed by Group 2 (50.0%). The median time from EOL disclosure to death was longer in Groups 1 and 4 (26 and 29.5 days, respectively), compared to Groups 2 and 3 (18.5 and 16 days, respectively).

SIGNIFICANCE OF RESULTS

A variety of expressions are used in EOL disclosure. Patterns of communication are influenced by patients' gender and type of illness (cancer or noncancer). Euphemisms do not seem to facilitate timely disclosure of life expectancy or patient participation. For health professionals, not only devising the expressions to alleviate their patients' distress when breaking bad news but also considering the communication process and patient background are essential.

Advance Care Planning: A Story of Trust Within the Family

As the family usually plays a central role at the end of life, the quality of family relationships may influence how individuals approach advance care planning (ACP). Our study investigates the associations of trust in relatives with regard to end-of-life (EOL) issues-used as a proxy measure of family relationship quality-with individuals' engagement in EOL discussions, advance directive (AD) awareness, approval and completion, and designation of a healthcare proxy. Using nationally representative data of adults aged 55 years and over from wave 6 (2015) of the Survey of Health, Ageing, and Retirement in Europe (SHARE) in Switzerland (n = 1911), we show that complete trust in relatives is related to higher engagement in ACP. Subject to patient consent, the family should, therefore, be included in the ACP process, as such practice could enhance patient-centered EOL care and quality of life at the end of life.

Middle-aged and older adults in Aids village: a mixed methods study on talking about death and well-being promotion based on social support theory

Introduction

Will about talking about death bring well-being? This study aims to explore the impact of talking about death on the subjective well-being of the rural middle-aged and older adults in China's "Aids village" from five dimensions: the way of talking about death, the attitude towards talking about death, the objects of talking about death with, the frequency of talking about death and the content of the death talk, and investigate whether social support played a mediating role during this process.

Methods

A field survey and in-depth interviews were conducted in Wen Lou village (a famous Chinese "Aids village"), and valid questionnaires were completed by the HIV/Aids-affected middle-aged and older adults. A series of linear regression analyses were conducted to detect whether the way of talking about death, the attitude towards talking about death, the objects of talking about death with, the frequency of talking about death and the content of the death talk predict the subjective well-being of the HIV/Aids-affected middle-aged and older adults. An empirical test for mediation effect was performed to examine whether social support played a mediating role during the process.

Results

It was found that the more frequent the middle-aged and older adults talk about death, the higher level of their subjective well-being is (ΔR2 = 0.056, 0.05 < p < 0.10), and during which process social support played a mediating role.

Discussion

The author believes that using "talking about death" as a kind of medical intervention, carrying out corresponding life education and death education, and developing a suitable hospice care model, may be a valuable way for the HIV/Aids-affected middle-aged and older adults in the rural area.

Stability of End-of-Life Care Wishes and Gender-Specific Characteristics of Outpatients with Advanced Cancer under Palliative Therapy: A Prospective Observational Study

INTRODUCTION

Early integration of palliative care and advance care planning (ACP) play an increasingly important role in the treatment of patients with advanced cancer. Advance directives (ADs) and patients' preferences regarding end-of-life (EoL) care are important aspects of ACP. In the outpatient setting, the prevalence of those documents and EoL care wishes is not well investigated, and changes in the longitudinal course are poorly understood.

METHODS

From June 2020 to August 2022, 67 outpatients with advanced solid tumors undergoing palliative cancer therapy were interviewed on the topic of ACP in a longitudinal course. From this database, the prevalence of ADs, healthcare proxy, EoL care wishes, and the need for counseling regarding these issues were collected. In addition, EoL care wishes were examined for their stability.

RESULTS

Fifty-one patients (76.1%) reported having ADs, and 41 patients (61.2%) reported having a healthcare proxy. Nineteen patients (37.3%) with ADs and 11 patients (68.7%) without ADs indicated a wish for counseling. Reported EoL care wishes remained stable over a period of approximately 6 months. Nevertheless, intraindividual changes occurred over time within the different EoL care preferences. The desire for resuscitation and dialysis were significantly higher in men than in women (resuscitation: 15 of 21 men [71.4%] versus 9 of 22 women [40.9%], odds ratio [OR] 3.611, 95% confidence interval [CI], 1.01-12.89, p = 0.048; dialysis: 16 of the 23 men [69.6%] versus 9 of the 25 women [36.0%], OR: 4.063, 95% CI: 1.22-13.58, p = 0.023).

CONCLUSION

Our results show a reasonably high percentage of ADs and healthcare proxies in our study cohort. The observed stability of EoL requests encourages the implementation of structured queries for ADs and healthcare proxy for outpatients undergoing palliative treatment. Our data suggest that gender-specific characteristics should be further investigated in this context.

Gender oncology: recommendations and consensus of the Italian Association of Medical Oncology (AIOM)

BACKGROUND

Following the development of gender medicine in the past 20 years, more recently in the field of oncology an increasing amount of evidence suggests gender differences in the epidemiology of cancers, as well as in the response and toxicity associated with therapies. In a gender approach, critical issues related to sexual and gender minority (SGM) populations must also be considered.

MATERIALS AND METHODS

A working group of opinion leaders approved by the Italian Association of Medical Oncology (AIOM) has been set up with the aim of drafting a shared document on gender oncology. Through the 'consensus conference' method of the RAND/University of California Los Angeles (UCLA) variant, the members of the group evaluated statements partly from the scientific literature and partly produced by the experts themselves [good practice points (GPPs)], on the following topics: (i) Healthcare organisation, (ii) Therapy, (iii) Host factors, (iv) Cancer biology, and (v) Communication and social interventions. Finally, in support of each specific topic, they considered it appropriate to present some successful case studies.

RESULTS

A total of 42 articles met the inclusion criteria, from which 50 recommendations were extracted. Panel participants were given the opportunity to propose additional evidence from studies not included in the research results, from which 32 statements were extracted, and to make recommendations not derived from literature such as GPPs, four of which have been developed. After an evaluation of relevance by the panel, it was found that 81 recommendations scored >7, while 3 scored between 4 and 6.9, and 2 scored below 4.

CONCLUSIONS

This consensus and the document compiled thereafter represent an attempt to evaluate the available scientific evidence on the theme of gender oncology and to suggest standard criteria both for scientific research and for the care of patients in clinical practice that should take gender into account.

Factors related to advance directives completion among cancer patients: a systematic review

INTRODUCTION

Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person's future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients.

METHODS

A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior.

RESULTS

Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients' age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: "Lack of knowledge of the ADs concept" and "Previous experience of the disease", the subjective norm category includes three subcategories: "Social support and interaction with family", "Respecting the patient's wishes" and "EOL care choices". Also, the category of perceived control behavior was categorized into two sub-categories: "Decision-making" and "Access to the healthcare system", as well as external factors affecting the model, including "socio-demographic characteristics".

CONCLUSION

The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.

Patients' Perspective on Termination of Pacemaker Therapy-A Cross-Sectional Anonymous Survey among Patients Carrying a Pacemaker in Germany

OBJECTIVE

To determine the opinions of patients regarding the withdrawal of pacemaker therapy.

PARTICIPANTS AND METHODS

A cross-sectional anonymous questionnaire was administered to patients visiting an outpatient cardiologic clinic for routine follow-up visits of pacemaker therapy or patients carrying a pacemaker admitted to a hospital between 2021 and 2022.

RESULTS

Three-hundred and forty patients answered the questionnaire. A total of 56% of the participants were male. The mean age was 81 years. The majority of respondents were very comfortable with their PM and felt well informed, with one exception: more than half of respondents were missing information on withdrawal of pacemaker therapy. Almost two-thirds wanted to decide for themselves if their pacemaker therapy was withdrawn regardless of whether they were ill or healthy. Almost 60% of patients would like the pacemaker to be turned off when dying. Women expressed this wish significantly more often than men.

CONCLUSION

Our survey shows that patients prefer to be informed on issues regarding the withdrawal of pacemakers as early as preimplantation. Also, patients would like to be involved in decisions that have to be made at the end of life, including decisions on withdrawal. Offers of conversations about this important issue should include information on special features of the patient's pacemaker, e.g., the absence or presence of pacemaker dependency. Knowledge about the pacemaker's functionality may prevent distress among individuals nearing their end of life when, for example, under the false impression that timely deactivation may allow for a more peaceful death.

Better than expected? Predictors of coping with expectation violations in the communication about death and dying

Background

End-of-life (EOL) communication is often avoided, especially among young adults. Negative expectations concerning EOL conversations with relatives or significant others are one major reason.

Objective

To investigate how best to violate negative expectations concerning EOL conversations by identifying predictors of coping with expectation violations in this context.

Methods

Vignettes describing expectation violations in the context of EOL communication were presented to a sample of 261 university students. In a first experiment, the credibility of the expectation-disconfirming information was manipulated. In a second experiment, the valence of the disconfirming evidence was manipulated. As outcome measures, the subjective likelihood of two different responses to the expectation violation was assessed: (1) ignoring the disconfirming evidence (immunization) and (2) changing expectations (accommodation).

Results

Overall, participants experiencing a worse-than-expected event showed more immunization [F(1, 257) = 12.15, p < 0.001, ηp = 0.05], while participants experiencing a better-than-expected event showed more accommodation [F(1, 257) = 30.98, p < 0.001, ηp = 0.11]. Participants with higher fear of death [F(1, 257) = 12.24, p < 0.001, ηp = 0.05] as well as higher death avoidance tendencies [F(1, 257) = 17.16, p < 0.001, ηp = 0.06] showed less accommodation in response to a better-than-expected event.

Conclusion

In general, young adults appear to update their expectations quickly in response to unexpectedly positive experiences in the context of EOL communication. However, individuals with higher fear of death and higher death avoidance tendencies appear to be at higher risk of maintaining negative expectations despite disconfirming evidence.

Effective communication in palliative care from the perspectives of patients and relatives: A systematic review

OBJECTIVES

In palliative care, effective communication is essential to adequately meet the needs and preferences of patients and their relatives. Effective communication includes exchanging information, facilitates shared decision-making, and promotes an empathic care relationship. We explored the perspectives of patients with an advanced illness and their relatives on effective communication with health-care professionals.

METHODS

A systematic review was conducted. We searched Embase, Medline, Web of Science, CINAHL, and Cochrane for original empirical studies published between January 1, 2015 and March 4, 2021.

RESULTS

In total, 56 articles on 53 unique studies were included. We found 7 themes that from the perspectives of patients and relatives contribute to effective communication: (1) open and honest information. However, this open and honest communication can also trigger anxiety, stress, and existential disruption. Patients and relatives also indicated that they preferred (2) health-care professionals aligning to the patient's and relative's process of uptake and coping with information; (3) empathy; (4) clear and understandable language; (5) leaving room for positive coping strategies, (6) committed health-care professionals taking responsibility; and (7) recognition of relatives in their role as caregiver. Most studies in this review concerned communication with physicians in a hospital setting.

SIGNIFICANCE OF RESULTS

Most patients and relatives appreciate health-care professionals to not only pay attention to strictly medical issues but also to who they are as a person and the process they are going through. More research is needed on effective communication by nurses, in nonhospital settings and on communication by health-care professionals specialized in palliative care.

End-of-life interventions in patients with cancer

OBJECTIVES

To describe variations in the receipt of potentially inappropriate interventions in the last 100 days of life of patients with cancer according to patient characteristics and cancer site.

METHODS

We conducted a population-based retrospective cohort study of cancer decedents in Ontario, Canada who died between 1 January 2013 and 31 December 2018. Potentially inappropriate interventions, including chemotherapy, major surgery, intensive care unit admission, cardiopulmonary resuscitation, defibrillation, dialysis, percutaneous coronary intervention, mechanical ventilation, feeding tube placement, blood transfusion and bronchoscopy, were captured via hospital discharge records. We used Poisson regression to examine associations between interventions and decedent age, sex, rurality, income and cancer site.

RESULTS

Among 151 618 decedents, 81.3% received at least one intervention, and 21.4% received 3+ different interventions. Older patients (age 95-105 years vs 19-44 years, rate ratio (RR) 0.36, 95% CI 0.34 to 0.38) and women (RR 0.94, 95% CI 0.93 to 0.94) had lower intervention rates. Rural patients (RR 1.09, 95% CI 1.08 to 1.10), individuals in the highest area-level income quintile (vs lowest income quintile RR 1.02, 95% CI 1.01 to 1.04), and patients with pancreatic cancer (vs colorectal cancer RR 1.10, 95% CI 1.07 to 1.12) had higher intervention rates.

CONCLUSIONS

Potentially inappropriate interventions were common in the last 100 days of life of cancer decedents. Variations in interventions may reflect differences in prognostic awareness, healthcare access, and care preferences and quality. Earlier identification of patients' palliative care needs and involvement of palliative care specialists may help reduce the use of these interventions at the end of life.

Palliative Care Interventions in Advanced Chronic Obstructive Pulmonary Disease: An Integrative Review

Background: Chronic obstructive pulmonary disease (COPD), the sixth leading cause of death in the United States, is associated with higher mortality rates in women. Women also experience tremendous symptom burden, including dyspnea, anxiety, and depression, in comparison to men with COPD. Palliative care (PC) provides symptom management and addresses advanced care planning for serious illness, but little is known about the use of PC in women with COPD. Objective: The purpose of this integrative review was to identify known PC interventions in advanced COPD and to understand the problem of gender and sex disparities. Methods: Whittemore and Knafl's methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used to guide this integrative review, and the quality of the articles was appraised using the Mixed Methods Appraisal Tool2018 version. A database search was conducted in PubMed, SCOPUS, ProQuest, and CINAHL complete between 2009 and 2021. Results: Application of search terms yielded 1005 articles. After screening 877 articles, 124 met inclusion criteria, resulting in a final sample of 15 articles. Study characteristics were evaluated for common concepts and synthesized using the Theory of Unpleasant Symptoms influencing factors (physiological, situational, and performance). All 15 studies discussed PC interventions with the focus on dyspnea management or improvement in quality of life. None of the studies identified in this review focused specifically on women with advanced COPD receiving PC, despite the significant impact that this illness has on women. Conclusion: It remains unknown if any intervention is more beneficial than another for women with advanced COPD. Future research is needed to provide an understanding of the unmet PC needs of women with advanced COPD.

"Double awareness"-adolescents and young adults coping with an uncertain or poor cancer prognosis: A qualitative study

Introduction

Adolescents and young adults with an uncertain or poor cancer prognosis (UPCP) are confronted with ongoing and unique age-specific challenges, which forms an enormous burden. To date, little is known about the way AYAs living with a UPCP cope with their situation. Therefore, this study explores how AYAs with a UPCP cope with the daily challenges of their disease.

Method

We conducted semi-structured in-depth interviews among AYAs with a UPCP. Patients of the three AYA subgroups were interviewed (traditional survivors, new survivors, low-grade glioma survivors), since we expected different coping strategies among these subgroups. Interviews were analyzed using elements of the Grounded Theory by Corbin and Strauss. AYA patients were actively involved as research partners.

Results

In total 46 AYAs with UPCP participated, they were on average 33.4 years old (age range 23-44) and most of them were woman (63%). Most common tumor types were low-grade gliomas (16), sarcomas (7), breast cancers (6) and lung cancers (6). We identified seven coping strategies in order to reduce the suffering from the experienced challenges: (1) minimizing impact of cancer, (2) taking and seeking control, (3) coming to terms, (4) being positive, (5) seeking and receiving support, (6) carpe diem and (7) being consciously alive.

Conclusion

This study found seven coping strategies around the concept of 'double awareness' and showcases that AYAs are able to actively cope with their disease but prefer to actively choose life over illness. The findings call for CALM therapy and informal AYA support meetings to support this group to cope well with their disease.

Elemental Analysis of Laryngeal Cancer Patients in Comparison with Controls Using Scalp Hair as an Analytical Tool

Laryngeal cancer, a rare form of head and neck cancer, is more common in men, and various factors play important roles in its etiology. In the current study, trace elemental contents in the scalp hair of laryngeal cancer patients and healthy subjects were evaluated. Selected essential and toxic elements were measured using flame atomic absorption spectrophotometry after the hair samples were digested with HNO₃-HClO₄. The mean/median levels of Pb in the scalp hair of patients were significantly higher than the healthy donors, but Sr, Zn, and Co exhibited comparatively lower levels in the laryngeal cancer patients. In comparison to healthy donors, the correlation pattern among the elements in the hair of the patients exhibited diverse mutual relationships. The multivariate apportionment of the elemental levels in the scalp hair of both donor groups was significantly divergent. The average elemental levels varied significantly among the cancer types (glottic, supraglottic, transglottic, and subglottic) as well as the cancer stages (I, II, III, IV). The average levels of the elements also exhibited considerable variations depending on the donors' habitat, gender, food, and smoking habits. Overall, the study revealed significantly divergent disparities among the elemental contents in the scalp hair of the laryngeal cancer patients in comparison with counterpart controls.

The decisional balance, attitudes, and practice behaviors, its predicting factors, and related experiences of advance care planning in Taiwanese patients with advanced cancer

Background

Patients with advanced cancer are prone to experience burdensome physical, psychological, and financial consequences. Healthcare providers may not fully appreciate advanced cancer patients’ medical care autonomy, such as at that emboded by Advance Care Planning (ACP), and by doing so may compromise their quality of end-of-life (EOL). Hence, it is essential for healthcare providers to effectively assess and communicate with patients’ regarding their medical decisions before their patients are incapacitated by their disease progression. The purpose of this investigation was to describe the decisional balance, attitudes, and practice behaviors of ACP and its predictors of ACP-related experiences in Taiwanese patients with advanced cancer.

Methods

This cross-sectional, descriptive study employed a mixed-methodsquantitative and qualitative design with a sample of 166 patients that were purposely recruited from in-patient oncology units at a regional teaching hospital in southern Taiwan. Study data consisted of patient replies to a 34-item self-report tool, Decisional Balance, Attitudes, Practice Behaviors of ACP (DAP-ACP) and 4 semi-structured questions.

Result

Findings indicated that, in general, study participants exhibited favorable ACP-decisional balance and positive ACP-attitudes & practice behaviors. The results also indicated that gender, educational level, and cancer diagnosis were associated with significant differences on the “ACP-decisional balance” and “ACP-attitudes” scales. In addition, our findings documented that the participants’ gender and educational level were significant predictors of both ACP-decisional balance and ACP-attitudes. Furthermore the participants’ ACP-practice behaviors were predicted by ACP-decisional balance, but not with their ACP-attitudes. The qualitative analysis of the semi-structured questions identified six themes in responses to current medical decision making (e.g., compliance with physician instructions, family engagement in treatment decision-making); and eight themes pertaining to future ACP-related concerns were identified (e.g., family conflict, effectiveness of time-limited trials).

Conclusion

To promote patients’ engagement in ACP, the healthcare professional need to assess and advocate patients’ concerns or attitudes regarding ACP in a timely manner. In addition, factors or concerns that might influence patients’ responses to ACP derived from both the quantitative and qualitative findings of this current study need to be considered especially in initiating the dialogue regarding ACP with patients with advanced cancer.

Trial registration

No. CYCH 2,019,072, Date of registration 5 Dec 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01073-5.

A Qualitative Exploration of End-of-Life Care Planning With Korean Americans: Awareness, Attitudes, Barriers, and Preferences

This study aimed to explore how Korean American older adults viewed and anticipated engaging in end-of-life (EOL) care planning. An exploratory qualitative research design was adopted for the study, and data were collected through 3 focus group interviews. A total of 30 Korean American older adults 65 years or older participated in the study. A total of 10 themes emerged and were organized into 5 categories: (1) awareness (varying experience in EOL care planning and insufficient understanding about advance directives), (2) attitudes (comfort with talking about EOL and favorable views toward EOL planning), (3) barriers (concerns about noncompliance and concerns about change of mind), (4) preference for natural dying (life-sustaining treatment as added pain and suffering and no meaning of life when relying on life-sustaining treatment), and (5) preference for EOL planning process (EOL planning initiated by physicians and involvement of close family members). This exploratory study provides crucial insights into awareness and concerns regarding EOL care planning among Korean American older adults, updating existing evidence about their EOL needs. These findings support a culturally grounded approach to promote EOL planning for ethnic/racial minority groups.

Acceptance of Advance Care Planning Among Young Adults in Shijiazhuang, China: A Mixed-Methods Study

Context: In the event of accidental trauma, incurable disease and public health emergencies, young adults are unable to participate in their own medical decisions, family members face the huge decision-making pressure and medical resources of the society were unevenly distributed. Objective: The purposes of this study is to investigate the Advanced Care Planning (ACP) acceptance and examine its influencing factors using sequential explanatory mixed methods in order to provide a basis for the formulation of later interventions. Methods: A cross-sectional study of young adults (N = 785) and 12 other young adults from two other communities were investigated from January 2021 to February 2022. Descriptive statistics and multiple linear regressions were conducted. Content analysis was performed on the qualitative data. Results: The primary factors that contributed to the acceptance of ACP were the natural acceptance of death, being female, having a high level of education, having a loved one diagnosed with a chronic disease, and having heard of ACP. Among young adults, the acceptance of ACP may be impeded by a fear of the unknown nature of death, a poor understanding of ACP, and family-led decision-making. Discussion: Our study found that 77.1% had not heard of ACP before participating in the study and showed potential to accept ACP-related interventions. The study highlighted the importance of implementing regular young adult education courses, promoting routine ACP knowledge, individualized education, discussing family member's disease experiences, conducting family meetings, and identifying young adult responsibilities and roles in implement ACP for young adults in China.

The WHOQOL-BREF instrument: Psychometric evaluation of the Greek version in patients with advanced cancer and pain and associations with psychological distress

OBJECTIVES

Assessment of the psychometric characteristics of the Greek version of the brief World Health Organization Quality of Life Instrument (WHOQOL-BREF) in patients with advanced cancer and pain, and exploration of the association between psychological distress and quality of life (QoL).

METHOD

The sample consisted of 145 patients with advanced cancer and pain who completed the WHOQOL-BREF, the Symptom Checklist-90 (SCL-90), and the Pain Visual Analogue Scale (VAS). In analysis, the following methods were used: Cronbach's alpha, Item Response Theory (IRT), polychoric, Pearson and polyserial correlation, t-test, and Linear regression.

RESULTS

The internal consistency was high for all domains of the WHOQOL-BREF (Cronbach's α ≥ 0.731). Similarly, with the exception of three items, the WHOQOL-BREF items has large discrimination parameters suggesting that they have a high ability in differentiating subjects. On SCL-90, the three dimensions with the highest scores were Depression, Somatization, and Anxiety. The overall score for psychological distress, the Global Severity Index (GSI), showed significant negative association with all the WHOQOL-BREF factor scores (Physical Health: B = -1.488, p < 0.001, Psychological Health: B = -1.688, p < 0.001, Social Relationships: B = -0.910, p < 0.001, Environment: B = -1.064, p < 0.001). Male gender was associated with lower scores for Social Relationships (B = -0.358, p = 0.007) and Environment (B = -0.293, p = 0.026).

SIGNIFICANCE OF RESULTS

The Greek version of the WHOQOL-BREF showed good psychometric properties in patients with advanced cancer and can be used as a reliable instrument in clinical practice. The level of psychological distress can be considered a determinant of QoL in patients with advanced cancer and pain, independently of pain intensity or other clinical characteristics. In cancer, the disease process can activate multiple physiological and psychological mechanisms that lead to a wide range of symptoms of psychological distress. To improve their QoL, psychological intervention focused on the identification and alleviation of psychological distress in patients with advanced cancer, and help in finding meaning in their experience, should be provided.

Expectations in the Communication About Death and Dying: Development and Initial Validation of the End-of-Life Conversations - Expectations Scale

End-of-life (EOL) conversations with relatives or significant others are often avoided. One reason can be negative expectations regarding these conversations. The present study was conducted to develop and initially validate the End-of-Life Conversations - Expectations Scale (EOLC-E). An exploratory factor analysis (N = 307) resulted in a 20-item version with three distinct dimensions: expected own emotional burden (α = .92), expected other person's emotional burden (α = .94) and communication self-efficacy (α = .89). The EOLC-E total score correlated significantly with communication apprehension about death (r = .62), fear of death (r = .58), death avoidance (r = .52) as well as readiness for end-of-life conversations (r = -.38) and occurrence of previous conversations (r = -.29). Results suggest that the EOLC-E is a reliable and valid instrument to assess death and dying communication expectations. This measure has utility in communication research focusing on optimizing expectations and increasing EOL communication.

Expectations, end-of-life fears and end-of-life communication among palliative patients with cancer and caregivers: a cross-sectional study

OBJECTIVES

During serious illness, open communication with caregivers can ensure high-quality care. Without end-of-life communication, caregivers may become surrogates and decision-makers without knowing the patient's preferences. However, expectations and fears may influence the initiation of communication. The present study investigates differences between palliative patients with cancer and caregivers regarding expectations of end-of-life communication, end-of-life fears and experiences with end-of-life communication.

DESIGN

A cross-sectional study using a semi-structured interview and a paper-based questionnaire SETTING: University Hospital in Germany.

PARTICIPANTS

151 participants: 85 palliative cancer patients (mean age: 62.8 years, 65.9% male) and 66 caregivers (mean age: 56.3 years, 28.8% male).

PRIMARY AND SECONDARY OUTCOME MEASURES

Expectations, end-of-life fears and experiences of end-of-life discussions.

RESULTS

Patients and caregivers wish for the patient to be self-determined. In general, participants reported more positive than negative expectations of end-of-life discussions. Importantly, concerns about emotionally burdening other person was rated much higher in an informal context than a professional context (F(1,149)=316 958, p<0.001, η_p²=0.680), even though the emotional relief was expected to be higher (F(1,149)=46.115, p<0.001, η_p²=0.236). Caregivers reported more fears about the last period of life and more fears about end-of-life discussions than palliative patients, whereas palliative patients tended to avoid the topics of death and dying to a greater extent.

CONCLUSIONS

There seems to exist a 'self-other' asymmetry: palliative patients and their caregivers expect substantial personal relief when openly talking about end-of-life issues, but also expect the other person to be burdened by such communication. Professionals repeatedly need to initiate end-of-life communication.

Willingness to Discuss End-of-Life Care Wishes Among Rural Black/African American Residents of the Alabama Black Belt

Willingness for end-of-life discussion and related factors among rural Blacks/African Americans of the Alabama Black Belt have not been well-studied. This study aims to assess their willingness for the discussion and examine its relationship with social determinants of health (SDH) and demographic factors. A cross-sectional survey was conducted with a convenience sampling of 182 participants. Most participants were willing to discuss end-of-life wishes with family (77.1%) or doctors (72.1%). Controlling for demographics, results from binary logistic regressions showed those with hospice awareness were more likely to have willingness for discussion with family (OR = 10.07, p < .01) and doctors (OR = 7.23, p < .05). Those who were older (50+) were less likely to have willingness for discussion with doctors (OR = 0.19, p < .05), whereas those who were more socially isolated were less likely to have willingness for discussion with family (OR = 0.53, p < .05). Therefore, end-of-life discussion efforts should focus on older, socially isolated individuals and consider hospice awareness.

Association Among End-Of-Life Discussions, Cancer Patients' Quality of Life at End of Life, and Bereaved Families' Mental Health

End-of-life discussions are essential for patients with advanced cancer, but there is little evidence about whether these discussions affect general ward patients and family outcomes. We investigated the status of end-of-life discussions and associated factors and their effects on patients' quality of death and their families' mental health. Participants in this retrospective cross-sectional observational study were 119 bereaved family members. Data were collected through a survey that included questions on the timing of end-of-life discussions, quality of palliative care, quality of patient death, and depression and grief felt by the families. Approximately 64% of the bereaved family members participated in end-of-life discussions between the patient and the attending physician, and 55% of these discussions took place within a month before death. End-of-life discussions were associated with the patients' prognostic perception as "incurable, though there is hope for a cure" and "patients' experience with end-of-life discussions with family before cancer." There was a small decrease in depression and grief for families of patients who had end-of-life discussions. Those who did not have end-of-life discussions reported lower quality of end-of-life care.

'It was like taking an inner bath': A qualitative evaluation of a collaborative advance care planning-approach

BACKGROUND

Impaired readiness may hinder purposeful advance care planning in cancer patients. To reduce barriers to participation in end-of-life decision-making, a collaborative intervention was developed combining a psycho-oncological approach of dignity-based and cognitive-behavioural interventions, followed by a standardised advance care planning-process.

AIM

To evaluate the novel collaborative advance care planning-approach by synthetising cancer patient and carer perspectives on communicational and relational effects.

DESIGN

As a sub-project of a mixed-methods evaluation study, we conducted an inductive content analysis of qualitative interviews with advanced cancer patients and caregivers to deeply explore the focused impact of a collaborative advance care planning-approach on communication and relationship dynamics.

SETTING/PARTICIPANTS

Twelve patients with advanced cancer and 13 carers who participated in a collaborative advance care planning-intervention.

RESULTS

The collaborative advance care planning-approach was consistently evaluated positively by participants. Transcriptions of the semi-structured interviews were coded, analysed and merged under three main themes concerning communicational and relationship dynamics: action readiness, content readiness and impact on future communication and relationship.

CONCLUSIONS

The novel intervention served to foster individual readiness - including action and content readiness - for advance care planning-discussions by addressing highly individualised barriers to participation, as well as specific end-of-life issues. In addition, societal readiness could be promoted. Although the brief psycho-oncological intervention could not fully meet the needs of all participants, it can be used to develop individual psychotherapeutic strategies to improve different facets of readiness. The collaborative advance care planning-approach might require more time and human resources, but could pioneer successful advance care planning.

Gender and Observed Complexity in Palliative Home Care: A Prospective Multicentre Study Using the HexCom Model

This study analyses gender differences in the complexity observed in palliative home care through a multicentre longitudinal observational study of patients with advanced disease treated by palliative home care teams in Catalonia (Spain). We used the HexCom model, which includes six dimensions and measures three levels of complexity: high (non-modifiable situation), medium (difficult) and low. Results: N = 1677 people, 44% women. In contrast with men, in women, cancer was less prevalent (64.4% vs. 73.9%) (p < 0.001), cognitive impairment was more prevalent (34.1% vs. 26.6%; p = 0.001) and professional caregivers were much more common (40.3% vs. 24.3%; p < 0.001). Women over 80 showed less complexity in the following subareas: symptom management (41.7% vs. 51,1%; p = 0.011), emotional distress (24.5% vs. 32.8%; p = 0.015), spiritual distress (16.4% vs. 26.4%; p = 0.001), socio-familial distress (62.7% vs. 70.1%; p = 0.036) and location of death (36.0% vs. 49.6%; p < 0.000). Men were more complex in the subareas of "practice" OR = 1.544 (1.25-1.90 p = 0.000) and "transcendence" OR = 1.52 (1.16-1.98 p = 0.002). Observed complexity is related to male gender in people over 80 years of age. Women over the age of 80 are remarkably different from their male counterparts, showing less complexity regarding care for their physical, psycho-emotional, spiritual and socio-familial needs.

'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication?

Uncertainty, fear to harm the patient, discomfort handling the discussion and lack of time are the most cited barriers to prognostic disclosure. Physicians can be reassured that patients desire the truth about prognosis and can manage the discussion without harm, including the uncertainty of the information, if approached in a sensitive manner. Conversational guides could provide support in preparing such difficult conversations. Communicating 'with realism and hope' is possible, and anxiety is normal for both patients and clinicians during prognostic disclosure. As a clinician pointed out: 'I had asked a mentor once if it ever got easier. - No. But you get better at it.'

Matters of Life and Death: An Experimental Study Investigating Psychological Interventions to Encourage the Readiness for End-of-Life Conversations

INTRODUCTION

Talking about death and dying is evoking discomfort in many persons, resulting in avoidance of this topic. However, end-of-life discussions can alleviate distress and uncertainties in both old and young adults, but only a minority uses this option in palliative care. Even in healthy populations, talking about death is often seen as alleviative and worthwhile, but rarely initiated.

OBJECTIVE

To investigate different psychological interventions (a) encouraging the readiness for end-of-life discussions and (b) changing death attitudes in healthy adults of different ages.

METHODS

168 participants were randomized to four different interventions (IG1: value-based intervention with end-of-life perspective, IG2: motivation-based intervention with end-of-life perspective, IG3: combination of IG1 and IG2, CG: control group). Primary outcome was the readiness to engage in end-of-life topics. Secondary outcomes were fear of death, fear of dying and death acceptance. Assessments took place before, directly after the intervention and at 2 weeks of follow up.

RESULTS

IG2 and IG3 reported significantly more changes in the readiness to engage in end-of-life discussions than the CG (F[5.61, 307] = 4.83, p < 0.001, ηp2 = 0.081) directly after the intervention. The effect of IG3 remained stable at the follow-up. There were no significant effects of the interventions on end-of-life fears or death acceptance. Acceptability of the interventions was very high.

CONCLUSIONS

Short interventions can be useful to encourage end-of-life discussions and could be integrated in health care programs. The efficacy and effectiveness of these short interventions in palliative patients are currently examined.

'Who would even want to talk about death?' A qualitative study on nursing students' experiences of talking about death with terminally ill patients with cancer

OBJECTIVES

This study aimed to describe nursing students' experiences of talking about death with terminally ill patients with cancer.

METHODS

The study adopted a qualitative design, and participants (n = 28) were final-year undergraduate nursing students. Data were collected by conducting in-depth semi-structured face-to-face interviews using a pilot-tested interview guide. The researchers followed a systematic data analysis procedure which is an appropriate method of analysis when aiming to create knowledge based on experiences and meanings from cross-case analysis.

RESULTS

The responses of the nursing students were subsumed under the following three themes: (1) 'balance on the rope', (2) 'who would even want to talk about death' and (3) 'need to talk but …'. The findings suggest that many nursing students do not believe that they are competent enough to talk about death with terminally ill patients with cancer, even though they believe it is essential to end-of-life care.

CONCLUSION

The findings underscore the importance of examining students' perspectives on death, which not only shapes their experiences of caring for terminally ill patients but also influences the quality of care. Further, students feel unprepared for talking to terminally ill patients with cancer and require support to avoid ignoring calls to speak about death.

Marginalized Males, Disparate COVID-19 Outcomes, and Health Equity: A Profile of Highest Risk

This paper is a direct response to Smith et al.'s (2020) call for more insight into health equity concerns pertaining to COVID-19 outcomes. The goal of this discussion is to offer the field with an evidence-informed 'avatar' representing the most-impacted group as it pertains to COVID-19 mortality and morbidity. Policy and practice implications are offered as a call to action for public health professionals to support these most impacted and highest risk communities.

The Difficulties in End-of-Life Discussions - Family Inventory (DEOLD-FI): Development and Initial Validation of a Self-Report Questionnaire in a Sample of Terminal Cancer Patients

CONTEXT

Open end-of-life communication is especially important within the patient-family unit of care and can positively affect their medical, psychological, and relational outcomes. Nevertheless, end-of-life discussions are often perceived as difficult and avoided.

OBJECTIVES

To develop and validate the Difficulties in End-of-Life Discussions - Family Inventory (DEOLD-FI) to allow a systematic assessment of reasons why people shy away from end-of-life discussions.

METHODS

Patients with advanced cancer were recruited and completed the DEOLD-FI and measures of avoidance of cancer communication, quality of life and distress, and the experienced difficulty as well as the occurrence of end-of-life discussions. Standard item analyses and an exploratory factor analysis were conducted. Construct validity was analysed through associations between the DEOLD-FI and the aforementioned measures.

RESULTS

Questionnaires were obtained from 112 participants (53% response rate; male 54%, mean age 64.9 years [range 33-94]). In the final 23-item version two factors were extracted: 'emotional burden due to end-of-life discussions' (α = 0.90) and "negative attitudes towards end-of-life discussions" (α = 0.91) explaining 69% of the variance (total scale α = 0.93). Construct validity was supported by its significant correlations with the reported difficulty in end-of-life discussions (r = 0.42) and avoidance of cancer communication (r = 0.40 to r = 0.46) and insignificant correlations with quality of life (r = -0.11), distress (r = 0.16), and physical well-being (r = 0.02). Those who had already engaged in end-of-life discussions showed significantly fewer communication barriers.

CONCLUSION

Results provide evidence that the DEOLD-FI is a valid and reliable instrument for the assessment of difficulties in end-of-life discussions. Benefits for clinical practice and research are discussed.

High-Intensity End-of-Life Care Among Patients With GI Cancer in Puerto Rico: A Population-Based Study

High-intensity care with undue suffering among patients with cancer at the end of life (EoL) is associated with poor quality of life. We examined the pattern and predictors of high-intensity care among patients with GI cancer in Puerto Rico.

Perception of death and preference for end-of-life care among Asian Buddhists living in Montreal, Canada

Dying with dignity is important in Western culture. The aim of this qualitative study was to explore how Asian Buddhists, exposed to Western cultures, perceive death and dying with dignity, and examine their preferences for end-of-life care. We interviewed 15 Asian Buddhists living in Montreal (Canada). Participants regarded death as inevitable, while a good/dignified death had to be natural, peaceful, and, most of all, conscious. Most preferred palliative care to medical-aid-in-dying and emphasized death preparation through daily contemplation of impermanence. Care providers' understanding and respect of Buddhist patients' perception of a dignified death might help facilitate this important transition.