Caregiver bereavement outcomes in advanced cancer: associations with quality of death and patient age

Bereaved Family Quality of Life Varies With Comorbid Psychological Distress and ICU-Care Quality

CONTEXT

Health-related quality of life (HRQOL) is highly endorsed, but HRQOL studies scarcely investigate the following: ICU family members; modifiable end-of-life (EOL) ICU-care factors; conjoint associations with prolonged grief disorder (PGD), post-traumatic stress disorder (PTSD), and depression; and long-term bereavement outcomes.

OBJECTIVES

Exploratorily investigate associations of PGD-PTSD-depressive-symptom states (resilient, subthreshold-depression dominant, PGD dominant, and PGD-PTSD-depression comorbid) and quality of EOL ICU care with families' HRQOL 6-24 months post loss.

METHODS

This cohort study examined symptoms of PGD (11 items of the PG-13), PTSD (Impact of Event Scale-Revised), and depression (Hospital Anxiety and Depression Scale), and HRQOL (Medical Outcomes Study 36-Item Short-Form Health Survey) among 303 ICU family members. Quality of EOL ICU care was measured by objective process-based care-quality indicators abstracted from medical records and classified by subjective family-assessed quality of patient dying and death (QODD). Associations were simultaneously examined by multivariate hierarchical linear modeling with resilient state and high QODD class as reference.

RESULTS

Physical and mental HRQOL were worse in the 3 more distressed symptom states, especially mental HRQOL which showed an incremental dose-response effect: subthreshold depression-dominant (β [95% CI]=-2.419 [-3.374, -1.464]), PGD-dominant (-8.366 [-10.116, -6.616]), and PGD-PTSD-depression comorbid (-14.736 [-17.772, -11.700]) states. Mental HRQOL was significantly worse in the 3 poorer QODD classes: moderate (-1.085 [-2.138, -0.032]), poor to uncertain (-4.362 [-5.616, -3.108]), and worst (-3.239 [-4.433, -2.045]). HRQOL was not associated with objective care-quality indicators.

CONCLUSION

Bereaved family members' HRQOL was significantly associated with PGD-PTSD-depressive-symptom states and QODD classes-both modifiable through high-quality EOL ICU care.

Factors of prolonged-grief-disorder symptom trajectories for ICU bereaved family surrogates

BACKGROUND

Bereaved people experience distinct trajectories of prolonged-grief-disorder (PGD) symptoms. A few studies from outside critical care investigated limited factors of PGD-symptom trajectories without a theoretical framework. We aimed to characterize factors associated with ICU bereaved surrogates' PGD-symptom trajectories, drawing from the integrative framework of predictors for bereavement outcomes, emphasizing factors modifiable by ICU care.

METHODS

Prospective cohort study of 291 family surrogates. Multinomial logistic regression was used to determine associations of three previously identified PGD-symptom trajectories (resilient [n = 242, 83.2%] as reference group, recovery [n = 35, 12.0%], and chronic [n = 14, 4.8%]) with risk factors. Factors included intrapersonal (demographics, personal vulnerabilities), interpersonal (perceived social support), bereavement-related (patient demographics, clinical characteristics, and patient-surrogate relationship), and death-circumstance (surrogate-perceived quality of patient dying and death [QODD] in ICUs classified as high, moderate, poor-to-uncertain, and worst QODD classes) factors.

RESULTS

Most surrogates were female (59.1%), the patient's adult child (54.0%), and about (standard deviation) 49.63 (12.53) years old. As surrogate age increased, recovery-trajectory membership decreased (adjusted odds ratio [95% confidence interval] = 0.918 [0.849, 0.993]) and chronic-trajectory membership increased (1.230 [1.010, 1.498]). Being married decreased membership in the recovery (0.186 [0.047, 0.729]) trajectory. Higher anxiety symptoms 1 month post loss increased membership in recovery (1.520 [1.256, 1.840]) and chronic (2.022 [1.444, 2.831]) trajectories. Spouses were more likely and adult-child surrogates were less likely than other relationships to be in the two more profound PGD-symptom trajectories. Membership in the chronic trajectory decreased (0.779 [0.614, 0.988]) as patient age increased. The poor-to-uncertain QODD class was associated with a nearly significant increase (4.342 [0.980, 19.248]) in membership in the recovery trajectory compared to the high QODD class.

CONCLUSIONS

Membership in the PGD-symptom trajectories was associated with factors modifiable by high-quality ICU care, including anxiety symptoms at early bereavement and surrogate-perceived QODD in the ICU. Clinicians should be sensitive to the psychological needs of at-risk family surrogates, provide high-quality end-of-life care to facilitate QODD, and promptly refer bereaved surrogates who suffer anxiety symptoms and profound and/or persistent PGD-symptoms for psychological support.

Pharmacological treatment of pain, dyspnea, death rattle, fever, nausea, and vomiting in the last days of life in older people: A systematic review

BACKGROUND

Evidence based guidelines for treatment of physical symptoms during the last days of life in older people are not available.

AIM

We wanted to synthesize the existing evidence on the pharmacological treatment of pain, dyspnea, death rattle, fever, nausea, and vomiting during the last days of life in older people to develop recommendations that can help guide clinical practice.

DESIGN

A systematic review was conducted (PROSPERO #CRD42023406100) and reported in accordance with PRISMA guidelines.

DATA SOURCES

MEDLINE and EMBASE were searched from inception till March 2023, together with national and international guideline databases.

RESULTS

Four predominantly descriptive studies on opioid use were included for the treatment of pain and four for dyspnea, without clear evidence for the choice of one specific opioid, nor a specific opioid dose. For death rattle, five randomized controlled trials and two retrospective studies were included. These provide evidence for the prophylactic treatment of death rattle with hyoscine butylbromide. For fever, nausea, and vomiting, no articles met the inclusion criteria.

CONCLUSION

Limited evidence exists to guide the pharmacological treatment of pain, dyspnea, death rattle, fever, nausea, and vomiting in the last days of life of older people. Other than the use of opioids for treatment of pain and dyspnea and prophylactic administration of hyoscine butylbromide to decrease the likelihood of developing death rattle, no specific recommendations can be formulated for use in clinical practice. This demonstrates the challenging nature of research in the last days of life of older people, despite its pressing need.

Associations between palliative-care consultations and end-of-life quality in cancer patients' last 6 months

PURPOSE

Improving end-of-life (EOL) quality for terminally ill cancer patients is crucial. However, associations between hospice/palliative care and EOL quality, as perceived by patients, are underreported. We aimed to examine the impact of palliative care consultative services on the EOL quality during cancer patients' last six months.

METHODS

In this prospective, longitudinal study, 174 cancer patients were divided into a palliative care consultative services group (n = 65) or a non palliative care consultative services group (n = 109). The impact of palliative care consultative services on EOL quality, assessed using the Quality of Dying and Death (QODD) scale at the first and last assessments within the patients' last six months, was analyzed by linear regression with generalized estimating equations, adjusting for covariates.

RESULTS

Cancer patients received palliative care consultative services a median of 34.0 days before death. There were significant main effects of groups, indicating that patients receiving palliative care consultative services had better QODD total scores (β [95% confidence interval] = 2.12 [0.32,3.93], p = .021), death preparation (3.80 [1.71,5.89], p < .001), and treatment preferences than the reference group (3.27 [0.90,5.64], p = .007). No group differences were found in other dimensions, including symptom and personal care, whole person concern, and time with family.

CONCLUSION

Palliative care consultative services significantly improved cancer patients' perceptions of death preparation, treatment preferences, and the QODD total score. Therefore, healthcare professionals should offer palliative care consultative services to cancer patients, initiate early referrals for such care, and implement effective and individualized interventions to enhance EOL quality.

Associations Between Family-Assessed Quality-of-Dying-and-Death Latent Classes and Bereavement Outcomes for Family Surrogates of ICU Decedents

OBJECTIVES

To examine associations between family surrogates' bereavement outcomes and four previously determined quality of dying and death (QODD) latent classes (high, moderate, poor-to-uncertain, and worst).

DESIGN

Prospective, longitudinal, observational study.

SETTING

Medical ICUs at two academically affiliated medical centers in Taiwan.

PATIENTS/PARTICIPANTS

Three hundred nine family surrogates responsible for decision-making for critically ill patients at high risk of death (Acute Physiology and Chronic Health Evaluation II scores > 20) from a disease.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Participants were assessed by the depression and anxiety subscales of the Hospital Anxiety and Depression Scale, the Impact of Event Scale-Revised, 11 items of the Prolonged Grief Disorder (PGD) scale, and the Medical Outcomes Study 36-Item Short-Form Health Survey at 1, 3, 6, 13, 18, and 24 months post-loss. We simultaneously examined associations of four QODD latent classes with physical and mental health-related quality of life (HRQOL) and symptoms of anxiety, depression, post-traumatic stress disorder (PTSD), and PGD assessed over 24 bereavement months using multivariate hierarchical linear modeling. Surrogates' distinct QODD latent classes assessed at 1-month post-loss were significantly associated with bereavement outcomes, except for physical HRQOL and PGD symptoms. Significantly more depressive symptoms and worse mental HRQOL (β [95% CI]) were reported by bereaved surrogates in the moderate (1.958 [1.144-2.772], -2.245 [-3.961 to -0.529]), poor-to-uncertain (2.224 [1.438-3.010], -7.026 [-8.683 to -5.369]), and worst (2.081 [1.215-2.964], -4.268 [-6.096 to -2.440]) QODD classes than those in the high QODD class. Bereaved surrogates in the moderate (2.095 [1.392-2.798]) and poor-to-uncertain (0.801 [0.123-1.480]) QODD classes reported more anxiety symptoms, whereas those in the poor-to-uncertain QODD class suffered more PTSD symptoms (2.889 [1.005-4.774]) than those in the high QODD class.

CONCLUSIONS

The four distinct QODD latent classes were significantly associated with ICU family surrogates' bereavement outcomes, suggesting targets to improve end-of-life care quality in ICUs.

Exposure to a Loved One's Death and Advance Care Planning: Moderating Effects of Age

Background: Despite documented benefits of Advance Care Planning (ACP), it is still under-utilized in the U.S. Our study aimed to examine whether experiencing a loved one's death is associated with one's own ACP behavior among adults in the U.S. and the potential moderating effect of age. Method: Using a nationwide cross-sectional survey design with probability sampling weights, our study included 1006 adults in the U.S. who participated in and completed the Survey on Aging and End-of-Life Medical Care. Three binary logistic regression models were established to investigate the relationship between death exposure and different aspects of ACP (i.e., informal conversations with family members and doctors and formal advance directives completion). The moderation analysis was subsequently conducted to examine moderating effects of age. Results: The exposure to a loved one's death was significantly associated with higher odds of having conversations with family about end-of-life medical care preferences among the 3 indicators of ACP (OR = 2.03, P < .001). Age significantly moderated the association between death exposure and ACP conversations with doctors (OR = .98, P = .017). The facilitation effect of death exposure on informal ACP engagement in discussing end-of-life medical wishes with doctors is stronger among younger adults than older adults. Conclusions: Exploring an individual's previous experience with a loved one's death might be an effective way to broach the concept of ACP among adults of all ages. This strategy may be particularly useful in facilitating discussions of end-of-life medical wishes with doctors among younger adults than older adults.

Factors Associated With Family Surrogate Decisional-Regret Trajectories

CONTEXT/OBJECTIVES

The scarce research on factors associated with surrogate decisional regret overlooks longitudinal, heterogenous decisional-regret experiences and fractionally examines factors from the three decision-process framework stages: decision antecedents, decision-making process, and decision outcomes. This study aimed to fill these knowledge gaps by focusing on factors modifiable by high-quality end-of-life (EOL) care.

METHODS

This observational study used a prior cohort of 377 family surrogates of terminal-cancer patients to examine factors associated with their membership in the four preidentified distinct decisional-regret trajectories: resilient, delayed-recovery, late-emerging, and increasing-prolonged trajectories from EOL-care decision making through the first two bereavement years by multinomial logistic regression modeling using the resilient trajectory as reference.

RESULTS

Decision antecedent factors: Financial sufficiency and heavier caregiving burden increased odds for the delayed-recovery trajectory. Spousal loss, higher perceived social support during an EOL-care decision, and more postloss depressive symptoms increased odds for the late-emerging trajectory. More pre- and postloss depressive symptoms increased odds for the increasing-prolonged trajectory. Decision-making process factors: Making an anticancer treatment decision and higher decision conflict increased odds for the delayed-recovery and increasing-prolonged trajectories. Making a life-sustaining-treatment decision increased membership in the three more profound trajectories. Decision outcome factors: Greater surrogate appraisal of quality of dying and death lowered odds for the three more profound trajectories. Patient receipt of anticancer or life-sustaining treatments increased odds for the late-emerging trajectory.

CONCLUSION

Surrogate membership in decisional-regret trajectories was associated with decision antecedent, decision-making process, and decision outcome factors. Effective interventions should target identified modifiable factors to address surrogate decisional regret.

Specialist palliative care until the very end of life - reports of family caregivers and the multiprofessional team

BACKGROUND

Specialist palliative care (SPC) includes care for incurably ill patients and their family caregivers at home or on a palliative care ward until the very end of life. However, in the last days of life, patients can rarely express their needs and little is known about SPC outcomes as reported by multiprofessional SPC teams and family caregivers.

METHODS

Using the Palliative Care Outcome Scale (POS; Score 0-40), proxy assessments of SPC outcomes in the patient's last 3 days of life were performed by SPC teams and primary family caregivers of three home care and three inpatient services. Additional questions were asked about problems solved 'particularly well' or 'inadequately' (last 7 days), which were content analyzed and quantified.

RESULTS

Proxy assessments by SPC teams were available in 142 patients (of whom 51% had died at home). Family caregiver assessments exist for a subgroup of 60 of these patients. SPC teams (POS total score: mean 13.8, SD 6.3) reported SPC outcomes slightly better than family caregivers (mean 16.7, SD 6.8). The POS items consistently rated as least affected (= 0) by both, SPC teams and family caregivers, were 'not wasted time' (team 99%/family caregivers 87%), 'information' (84%/47%) and 'support' (53%/31%). Items rated as most affected (= 4) were 'patient anxiety' (31%/51%), 'life not worthwhile' (26%/35%) and 'no self-worth' (19%/30%). Both groups indicated more problems solved 'particularly well' than 'inadequately'; the latter concerned mainly clinically well-known challenges during end-of-life care and family caregiver care.

CONCLUSIONS

This study shows the range and type of symptoms and other concerns reported in the patient's last days. Starting points for further improvements in family caregiver care and psychosocial and spiritual issues were identified.

What If… Caregivers' Subsequent Workforce Participation Was a Measure of Palliative Care Services' Impact? An Hypothesis-Generating Study

Background: Hospice/palliative care emphasizes excellent care for patients, but what about longer-term caregiver outcomes after their caregiving role? What is the role of services in working to ensure that caregivers can re-engage with all aspects of life, including paid employment given that this is an identified stressor for caregivers? Aim: This hypothesis-generating study aimed to explore self-reported, post-care workforce participation, and any association with hospice/palliative care contact. Design: Cross-sectional random population interviews. Setting/Participants: People in the general population were randomly selected for face-to-face interviews about well-being including end-of-life care in South Australia. Questions included experiences of people dying an expected death and whether interviewees provided care. Demographic data included current workforce participation. A regression model explored associations with workforce participation. Results: Of 8945 interviews over three years, 171 participants aged 20-60 years (working age) provided intermittent hands-on care: two in five were men and two in three had qualifications beyond high school; one in two decedents had accessed palliative care services. Reflecting the bivariable analyses, logistic regression models showed associations with workforce participation and: being male (odds ratio [OR] 6.71); use of palliative care services (OR 4.85); and higher levels of education (OR 3.54). Conclusion: An association between workforce participation after caregiving ceased and the use of palliative care services was described, controlling for key factors. Reasons may include continued working, greater rates of return to work, earlier return to work or that people in the workforce are more likely to access services.

Predictors of Complicated Grief in Caregivers of Palliative Care Patients

Introduction: It is important to identify the factors s associated with complicated grief (CG) in order to prevent it. Objective: To determine the factors associated with CG in the end-of-life phase within the palliative care context. Method: The PRISMA model was followed for the review. We accessed the following databases: PUBMED, SCOPUS, and PsycoINFO, to review publications from 2006. Results: A total of 17 studies were obtained. A direct relationship between factors prior to bereavement and CG is established: intensity of anticipated grief, previous mental and physical health of the caregiver, social support; quality of patient care, communication at the end-of-life, preparation for death, spirituality, and sociodemographic factors. Conclusions: Previous mental health and level of anticipatory grief in the main caregiver are shown to be the most powerful predictors of CG. Patient age and quality of care are factors considered as strong predictors of CG in almost every study.

Assessment of an Instrument to Measure Interdisciplinary Staff Perceptions of Quality of Dying and Death in a Pediatric Cardiac Intensive Care Unit

Importance

Lack of pediatric end-of-life care quality indicators and challenges ascertaining family perspectives make staff perceptions valuable. Cardiac intensive care unit (CICU) interdisciplinary staff play an integral role supporting children and families at end of life.

Objectives

To evaluate the Pediatric Intensive Care Unit Quality of Dying and Death (PICU-QODD) instrument and examine differences between disciplines and end-of-life circumstances.

Design, Setting, and Participants

This cross-sectional survey included staff at a single center involved in pediatric CICU deaths from July 1, 2019, to June 30, 2021.

Exposures

Staff demographic characteristics, intensity of end-of-life care (mechanical support, open chest, or cardiopulmonary resuscitation [CPR]), mode of death (discontinuation of life-sustaining therapy, treatment limitation, comfort care, CPR, and brain death), and palliative care involvement.

Main Outcomes and Measures

PICU-QODD instrument standardized score (maximum, 100, with higher scores indicating higher quality); global rating of quality of the moment of death and 7 days prior (Likert 11-point scale, with 0 indicating terrible and 10, ideal) and mode-of-death alignment with family wishes.

Results

Of 60 patient deaths (31 [52%] female; median [IQR] age, 4.9 months [10 days to 7.5 years]), 33 (55%) received intense care. Of 713 surveys (72% response rate), 246 (35%) were from nurses, 208 (29%) from medical practitioners, and 259 (36%) from allied health professionals. Clinical experience varied (298 [42%] ≤5 years). Median (IQR) PICU-QODD score was 93 (84-97); and quality of the moment of death and 7 days prior scores were 9 (7-10) and 5 (2-7), respectively. Cronbach α ranged from 0.87 (medical staff) to 0.92 (allied health), and PICU-QODD scores significantly correlated with global rating and alignment questions. Mean (SD) PICU-QODD scores were more than 3 points lower for nursing and allied health compared with medical practitioners (nursing staff: 88.3 [10.6]; allied health: 88.9 [9.6]; medical practitioner: 91.9 [7.8]; P < .001) and for less experienced staff (eg, <2 y: 87.7 [8.9]; >15 y: 91, P = .002). Mean PICU-QODD scores were lower for patients with comorbidities, surgical admissions, death following treatment limitation, or death misaligned with family wishes. No difference was observed with palliative care involvement. High-intensity care, compared with low-intensity care, was associated with lower median (IQR) rating of the quality of the 7 days prior to death (4 [2-6] vs 6 [4-8]; P = .001) and of the moment of death (8 [4-10] vs 9 [8-10]; P =.001).

Conclusions and Relevance

In this cross-sectional survey study of CICU staff, the PICU-QODD showed promise as a reliable and valid clinician measure of quality of dying and death in the CICU. Overall QODD was positively perceived, with lower rated quality of 7 days prior to death and variation by staff and patient characteristics. Our data could guide strategies to meaningfully improve CICU staff well-being and end-of-life experiences for patients and families.

Exploring Experiences of Bereaved Caregivers of Older Adult Patients With Acute Myeloid Leukemia

Caregivers of older adults with acute myeloid leukemia (AML) are requiring more support now that novel, nonintensive therapies, such as hypomethylating agents and venetoclax, are shifting the burden of care to the outpatient setting. Early findings from a larger study describe supportive care needs from the perspective of bereaved caregivers that align with existing research, informing the development of best practices for oncology nurses who support caregivers of older adults with AML.