Recordings of consultations are beneficial in the transition from curative to palliative cancer care: A pilot-study in patients with oesophageal or head and neck cancer

Introducing palliative care in advanced cancer: a systematic review

BACKGROUND

Negative perceptions about palliative care (PC), held by patients with cancer and their families, are a barrier to early referral and the associated benefits. This review examines the approaches that support the task of introducing PC to patients and families and describes any evaluations of these approaches.

METHODS

A systematic review with a systematic search informed by the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines was performed on the online databases MEDLINE, PsychInfo and CINAHL from May 2022 to July 2022. Identified studies were screened by title and abstract, and included if they were empirical studies and described an approach that supported the introduction of PC services for adult patients. A narrative-synthesis approach was used to extract and present the findings.

RESULTS

Searches yielded 1193 unique manuscripts, which, following title and abstract screening, were reduced to 31 papers subject to full-text review, with a final 12 studies meeting eligibility criteria. A diverse range of included studies described approaches used to introduce palliative care, which may be broadly summarised by four categories: education, clinical communication, building trust and rapport and integrative system approaches.

CONCLUSION

While educational approaches were helpful, they were less likely to change behaviours, with focused communication tasks also necessary to facilitate PC introduction. An established relationship and trust between patient and clinician were foundational to effective PC discussions. A framework to assist clinicians in this task is likely to be multidimensional in nature, although more quantitative research is necessary to establish the most effective methods and how they may be incorporated into clinical practice.

Interventions for interpersonal communication about end of life care between health practitioners and affected people

BACKGROUND

Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes.

OBJECTIVES

To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing.

SELECTION CRITERIA

This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life,  we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes.

DATA COLLECTION AND ANALYSIS

Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies.

MAIN RESULTS

Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials.  Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication.  Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations.  Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions  (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life.  Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear.

AUTHORS' CONCLUSIONS

Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.

Consultation Recording: What Is the Added Value for Patients Aged 50 Years and Over? A Systematic Review

This systematic review aimed to provide medical professionals with insight into beneficial and harmful effects of consultation recording for patients aged 50 years and over. This insight could enable medical professionals to decide on whether or not to promote consultation recording in their practice. The systematic literature search was performed in six databases; additional relevant articles were sought using the snowball method. Studies were included that investigated the value of consultation recording for patients aged 50 years and over. The selected studies were analyzed on affective cognitive outcomes, behavioral outcomes, and health outcomes. Twenty-five studies of both qualitative and quantitative design were included. Consultation recordings mainly improved patient satisfaction, recall, fulfillment of information needs, and decision-making. Both positive and negative effects were reported on anxiety. The recordings did not distinctly affect functional outcomes or quality of life. In conclusion, consultation recording positively influenced patients' affective cognitive and behavioral outcomes, and the negative effects of consultation recording were minor. Because of the positive effects of consultation replay, we recommend that doctors promote consultation recording among their patients of 50 years and over. However, more studies are necessary among older patients because this patient population is underrepresented in the current literature.

Are the MORECare guidelines on reporting of attrition in palliative care research populations appropriate? A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Palliative care trials have higher rates of attrition. The MORECare guidance recommends applying classifications of attrition to report attrition to help interpret trial results. The guidance separates attrition into three categories: attrition due to death, illness or at random. The aim of our study is to apply the MORECare classifications on reported attrition rates in trials.

METHODS

A systematic review was conducted and attrition classifications retrospectively applied. Four databases, EMBASE; Medline, CINHAL and PsychINFO, were searched for randomised controlled trials of palliative care populations from 01.01.2010 to 08.10.2016. This systematic review is part of a larger review looking at recruitment to randomised controlled trials in palliative care, from January 1990 to early October 2016. We ran random-effect models with and without moderators and descriptive statistics to calculate rates of missing data.

RESULTS

One hundred nineteen trials showed a total attrition of 29% (95% CI 28 to 30%). We applied the MORECare classifications of attrition to the 91 papers that contained sufficient information. The main reason for attrition was attrition due to death with a weighted mean of 31.6% (SD 27.4) of attrition cases. Attrition due to illness was cited as the reason for 17.6% (SD 24.5) of participants. In 50.8% (SD 26.5) of cases, the attrition was at random. We did not observe significant differences in missing data between total attrition in non-cancer patients (26%; 95% CI 18-34%) and cancer patients (24%; 95% CI 20-29%). There was significantly more missing data in outpatients (29%; 95% CI 22-36%) than inpatients (16%; 95% CI 10-23%). We noted increased attrition in trials with longer durations.

CONCLUSION

Reporting the cause of attrition is useful in helping to understand trial results. Prospective reporting using the MORECare classifications should improve our understanding of future trials.

Patient, nursing and medical staff experiences and perceptions of the care of people with palliative esophagogastric cancer: a systematic review of the qualitative evidence

BACKGROUND

Esophagogastric cancer is the fifth most common malignancy and its incidence is increasing. The disease progresses quickly and five-year survival rates are poor. Treatment with palliative intent is provided for the majority of patients but there remains a lack of empirical evidence on the most effective service models to support esophagogastric cancer patients.

OBJECTIVES

The overall objective of this systematic review was to synthesize the best available evidence on the experiences and perceptions of patients and health professionals with regard to the care of people diagnosed with palliative esophagogastric cancer.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

The review considered studies that included patients diagnosed with palliative esophagogastric cancer and any health professionals involved in the delivery of palliative care to this patient group in a hospital, home or community setting.

PHENOMENA OF INTEREST

The review considered studies that investigated the experiences and perceptions of people diagnosed with palliative esophagogastric cancer and staff working with these people.

CONTEXT

Studies that were carried out in any setting, including in-patient and outpatient areas, specialist cancer and non-specialist palliative care services and those were any patient were in receipt or had experiences of palliative care services were considered. All types of health practitioners delivering palliative care to esophagogastric cancer patients were considered.

TYPES OF STUDIES

Studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, feminist research and narrative approaches were considered. Mixed methods studies were considered in the review only if qualitative findings were reported separately.

SEARCH STRATEGY

A three-step search strategy was utilized. A total 11 databases were searched for studies from 2000 onward, followed by hand searching of reference lists.

METHODOLOGICAL QUALITY

Methodological quality was assessed using the Joanna Briggs Institute Qualitative Assessment and Review Instrument critical appraisal tool (JBI-QARI).

DATA EXTRACTION

Qualitative findings were extracted using the JBI-QARI data extraction Instrument.

DATA SYNTHESIS

Qualitative research findings were pooled using a pragmatic meta-aggregative approach.

RESULTS

The review included two publications. There were 46 findings which were aggregated into four categories and one overall synthesized finding: "In addition to support for physical needs, patients need support that takes into account changing life situations to achieve the best quality of life."

CONCLUSIONS

The review shows that patients value services and support that addresses their complex, fluctuating and highly individual needs. No evidence was uncovered regarding how these services should be designed and delivered.

Should consultation recording use be a practice standard? A systematic review of the effectiveness and implementation of consultation recordings

OBJECTIVE

To conduct a systematic review of the effectiveness of consultation recordings and identify factors contributing to their successful implementation in health-care settings.

METHODS

A systematic review was conducted for quantitative studies examining the effectiveness of consultation recordings in health care. Two independent reviewers assessed the relevance and quality of retrieved quantitative studies by using standardized criteria. Study findings were examined to determine consultation recording effectiveness and to identify barriers and facilitators to implementation. A supplementary review of qualitative evidence was performed to further explicate implementation factors.

RESULTS

Of the 3373 articles retrieved in the quantitative search, 26 satisfied the standardized inclusion criteria (12 randomized controlled trials, 1 quasi-experiment, and 13 cross-sectional studies). Most patients found consultation recordings beneficial. Statistically significant evidentiary support was found for the beneficial impact of consultation recordings on the following patient reported outcomes: knowledge, perception of being informed, information recall, decision-making factors, anxiety, and depression. Implementation barriers included strength of evidence concerns, patient distress, impact of the recording on consultation quality, clinic procedures, medico-legal issues, and resource costs. Facilitators included comfort with being recorded, clinical champions, legal strategies, efficient recording procedures, and a positive consultation recording experience.

CONCLUSIONS

Consultation recordings are valuable to patients and positively associated with patient-reported outcomes. Successful integration of consultation recording use into clinical practice requires an administratively supported, systematic approach to addressing implementation factors.

Feasibility and Pilot Studies in Palliative Care Research: A Systematic Review

CONTEXT

Feasibility and pilot study designs are common in palliative care research. Finding standard guidelines on the structure and reporting of these study types is difficult.

OBJECTIVES

In feasibility and pilot studies in palliative care research, to determine 1) how commonly a priori feasibility are criteria reported and whether results are subsequently reported against these criteria? and 2) how commonly are participants' views on acceptability of burden of the study protocol assessed?

METHODS

Four databases (OVID Medline, EMBASE, CINAHL, and PubMed via caresearch.com.au.) were searched. Search terms included palliative care, terminal care, advance care planning, hospice, pilot, feasibility, with a publication date between January 1, 2012 and December 31, 2013. Articles were selected and appraised by two independent reviewers.

RESULTS

Fifty-six feasibility and/or pilot studies were included in this review. Only three studies had clear a priori criteria to measure success. Sixteen studies reported participant acceptability or burden with measures. Forty-eight studies concluded feasibility.

CONCLUSION

The terms "feasibility" and "pilot" are used synonymously in palliative care research when describing studies that test for feasibility. Few studies in palliative care research outline clear criteria for success. The assessment of participant acceptability and burden is uncommon. A gold standard for feasibility study design in palliative care research that includes both clear criteria for success and testing of the study protocol for participant acceptability and burden is needed. Such a standard would assist with consistency in the design, conduct and reporting of feasibility and pilot studies.

Interventions for healthcare professionals, organizations and patients to enhance quality of life for people diagnosed with palliative esophagogastric cancer: a systematic review

BACKGROUND

Esophagogastric (EG) cancer is the fifth most common malignancy, and its incidence is increasing. The disease is fast paced, and five-year survival rates are poor. Treatment with palliative intent is provided for the majority of patients but there remains a lack of empirical evidence into the most effective service models to support EG cancer patients.

OBJECTIVES

The overall objective of this quantitative systematic review was to establish best practice in relation to interventions targeted at healthcare professionals or the structures in which healthcare professionals deliver care (i.e. models of care and practice) and patients (diagnosed with palliative EG cancer) to enhance the quality of life for people diagnosed with palliative EG cancer.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

The current review considered studies that included patients diagnosed with palliative EG cancer and any health professionals involved in the delivery of palliative care to this patient group in a hospital, home or community setting.

TYPES OF INTERVENTION

The current review considered studies that evaluated any intervention or combination of intervention strategies aimed at healthcare professionals, organizations or patients to improve quality of life for people diagnosed with palliative EG cancer.

TYPES OF STUDIES

The current review considered both experimental and epidemiological study designs. Studies were excluded that evaluated: screening programs, pharmacology alone, palliative oncology and palliative endoscopy.

OUTCOMES

The primary outcome measure was objectively measured quality of life.

SEARCH STRATEGY

A three-step search strategy was utilized. Sixteen databases were searched for papers from the year 2000 onward and followed by hand searching of reference lists.

METHODOLOGICAL QUALITY

Methodological quality was not assessed as no articles were found that met the inclusion criteria.

DATA EXTRACTION

Data extraction was not possible as no articles were found that met the inclusion criteria.

DATA SYNTHESIS

It was not possible to complete data synthesis as no articles were found that met the inclusion criteria.

RESULTS

Comprehensive searching and study selection process failed to identify any studies that were eligible for inclusion in the review.

CONCLUSION

There is currently a lack of published evidence to establish which interventions and strategies are most effective in delivering services to patients diagnosed with palliative EG cancer in terms of service structure, process and delivery.

A systematic review of evidence for end-of-life communication interventions: Who do they target, how are they structured and do they work?

OBJECTIVE

To identify and synthesise evidence for interventions targeting end-of-life communication.

METHODS

Database, reference list and author searches were conducted to identify evaluations of end-of-life communication-focussed interventions. Data were extracted, synthesised and QUALSYST quality analyses were performed.

RESULTS

Forty-five studies met inclusion criteria. Interventions targeted patients (n=6), caregivers (n=3), healthcare professionals (HCPs n=24) and multiple stakeholders (n=12). Interventions took various forms including communication skills training, education, advance care planning and structured practice changes. Substantial heterogeneity in study designs, outcomes, settings and measures was apparent and study quality was variable.

CONCLUSION

A substantial number of end-of-life communication interventions have been evaluated. Interventions have particularly targeted HCPs in cancer settings, though patient, caregiver and multi-focal interventions have also been evaluated. While some interventions were efficacious in well-designed RCTs, most evidence was from less robust studies. While additional interventions targeting patients and caregivers are needed, multi-focal interventions may more effectively remove barriers to end-of-life communication.

PRACTICE IMPLICATIONS

Despite the limitations evident in the existing literature, healthcare professionals may still derive useful insights into effective approaches to end-of-life communication if appropriate caution is exercised. However, additional RCTs, implementation studies and cost-benefit analyses are required to bolster arguments for implementing and resourcing communication interventions.

Death in the Digital Age: A Systematic Review of Information and Communication Technologies in End-of-Life Care

BACKGROUND

End-of-life (EOL) communication plays a critical role in ensuring that patients receive care concordant with their wishes and experience high quality of life. As the baby boomer population ages, scalable models of end-of-life communication will be needed to ensure that patients receive appropriate care. Information and communication technologies (ICTs) may help address the needs of this generation; however, few resources exist to guide the use of ICTs in EOL care.

OBJECTIVE

The primary objective was to identify the ICTs being used in EOL communication. The secondary objective was to compare the effectiveness of different ICTs in EOL communication.

METHODS

The study was a systematic review, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We systematically searched seven databases for experimental and observational studies on EOL communication between doctors and patients using ICTs, published in 1997-2013.

RESULTS

The review identified 38 relevant articles. Eleven types of technology were identified: video, website, telephone, videoconferencing, e-mail, telemonitoring, Internet search, compact disc, fax, PalmPilot, and short message service (SMS) text messaging. ICTs were most commonly used to provide information or education, serve as decision aids, promote advance care planning (ACP), and relieve physical symptom distress.

CONCLUSIONS

The use of ICTs in EOL care is a small but growing field of research. Additional research is needed to adapt older, analog technologies for use in the digital age. Many of the interventions discussed in this review do not take full advantage of the affordances of mobile, connected health ICTs. The growing evidence base for e-health applications in related fields should guide future interventions in EOL care.

Providing recording of clinical consultation to patients - a highly valued but underutilized intervention: a scoping review

OBJECTIVE

The benefits of providing patients with recorded clinical consultations have been mostly investigated in oncology settings, generally demonstrating positive outcomes. There has been limited synthesis of evidence about the practice in wider context. Our aim was to summarize, in a scoping review, the evidence about providing consultation recordings to patients.

METHODS

We searched seven literature databases. Full text articles meeting the inclusion criteria were retrieved and reviewed. Arksey and O'Malley's framework for scoping studies guided the review process and thematic analysis was undertaken to synthesize extracted data.

RESULTS

Of 5492 abstracts, 33 studies met the inclusion criteria. Between 53.6% and 100% (72% weighted average) of patients listened to recorded consultations. In 60% of reviewed studies patients shared the audio-recordings with others. Six themes identified in the study provided evidence for enhanced information recall and understanding by patients, and positive reactions to receiving recorded consultations. There has been limited investigation into the views of providers and organizations. Medico-legal concerns have been reported.

CONCLUSION

Patients place a high value on receiving audio-recordings of clinical consultations and majority benefit from listening to consultation recordings.

PRACTICE IMPLICATIONS

Further investigation of the ethical, practical and medico-legal implications of routinely providing recorded consultations is needed.