Maintaining integrity in the face of death: a grounded theory to explain the perspectives of people affected by lung cancer about the expression of wishes for end of life care

Preserving the integrity of personhood in people with advanced cancer: An in-depth qualitative study among patients, relatives, and care professionals

BACKGROUND

Every advanced cancer diagnosis brings enormous challenges to patients and their relatives on numerous levels: be it physical, practical, social challenges, or on a more personal level. While specific aspects have been researched before, an overarching approach is lacking.

AIM

To understand the lived experiences of people with advanced cancer, to identify gaps along the cancer care continuum, to identify potential opportunities for meaningful interventions and to develop a theoretical framework for practitioners and researchers.

DESIGN

A qualitative study using in-depth interviews with patients, relatives, and care professionals. Interviews were transcribed verbatim and analysed using a conventional content analysis.

SETTING/PARTICIPANTS

Fifty-four interviews with 17 patients from a university oncology department and palliative care service, 15 relatives and 22 care professionals from physicians to funeral directors. All interviewees were recruited by a German university hospital.

RESULTS

We developed a novel model describing the diagnosis with advanced cancer as a highly disruptive experience that threatens to challenge the integrity of personhood in cancer patients through four areas: communication, knowledge, relationships, and confidence. We were able to identify factors leading to disintegration in these areas and factors supporting a restoration of integrity of personhood.

CONCLUSIONS

The developed model provides a more thorough understanding of patients lived experiences. It can help to develop new interventions along the cancer care continuum to support patients in the complex challenges they face. These interventions should focus on supporting the integrity of personhood.

A qualitative study on redefining normality in relatives of patients with advanced cancer

OBJECTIVE

To obtain insight into adaptation processes of redefining normality and its influencing factors in relatives of patients with advanced cancer.

METHODS

An exploratory qualitative study among relatives of patients with advanced cancer was conducted. Participants were purposively recruited. Ten in-depth individual (relative only) and 16 dyad (relative and patient together) interviews were conducted, transcribed verbatim, and analyzed by means of thematic analysis, drawing on elements of grounded theory, combining both inductive and deductive elements.

RESULTS

Two adaptation processes of (redefining) normality were identified: assimilation and accommodation. The latter was found to be the main way of adapting to new events. Assimilative coping strategies entailed "continuing to do the same activities as done before the disease," "difficulty accepting the situation," "avoiding to think about the disease," and "living in the short term." Accommodative strategies involved "arranging practical matters," "thinking about the future," "doing what is feasible," "engaging in new activities," "accepting the situation," "seeking distraction," "living in the short term," and "focusing on what truly matters in life." The interplay between the diagnosis and treatment of cancer, a deteriorating disease status, and the accompanying uncertainty about the future was of influence on the relatives' coping strategies.

CONCLUSION

When the new situation is too divergent to assimilate, accommodation may be necessary for relatives to cope with the growing complexity of the consequences of their loved one's illness. Accommodative coping then involves accepting the changing reality and actively making the necessary adjustments to build resilience and cope with the new circumstances.

The Hematology Cancer Patient Experience of "Facing Death" in the Last Year of Life: A Constructivist Grounded Theory Study

BACKGROUND

For hematology cancer patients, the process of dying is described as "troublesome." Qualitative studies have focused on views of healthcare professionals and caregiver stakeholders. To date, there have been no studies from the patient's perspective on facing death while in the last year of life.

OBJECTIVE

The aim of this study was to develop an understanding of the hematology cancer patient's experience of the process of dying in the last year of life.

METHODS

The study method was constructivist grounded theory using semistructured interviews, a constant comparison technique, and memoing to collection and analysis of data. The 21 participants were attending a UK cancer center, a cancer unit, or a hospice.

RESULTS

This article describes 1 core category within the incurable hematology cancer illness trajectory through 4 subcategories: transitional phase, chronic phase, dying phase, and liminal phase.

CONCLUSION

This unique study illustrates that, although life can be prolonged, "facing death" still occurs upon hospitalization and relapse regularly over the illness trajectory.

IMPLICATIONS FOR PRACTICE

It is important that clinical practice acknowledges those participants in an incurable illness trajectory while living are focused on avoiding death rather than the ability to cure the disease. Services need to be responsive to the ambiguity of both living and dying by providing holistic management simultaneously, especially after critical episodes of care, to enhance the process of care in the last year of life, and assessment should incorporate the discussion of experiencing life-threatening events.

The perception of life and death in patients with end-of-life stage cancer: A systematic review of qualitative research

PURPOSE

This study aims to clarify the perceptions on life and death among patients with the end-of-life stage cancer through a systematic review.

METHODS

The search strategy combined MeSH terminology with free text searches, and was applied to the PubMed, CINAHL, Embase, and ICHUSHI (Japan Medical Abstracts Society) databases covering from 2010 to 5/2022. To ensure the quality of the research included, the Critical Appraisal Skills Program Qualitative Studies Checklist was used. Data relating to the perceptions of life and death of patients with the end-of-life stage cancer was extracted and analyzed with reference to qualitative meta-synthesis methods.

RESULTS

Ultimately, 50 studies were included. Five themes were derived based on the perceptions of life and death of patients with the end-of-life stage cancer: despair, making sense of death, how to live the rest of life, special feelings for loved ones, and fluctuation. By making sense of death in their own way, and reconciling it with their current situation, patients with the end-of-life stage cancer, even in despair over their impending death, look ahead into the future and their surroundings and consider how they would live the remaining time they have. During this time, the special feelings they have for their loved ones make an impact.

CONCLUSIONS

An important new finding from this study lies in the fact that the patients' desire to live as ordinary people who were not patients were expressed as a face that they hid from their families. Further research is needed in low-income countries/regions.

Experiences and perspectives of healthcare professionals implementing advance care planning for people suffering from life-limiting illness: a systematic review and meta-synthesis of qualitative studies

BACKGROUND

Life-limited patients may lose decision-making abilities during disease progression. Advance care planning can be used as a discussion method for healthcare professionals to understand patients' future care preferences. However, due to many difficulties, the participation rate of healthcare professionals in advance care planning is not high.

AIM

To explore the facilitators of and barriers to healthcare professionals' provision of advance care planning to life-limited patients to better implement it for this population.

METHODS

We followed ENTREQ and PRISMA to guide this study. We conducted a systematic search of PubMed, Web of Science, Embase, CINAHL, PsycINFO, CNKI, and SinoMed to include qualitative data on the experiences and perspectives of healthcare professionals in different professional fields in providing advance care planning for life-limited patients. The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research was used to assess the quality of the included studies.

RESULTS

A total of 11 studies were included. Two themes were identified: unsupported conditions and facilitative actions. Healthcare professionals regarded cultural concepts, limited time, and fragmented record services as obstacles to implementation. They had low confidence and were overly concerned about negative effects. They needed to possess multiple abilities, learn to flexibly initiate topics, and facilitate effective communication based on multidisciplinary collaboration.

CONCLUSION

Healthcare professionals need an accepting cultural environment to implement advance care planning, a sound legal system, financial support, and a coordinated and shared system to support them. Healthcare systems need to develop educational training programs to increase the knowledge and skills of healthcare professionals and to promote multidisciplinary collaboration to facilitate effective communication. Future research should compare the differences in the needs of healthcare professionals in different cultures when implementing advance care planning to develop systematic implementation guidelines in different cultures.

Communication with patients with limited prognosis-an integrative mixed-methods evaluation study

PURPOSE

Oncological societies advocate the continuity of care, specialized communication, and early integration of palliative care. To comply with these recommendations, an interprofessional, longitudinally-structured communication concept, the Milestone Communication Approach (MCA), was previously developed, implemented, and evaluated. Our research question is: what are possible explanations from the patient perspective for prognosis and advance care planning being rarely a topic and for finding no differences between MCA and control groups concerning distress, quality of life, and mood?

METHODS

A pragmatic epistemological stance guided the study. A mixed-methods design was chosen including a pragmatic randomized trial (n = 171), qualitative interviews with patients (n = 13) and caregivers (n = 12), and a content analysis (133 milestone conversations, 54 follow-up calls). Data analysis involved the pillar integration process.

RESULTS

Two pillar themes emerged: 1 "approaching prognosis and advance care planning"; 2 "living with a life-threatening illness". Information on prognosis seemed to be offered, but patients' reactions were diverse. Some patients have to deal with having advanced lung cancer while nonetheless feeling healthy and seem not to be ready for prognostic information. All patients seemed to struggle to preserve their quality of life and keep distress under control.

CONCLUSION

Attending to patients' questions, worries and needs early in a disease trajectory seems key to helping patients adjust to living with lung cancer. If necessary clinicians should name their predicament: having to inform about prognosis versus respecting the patients wish to avoid it. Research should support better understanding of patients not wishing for prognostic information to successfully improve communication strategies.

TRIAL REGISTRATION

Registration: German Clinical Trial Register No. DRKS00013649, registration date 12/22/2017, ( https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013649 ) and No. DRKS00013469, registration date 12/22/2017, ( https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013469 ).

We were in the fight together: The expectations of bereaved caregivers of patients with acute myeloid leukemia from diagnosis to death

PURPOSE

Patients with hematologic malignancies are more optimistic than their oncologists and their expectations may be a barrier to timely hospice care. Patient expectations toward the end of life (EOL), however, have not been characterized. In this study, we analyzed interviews of bereaved caregivers to understand the expectations of patients diagnosed with acute myeloid leukemia and the factors that influenced those expectations, from diagnosis until death.

METHODS

Bereaved caregivers (n = 19) participated in an in-depth interview that included open-ended and semi-structured prompts, within 18 months following patient death. Interviews were analyzed using a modified grounded theory qualitative approach and constant comparative methods.

RESULTS

We identified three themes relevant to expectations: Taking Stock, Being Stuck, and Disruption. Caregivers described clear and optimistic early expectations that AML is treatable. It was understood that treatment was required to survive. Later, when treatment options were limited, patients and caregivers became stuck in a belief that the patient could continue to live indefinitely on supportive care or at least until new more effective treatments were available. Caregivers often realized that the patient was at the end of life only when faced with a disruption, an event or conversation that changed their expectations for indefinite patient survival.

CONCLUSIONS

Caregivers described continued expectations for patient survival until presented with irrefutable evidence to the contrary. The study suggests patients and caregivers may make better EOL care decisions if their early optimism is deliberately moderated by ongoing conversations with clinicians that highlight the sentinel events that signal treatment failure and explain how expectations and goals are changing from living a longer life to dying a more comfortable death.

'End of life': a concept analysis

BACKGROUND

The concept of end of life (EOL), as in the term end-of-life care, is used synonymously in both palliative and terminal care. Practitioners and researchers both require a clearer specification of the end-of-life concept to be able to provide appropriate care in this phase of life and to conduct robust research on a well-described theoretical basis.

AIMS

The aim of this study was to critically analyse the end-of-life concept and its associated terminology.

METHOD

A concept analysis was performed by applying Rodgers' evolutionary concept analysis method.

FINDINGS

Time remaining, clinical status/physical symptoms, psychosocial symptoms and dignity were identified as the main attributes of the concept. Transition into the end-of-life phase and its recognition were identified as antecedents. This study demonstrates that end-of-life care emerged following the application of the 'end-of-life concept' to clinical practice.

CONCLUSION

The early recognition of the end-of-life phase seems to be crucial to ensuring an individual has well-managed symptoms and a dignified death.

Care dependency of patients and residents at the end of life: A secondary data analysis of data from a cross-sectional study in hospitals and geriatric institutions

AIMS AND OBJECTIVES

The holistic care dependency concept can be applied to gain comprehensive insights into individuals' care needs in the end-of-life (EoL) phase. This study was carried out to measure and characterise the "care dependency" phenomenon in this phase and to obtain deeper knowledge about this phenomenon.

BACKGROUND

The end of a human life is often characterised by a physical decline, often implying that a high amount of care is needed. Non-malignant diseases can develop unpredictably; therefore, it is difficult to detect the onset of the EoL phase.

DESIGN

Data were collected in a cross-sectional multicentre study, using the Austrian Nursing Quality Measurement 2.0.

METHODS

Descriptive and multivariate statistical methods were used. Care dependency was measured with the Care Dependency Scale (CDS). The study follows the STROBE guideline.

RESULTS

Ten per cent (n = 389) of the sample (N = 3589) were allocated to "a pathway for management of patients at the end of life." The patients and residents in the EoL phase are significantly older and more often diagnosed with dementia, and circulatory system and musculoskeletal system diseases. Of these patients, 60% were care dependent completely or to a great extent. Dementia and age represent main influencing factors that affect the degree of care dependency at the end of life.

CONCLUSION

Our results show that the "typical" EoL patient or resident is female, old and affected by dementia and/or circulatory system diseases. Dementia and age were identified as main factors that contribute to very high care dependency.

RELEVANCE TO CLINICAL PRACTICE

The measurement of care dependency may support the identification of special care needs in the EoL phase. Gaining deeper knowledge about the care dependency phenomenon can also help healthcare staff better understand the needs of patients with non-malignant conditions in their last phase of life.

Feasibility and acceptability of introducing advance care planning on a thoracic medicine inpatient ward: an exploratory mixed method study

BACKGROUND AND AIMS

Advance care planning (ACP) is communication about wishes and preferences for end-of-life care. ACP is not routinely used in any Norwegian hospitals. We performed a pilot study (2014-2017) introducing ACP on a thoracic medicine ward in Norway. The aims of this study were to explore which topics patients discussed during ACP conversations and to assess how patients, relatives and clinicians experienced the acceptability and feasibility of performing ACP.

METHODS

Conversations were led by a study nurse or physician using a semistructured guide, encouraging patients to talk freely. Each conversation was summarised in a report in the patient's medical record. At the end of the pilot period, clinicians discussed their experiences in focus group interviews. Reports and transcribed interviews were analysed using systematic text condensation.

RESULTS

Fifty-one patients participated in ACP conversations (41-86 years; 9 COPD, 41 lung cancer, 1 lung fibrosis; 11 women); 18 were accompanied by a relative. Four themes emerged: (1) disturbing symptoms, (2) existential topics, (3) care planning and (4) important relationships. All participants appreciated the conversations. Clinicians (1 physician and 7 nurses) participated in two focus group interviews. Reports from ACP conversations revealed patient values previously unknown to clinicians; important information was passed on to primary care. Fearing they would deprive patients of hope, clinicians acted as gatekeepers for recruitment. Although they reported barriers during recruitment, many clinicians saw ACP as pertinent and called for time and skills to integrate it into their daily clinical practice.

CONCLUSIONS

Patients, relatives and clinicians showed a positive attitude towards ACP. Focusing on present and future symptom control may be an acceptable way to introduce ACP. Important aspects for implementing ACP in this patient group are management support, education, training, feasible routines and allocated time to perform the conversations.

Concerns and Fear of Esophageal Cancer in Relatives of Patients with Cancer: a Qualitative Study

INTRODUCTION

Due to its complications and mortality, cancer is a vital public health problem and one of the most frightening diseases, and its development causes a sense of risk, problems, and discomforts for all, including family of patients. The aim of this study was to elaborate on the concerns and fear of esophageal cancer in relatives with cancer illness.

METHODS

Using a content analysis approach, this qualitative study was carried out in Golestan, North of Iran, in 2018. Participants were one of the family members of a patient with esophageal cancer who were selected purposefully. Data were collected using semi-structured and deep interviews and continued until data saturation was achieved. Twenty-three participants were interviewed. Interviews were transcribed line by line and were coded and categorized, and concepts were extracted accordance with qualitative content analysis approach, using MAXQDA 11 software.

RESULT

Following data analysis on the concerns and fear of cancer among relatives of patients, the main themes "fear of social consequences," "fear of treatment consequences," "fear of psychological consequences," "cancer phobia," "concern about lack of information on the disease," "fear of disease reactions," and "fear of disease-related changes" were extracted.

CONCLUSIONS

Family of patients with esophageal cancer were afraid of disease-induced consequences and lack of knowledge about the disease. Through educating people about the symptoms of the disease, we can reduce their fears and empower them for self-caring and preventing cancer.

Realization and personalization by facing fatality: A grounded theory of developing the view of dying in people with heart failure

AIM

To explore how people with heart failure develop and change their views of dying and death.

DESIGN

A Straussian grounded theory approach.

METHODS

Purposive and theoretical sampling were used. Data collection and analysis were repeated until reaching data saturation using the constant comparative method. We conducted semi-structured interviews between January 2019 and July 2020 with 24 people with heart failure from a university and a community hospital in Japan.

RESULTS

Initially, participants' views of dying and death were unrelated to their disease. After the first turning point, namely the confirmation of the deterioration and incurability of the disease, their views became related to their own disease, adding to the suffering caused by the exacerbated symptoms. After the second turning point, namely when participants became tormented by the inevitability of death, they added their struggles with physical, psychological, and spiritual pain owing to medical interventions to their views of dying and death. Only a few participants reached the last stage of this process as it was emotionally distressing; some chose not to proceed to the next stage.

CONCLUSION

Participants develop their views of dying and death gradually and in stages while they experience two turning points. Healthcare providers need to address this process while keeping in mind that proceeding this process requires some turning points, and it can be painful.

IMPACT

This study provides a theoretical framework on the development of the views regarding dying and death of people with heart failure; it showed that these people need some turning points and to pass through stages to develop/individualize their views, and that this process is inherently distressing. This theory provides a cornerstone for healthcare professionals to understand the disease-specific transition in views of dying and psychological readiness, and it may help establish a therapeutic relationship that includes advance care planning.

Unraveling patients' readiness in advance care planning conversations: a qualitative study as part of the ACTION Study

PURPOSE

Patients' readiness for advance care planning (ACP) is often considered a prerequisite for starting ACP conversations. Healthcare professionals' uncertainty about patients' readiness hampers the uptake of ACP in clinical practice. This study aims To determine how patients' readiness is expressed and develops throughout an ACP conversation.

METHODS

A qualitative sub-study into the ACTION ACP conversations collected as part of the international Phase III multicenter cluster-randomized clinical trial. A purposeful sample was taken of ACP conversations of patients with advanced lung or colorectal cancer who participated in the ACTION study between May 2015 and December 2018 (n = 15). A content analysis of the ACP conversations was conducted.

RESULTS

All patients (n = 15) expressed both signs of not being ready and of being ready. Signs of being ready included anticipating possible future scenarios or demonstrating an understanding of one's disease. Signs of not being ready included limiting one's perspective to the here and now or indicating a preference not to talk about an ACP topic. Signs of not being ready occurred more often when future-oriented topics were discussed. Despite showing signs of not being ready, patients were able to continue the conversation when a new topic was introduced.

CONCLUSION

Healthcare professionals should be aware that patients do not have to be ready for all ACP topics to be able to participate in an ACP conversation. They should be sensitive to signs of not being ready and develop the ability to adapt the conversation accordingly.

Patient and caregiver perspectives on early identification for advance care planning in primary healthcare settings

Background

As part of a broader study to improve the capacity for advance care planning (ACP) in primary healthcare settings, the research team set out to develop and validate a computerized algorithm to help primary care physicians identify individuals at risk of death, and also carried out focus groups and interviews with relevant stakeholder groups. Interviews with patients and family caregivers were carried out in parallel to algorithm development and validation to examine (1) views on early identification of individuals at risk of deteriorating health or dying; (2) views on the use of a computerized algorithm for early identification; and (3) preferences and challenges for ACP.

Methods

Fourteen participants were recruited from two Canadian provinces. Participants included individuals aged 65 and older with declining health and self-identified caregivers of individuals aged 65 and older with declining health. Semi-structured interviews were conducted via telephone. A qualitative descriptive analytic approach was employed, which focused on summarizing and describing the informational contents of the data.

Results

Participants supported the early identification of patients at risk of deteriorating health or dying. Early identification was viewed as conducive to planning not only for death, but for the remainder of life. Participants were also supportive of the use of a computerized algorithm to assist with early identification, although limitations were recognized. While participants felt that having family physicians assume responsibility for early identification and ACP was appropriate, questions arose around feasibility, including whether family physicians have sufficient time for ACP. Preferences related to the content of and approach to ACP discussions were highly individualized. Required supports during ACP include informational and emotional supports.

Conclusions

This work supports the role of primary care providers in the early identification of individuals at risk of deteriorating health or death and the process of ACP. To improve ACP capacity in primary healthcare settings, compensation systems for primary care providers should be adjusted to ensure appropriate compensation and to accommodate longer ACP appointments. Additional resources and more established links to community organizations and services will also be required to facilitate referrals to relevant community services as part of the ACP process.

Living in the moment for people approaching the end of life: A concept analysis

BACKGROUND

'Living in the moment' is an essential part of dignity-conserving practice in end-of-life care settings. Although living in the moment is important for care at the end of life, from the perspective of both the person and their family, there is no clear conceptual understanding of what it represents.

OBJECTIVE

To explore the concept of 'living in the moment' in the context of dignity-conserving care at the end of life.

DESIGN

A concept analysis.

DATA SOURCES

The databases of Medline, CinAHL, PubMed, Web of Science, PsycINFO, SocINDEX and Cochrane were searched for studies published between 1941 and 2019, and searches of dictionaries and grey literature, as well as hand-searching were conducted, to yield qualitative, mixed methods and systematic reviews published in English, related to the term 'living in the moment'.

METHOD

The methods of Walker and Avant were used to identify antecedents, attributes and consequences of the concept of 'living in the moment'.

RESULTS

The literature review generated a total of 37 papers for this concept analysis. The attributes identified were (1) simple pleasure, (2) prioritising relationships, (3) living each day to the fullest, (4) maintaining normality, and (5) not worrying about the future. The antecedents were (1) awareness of dying, (2) living with life-threatening illness, (3) positive individual growth, and (4) living with an uncertain future. The consequences were (1) a good quality of life, (2) preserving dignity, and (3) coping with the uncertainty of life.

CONCLUSIONS

A universal definition and conceptual model of the main concept, including theoretical relationships between its antecedents, attributes and consequences, was developed. The definition and proposed conceptual model can allow instruments to be developed that measure the effects, existence or attributes of the concept, and identify a theoretical model, and can also lead to new perspectives and strategies for implementation by nurses to improve dignified person-centred care at the end of life.

Integrating nurse-facilitated advance care planning for patients newly diagnosed with advanced lung cancer

BACKGROUND

Advance care planning (ACP) is well recognised as an important component of palliative care. However, there is still a need to explore ways in which it can become a part of routine practice, ensuring a timely and person-centred discussion.

OBJECTIVES

To explore patients newly diagnosed with advanced lung cancer and their family members' experiences of engaging in a person-centred and structured ACP discussion facilitated by palliative care nurses in an outpatient oncology clinic at the University Hospital of Iceland.

METHODS

An exploratory qualitative design employing semi-structured interviews and thematic analysis. The intervention included a structured ACP discussion, aided by a booklet.

RESULTS

Key themes emerged describing families' and patients' experiences and highlighted that the timing and approach of the ACP discussion was appropriate and helpful, even though the discussion was sensitive and difficult. Using a routine approach with a flexible structure normalised the discussion and made it easier for the patients to take the lead in the discussion.

CONCLUSIONS

ACP discussion can be part of an integrated palliative care and oncology service if implemented in a systematic way.

Exploration of Patients' Spiritual/Religious Beliefs and Resuscitation Decisions

Artificial resuscitation has potential to reverse a premature death or to prolong the dying process. The resuscitation decision is one of life and death making it imperative that healthcare providers understand patients' beliefs. Making the decision to resuscitate has been associated with patients' spiritual/religious beliefs. Clinicians' assumptions based upon a patients' religion or spiritual beliefs may bias the resuscitation decision. The purpose of this study was to determine associations between hospitalized patients' spiritual/religious beliefs and their resuscitation decisions. A single-site, correlational study was conducted with a convenience sample of hospitalized patients in Honolulu, HI. Patients were enrolled November 2015 to January 2016. Spiritual/religious beliefs were assessed using two validated metrics. Two questions were used to determine the resuscitation decision (chest compressions and intubation). The sample of 84 patients represented no ethnic majority among Caucasian, Asian, and Native Hawaiian/Pacific Islander. Seventy-nine percent of the participants identified theistic spiritual beliefs. No associations were found between resuscitation decisions with either spiritual/religious beliefs or demographic characteristics of this study sample. Interestingly, 20% of the participants answered yes to only one of the resuscitation decision questions. Thus, providers' assumptions should not be made about an association between spiritual/religious beliefs and resuscitation decisions. It is imperative that patients are aware of the necessity for both medical interventions of chest compressions and intubation. Further research should address the complexity of the resuscitation decision, including patients understanding of medical interventions and anticipated prognosis, and other influencing factors.

Thematic Analysis of Interprofessional Provider Perceptions of Pediatric Death

PURPOSE

Though provider and patient perceptions of death are characterized in the adult population literature, there is limited information related to providers' perceptions in pediatric and neonatal patients. The purpose of this study was to better understand how interprofessional care team members perceive and experience neonatal and pediatric end-of-life situations.

DESIGN AND METHODS

This survey questionnaire was administered to interprofessional providers following their participation in an institutional workshop, as part of an ongoing institutional effort to improve end-of-life experiences for patients/family and providers. Interprofessional care providers completed an electronic survey consisting of closed-ended and one open-ended question to elicit their perceptions of their participation in end of life care for a recent neonatal/pediatric patient in the period before the child's death.

RESULTS

The qualitative analysis of 306 free-text responses commenting on the deaths of 138 patients, contained within 880 completed mixed-method surveys, is described. Thematic analysis of the free text discovered three primary themes from the data: favorable aspects of the death experience, unfavorable aspects of the experience, and combined favorable and unfavorable aspects. Four subthemes contributed to the themes; namely, language, parental presence, trust/rapport in provider relationships and inclusion in decision-making, communication, and culture.

CONCLUSIONS

Multiple factors contribute to how interprofessional care providers perceive end-of-life care experiences for neonatal/pediatric patients. The same death may be perceived differently by different providers.

PRACTICE IMPLICATIONS

Understanding favorable and unfavorable aspects of providing end-of-life care will support strategies to provide resources, education and support to facilitate coping and resiliency in care providers.

Patients' Autonomy at the End of Life: A Critical Review

CONTEXT

The predominating definition of autonomy as a capacity to make an independent rational choice may not be suitable for patients in palliative care. Therefrom arises the actual need for more contextualized perspectives on autonomy to promote the quality of life and satisfaction with care of terminally ill patients.

OBJECTIVES

This review aimed to develop a theoretical structural model of autonomy at the end of life based on patients' end-of-life care preferences.

METHODS

In this review, we used systematic strategy to integrate and synthesize findings from both qualitative and quantitative studies investigating patients' view on what is important at the end of life and which factors are related to autonomy. A systematic search of EMBASE (OVID), MEDLINE (OVID), Academic Search Complete (EBSCO), CINAHL (EBSCO), and PsycINFO (EBSCO) was conducted for studies published between 1990 and December 2015 providing primary data from patients with advanced disease.

RESULTS

Of the 5540 articles surveyed, 19 qualitative and eight quantitative studies met the inclusion criteria. We identified two core structural domains of autonomy: 1) being normal and 2) taking charge. By analyzing these domains, we described eight and 13 elements, respectively, which map the conceptual structure of autonomy within this population of patients.

CONCLUSION

The review shows that maintaining autonomy at the end of life is not only a concern of making choices and decisions about treatment and care but that emphasis should be also put on supporting the patients' engagement in daily activities, in contributing to others, and in active preparation for dying.

Patients and informal caregivers' experiences of burden of treatment in lung cancer and chronic obstructive pulmonary disease (COPD): a systematic review and synthesis of qualitative research

OBJECTIVE

To identify, characterise and explain common and specific features of the experience of treatment burden in relation to patients living with lung cancer or chronic obstructive pulmonary disease (COPD) and their informal caregivers.

DESIGN

Systematic review and interpretative synthesis of primary qualitative studies. Papers were analysed using constant comparison and directed qualitative content analysis.

DATA SOURCES

CINAHL, EMBASE, MEDLINE, PsychINFO, Scopus and Web of Science searched from January 2006 to December 2015.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Primary qualitative studies in English where participants were patients with lung cancer or COPD and/or their informal caregivers, aged >18 years that contain descriptions of experiences of interacting with health or social care in Europe, North America and Australia.

RESULTS

We identified 127 articles with 1769 patients and 491 informal caregivers. Patients, informal caregivers and healthcare professionals (HCPs) acknowledged lung cancer's existential threat. Managing treatment workload was a priority in this condition, characterised by a short illness trajectory. Treatment workload was generally well supported by an immediacy of access to healthcare systems and a clear treatment pathway. Conversely, patients, informal caregivers and HCPs typically did not recognise or understand COPD. Treatment workload was balanced with the demands of everyday life throughout a characteristically long illness trajectory. Consequently, treatment workload was complicated by difficulties of access to, and navigation of, healthcare systems, and a fragmented treatment pathway. In both conditions, patients' capacity to manage workload was enhanced by the support of family and friends, peers and HCPs and diminished by illness/smoking-related stigma and social isolation.

CONCLUSION

This interpretative synthesis has affirmed significant differences in treatment workload between lung cancer and COPD. It has demonstrated the importance of the capacity patients have to manage their workload in both conditions. This suggests a workload which exceeds capacity may be a primary driver of treatment burden.

PROSPERO REGISTRATION NUMBER

CRD42016048191.

Theories of Health Care Decision Making at the End of Life: A Meta-Ethnography

The aim of this meta-ethnography is to appraise the types and uses of theories relative to end-of-life decision making and to develop a conceptual framework to describe end-of-life decision making among patients with advanced cancers, heart failure, and amyotrophic lateral sclerosis (ALS) and their caregivers or providers. We used PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases to extract English-language articles published between January 2002 and April 2015. Forty-three articles were included. The most common theories included decision-making models ( n = 14) followed by family-centered ( n = 11) and behavioral change models ( n = 7). A conceptual framework was developed using themes including context of decision making, communication and negotiation of decision making, characteristics of decision makers, goals of decision making, options and alternatives, and outcomes. Future research should enhance and apply these theories to guide research to develop patient-centered decision-making programs that facilitate informed and shared decision making at the end of life among patients with advanced illness and their caregivers.

Advance care planning: A systematic review about experiences of patients with a life-threatening or life-limiting illness

BACKGROUND

Advance care planning is seen as an important strategy to improve end-of-life communication and the quality of life of patients and their relatives. However, the frequency of advance care planning conversations in practice remains low. In-depth understanding of patients' experiences with advance care planning might provide clues to optimise its value to patients and improve implementation.

AIM

To synthesise and describe the research findings on the experiences with advance care planning of patients with a life-threatening or life-limiting illness.

DESIGN

A systematic literature review, using an iterative search strategy. A thematic synthesis was conducted and was supported by NVivo 11.

DATA SOURCES

The search was performed in MEDLINE, Embase, PsycINFO and CINAHL on 7 November 2016.

RESULTS

Of the 3555 articles found, 20 were included. We identified three themes in patients' experiences with advance care planning. 'Ambivalence' refers to patients simultaneously experiencing benefits from advance care planning as well as unpleasant feelings. 'Readiness' for advance care planning is a necessary prerequisite for taking up its benefits but can also be promoted by the process of advance care planning itself. 'Openness' refers to patients' need to feel comfortable in being open about their preferences for future care towards relevant others.

CONCLUSION

Although participation in advance care planning can be accompanied by unpleasant feelings, many patients reported benefits of advance care planning as well. This suggests a need for advance care planning to be personalised in a form which is both feasible and relevant at moments suitable for the individual patient.

Transitions as experienced by persons in palliative care circumstances and their families - a qualitative meta-synthesis

Background

When receiving palliative care, patients and their families experience altered life situations in which they must negotiate challenges in daily life, increased care and new roles. With limited time, they also experience emotional changes that relate to their uncertain future. Transitions experienced in such situations are often studied by focusing on individual aspects, which are synthesized in the following study. The aim was to conduct a qualitative meta-synthesis to explore the experiences patients and their families gain during transitions in palliative care circumstances.

Methods

A qualitative meta-synthesis was conducted following an inductive approach as proposed by Sandelowski and Barroso. Inclusion criteria were studies with adult persons in palliative situations and articles published in English or German. Relevant articles were identified by researching the Pubmed and Cinahl databases, as well as by hand searches in journals and reference lists for the period 2000–2015. The findings of each study were analyzed using initial coding, followed by axial and selective coding in this order. Consequently, a conceptual model was derived from the categories.

Results

In total 2225 articles were identified in the literature search. Finally, 14 studies were included after the selection process. The central phenomenon observed among palliative care patients and their families was maintaining normality during transitions. Transitions are initially experienced unconsciously until a crisis occurs and responsive actions are necessary, which encourages patients and families to perceive the situation consciously and develop strategies for its negotiation. Patients remain caught between hopelessness and valuing their remaining time alive. As the illness progresses, informal caregivers reprioritize and balance their roles, and after death, family members inevitably find themselves in changed roles.

Conclusions

In palliative care situations, transitions are experienced differently by patients and their families in a constant phenomenon that oscillates between unconscious and conscious perceptions of transitions. The derived conceptual model offers an additional perspective to existing models and helps to clarify the phenomenon in practical settings. The study promotes a differentiated conceptual view of transitions and emphasizes patients’ and families’ perspectives.

Cancer patients' motives for psychosocial consultation-Oncology social workers' perceptions of 226 patient cases

OBJECTIVE

Although oncology social workers (OSWs) have emerged as a core profession in the provision of psychosocial services, there is a lack of empirical studies that describe their daily clinical work with patients. The overall aim of this study was to explore cancer patients' motives for consulting an OSW.

METHODS

From a nationwide survey, we used data from 226 patient cases that OSWs met face to face. The OSWs were asked to describe how the case was referred to them, the patient's characteristics, and what they perceived as the patient's motives for contacting them as well as additional motives that came up during the consultations.

RESULTS

Patients have different motives for consulting an OSW, and these motives change over the course of consultations; while feelings associated with being diagnosed with cancer were often the initial motive, questions associated with moving on in life and dealing with relationships and the overall life situation were added over time.

CONCLUSIONS

The results show that Swedish OSWs' function is multifaceted and that the initial motives among patients rarely predict the content in consultations over time. Based on the diversity of motives, it seems obvious that OSWs (at least in Sweden) need a broad education in the psychology of counselling. It also seems obvious that even if patients initially were referred by health care staff to the OSW due to psychological reactions to being ill, staff should also be attentive to the fact that relational and socio-economic/juridical issues are of great concern for the patients.

Evaluation of an advance care planning web-based resource: applicability for cancer treatment patients

PURPOSE

The purpose of this study was to explore the acceptability, applicability, and understandability of a promising advance care planning (ACP) web-based resource for use with oncology patients, and determine whether revisions to the website would be necessary before implementation into oncology care. The resource is called PREPARE ( www.prepareforyourcare.org ) and it had not been tested for use within oncology, but had previously been shown to influence the readiness of older, community-dwelling adults to engage in ACP behaviors.

METHODS

This qualitative descriptive study included participants receiving cancer medications and one participant on watchful waiting post-chemotherapy (n = 21). Data were collected via cognitive interviewing, followed by a brief semi-structured interview to gather a meaningful account of the participants' experience with PREPARE. Content analysis resulted in a comprehensive summary of what participants liked and did not like about the resource, as well as suggestions for change.

RESULTS

Overall, participants agreed PREPARE was acceptable, applicable, and understandable for cancer patients. A small number of participants had difficulty with the life-limiting language found within the website and this requires follow-up to determine whether the language causes distress or disengagement from ACP. These findings extend our understanding of barriers to engagement in ACP that appear unique to cancer patients receiving active treatment.

CONCLUSIONS

Results indicated that PREPARE is a reflective, capacity-building ACP resource that was acceptable, applicable, and understandable for use in oncology. These findings offer direction for both research and practice.

The role of informal caregivers at the end of life: providing support through Advance Care Planning

In the palliative phase of a person's illness, the needs of the patient and informal caregivers are paramount. Caregivers often look to palliative care practitioners for support, guidance and emotional comfort. This article reviews the role of the informal caregiver at the end of life, summarising their concerns and needs. The paper also highlights caregiver difficulties in making the coping transition when the patient's medical condition becomes advanced and they require end-of-life care. The focus of the review is placed on discussions about Advanced Care Planning (ACP). ACP is a complex legal, ethical and practical issue that can enable caregivers to consider future strategies and enable them to provide high quality care at the end of life. The paper looks at some of the ethical and legal issues associated with this sensitive end-of-life issue.

[The acceptability of the intervention Revie ⊕ : the nurses’ perceptions and experiences]

Persons with advanced cancer experience high levels of existential distress due to being confronted with their mortality, which leads to feelings of lack of sense, or discouragement. It is important to develop interventions to relieve existential distress to promote the dignity of persons with advanced cancer in order to help them live this difficult experience in the best possible way. A new intervention, called Revie ⊕ and conducted by nurses, was developed. A feasibility study was conducted with 41 patients with advanced cancer in the ambulatory and hospital sector of a university hospital in Switzerland to determine the acceptability of Revie ⊕. The purpose of this article is to present the intervention’s acceptability from the perspective of the nurses. Nurses conducting the intervention were asked to complete a questionnaire, maintain personal notes, and to participate in one focus group. Descriptive statistics were used to analyze the questionnaire. Thematic analysis was applied to analyze the nurses’ personal notes and focus group data. Results indicate that nurses consider Revie ⊕ to be a beneficial intervention for the patients and also for their professional posture. As a consequence, the nurses wish for its implementation into practice. Recommendations are proposed to promote further implementation.

To carry on as before: A meta-synthesis of qualitative studies in lung cancer

As a complement to quantitative studies, qualitative studies give us a better understanding of how persons affected by lung cancer live their everyday lives and how they deal with the obvious strain of having lung cancer. Because qualitative studies are based on only a few participants in specific contexts, the purpose of the present study is to synthesize knowledge from these qualitative studies to get a more general picture of the everyday lives of patients with lung cancer. A search on PubMed, CINAHL, Medline and PsychInfo yielded 383 hits. After exclusion we found 16 studies that focused on how these patients lived, reflected, and dealt with their new life situation. These studies comprised 393 interviews with 283 patients with primary lung cancer, and the findings from these studies were synthesized into a core process with subcategories. The overarching process was that the patients were eager "to carry on as before". They wanted to resume their former everyday life, and their views on their relationships with their bodies and side effects of treatments, their families, the health care staff, and with dying and death were very much related to how these could assist the core process. The synthesis presented here suggests that health care in consultations with patients with lung cancer should defer to the importance of the patient's core idea that life carries on despite the fact that it will probably soon come to an end.

The Experience of Caregivers Living with Cancer Patients: A Systematic Review and Meta-Synthesis

The objectives of this meta-synthesis were to: (1) explore the experience of caregivers who were caring for cancer patients, including their perceptions and responses to the situation; and (2) describe the context and the phenomena relevant to the experience. Five databases were used: CINAHL, MEDLINE, Academic Search, Science Direct, and a Thai database known as the Thai Library Integrated System (ThaiLIS). Three sets of the context of the experience and the phenomena relevant to the experience were described. The contexts were (1) having a hard time dealing with emotional devastation; (2) knowing that the caregiving job was laborious; and (3) knowing that I was not alone. The phenomenon showed the progress of the caregivers’ thoughts and actions. A general phenomenon of the experience—balancing my emotion—applied to most of the caregivers; whereas, more specific phenomenon—keeping life as normal as possible and lifting life above the illness—were experienced by a lesser number of the caregivers. This review added a more thorough explanation of the issues involved in caregiving for cancer patients. A more comprehensive description of the experience of caregiving was described. The findings of this review can be used to guide clinical practice and policy formation in cancer patient care.

Advance care planning for cancer patients: a systematic review of perceptions and experiences of patients, families, and healthcare providers

BACKGROUND

Patients with advanced cancer may benefit from end of life (EOL) planning, but there is evidence that their willingness and desire to engage in advance care planning (ACP) varies. The reasons for this remain poorly understood. Previous reviews on ACP most commonly report outcome measures related to medical interventions and type of care. Synthesis of the literature, which aims to illuminate the salient characteristics of ACP and investigates the psychological and social features of preparation for the EOL, is required.

METHODS

We searched Medline, EMBASE, PsychINFO, CINAHL, and the Cochrane Central Register of Controlled Trials for studies on perceptions or experiences regarding ACP of adults with cancer, family, friends, or professionals caring for this group. Databases were searched from earliest records to 19 November 2014. A thematic analysis of the literature generated conceptual themes.

RESULTS

Of the 2483 studies identified, 40 were eligible for inclusion. Studies addressed the relational nature of ACP, fear surrounding ACP, the conceptual complexity of autonomy, and the influence of institutional culture and previous healthcare experiences on ACP.

CONCLUSIONS

The complex social and emotional environments within which EOL planning is initiated and actioned are not sufficiently embedded within standardized ACP. The notion that ACP is concerned principally with the 'right' to self-determination through control over treatment choices at the EOL may misrepresent the way that ACP actually occurs in cancer care and ultimately conflict with the deeper concerns and needs of patients, who experience ACP as relational, emotional, and social.

Care and communication between health professionals and patients affected by severe or chronic illness in community care settings: a qualitative study of care at the end of life

Background

Advance care planning (ACP) enables patients to consider, discuss and, if they wish, document their wishes and preferences for future care, including decisions to refuse treatment, in the event that they lose capacity to make decisions for themselves. ACP is a key component of UK health policy to improve the experience of death and dying for patients and their families. There is limited evidence about how patients and health professionals understand ACP, or when and how this is initiated. It is evident that many people find discussion of and planning for end of life care difficult, and tend to avoid the topic.

Aim

To investigate how patients, their relatives and health professionals initiate and experience discussion of ACP and the outcomes of advance discussions in shaping care at the end of life.

Design and data collection

Qualitative study with two workstreams: (1) interviews with 37 health professionals (general practitioners, specialist nurses and community nurses) about their experiences of ACP; and (2) longitudinal case studies of 21 patients with 6-month follow-up. Cases included a patient and, where possible, a nominated key relative and/or health professional as well as a review of medical records. Complete case triads were obtained for 11 patients. Four cases comprised the patient alone, where respondents were unable or unwilling to nominate either a family member or a professional carer they wished to include in the study. Patients were identified as likely to be within the last 6 months of life. Ninety-seven interviews were completed in total.

Setting

General practices and community care settings in the East Midlands of England.

Findings

The study found ACP to be uncommon and focused primarily on specific documented tasks involving decisions about preferred place of death and cardiopulmonary resuscitation, supporting earlier research. There was no evidence of ACP in nearly half (9 of 21) of patient cases. Professionals reported ACP discussions to be challenging. It was difficult to recognise when patients had entered the last year of life, or to identify their readiness to consider future planning. Patients often did not wish to do so before they had become gravely ill. Consequently, ACP discussions tended to be reactive, rather than pre-emptive, occurring in response to critical events or evidence of marked deterioration. ACP discussions intersected two parallel strands of planning: professional organisation and co-ordination of care; and the practical and emotional preparatory work that patients and families undertook to prepare themselves for death. Reference to ACP as a means of guiding decisions for patients who had lost capacity was rare.

Conclusions

Advance care planning remains uncommon, is often limited to documentation of a few key decisions, is reported to be challenging by many health professionals, is not welcomed by a substantial number of patients and tends to be postponed until death is clearly imminent. Current implementation largely ignores the purpose of ACP as a means of extending personal autonomy in the event of lost capacity.

Future work

Attention should be paid to public attitudes to death and dying (including those of culturally diverse and ethnic minority groups), place of death, resuscitation and the value of anticipatory planning. In addition the experiences and needs of two under-researched groups should be explored: the frail elderly, including those who manage complex comorbid conditions, unrecognised as vulnerable cases; and those patients affected by stigmatised conditions, such as substance abuse or serious mental illness who fail to engage constructively with services and are not recognised as suitable referrals for palliative and end of life care.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Mutual Needs and Wishes of Cancer Patients and Their family Caregivers During the Last Week of Life: A Descriptive Phenomenological Study

The last week of life represents an important time for people dying of cancer and their families. To explore the needs and wishes of patients and their caregivers during the last week of life at home, a descriptive phenomenological study was undertaken in a home care facility located in the northeast of Italy. A purposeful sample of participants affected by advanced cancer was included. For each included patient, a family member assuming the role of principal caregiver was also included. A total of 11 dyads (22 people) were selected and interviewed on a weekly basis. A series of qualitative, semistructured interviews was conducted. Each conversation was intended to provide researchers with an overview of the patient's and family caregiver's needs and wishes. The last interview conducted before the patient died was selected and considered for the analysis performed by researchers independently, who then worked closely together for theme triangulations. Needs and wishes in the last week of life were focused on four main themes: (a) Remaining attached to my life ("I wish I was doing things like I used to"); (b) Detaching myself from life, immediately ("I wish this Calvary were over"); (c) Dealing with the dying process ("Waiting in fear"); and (d) Starting to think of life without each other ("Unshared worries"). In order to improve personalized care in the last week of life, nurses are encouraged to assess both patient and caregiver needs and wishes, as well as their reciprocal influence and correspondence, to identify each patient-caregiver unit's unique holistic care priorities.

Relatives' participation at the time of death: standardisation in pre and post-mortem care in a palliative medical unit

PURPOSE

The aim of this study was to illuminate the development of standardisation of relatives' participation at the time of death in the Palliative Medical Unit and to explore if the implementation of standardisation brought palliative care more in line with its ideology.

METHODS

A registration form was developed and utilized by the Palliative Medical Unit nurse in charge of the patient and family to register to what extent relatives participated at the time of death. The study consists of two data sets named evaluation 1 and 2. Evaluation 1 includes data collected during the period 01.11.1995-31.12.1999, representing 73% of all deaths (N = 244). Evaluation 2 includes data collected during the period 01.01.2003-31.12.2009, representing 71% of all deaths (N = 400). The data was analysed in SPSS, covering primarily the frequency of participation and correlation between evaluation 1 and evaluation 2.

RESULTS

Relatives are more often present at the moment of death, while nurses are less present at this moment. Additionally, Palliative Medical Unit nurses use more time to inform and discuss relatives' participation in pre and post-mortem care, as well as making agreements with relatives after death occurs.

CONCLUSION

Important premises for successful standardisation are fostering Palliative Medical Unit nurses' knowledge about various aspects of pre and post-mortem care through regular evaluation and an educational programme providing staff with necessary time, awareness and skills. In addition nurses also require sufficient amount of time in the clinic.

Stakeholder perceptions of thoracic rapid tissue donation: An exploratory study

Rapid autopsy or rapid tissue donation (RTD) is a novel method of tissue procurement in which 'fresh' tissue is collected within 2-6 h following the death of a patient. While the use of RTD offers many opportunities to develop new therapies for lung cancer patients, it raises ethical concerns. The purpose of this study was to examine knowledge, perceptions and ethical concerns about recruiting patients for an RTD program. To achieve research goals, we conducted six focus groups, each containing 5-10 participants (N = 38). Participants were cancer patients (n = 17) their caregivers (n = 6), physicians (n = 6) and clinic staff (n = 9) from the Thoracic Oncology Program at Moffitt Cancer Center, in Tampa, Florida, USA. All focus groups were audio-recorded and conducted using a semi-structured focus group guide. The transcripts were analyzed using hand-coding methods. Data were coded independently by at least two researchers, and an inter-rater reliability rate of ≥90% was achieved. Knowledge about RTD was low among all groups, with physicians having slightly higher knowledge; all groups agreed that RTD offered major benefits to cancer research; physicians and clinic staff were mainly concerned about making a patient feel uncomfortable and reducing hope, while, patients and family members were more concerned about logistics and how the family would be affected during tissue retrieval. All groups agreed the physician was the appropriate person to begin a discussion about RTD and that recruitment should be individualized. All groups reported that physician training is necessary, as well as an awareness campaign for patients and families to be more receptive about RTD. The results of this study suggested more education is needed for all stakeholders to learn about RTD prior to the initiation of a research program. Our approach of querying all stakeholders provides a firm foundation for future training modules regarding RTD programs in lung cancer.

Understanding how cancer patients actualise, relinquish, and reject advance care planning: implications for practice

PURPOSE

Although advance care planning (ACP) is recognised as integral to quality cancer care, it remains poorly integrated in many settings. Given cancer patients' unpredictable disease trajectories and equivocal treatment options, a disease-specific ACP model may be necessary. This study examines how Australian cancer patients consider ACP. Responses will inform the development of an Australian Cancer Centre's ACP programme.

METHODS

A constructivist research approach with grounded theory design was applied. Eighteen adults from lung and gastro-intestinal tumour streams participated. Participants first described their initial understanding of ACP, received ACP information, and finally completed a semi-structured interview assisted by the vignette technique. Qualitative inter-rater reliability was integrated.

RESULTS

Participants initially had scant knowledge of ACP. On obtaining further information, their responses indicated that: For cancer patients, ACP is an individualised, dynamic, and shared process characterised by myriad variations in choices to actualise, relinquish, and/or reject its individual components (medical enduring power of attorney, statement of choices, refusal of treatment certificate, and advanced directive). Actualisation of each component involves considering, possibly conversing about, planning, and communicating a decision, usually iteratively. Reactions can change over time and are informed by values, memories, personalities, health perceptions, appreciation of prognoses, and trust or doubts in their substitute decision makers.

CONCLUSION

Findings endorse the value of routinely, though sensitively, discussing ACP with cancer patients at various time points across their disease trajectory. Nonetheless, ACP may also be relinquished or rejected and ongoing offers for ACP in some patients may be offensive to their value system.