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Gurgenci T, O'Leary C, Philip J, Bruera E, Davis M, Agar MR, Hui D, Zimmermann C, Yennu S, Hardy J, Mercadante S, Rosa WE, Good P. Top Ten Tips Palliative Care Clinicians Should Know About Designing a Clinical Trial in Palliative Care. J Palliat Med 2024. [PMID: 39167532 DOI: 10.1089/jpm.2024.0259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024] Open
Abstract
The palliative care field is experiencing substantive growth in clinical trial-based research. Randomized controlled trials provide the necessary rigor and conditions for assessing a treatment's efficacy in a controlled population. It is therefore important that a trial is meticulously designed from the outset to ensure the integrity of the ultimate results. In this article, our team discusses ten tips on clinical trial design drawn from collective experiences in the field. These ten tips cover a range of topics that can prove challenging in trial design, from developing initial methodologies to planning sample size and powering the trial, as well as collaboratively navigating the ethical issues of trial initiation and implementation as a cohesive team. We aim to help new researchers design sound trials and continue to grow the evidence base for our specialty. The guidance provided here can be used independently or in addition to the ten tips provided by this team in a separate article focused on what palliative care clinicians should know about interpreting a clinical trial.
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Affiliation(s)
- Taylan Gurgenci
- Department of Palliative and Supportive Care, Brisbane, Queensland, Australia
- Cancer Program, Mater Research Institute-University of Queensland, Brisbane, Queensland, Australia
| | - Cian O'Leary
- Cancer Services, Mater Health, Brisbane, Queensland, Australia
| | - Jennifer Philip
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Palliative Care, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
- Department of Palliative Care, Palliative Care Service, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, & Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Mellar Davis
- Director of Palliative Care Research at Geisinger Medical Center, Geisinger Commonwealth School of Medicine, Scranton PA, Danville, Pennsylvania, USA
| | - Meera R Agar
- Faculty of Health,IMPACCT, University of Technology Sydney, Sydney, New South Wales, Australia
| | - David Hui
- Department of Palliative, Rehabilitation, & Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Sriram Yennu
- Department of Palliative, Rehabilitation, & Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Janet Hardy
- Cancer Program, Mater Research Institute-University of Queensland, Brisbane, Queensland, Australia
| | - Sebastiano Mercadante
- Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Phillip Good
- Department of Palliative and Supportive Care, Brisbane, Queensland, Australia
- Department of Palliative Care, St Vincent's Private Hospital, Brisbane, Queensland, Australia
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Maeda W, Saif-Ur-Rahman KM, Muraya T, Hirakawa Y. Consideration points in the decision making in chronic respiratory diseases. J Rural Med 2024; 19:158-165. [PMID: 38975035 PMCID: PMC11222620 DOI: 10.2185/jrm.2023-044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 03/27/2024] [Indexed: 07/09/2024] Open
Abstract
Objective: Even though dynamic multidisciplinary team discussions are crucial for end-of-life care management and decisions concerning chronic obstructive pulmonary disease (COPD), the details of the discussion contents remain poorly understood. This study aimed to identify essential considerations in decision-making for patients with chronic respiratory diseases to enhance a consensus-based approach. Materials and Methods: A qualitative content analysis of focus group conversations on published clinical case reports in the Japanese community about end-of-life care for patients with chronic respiratory disorders was conducted. The cases were searched through Igaku Chuo Zasshi (ICHUSHI) and Google in February 2021, using the keywords: "COPD", "chronic respiratory diseases", and "end-of-life care". A total of 41 healthcare professionals participated in the focus group discussions. Results: Four major themes evolved from the qualitative content analysis: unpredictable disease prognosis and stages, low awareness of patients on disease severity, acute exacerbations, and home oxygen therapy (HOT). The participants perceived that assessment of severity and prognosis in chronic respiratory diseases such as COPD was a core discussion point to enhance patients' decision-making. The study's findings also indicated that healthcare providers evaluate the influence of acute aggravation of the condition on patients' perceived health status and decision-making. Conclusion: The study reaffirms the significance of informed consent in patients with chronic respiratory disease. It details how, after a thorough assessment of disease severity, patients are given personalized explanations of standardized HOT. This approach ensures they fully understand the unpredictable nature and various stages of their condition resulting from acute exacerbations.
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Affiliation(s)
- Wakae Maeda
- Department of Healthcare Quality and Patient Safety, Nagoya University Graduate School of Medicine, Japan
| | - K M Saif-Ur-Rahman
- College of Medicine, Nursing and Health Sciences, University of Galway, Ireland
- Evidence Synthesis Ireland and Cochrane Ireland, University of Galway, Ireland
| | - Tsukasa Muraya
- Faculty of Contemporary Social Studies, Chikushi Jogakuen University, Japan
| | - Yoshihisa Hirakawa
- Department of Health Research and Innovation, Aichi Comprehensive Health Science Center, Japan
- Department of Public Health and Health Systems, Graduate School of Medicine, Nagoya University, Japan
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Umberfield EE, Fields MC, Lenko R, Morgan TP, Adair ES, Fromme EK, Lum HD, Moss AH, Wenger NS, Sudore RL, Hickman SE. An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go? J Am Med Dir Assoc 2024; 25:557-564.e8. [PMID: 38395413 PMCID: PMC10996838 DOI: 10.1016/j.jamda.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES POLST is widely used in the care of seriously ill patients to document decisions made during advance care planning (ACP) conversations as actionable medical orders. We conducted an integrative review of existing research to better understand associations between POLST use and key ACP outcomes as well as to identify directions for future research. DESIGN Integrative review. SETTING AND PARTICIPANTS Not applicable. METHODS We queried PubMed and CINAHL databases using names of POLST programs to identify research on POLST. We abstracted study information and assessed study design quality. Study outcomes were categorized using the international ACP Outcomes Framework: Process, Action, Quality of Care, Health Status, and Healthcare Utilization. RESULTS Of 94 POLST studies identified, 38 (40%) had at least a moderate level of study design quality and 15 (16%) included comparisons between POLST vs non-POLST patient groups. There was a significant difference between groups for 40 of 70 (57%) ACP outcomes. The highest proportion of significant outcomes was in Quality of Care (15 of 19 or 79%). In subdomain analyses of Quality of Care, POLST use was significantly associated with concordance between treatment and documentation (14 of 18 or 78%) and preferences concordant with documentation (1 of 1 or 100%). The Action outcome domain had the second highest positive rate among outcome domains; 9 of 12 (75%) Action outcomes were significant. Healthcare Utilization outcomes were the most frequently assessed and approximately half (16 of 35 or 46%) were significant. Health Status outcomes were not significant (0 of 4 or 0%), and no Process outcomes were identified. CONCLUSIONS AND IMPLICATIONS Findings of this review indicate that POLST use is significantly associated with a Quality of Care and Action outcomes, albeit in nonrandomized studies. Future research on POLST should focus on prospective mixed methods studies and high-quality pragmatic trials that assess a broad range of person and health system-level outcomes.
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Affiliation(s)
- Elizabeth E Umberfield
- Division of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN, USA; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, USA.
| | - Matthew C Fields
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
| | - Rachel Lenko
- Department of Nursing, School of Health, Calvin University, Grand Rapids, MI, USA
| | - Teryn P Morgan
- Center for Biomedical Informatics, Regenstrief Institute, Inc, Indianapolis, IN, USA; Department of BioHealth Informatics, School of Informatics and Computing, Indiana University, Indianapolis, IN, USA
| | | | - Erik K Fromme
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alvin H Moss
- Center for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, WV, USA; Divisions of Nephrology and Palliative Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Susan E Hickman
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
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Shalev D, Brenner K, Carlson RL, Chammas D, Levitt S, Noufi PE, Robbins-Welty G, Webb JA. Palliative Care Psychiatry: Building Synergy Across the Spectrum. Curr Psychiatry Rep 2024; 26:60-72. [PMID: 38329570 DOI: 10.1007/s11920-024-01485-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 02/09/2024]
Abstract
PURPOSE OF REVIEW Palliative care (PC) psychiatry is a growing subspecialty focusing on improving the mental health of those with serious medical conditions and their caregivers. This review elucidates the current practice and ongoing evolution of PC psychiatry. RECENT FINDINGS PC psychiatry leverages training and clinical practices from both PC and psychiatry, addressing a wide range of needs, including enhanced psychiatric care for patients with serious medical illness, PC access for patients with medical needs in psychiatric settings, and PC-informed psychiatric approaches for individuals with treatment-refractory serious mental illness. PC psychiatry is practiced by a diverse workforce comprising hospice and palliative medicine-trained psychiatrists, psycho-oncologists, geriatric psychiatrists, other mental health professionals, and non-psychiatrist PC clinicians. As a result, PC psychiatry faces challenges in defining its operational scope. The manuscript outlines the growth, current state, and prospects of PC psychiatry. It examines its roles across various healthcare settings, including medical, integrated care, and psychiatric environments, highlighting the unique challenges and opportunities in each. PC psychiatry is a vibrant and growing subspecialty of psychiatry that must be operationalized to continue its developmental trajectory. There is a need for a distinct professional identity for PC psychiatry, strategies to navigate administrative and regulatory hurdles, and greater support for novel clinical, educational, and research initiatives.
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Affiliation(s)
- Daniel Shalev
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, 525 East 68thStreet, Box 39, New York, NY, 10065, USA.
| | - Keri Brenner
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Rose L Carlson
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, 525 East 68thStreet, Box 39, New York, NY, 10065, USA
| | - Danielle Chammas
- Department of Medicine, University of California: San Francisco, San Francisco, CA, USA
| | - Sarah Levitt
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Paul E Noufi
- Department of Medicine, Georgetown University, Baltimore, MD, USA
| | | | - Jason A Webb
- Department of Medicine, Oregon Health and Sciences University, Portland, OR, USA
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Zuo JX, Ruskin A, Bauer MR. Who Gets to Determine Whether Home Is "Unsafe" at the End of Life? Fed Pract 2023; 40:368-372. [PMID: 38567121 PMCID: PMC10984679 DOI: 10.12788/fp.0434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background At the end of life, some patients wish to be discharged directly home from the hospital, but health care teams may consider this unsafe, raising concerns for capacity and risk. However, defining risk is subjective and impacted by values, preferences, and clinical status. Accommodating patient preferences in discharge destinations can promote autonomy, dignity, and quality of life at the end of life. Observations We developed a risk assessment framework to help clinicians objectively identify risk factors and protective factors and develop a comprehensive discharge plan. We applied this framework to a veteran nearing the end of life and he was able to successfully return home from the hospital. Conclusions Approaching end-of-life discharges with a framework can inform discharge planning and lessen the risk of adverse events. Importantly, this framework can help clinicians communicate better and partner with patients and their loved ones in prioritizing patient values and preferences.
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Affiliation(s)
- Jessica X Zuo
- University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Andrea Ruskin
- Veterans Affairs Connecticut Healthcare System, West Haven
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Pedrosa Carrasco AJ, Berlin P, Betker L, Riera-Knorrenschild J, von Blanckenburg P, Seifart C. Developing a care pathway for hospital-based advance care planning for cancer patients: A modified Delphi study. Eur J Cancer Care (Engl) 2022; 31:e13756. [PMID: 36268891 DOI: 10.1111/ecc.13756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 10/03/2022] [Accepted: 10/09/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective of this study is to develop a care pathway for a hospital-based advance care planning service for cancer patients. METHODS A web-based modified Delphi study consulted an expert panel consisting of a convenience sample of stakeholders including professionals with a special interest in advance care planning as well as a 'public and patient involvement group'. After generating ideas for core elements of a care pathway in the first round, numerical ratings and rankings informed the multi-professional research steering group's decision process eventually resulting in a final pathway. RESULTS The 41 participants in the Delphi study identified 177 potential core elements of the pathway in the first round. In two further rounds, consensus was reached on a final version of the pathway with 148 elements covering the 10 domains: prerequisites, organisation and coordination, identification and referral, provision of information, information sources, family involvement, advance care planning discussion, documentation, update and quality assurance. CONCLUSION We propose a care pathway for advance care planning for hospital patients with cancer based on the results of a Delphi study that reached consensus on an implementation strategy. Our study pioneers the standardisation of the process and provides input for further policy and research with the aim of aligning cancer patients' care with their preferences and values.
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Affiliation(s)
| | - Pia Berlin
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Liv Betker
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Jorge Riera-Knorrenschild
- Department of Haematology, Oncology and Immunology, University Hospital of Giessen and Marburg, Marburg, Germany
| | - Pia von Blanckenburg
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Carola Seifart
- Research Group Medical Ethics, Philipps-University Marburg, Marburg, Germany
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Hordijk M, Vermeulen SF, Bunnik EM. The ‘false hope’ argument in discussions on expanded access to investigational drugs: a critical assessment. MEDICINE, HEALTH CARE AND PHILOSOPHY 2022; 25:693-701. [PMID: 35951276 PMCID: PMC9366814 DOI: 10.1007/s11019-022-10106-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/27/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022]
Abstract
When seriously ill patients reach the end of the standard treatment trajectory for their condition, they may qualify for the use of unapproved, investigational drugs regulated via expanded access programs. In medical-ethical discourse, it is often argued that expanded access to investigational drugs raises ‘false hope’ among patients and is therefore undesirable. We set out to investigate what is meant by the false hope argument in this discourse. In this paper, we identify and analyze five versions of the false hope argument which we call: (1) the limited chance at benefit argument, (2) the side effects outweighing benefits argument, (3) the opportunity costs argument, (4) the impossibility of making informed decisions argument, and (5) the difficulty of gaining access argument. We argue that the majority of these five versions do not provide normative ground for disqualifying patients’ hopes as false. Only when hope is rooted in a mistaken belief, for example, about the likelihood of benefits or chances on medical risks, or when hope is directed at something that cannot possibly be obtained, should it be considered false. If patients are adequately informed about their odds of obtaining medical benefit, however small, and about the risks associated with an investigational treatment, it is unjustified to consider patients’ hopes to be false, and hence, to deny them access to investigational drug based on that argument.
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Bittlinger M, Bicer S, Peppercorn J, Kimmelman J. Ethical Considerations for Phase I Trials in Oncology. J Clin Oncol 2022; 40:3474-3488. [PMID: 35275736 DOI: 10.1200/jco.21.02125] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Phase I trials often represent the first occasion where new cancer strategies are tested in patients. Various developments in cancer biology, methodology, regulation, and medical ethics have altered the ethical landscape of such trials. We provide a narrative review of contemporary ethical challenges in design, conduct, and reporting of phase I cancer trials and outline recommendations for addressing each. We organized our review around four topics, supplementing the first three with scoping reviews: (1) benefit/risk, (2) research biopsies, (3) therapeutic misconception and misestimation, and (4) reporting. The main ethical challenges of conducting phase I trials stem from three issues. First, phase I trials often involve higher research burden and scientific uncertainty compared with other cancer trials. Second, many patients arrive at phase I trials at a transitional point in their illness trajectory where they have exhausted standard survival-extending options. Third, phase I trial results play a major role in informing downstream drug development and regulatory decisions. Together, these issues create distinct pressures for study design, ethical review, informed consent, and reporting. Developments in methodology, regulation, cancer biology, and ethical awareness have helped mitigate some of these challenges, while introducing others. We conclude our review with a series of recommendations regarding trial design, ethical review, consent, and reporting. We also outline several unresolved questions that, if addressed, would strengthen the ethical foundation of phase I cancer trials.
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Affiliation(s)
- Merlin Bittlinger
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
| | - Selin Bicer
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
| | | | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
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Wall LM. Ethics Education: Using Storytelling to Teach Ethics to Novice Oncology Nurses. Clin J Oncol Nurs 2021; 25:E63-E68. [PMID: 34800108 DOI: 10.1188/21.cjon.e63-e68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Oncology nurses face unique challenges in the care of patients from culturally diverse backgrounds. Culture, values, and preferences play important roles in patient decision-making regarding goals of care and treatment. OBJECTIVES This article describes the content and outcome of an educational seminar for nurse residents, which uses storytelling to highlight the relationship between dynamic cultural influences and ethical decision-making. METHODS A 75-minute didactic seminar using storytelling, role-playing, and simulation was incorporated into a nurse residency program. Stories illustrate the role of oncology nurses in protecting and advocating for vulnerable patients, respecting and accommodating cultural differences, and increasing self-awareness of personal values that may influence decisions. Tests were administered to participants before, immediately after, and three months after the seminar to measure changes in knowledge. FINDINGS Over one year, 107 novice oncology nurses, in five cohorts, attended the seminar. Results demonstrated an overall increase and sustainment of knowledge regarding ethical decision-making in nurse residents and illustrated the effectiveness of storytelling as a method to promote ethical decision-making among staff.
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Harrison RA, Ou A, Naqvi SMAA, Naqvi SM, Weathers SPS, O'Brien BJ, de Groot JF, Bruera E. Aggressiveness of care at end of life in patients with high-grade glioma. Cancer Med 2021; 10:8387-8394. [PMID: 34755486 PMCID: PMC8633215 DOI: 10.1002/cam4.4344] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 09/11/2021] [Indexed: 11/30/2022] Open
Abstract
Background Patients with high‐grade glioma (HGG) face unique challenges toward the end of life (EoL), given their aggressive trajectory and neurologic deterioration. Aggressiveness of medical care at EoL has been identified as an important quality metric for oncology patients. At this time, limited data exist around the nature of EoL care of patients with HGG. Methods Patients with HGG and palliative care (PC) referral seen between 2010 and 2015 were identified (N = 80). Of these, N = 52 met inclusion criteria. Random selections of patients with (1) HGG not referred to PC (n = 80), and (2) non‐CNS cancers with PC referral (n = 80) were identified for comparison. A composite score of aggressiveness of medical care at EoL was calculated for each patient from predetermined variables. A time of eligibility for PC was defined for each patient when predetermined criteria based on symptom burden, functional status, and prognosis were met. Results Among the patients analyzed with HGG referred to PC, 59.6% (N = 31) were referred as inpatients, and 53.8% (N = 28) were referred within the last 12 weeks of life. Patients with HGG had similar aggressiveness of care at EoL regardless of PC referral, and HGG patients had less aggressive care at EoL than patients with non‐CNS cancers (p = 0.007). Care was more aggressive at EoL in HGG patients who received late versus early PC referrals (p = 0.012). Motor weakness at time of eligibility (OR = 2.55, p = 0.002) and more disease progressions (OR = 1.25, p = 0.043) were associated with less aggressive care at EoL. Conclusions Early clinical‐ and disease‐related features predict the aggressiveness of medical care at EoL in patients with HGG. Formal PC consultation is used infrequently and suboptimally in patients with HGG. Our data suggest that the role of PC in improving EoL outcomes in HGG warrants further evaluation.
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Affiliation(s)
- Rebecca A Harrison
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexander Ou
- Hospital Corporation of America Healthcare, Houston, Texas, USA
| | - Syed M A A Naqvi
- Department of Palliative, Integrative, and Rehabilitative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Syed M Naqvi
- Department of Internal Medicine, University of Kentucky College of Medicine, Bowling Green, Kentucky, USA
| | - Shiao-Pei S Weathers
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Barbara J O'Brien
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - John F de Groot
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Integrative, and Rehabilitative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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McFarland DC, Voigt L, Alici Y. Decisional capacity determination and serious mental illness in oncology: Implications for equitable and beneficent care. Psychooncology 2021; 30:2052-2059. [PMID: 34510606 DOI: 10.1002/pon.5812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/06/2021] [Accepted: 08/17/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients with Serious Mental Illness (SMI) have worse survival compared to cancer patients without SMI after controlling for delayed diagnosis. Decision-making capacity (DMC) may be impaired in both populations (cancer or SMI). DMC may be further impaired based on coupled vulnerability factors that challenge Shared Decision Making (SDM) for patients with cancer and SMI. METHODS Psychiatric consultations for DMC in hospitalized patients with cancer (n = 97) were consecutively evaluated across a single institution cancer center. SMI data, demographic, and cancer-related variables were obtained from the medical record. Descriptive data were contrasted in patients with and without DMC and used for logistic regression modeling. RESULTS Overall, 42% had DMC with no significant differences based on SMI (χ2 = 2.60, p = 0.11). Patients with SMI were younger, receiving anticancer treatment, and were less likely facing end of life issues. Age (OR 1.03, p = 0.05) and no recent anticancer treatments (OR 0.34, p = 0.02) were associated with decisional incapacity. At 3 months post discharge, almost two-thirds were dead with no difference based on SMI (χ2 = 0.01, p = 0.91). But End of Life (EOL) concerns were documented in 63% of non-SMI patients and only 36% of SMI patients (χ2 = 5.63, p = 0.02). Healthcare proxy (16%), four determinates of DMC (22%), and repeated psychiatric DCM assessments (35%) were documented with no differences based on SMI. CONCLUSION SDM is not equitable for cancer patients with SMI. Advanced directives and a robust effort to provide value-congruent care for patient with SMI who develop cancer may lessen this health inequity for cancer patients with SMI.
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Affiliation(s)
- Daniel C McFarland
- Department of Medicine, Northwell Health Cancer Institute, Lenox Hill Hospital, New York, USA
| | - Louis Voigt
- Department of Anesthesia and Critical Care Medicine, Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, USA.,Department of Anesthesiology, Pain, and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, USA
| | - Yesne Alici
- Department of Anesthesia and Critical Care Medicine, Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, USA.,Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, USA
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12
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Borysowski J, Górski A. Ethics framework for treatment use of investigational drugs. BMC Med Ethics 2020; 21:116. [PMID: 33208140 PMCID: PMC7672838 DOI: 10.1186/s12910-020-00560-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 11/10/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Expanded access is the use of investigational drugs (IDs) outside of clinical trials. Generally it is performed in patients with serious and life-threatening diseases who cannot be treated satisfactorily with authorized drugs. Legal regulations of expanded access to IDs have been introduced among others in the USA, the European Union (EU), Canada and Australia. In addition, in the USA an alternative to expanded access is treatment under the Right-to-Try law. However, the treatment use of IDs is inherently associated with a number of ethically relevant problems. MAIN TEXT The objective of this article is to present a coherent framework made up of eight requirements which have to be met for any treatment use of an ID to be ethical. These include a justified need for the use of an ID, no threat to clinical development of the ID, adequate scientific evidence to support the treatment, patient's benefit as the primary goal of the use of an ID, informed decision of a patient, fair access of patients to IDs, independent review, as well as the dissemination of treatment results. CONCLUSIONS While this framework is essentially consistent with the legal regulations of expanded access of the USA, the EU, Canada and Australia, it is substantially wider in scope because it addresses some important issues that are not covered by the regulations. Overall, the framework that we developed minimizes the risks and threats, and maximizes potential benefits to each of the four key stakeholders involved in the treatment use of IDs including patients, doctors, drug manufacturers, and society at large.
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Affiliation(s)
- Jan Borysowski
- Department of Clinical Immunology, Medical University of Warsaw, Nowogrodzka Str. 59, 02-006, Warsaw, Poland.
- Centre for Studies on Research Integrity, Institute of Law Studies, Polish Academy of Sciences, Nowy Świat 72, 00-330, Warsaw, Poland.
| | - Andrzej Górski
- Laboratory of Bacteriophages, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Rudolfa Weigla Str. 12, 53-114, Wrocław, Poland
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13
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Levoy K, Tarbi EC, De Santis JP. End-of-life decision making in the context of chronic life-limiting disease: a concept analysis and conceptual model. Nurs Outlook 2020; 68:784-807. [PMID: 32943221 PMCID: PMC7704858 DOI: 10.1016/j.outlook.2020.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 06/26/2020] [Accepted: 07/10/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Conceptual ambiguities prevent advancements in end-of-life decision making in clinical practice and research. PURPOSE To clarify the components of and stakeholders (patients, caregivers, healthcare providers) involved in end-of-life decision making in the context of chronic life-limiting disease and develop a conceptual model. METHOD Walker and Avant's approach to concept analysis. FINDINGS End-of-life decision making is a process, not a discrete event, that begins with preparation, including decision maker designation and iterative stakeholder communication throughout the chronic illness (antecedents). These processes inform end-of-life decisions during terminal illness, involving: 1) serial choices 2) weighed in terms of potential outcomes 3) through patient and caregiver collaboration (attributes). Components impact patients' death, caregivers' bereavement, and healthcare systems' outcomes (consequences). DISCUSSION Findings provide a foundation for improved inquiry into and measurement of the end-of-life decision making process, accounting for the dose, content, and quality the antecedent and attribute factors that collectively contribute to outcomes.
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Affiliation(s)
- Kristin Levoy
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA.
| | - Elise C Tarbi
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Joseph P De Santis
- University of Miami School of Nursing and Health Studies, Coral Gables, FL
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14
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Goswami R, Moore J, Bruera E, Hui D. Assessment of the Decision-Making Capacity for Clinical Research Participation in Patients With Advanced Cancer in the Last Weeks of Life. J Pain Symptom Manage 2020; 60:400-406. [PMID: 32105788 PMCID: PMC8641043 DOI: 10.1016/j.jpainsymman.2020.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 01/14/2023]
Abstract
CONTEXT Few studies have examined how clinicians assess decision-making capacity for research in the last weeks of life. OBJECTIVES We examined the decision-making capacity for participation in a research study and its association with clinician impression and delirium among patients with cancer with days to weeks of life expectancy. METHODS Patients admitted to our palliative and supportive care unit were approached for a prospective observational study. We assessed for their decision-making capacity based on clinical impression of physician and nurse, Memorial Delirium Assessment Scale (MDAS), and the MacArthur Competency Assessment Tool for Clinical Research (MacCAT-CR). RESULTS Among the 206 patients, 131 patients (64%) did not require MacCAT-CR assessment because they were overtly delirious or unresponsive; 37 (18%) patients were alert but did not complete the MacCAT-CR assessment for other reasons, and 38 patients (18%) completed the MacCAT-CR assessment. Among these 38 patients, five (13%) patients were incapable and had normal albeit significantly higher MDAS scores compared with those who were capable (1.8 vs. 4.2; P = 0.002). Compared against MacCAT-CR and MDAS, the overall agreement with capacity assessment with a clinician was 88% (95% CI 82-93) for physicians and 90% (95% CI 82-94) for nurses. The area under the receiver operating characteristics curve was 0.93 (95% CI 0.88-0.96) for physicians and 0.94 (95% CI 0.89-0.97) for nurses, suggesting high discrimination. CONCLUSION Most patients in the palliative and supportive care unit lacked decision-making capacity for participation in clinical research. Clinician impression had high accuracy. Few patients with normal MDAS were found to be incapable with MacCAT-CR assessment.
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Affiliation(s)
- Rachna Goswami
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Jessica Moore
- Department of Critical Care and Respiratory Care, MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA.
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15
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Griffiths AW, Ashley L, Kelley R, Cowdell F, Collinson M, Mason E, Farrin A, Henry A, Inman H, Surr C. Decision-making in cancer care for people living with dementia. Psychooncology 2020; 29:1347-1354. [PMID: 32567082 DOI: 10.1002/pon.5448] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/20/2020] [Accepted: 06/17/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Increasing numbers of people are expected to live with comorbid cancer and dementia. Cancer treatment decision-making for these individuals is complex, particularly for those lacking capacity, requiring support across the cancer care pathway. There is little research to inform practice in this area. This ethnographic study reports on the cancer decision-making experiences of people with cancer and dementia, their families, and healthcare staff. METHODS Participant observations, informal conversations, semi-structured interviews, and medical note review, in two NHS trusts. Seventeen people with dementia and cancer, 22 relatives and 19 staff members participated. RESULTS Decision-making raised complex ethical dilemmas and challenges and raised concerns for families and staff around whether correct decisions had been made. Whose decision it was and to what extent a person with dementia and cancer was able to make decisions was complex, requiring careful and ongoing consultation and close involvement of relatives. The potential impact dementia might have on treatment understanding and toleration required additional consideration by clinicians when evaluating treatment options. CONCLUSIONS Cancer treatment decision-making for people with dementia is challenging, should be an ongoing process and has emotional impacts for the individual, relatives, and staff. Longer, flexible, and additional appointments may be required to support decision-making by people with cancer and dementia. Evidence-based decision-making guidance on how dementia impacts cancer prognosis, treatment adherence and efficacy is required.
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Affiliation(s)
- Alys Wyn Griffiths
- Centre for Dementia Research, School of Health & Community Studies, Leeds Beckett University, Leeds, UK
| | - Laura Ashley
- School of Social Sciences, Leeds Beckett University, Leeds, UK
| | - Rachael Kelley
- Centre for Dementia Research, School of Health & Community Studies, Leeds Beckett University, Leeds, UK
| | - Fiona Cowdell
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
| | - Michelle Collinson
- Clinical Trials Research Unit, Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ellen Mason
- Clinical Trials Research Unit, Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ann Henry
- Clinical Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,School of Medicine, University of Leeds, Leeds, UK
| | - Hayley Inman
- Oncology Services, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Claire Surr
- Centre for Dementia Research, School of Health & Community Studies, Leeds Beckett University, Leeds, UK
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16
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Kang E, Lee J, Choo J, Min J, Yun YH. Randomized Controlled Trial of Advance Care Planning Video Decision Aid for the General Population. J Pain Symptom Manage 2020; 59:1239-1247. [PMID: 31866488 DOI: 10.1016/j.jpainsymman.2019.12.353] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/10/2019] [Accepted: 12/11/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Advance care planning (ACP) in a healthy general population could improve the quality of care when a health problem arises. OBJECTIVES The purpose of this study was to evaluate the efficacy of video decision support aid in increasing the intention to document ACP in the general healthy population. METHODS In this randomized controlled trial, we enrolled 250 members of the general population (aged 20 years and older and determined to be healthy), stratified by age and sex. The intervention was a video that provided information about ACP and end-of-life care options such as cardiopulmonary resuscitation (CPR) and palliative care. An attention-control arm was given a booklet about advance directives. Primary outcome was a change in intention to document ACP. Secondary outcomes included the intention to refuse CPR at terminal status, CPR and palliative care knowledge score, and the Hospital Anxiety and Depression Scale. RESULTS About 250 participants were randomly assigned, half to the video-assisted intervention group and half to the attention-control group. Within one week postintervention, the intention to document ACP was significantly higher in the video-assisted intervention arm (68.0% vs. 39.2%; P < 0.001), and changes in the intention to document ACP were significantly greater in the video group than in the brochure group (P = 0.008; Δ = 14.4%). Palliative care knowledge score was also significantly increased in the video group (P = 0.036). CONCLUSION A well-constructed video decision support intervention can increase the intention to document ACP in the general population that presumably had little opportunity to discuss ACP with physicians.
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Affiliation(s)
- EunKyo Kang
- Department of Family Medicine, Seoul National University Hospital, Jongno gu, Seoul, Korea; Institute for Public Health and Medical Service, Seoul National University Hospital, Jongno-gu, Seoul, Korea
| | - Jihye Lee
- Department of Biomedical Science, Seoul National University College of Medicine, Jongno gu, Seoul, Korea
| | - Jiyeon Choo
- Department of Biomedical Science, Seoul National University College of Medicine, Jongno gu, Seoul, Korea
| | - JeongHee Min
- Department of Biomedical Science, Seoul National University College of Medicine, Jongno gu, Seoul, Korea
| | - Young Ho Yun
- Department of Family Medicine, Seoul National University Hospital, Jongno gu, Seoul, Korea; Department of Biomedical Science, Seoul National University College of Medicine, Jongno gu, Seoul, Korea.
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17
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Addressing the quality of communication with older cancer patients with cognitive deficits: Development of a communication skills training module. Palliat Support Care 2020; 18:419-424. [PMID: 32295656 PMCID: PMC7572740 DOI: 10.1017/s1478951520000218] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Effective communication is an essential part of patient-centered care. The complexity of cancer care in older adults makes communication challenging, particularly when older patients have cognitive deficits and lose their autonomy. This paper describes the development, implementation, and evaluation of a communication skills training module for health care providers (HCPs) who work with older adults with cancer, with or at risk of developing cognitive deficits. METHOD Using a pre-post single arm study design, 99 HCPs from a comprehensive cancer center in North-East USA, who worked primarily with geriatric patients, participated in the study. Participants included Advance Practice Providers (including Nurse Practitioners and Physician Assistants; n = 24, 24.2%); nurses (n = 23, 23.2%), social workers (n = 14, 14.1%), physicians (n = 13, 13.1%), and "other" HCPs (including occupational therapists, physical therapists, and psychologists; n = 20, 20.2%). The HCPs participated in a one-day geriatric communication skills training program in groups of 12-15 over a 2-year period. Participants complete pre-post surveys on module evaluation and perception of self-efficacy as well as pre-post video-recorded Standardized Patient Assessment (SPA) to evaluate communication skill uptake. RESULTS Most participants evaluated the module positively; over 90% indicated that they agreed or strongly agreed with five of the six module evaluation items. HCPs' self-efficacy in communicating with cancer patients with cognitive deficits significantly increased from pre- to post-module training. There was a significant increase in the following communication skill use from pre- to post-training: checking patient preferences, declaring agenda, and inviting agenda. SIGNIFICANCE OF RESULTS Results demonstrated a successful implementation of the program as evidenced through favorable program evaluation, significant gains in self-efficacy, as well as significant improvement in several communication skills.
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18
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Schultz IZ, Stewart AM, Sepehry AA. Determination of Competency for High-Gravity Life-Death Decision-Making. PSYCHOLOGICAL INJURY & LAW 2019. [DOI: 10.1007/s12207-019-09361-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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19
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Buiar PG, Goldim JR. Barriers to the composition and implementation of advance directives in oncology: a literature review. Ecancermedicalscience 2019; 13:974. [PMID: 31921345 PMCID: PMC6946425 DOI: 10.3332/ecancer.2019.974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Indexed: 12/21/2022] Open
Abstract
The advance directive (AD) is an important resource in oncology and all areas of medicine directly involved in the care of palliative patients. It provides people with the right to have their living wills honoured when they cannot respond by themselves. Despite their importance, ADs are still underused in most countries due to multiple factors. The objective of this review is to better categorise the barriers and difficulties that could impair the composition and implementation of ADs, allowing direct efforts against these obstacles. After the literature review, we believe that there would be five steps in the trajectory of an AD (discussion, composition, registration, access and implementation) and that all those steps can be affected by factors involving the health systems and professionals, the patient themselves and relatives or caregivers.
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Affiliation(s)
- Pedro Grachinski Buiar
- Medical Oncology Department, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0001-5144-1197
| | - José Roberto Goldim
- Bioethics Division, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0003-2127-6594
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20
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Hewins W, Zienius K, Rogers JL, Kerrigan S, Bernstein M, Grant R. The Effects of Brain Tumours upon Medical Decision-Making Capacity. Curr Oncol Rep 2019; 21:55. [PMID: 31049786 PMCID: PMC6495430 DOI: 10.1007/s11912-019-0793-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of Review Informed consent is the integral part of good medical practice in patients with brain tumours. Capacity to consent may be affected by the brain disorder or its treatment. We intend to draw upon the current neuro-oncology literature to discuss the influence intracranial tumours have upon patients’ capacity to consent to treatment and research. Recent Findings We performed a systematic review of studies of capacity to consent for treatment or research in patients with intracranial tumours. The search retrieved 1597 papers of which 8 were considered eligible for review. Summary Although there are obvious inherent limitations to solely assessing cognition, most research consistently demonstrated increased risk of incapacity in brain tumour patients with cognitive impairment. Specific items in cognitive screening batteries, for example Semantic Verbal Fluency Test (SVFT), Hopkins Verbal Learning Test (HVLT-Recall), and Trail Making Test A/B (TMT), are simple, easily applied tests that may act as significant red flags to identify patients at increased risk of incapacity and who subsequently will require additional cognitive/psychiatric evaluation or more formal tests for capacity to consent for treatment or research.
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Affiliation(s)
- Will Hewins
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, EH4 2XU, Scotland.,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Karolis Zienius
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, EH4 2XU, Scotland
| | | | - Simon Kerrigan
- Department of Neurology, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - Mark Bernstein
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Robin Grant
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, EH4 2XU, Scotland. .,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK.
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21
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Kolva E, Rosenfeld B, Saracino RM. Neuropsychological Predictors of Decision-Making Capacity in Terminally Ill Patients with Advanced Cancer. Arch Clin Neuropsychol 2019; 35:1-9. [PMID: 31328219 PMCID: PMC7014974 DOI: 10.1093/arclin/acz027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/15/2019] [Accepted: 05/31/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The purpose of this cross-sectional study was to identify the neuropsychological underpinnings of decision-making capacity in terminally ill patients with advanced cancer. METHOD Participants were 108 English-speaking adults. More than half (n = 58) of participants had a diagnosis of advanced cancer and were receiving inpatient palliative care; the rest were healthy adults. Participants completed a measure of decision-making capacity that assesses four legal standards of capacity (Choice, Understanding, Appreciation, and Reasoning), and several measures of neuropsychological functioning. RESULTS Patients with terminal cancer were significantly more impaired on measures of capacity and neuropsychological functioning. Surprisingly, in the terminally ill sample, there were no significant correlations between neuropsychological functioning and decision-making capacity. CONCLUSION The terminally ill sample exhibited high levels of neuropsychological impairment across multiple cognitive domains. However, few of the measures of neuropsychological functioning were significantly associated with performance on the decisional capacity subscales in the terminally ill sample. It is possible that end-of-life decisional capacity is governed by general, rather than domain-specific, cognitive abilities.
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Affiliation(s)
- Elissa Kolva
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | | | - Rebecca M Saracino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY USA
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22
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Schildmann J, Bruns F. Informed Consent and Phase I Trials: Cognitive Failure and Additional Challenges to Informed Decision Making. J Clin Oncol 2019; 37:169. [PMID: 30433847 DOI: 10.1200/jco.18.01136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jan Schildmann
- Jan Schildmann, MD, PhD, and Florian Bruns, MD, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Florian Bruns
- Jan Schildmann, MD, PhD, and Florian Bruns, MD, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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23
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Hlubocky FJ, Daugherty CK. Reply to J. Schildmann et al. J Clin Oncol 2019; 37:170-171. [DOI: 10.1200/jco.18.01495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Fay J. Hlubocky
- Fay J. Hlubocky, PhD, and Christopher K. Daugherty, MD, The University of Chicago, Chicago, IL
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24
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Seaman JB. Invited Perspective on "Assessing the Decision Making Capacity of Terminally Ill Patients with Cancer. Am J Geriatr Psychiatry 2018; 26:532-533. [PMID: 29501412 DOI: 10.1016/j.jagp.2017.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 12/26/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Jennifer B Seaman
- School of Nursing, Department of Acute and Tertiary Care, University of Pittsburgh, Pittsburgh, PA.
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