Discrepant perceptions about end-of-life communication: a systematic review

Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU

Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.

Mechanisms of end-of-life communication contributing to optimal care at the end of life: a review of reviews

BACKGROUND

End-of-life communication is an essential component of high-quality care, but its potential mechanisms for improving care are not well understood.

OBJECTIVES

To summarise the potential mechanisms by which end-of-life communication may contribute to enhanced end-of-life care in any setting.

DESIGN

An overview of systematic reviews, with a narrative synthesis of results. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Study quality was assessed using the AMSTAR (A MeaSurement Tool to Assess Reviews) tool.

DATA SOURCES

CINAHL, MEDLINE, Cochrane, SSCI and PsycINFO databases, were searched from inception to January 2024. Manual searches were also conducted.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Systematic reviews (published in English) related to end-of-life communication, where the target population was adult patients in their last year of life, relatives, caregivers and/or healthcare professionals involved in communicating with dying patients.

RESULTS

We reviewed 35 eligible studies. The reviews suggest potential mechanisms of effective end-of-life communication including collaborative decision-making, tailoring communication to individuals, using effective communication strategies and incorporating communication skills into practice. The reviews also highlighted barriers related to patients, professionals and organisations.

CONCLUSION

This review highlights a nuanced understanding of potential mechanisms of end-of-life communication, emphasising the need for tailored training, policy enhancements and interprofessional collaboration. It calls on healthcare professionals to reflect on their practices, advocating for co-designing a person-centred communication model that addresses patient preferences at the end of life. Importantly, in culturally diverse contexts, there is a need for a communication paradigm that embraces diversity to provide truly empathetic and effective end-of-life care. This concise roadmap may foster compassionate, dignified and effective end-of-life communication.

TRIAL REGISTRATION NUMBER

Protocol registered with PROSPERO (CRD42022271433, 29 March 2022).

Psychological factors and prognostic communication preferences in advanced cancer: multicentre study

OBJECTIVES

Communication regarding prognosis to patients with advanced cancer is fundamental for informed medical decision making. Our objective was to analyse (1) the proportion of subjects with advanced cancer who prefer to know their prognosis, (2) the characteristics associated with patients' preference for prognostic information, (3) the psychological factors that impact the preference to know prognosis and 4) the concordance between preference for prognostic information perceived among physicians and patients.

METHODS

A prospective, cross-sectional design was adopted. Data were collected from 748 participants with advanced cancer at 15 tertiary hospitals in Spain. Participants completed the following questionnaires: Mental Adjustment to Cancer; Trust in the Physician; Uncertainty in Illness Scale Patient's Prognostic Preferences.

RESULTS

Fifty-two per cent of advanced cancer sufferers preferred to know the prognosis of their disease. Compared with participants who preferred not to know, those who did reported more uncertainty, greater satisfaction with their physician and higher scores on positive attitude (all p=0.001). Thirty-seven per cent of the physicians believed that patients want to know their prognosis, indicating that they underestimate the number of such patients. No significant differences were found regarding preference to know prognosis as a function of sociodemographic and clinical variables.

CONCLUSIONS

A substantial proportion of individuals with advanced cancer prefer to know the prognosis of their disease. It appears that knowing their prognosis was mainly motivated by a need to maintain a positive attitude, lessen uncertainty and by satisfaction with the physician. It is important to explore patients' preferences for information to offer more personalised communication.

How do hospital providers perceive and experience the information-delivery process? A qualitative exploratory study

Objective

To explore how professionals deal with informing their patients and how they experience the process per se, in order to deepen understanding of the issues involved and to identify areas of focus for improvement.

Methods

Semi-structured qualitative interviews were conducted with 13 hospital professionals at Lausanne University Hospital, Switzerland.

Results

Information includes feedback, practical information, patient condition, treatment/process of care, and educational material. Information-delivery is a process that involves informing the patient then checking patient reception of the information. The main expected outcome is patient action. Providers can feel trapped, guilty, inadequate, powerless, disenchanted when the process fails to achieve its expected purpose.

Conclusions

Informing and checking strategies are not implemented optimally, and providers could benefit from guidance in order to decrease discomfort and become more proficient at delivering information.

Innovation

Addressing the information-delivery process per se provides us with a novel insight into the complexity of the process and contributes to identifying essential ingredients of future innovative training programs for providers at large.

Brain-Computer interfaces for communication: preferences of individuals with locked-in syndrome, caregivers and researchers

OBJECTIVES

The development of Brain-Computer Interfaces to restore communication (cBCIs) in people with severe motor impairment ideally relies on a close collaboration between end-users and other stakeholders, such as caregivers and researchers. Awareness about potential differences in opinion between these groups is crucial for development of usable cBCIs and access technology (AT) in general. In this study, we compared the opinions of prospective cBCI users, their caregivers and cBCI researchers regarding: (1) what applications would users like to control with a cBCI; (2) what mental strategies would users prefer to use for cBCI control; and (3) at what stage of their clinical trajectory would users like to be informed about AT and cBCIs.

METHODS

We collected data from 28 individuals with locked-in syndrome, 29 of their caregivers and 28 cBCI researchers. The questionnaire was supported with animation videos to explain different cBCI concepts, the utility of which was also assessed.

RESULTS

Opinions of the three groups were aligned with respect to the most desired cBCI applications, but diverged regarding mental strategies and the timing of being informed about cBCIs. Animation videos were regarded as clear and useful tools to explain cBCIs and mental strategies to end-users and other stakeholders.

CONCLUSIONS

Disagreements were clear between stakeholders regarding which mental strategies users prefer to use and when they would like to be informed about cBCIs. To move forward in the development and clinical implementation of cBCIs, it will be necessary to align the research agendas with the needs of the end-users and caregivers.IMPLICATIONS FOR REHABILITATIONBrain-Computer Interfaces may offer people with severe motor impairment a brain-based and muscle-independent approach to control communication-technology. The successful development of communication BCIs (cBCIs) relies on a close collaboration between end-users and other stakeholders, such as caregivers and researchers.Our work reveals that people with locked-in syndrome (end-users), their caregivers and researchers developing cBCIs agree that direct and private forms of communication are the most desired cBCI applications, but disagree regarding the preferred mental strategies for cBCI control and when to be informed about cBCIs.Animation videos are an effective tool for providing information to individuals, independent of their level of health literacy, regarding the concept of cBCIs and mental strategies for control.The misalignment in opinions of different groups of stakeholders about cBCIs strengthens the argument for a user-centered design approach in the development of cBCIs and access technology designed for daily life usage.

Mortality Conversations Between Male Veterans and Their Providers Prior to Dysvascular Lower Extremity Amputation

BACKGROUND

Among patients facing lower extremity amputation due to dysvascular disease, the mortality risk is very high. Given this, as well as the importance of a patient-centered approach to medical care, informing patients about their possible risk of dying may be important during preoperative shared decision-making. The goal of this investigation was to gain an understanding of patient and provider experiences discussing mortality within the context of amputation within the Veterans Health Administration.

METHODS

Semistructured interviews were performed with Veterans with peripheral arterial disease and/or diabetes, vascular and podiatric surgeons, and physical medicine and rehabilitation physicians. Interviews were analyzed using team-based content analysis to identify themes related to amputation-level decisions.

RESULTS

We interviewed 22 patients and 21 surgeons and physicians and identified 3 themes related to conversations around mortality: (1) both patients and providers report that mortality conversations are not common prior to amputation; (2) while most providers find value in mortality conversations, some express concerns around engaging in these discussions with patients; and (3) some patients perceive mortality conversations as unnecessary, but many are open to engaging in the conversation.

CONCLUSIONS

Providers may benefit from introducing the topic with patients, including providing the context for why mortality conversations may be valuable, with the understanding that patients can always decline to participate should they not be interested or comfortable discussing this issue.

Communication about early palliative care: A qualitative study of oncology providers' perspectives of navigating the artful introduction to the palliative care team

Background

Despite robust evidence for the integration of early palliative care for patients with advanced cancer, many patients still access this approach to care late. Communication about the introduction of Early Palliative Care is an important skill of healthcare providers working in this setting. In the context of limited community understanding about palliative care, patients and their families may express fear or negative reactions to its early introduction. Health professionals may lack the confidence or skill to describe the role and benefits of early palliative care.

Aim

This study sought to explore clinicians' perspectives on communication about referral to early palliative care, specifically identifying facilitators in undertaking this communication task.

Methods

An exploratory qualitative study set within a tertiary oncology service in Victoria, Australia. Semi-structured interviews were conducted with purposively sampled oncology clinicians exploring their perspectives on communication about referral to early palliative care. A reflexive thematic analysis was undertaken by two researchers, including both latent and semantic coding relevant to the research question. Reporting of the research was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

Results

Twelve oncology clinicians (58% female, with 67% > 15 years clinical experience) from medical oncology, surgical oncology, and haematology participated. The artful navigation of communication about early palliative care was characterised by the need for a 'spiel' involving the adoption of a series of strategies or 'tactics' when introducing this service. These themes included: 1) Using carefully selected and rehearsed language; 2) Framing in terms of symptom control; 3) Framing as additive to patient care; 4) Selling the service benefits of early palliative care; 5) Framing acceptance of referral as an altruistic act; and 6) Adopting a phased approach to delivering information about palliative care.

Implications

This study highlights the wide ranging and innovative communication strategies and skills required by health professionals to facilitate referral to early palliative care for cancer patients and their families. Future focus on upskilling clinicians around communication of this topic will be important to ensure successful implementation of models of early palliative care in routine cancer care.

Discussing brain magnetic resonance imaging results for neonates with hypoxic-ischemic encephalopathy treated with hypothermia: A challenge for clinicians and parents

Context

Clinicians use brain magnetic resonance imaging (MRI) to discuss neurodevelopmental prognosis with parents of neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH).

Purpose

To investigate how clinicians and parents discuss these MRI results in the context of HIE and TH and how these discussions could be facilitated and more meaningful for parents.

Procedures

Mixed-methods surveys with open-ended and closed-ended questions were completed by two independent groups. (1) Clinicians responded to clinical vignettes of neonates with HIE treated with TH with various types of clinical features, evolution and extent of brain injury and questions about how they discuss brain MRI results in this context. (2) Parents of children with HIE treated with TH responded to questions about the discussion of MRI that they had while still in the neonatal intensive care unit and were asked to place it in perspective with the outcomes of their child when he/she reached at least 2 years of age. Open-ended responses were analyzed using a thematic analysis approach. Closed-ended responses are presented descriptively.

Results

Clinicians reported uncertainty, lack of confidence, and limitations when discussing brain MRI results in the context of HIE and TH. Brain MRI results were "usually" (53%) used in the prognostication discussion. When dealing with day-2 brain MRIs performed during TH, most clinicians (40%) assumed that the results of these early MRIs were only "sometimes" accurate and only used them "sometimes" (33%) to discuss prognosis; a majority of them (66%) would "always" repeat imaging at a later time-point to discuss prognosis. Parents also struggled with this uncertainty, but did not discuss limitations of MRI as often. Parents raised the importance of the setting where the discussion took place and the importance to inform them as quickly as possible. Clinicians identified strategies to improve these discussions, including interdisciplinary approach, formal training, and standardized approach to report brain MRI. Parents highlighted the importance of communication skills, the stress, the hope surrounding their situation, and the need to receive answers as soon as possible. The importance of showing the pictures or making representative drawing of the injury, but also highlighting the not-injured brain, was also highlighted by parents.

Conclusions

Discussing brain MRI results for neonates with HIE treated with TH are challenging tasks for clinicians and daunting moments for parents.

Information concealment in palliative patients: Development and pilot study of a new scale for caregivers

Previous studies on palliative care have assessed the phenomenon of Information Concealment (IC), confirmed its relevance and emphasised the need to have a scale for its assessment. The aim of this study was to design and validate such an instrument. The sample comprised 150 palliative caregivers (23 men and 127 women). The dimensionality of the items of the Information Concealment Scale for Caregivers (ECOI) was assessed using Exploratory Factor Analysis and an optimal implementation of parallel analysis. Reliability and criterion validity were analysed using sample data. The ECOI comprises three factors: Concealment or dissimulation about the disease, misrepresentation of the real situation and control of the information. The scale has excellent reliability and shows criterion validity. Therefore, the ECOI is a reliable and valid instrument to objectively measure IC among Spanish caregivers in palliative care settings.

A prospective cross-sectional survey comparing patient and provider expectations regarding ovarian cancer prognosis

•

Providers believe prognostic discussions are important for ovarian cancer patients.

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Providers report having prognostic conversations more often than patients.

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Ovarian cancer patients and providers have different expectations surrounding treatment, remission, and survival.

•

Age, marital status, religion, and cancer stage may affect patient perceptions of ovarian cancer prognosis.

Introduction

There is limited data comparing patient and physician expectations regarding ovarian cancer prognosis. Our primary objective was to compare physician and patient estimates of survival to 6 months, 1 year, and 5 years; secondary objectives included comparing provider and patient responses on the likelihood of requiring future treatments and categorizing patient and provider preferences regarding communication about prognosis.

Methods

A prospective cross-sectional survey was delivered to 10 gynecologic oncology providers and 50 adult ovarian cancer patients from November 2015-April 2016 at one institution. Descriptive statistics were used to categorize survey answers and compare survey answers between patients and providers; multivariable logistic regression evaluated patient survey responses.

Results

All providers (100%) believed treating providers should discuss prognosis and 90% reported having prognostic conversations with patients, compared to 63%, 37%, and 4% of patients who reported discussing prognosis, living wills/advance directives, and palliative care/hospice services, respectively, with their provider. Compared to their provider, patients gave significantly lower estimations of requiring any future therapy (mean score 84.6 vs 74, p <.001) and future chemotherapy (mean score 84.1 vs 69.8, p <.001) and significantly higher estimations of requiring future surgery (mean score 23.3 vs 40, p <.001), achieving remission (mean score 33.5 vs 47.5, p =.009), survival to 1 year (mean score 77.1 vs 86.4, p =.002), and survival to 5 years (mean score 40.5 vs 61.3, p <.001).

Conclusions

Although gynecologic oncology providers believe it is important to discuss prognosis and end-of-life care, there are gaps in communication, knowledge, and expectations between providers and ovarian cancer patients.

Voicing their choices: Advance care planning with adolescents and young adults with cancer and other serious conditions

OBJECTIVES

To determine whether engaging in advance care planning (ACP) using a formal tool, Voicing My CHOiCES (VMC), would alleviate adolescent and young adults (AYAs) anxiety surrounding ACP and increase social support and communication about end-of-life care preferences with family members and health care providers (HCPs).

METHODS

A total of 149 AYAs aged 18-39 years receiving cancer-directed therapy or treatment for another chronic medical illness were enrolled at seven US sites. Baseline data included prior ACP communication with family members and HCPs and measures of generalized anxiety, ACP anxiety, and social support. Participants critically reviewed each page of VMC and then completed three pages of the document. ACP anxiety was measured again immediately after the completion of VMC pages. One month later, participants repeated anxiety and social support measures and were asked if they shared what they had completed in VMC with a family member or HCP.

RESULTS

At baseline, 50.3% of participants reported that they previously had a conversation about EoL preferences with a family member; 19.5% with an HCP. One month later, 65.1% had subsequently shared what they wrote in VMC with a family member; 8.9% shared with an HCP. Most (88.6%) reported they would not have had this conversation if not participating in the study. No significant changes occurred in social support. There was an immediate drop in anxiety about EoL planning after reviewing VMC which persisted at 1 month. Generalized anxiety was also significantly lower 1 month after reviewing VMC.

SIGNIFICANCE OF RESULTS

Having a document specifically created for AYAs to guide ACP planning can decrease anxiety and increase communication with family members but not necessarily with HCPs. Future research should examine ways ACP can be introduced more consistently to this young population to allow their preferences for care to be heard, respected, and honored, particularly by their healthcare providers.

Prognostic communication about lung cancer in the precision oncology era: A multiple-perspective qualitative study

BACKGROUND

Although most patients with cancer prefer to know their prognosis, prognostic communication between oncologists and patients is often insufficient. Targeted therapies for lung cancer improve survival yet are not curative and produce variable responses. This study sought to describe how oncologists communicate about prognosis with patients receiving targeted therapies for lung cancer.

METHODS

This qualitative study included 39 patients with advanced lung cancer with targetable mutations, 14 caregivers, and 10 oncologists. Semistructured interviews with patients and caregivers and focus groups or interviews with oncologists were conducted to explore their experiences with prognostic communication. One oncology follow-up visit was audio-recorded per patient. A framework approach was used to analyze interview transcripts, and a content analysis of patient-oncologist dialogue was conducted. Themes were identified within each source and then integrated across sources to create a multidimensional description of prognostic communication.

RESULTS

Six themes in prognostic communication were identified: Patients with targetable mutations develop a distinct identity in the lung cancer community that affects their information-seeking and self-advocacy; oncologists set high expectations for targeted therapy; the uncertain availability of new therapies complicates prognostic discussions; patients and caregivers have variable information preferences; patients raise questions about progression by asking about physical symptoms or scan results; and patients' expectations of targeted therapy influence their medical decision-making.

CONCLUSIONS

Optimistic patient-oncologist communication shapes the expectations of patients receiving targeted therapy for lung cancer and affects their decision-making. Further research and clinical guidance are needed to help oncologists to communicate uncertain outcomes effectively.

Three strategies when physicians provide complex information in interactions with patients: How to recognize and measure them

OBJECTIVE

To define and operationalize three taught strategies for providing information in interactions with patients using videos collected in a randomized controlled trial (RCT).

METHODS

This was a qualitative exploratory study embedded in a randomized controlled design, using microanalysis of face-to-face dialogue as an inductive video analysis method to operationalize physicians' use of three information-provision strategies. Data were 34 video-recorded simulated (but unscripted) interactions between 17 physicians and 34 multiple sclerosis patients collected before and after a brief course on information provision. We operationalized (1) mapping the patient's preferences and (2) checking the patient's understanding, and pauses indicative of (3) portioning information.

RESULTS

Results are detailed analytical definitions, criteria, and assessable, quantifiable outcomes for each of the three strategies. Patients responded to portioning pauses as expected: whereas 91% of these pauses elicited an immediate patient response, only 23% of non-portioning pauses did so.

CONCLUSION

Our methods revealed how to define and evaluate information sharing strategies physicians used within the contingencies of clinical interaction.

PRACTICE IMPLICATIONS

Findings provide applicable methods to teach, analyze, and evaluate information sharing strategies and indications for further training.

Los deseos de información en pacientes con cáncer avanzado

Objetivo: Comprobar los deseos de información, y las variables asociadas a ello, en los pacientes con cáncer avanzado atendidos por un Equipo de Soporte Hospitalario de Cuidados Paliativos. Método: Noventa pacientes con cáncer avanzado, fueron evaluados, mediante una entrevista estructurada sobre si tenían información sobre su enfermedad de los siguientes tipos: diagnóstico, curación, gravedad, objetivos del tratamiento y final de vida, y de su deseo de tener información en cada uno de esto cinco tipos de información. Además, se recogieron los datos sociodemográficos y clínicos, y se administraron: la Escala de Capacidad Funcional, el Índice de Comorbilidad de Charlson, y la Escala de Ansiedad y Depresión Hospitalaria. Resultados. Los resultados muestraron que la mayoría de los pacientes estaban informados del diagnóstico, y de la gravedad, pero no de los objetivos de tratamiento, la curación y el final de vida. De los pacientes no informados el 77,8% (14) deseaban conocer el diagnostico, el 60,0% (11) la gravedad, el 77,8% (35) el objetivo del tratamiento, el 76,7% (24) la curación y un 34,4% (10) el final de vida. Las variables asociadas al deseo de: a) información diagnóstica fueron: tener un cuidador principal más joven (p=,023); con pareja (p=,018), no religiosos (p=,025) y mayor número de visitas a urgencias (p=,004); b) información sobre gravedad fueron: ser joven (p=,009); con pareja (p=,04), y mejor estado ánimo (p=,009); c). Información sobre objetivos del tratamiento: ser joven (p=,001), Con pareja (p=,04), mejor estado ánimo (p=,001). d) información sobre curación: ser hombre (p=,018), con pareja (p=,04), no religiosos (p=,023). En el caso de información sobre el tiempo de vida no se encontró ninguna diferencia significativa. Conclusiones: es necesario valorar los deseos información que tienen los pacientes de forma individualizada y en las diferentes variables de información, y por ello la creación de una herramienta estandarizada en futuras investigaciones es una prioridad. La mayoría de los pacientes con cáncer avanzado están informados del diagnóstico y gravedad, pero existe un déficit de información en curación, objetivos del tratamiento y especialmente en la información del final de vida y destaca más aun, que un alto porcentaje de los pacientes no informados sí desearían recibir información, principalmente sobre los objetivos del tratamiento, sobre todo los más jóvenes, con pareja y no religiosos y con mejor estado de ánimo. Una calidad asistencial óptima en pacientes con cáncer avanzado requiere cubrir sus deseos de información.

Characterizing uncertainty in goals-of-care discussions among black and white patients: a qualitative study

BACKGROUND

Uncertainty has been associated with distress and poorer quality of life in patients with advanced cancer. Prior studies have focused on prognostic uncertainty; little is known about other types of uncertainty that patients and family members experience when discussing goals of care. Understanding the types of uncertainty expressed and differences between Black and White patients can inform the development of uncertainty management interventions.

METHODS

This study sought to characterize the types of uncertainty expressed by Black and White patients and family members within the context of information needs during inpatient goals-of-care discussions. We performed a secondary analysis of transcripts from 62 recorded goals-of-care discussions that occurred between 2012 and 2014 at an urban, academic medical center in the United States. We applied an adapted taxonomy of uncertainty to data coded as describing information needs and used an inductive qualitative analysis method to analyze the discussions. We report the types of uncertainty expressed in these discussions.

RESULTS

Fifty discussions included patient or family expressions of information needs. Of these, 40 discussions (n=16 Black and n=24 White) included statements of uncertainty. Black and White patients and families most frequently expressed uncertainty related to processes and structures of care (system-centered uncertainty) and to treatment (scientific uncertainty). Statements of prognostic uncertainty focused on quantitative information among Whites and on qualitative information and expectations for the future among Blacks.

CONCLUSIONS

Black and White patients and families frequently expressed system-centered uncertainty, suggesting this may be an important target for intervention. Addressing other sources of uncertainty, such as prognostic uncertainty, may need more tailored approaches.

Difficulties Facing Junior Physicians and Solutions Toward Delivering End-of-Life Care for Patients with Cancer: A Nationwide Survey in Japan

BACKGROUND

Junior physicians' perceived difficulty in end-of-life care of patients with cancer has not been structurally investigated; therefore, current challenges and solutions in this area remain unknown.

OBJECTIVES

To identify some difficulties junior physicians face in delivering end-of-life care for patients with cancer and to clarify the support required to reduce these difficulties.

DESIGN

A nationwide survey was conducted in over 300 institutions selected randomly from 1037 clinical training hospitals in Japan.

PARTICIPANTS

From each of these institutions, two resident physicians of postgraduate year (PGY) 1 or 2, two clinical fellows of PGY 3-5, and an attending physician were requested to respond to the survey.

MEASUREMENTS

The survey investigated issues regarding end-of-life care using the palliative care difficulties scale with two additional domains ("discussion about end-of-life care" and "death pronouncement"). Items related to potential solutions for alleviating the difficulties as well were investigated.

RESULTS

A total of 198 resident physicians, 134 clinical fellows, and 96 attending physicians responded to the survey (response rate: 33.0%, 22.3%, and 32.0%). The results revealed that junior physicians face difficulties within specific domains of end-of-life care. The most challenging domain comprised communication and end-of-life discussion with patients and family members, symptom alleviation, and death pronouncement. The most favored supportive measure for alleviating these difficulties was mentorship, rather than educational opportunities or resources regarding end-of-life care.

CONCLUSION

The findings of this study reveal the need for further effort to enrich the mentorship and support systems for junior physicians delivering end-of-life care.

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

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

Quality of dying in hospital general wards: a cross-sectional study about the end-of-life care

Background

In the last decade, access to national palliative care programs have improved, however a large proportion of patients continued to die in hospital, particularly within internal medicine wards.

Objectives

To describe treatments, symptoms and clinical management of adult patients at the end of their life and explore whether these differ according to expectation of death.

Methods

Single-centre cross-sectional study performed in the medical and surgical wards of a large tertiary-level university teaching hospital in the north of Italy. Data on nursing interventions and diagnostic procedure in proximity of death were collected after interviewing the nurse and the physician responsible for the patient. Relationship between nursing treatments delivered and patients’ characteristics, quality of dying and nurses’ expectation about death was summarized by means of multiple correspondence analysis (MCA).

Results

Few treatments were found statistically associated with expectation of death in the 187 patients included. In the last 48 h, routine (70.6%) and biomarkers (41.7%) blood tests were performed, at higher extent on patients whose death was not expected. Many symptoms classified as severe were reported when death was highly expected, except for agitation and respiratory fatigue which were reported when death was moderately expected. A high Norton score and absence of anti-bedsore mattress were associated with unexpected death and poor quality of dying, as summarized by MCA. Quality of dying was perceived as good by nurses when death was moderately and highly expected. Physicians rated more frequently than nurses the quality of dying as good or very good, respectively 78.6 and 57.8%, denoting a fair agreement between the two professionals (k = 0.24, P <  0.001). The palliative care consultant was requested for only two patients.

Conclusion

Staff in medical and surgical wards still deal inadequately with the needs of dying people. Presence of hospital-based specialist palliative care could lead to improvements in the patients’ quality of life.

Communication at the End of Life

End-of-life patients experience physical, mental, social, and existential distress. While medical personnel provide medication and care to alleviate patients' distress, listening to and interacting with patients remains essential for understanding their psychological condition. The most important tool, though difficult to implement in practice, is end-of-life discussion (EOLD). EOLD has been shown to have positive effects on end-of-life treatment choices, achievement of patients' life goals, improvements in the quality of life of patients and their families, and the prevention of depression and complicated grief among bereaved family members. EOLD is not often undertaken in clinical practice, however, due to hesitancy among medical personnel and patients for various reasons. In order to conduct an EOLD, the patient's judgment, psychiatric illnesses such as delirium and depression, and psychological issues such as the side effects of psychotropic drugs, denial, and collusion must be evaluated. Open and honest conversation, treatment goal setting, the doctor's familiarity with the patient's background, and attentiveness when providing information are important elements for any dialogue. Meaning-centered psychotherapy was developed to alleviate the existential distress of cancer patients, and its application may promote EOLD. The future development of meaning-centered psychotherapy in practice and in research is expected to further promote EOLD.

The relationship between caregivers' perceptions of end-of-life care in long-term care and a good resident death

OBJECTIVE

Quality end-of-life (EOL) care is critical for dying residents and their family/friend caregivers. While best practices to support resident comfort at EOL in long-term care (LTC) homes are emerging, research rarely explores if and how the type of care received at EOL may contribute to caregivers' perceptions of a good death. To address this gap, this study explored how care practices at EOL contributed to caregivers' perceptions of a good resident death.

METHOD

This study used a retrospective cross-sectional survey design. Seventy-eight participants whose relative or friend died in one of five LTC homes in Canada completed self-administered questionnaires on their perceptions of EOL care and perceptions of a good resident death.

RESULTS

Overall, caregivers reported positive experiences with EOL care and perceived residents to have died a good death. However, communication regarding what to expect in the final days of life and attention to spiritual issues were often missing components of care. Further, when explored alongside direct resident care, family support, and rooming conditions, staff communication was the only aspect of EOL care significantly associated with caregivers' perceptions of a good resident death.

SIGNIFICANCE OF RESULTS

The findings of this study suggest that the critical role staff in LTC play in supporting caregivers' perceptions of a good resident death. By keeping caregivers informed about expectations at the very end of life, staff can enhance caregivers' perceptions of a good resident death. Further, by addressing spiritual issues staff may improve caregivers' perceptions that residents were at peace when they died.

The impact of uncertainty on bereaved family's experiences of care at the end of life: a thematic analysis of free text survey data

Background

Inequities in the provision of palliative care for people with cardiac disease have been well documented in the literature. Despite experiencing significant palliative care needs, those with cardiac disease are less likely to be referred to specialist palliative care services and more likely to die in a hospital when compared to those with cancer. The unpredictable trajectory of heart failure has been identified as a key barrier to providing palliative care with many people experiencing a long period of stability with appropriate medical treatment. However, as the disease progresses and cardiac function deteriorates, exacerbations of acute decompensation can lead to what is often perceived to be ‘sudden’ death. The aim of this study is to explore the impact of uncertainty on how death is remembered by bereaved family members of people with heart disease.

Methods

Thematic analysis of free text collected during a postal survey of bereaved family’s experiences of healthcare services in the last 3 months of life using the New Zealand version of the VOICES questionnaire was undertaken. Data was analysed using a three-dimensional conceptual framework of “scientific uncertainty”.

Results

Eight hundred and twenty-seven completed questionnaires were received of which 12.6% (n = 105) indicated that they had cared for someone at the end of life with cardiac disease. Experiences of uncertainty were found to have a significant impact upon bereaved family. Four key themes were identified; distrust in healthcare professionals, stories left incomplete, loss, regret and missed opportunity and disempowerment.

Conclusions

This study highlights the ongoing impact on bereaved family when uncertainty is not made explicit in conversations regarding end of life for people with heart disease. Timely and sensitive conversations regarding the uncertainty of when death may occur is an important factor in ensuring that bereaved family are not left with unresolved narratives. Reframing how we think and talk about uncertainty in end of life care is important, as clinicians’ uncertainties may not always reflect or match up with families’ uncertainties. Being explicit about our inability to be certain about the timing of death may thus lead to a more positive and complete experience for bereaved family.

Exploring the perceptions of advanced practitioner radiographers at a single breast screening unit in extending their role from delivering benign to malignant biopsy results; a preliminary study

OBJECTIVE

The study aims to explore the perceptions of advanced practice radiographers (APRs) currently giving benign biopsy results to extend their role to deliver NHS Breast Screening Programme (NHSBSP) malignant outcomes. In the UK, APRs are appropriately trained to deliver results, yet traditionally have been cultured not to. Increasing pressures on NHSBSP units are a key driver for APR evolvement. A significant lack of published research provides the rationale for the study, combined with an identified service need.

METHODS

Following ethical approval, a grounded theory design was applied to interview six APRs individually in a single breast screening unit. Extracted themes were considered during a subsequent focus group.

RESULTS

Five core themes identified; (i) role of the APR, (ii) patient experience, (iii) efficiency, (iv) role boundaries, and (v) delivering results.The findings indicate the ambiguity of radiographers delivering results within their profession, outlining the potential impact on themselves and patients. Mammography APRs are skilled to deliver results, and whilst enforced barriers may restrict extension a supportive environment can overcome these. Additional training is necessary to implement the role in the screening service.

CONCLUSION

Identified within their scope of practice; APRs have the ability with appropriate training and peer support to effectively deliver results with a patient-centred approach.

ADVANCES IN KNOWLEDGE

This study has identified important enabling factors and challenges concerning role extension in the delivery of breast biopsy results. The apparent suitability of APRs to communicate results may address breast service pressures, with benefit to patients and the radiology profession.

End-of-life care after the legal introduction of advance directives: A qualitative study involving healthcare professionals and family caregivers of patients with amyotrophic lateral sclerosis

BACKGROUND

Advance care planning and advance directives play a key role in the care of life-threatening illnesses such as amyotrophic lateral sclerosis.

AIM

The aim of the present study is to explore how the introduction of these features by law improves the experience of end-of-life care.

DESIGN

Five focus groups were conducted in Italy 1 year after the new law on advance directives was introduced.

SETTING/PARTICIPANTS

Purposive sampling was used to recruit 24 health professionals and 23 family caregivers of patients with amyotrophic lateral sclerosis, for a total of 47 participants.

RESULTS

The thematic analysis, conducted through the use of ATLAS.ti software, identified four thematic areas: best practices, managing difficulties, care relationships and proposals. The results indicated a lack of organization, collaboration and continuity on the part of healthcare services and professionals, a lack of information on palliative care, advance care planning, and advance directives. End-of-life care is often left to the good will of the individual professional. Difficulties can also derive from ethical dilemmas concerning end-of-life decision-making and from a lack of communication and relationships between health professionals, patients and their families.

CONCLUSION

The introduction of advance directives by law has not been sufficient to improve end-of-life care. In order to make legal regulation effective, the organization of healthcare services needs to be improved and clearer procedures have to be implemented and shared with patients and families.

Talking about death and dying in a hospital setting - a qualitative study of the wishes for end-of-life conversations from the perspective of patients and spouses

Background

End-of-life (EOL) conversations are highly important for patients living with life-threatening diseases and for their relatives. Talking about the EOL is associated with reduced costs and better quality of care in the final weeks of life. However, there is therefore a need for further clarification of the actual wishes of patients and their relatives concerning EOL conversations in an acute hospital setting.

Aim

The purpose of this study was to explore the wishes of patients and their relatives with regard to talking about the EOL in an acute hospital setting when living with a life-threatening disease.

Methods

This study is a qualitative study using semi-structured in-depth interviews. A total of 17 respondents (11 patients and six spouses) participated. The patients were identified by the medical staff in a medical and surgical ward using SPICT™. The interview questions were focused on the respondents’ thoughts on and wishes about their future lives, as well as on their wishes regarding talking about the EOL in a hospital setting.

Results

This study revealed that the wish to talk about the EOL differed widely between respondents. Impairment to the patients’ everyday lives received the main focus, whereas talking about EOL was secondary. Conversations on EOL were an individual matter and ranged from not wanting to think about the EOL, to being ready to plan the funeral and expecting the healthcare professionals to be very open about the EOL. The conversations thus varied between superficial communication and crossing boundaries.

Conclusion

The wish to talk about the EOL in an acute hospital setting is an individual matter and great diversity exists. This individualistic stance requires the development of conversational tools that can assist both the patients and the relatives who wish to have an EOL conversation and those who do not. At the same time, staff should be trained in initiating and facilitating EOL discussions.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12904-020-00675-1.

"Maintaining hope:" challenges in counseling latino patients with advanced cancer

BACKGROUND

Latino cancer patients are at risk of poor psychological adjustment. Therapeutic effectiveness in treating Latino cancer patients with advanced cancer requires managing distress, therapeutic skill, and cultural competency. This mixed-methods study explored mental health providers' perceptions of the challenging aspects of counseling and caring for Latino patients with advanced cancer.

METHODS

Mental health providers providing services to Latino or Hispanic cancer patients received an emailed web-based survey with open- and closed-ended questions. Providers included psychiatrists, psychologists, social workers, counselors, and other mental health professionals. We invited 154 providers to participate from July 2015 to January 2017. One hundred and four accessed the survey, and 66 eligible providers responded, for a response rate of 43%. Analyses were used to explore whether clinical experience factors and training characteristics were associated with perceiving conversations about cancer (diagnosis, prognosis, and end-of-life) as challenging. Second, the challenging aspects of these conversations were explored qualitatively. Four independent coders coded responses; an inductive content analysis was utilized to analyze the data.

RESULTS

Mental health providers describe encountering many challenges in their therapeutic discussions with Latino cancer patients.

CONCLUSIONS

It is imperative to understand the factors associated with the perceived difficulty of these conversations, as well as the characteristics of these conversations, to develop culturally sensitive interventions and programs for patients and training interventions for providers.

InterRAI assessments: opportunities to recognise need for and implementation of palliative care interventions in the last year of life?

OBJECTIVES

To explore how interRAI assessments could be used to identify opportunities to integrate palliative care into a plan of care.

METHODS

A population-based, cross-sectional design using unique identifiers to link deaths with a national interRAI database. Data were analysed using logistic regression models and chi-square tests.

RESULTS

A total of 4869 people died over a 12-month period in one district health board area; 50.9% (n = 2478) received one or more interRAI assessments in the year before death. Diagnosis impacted on the type and timing of interRAI assessments and the recognition of end-stage disease.

CONCLUSION

People in the last year of life experience frequent interRAI assessments. There are opportunities to identify people who might benefit from a palliative care approach. Future research is needed to understand how interRAI assessors can be supported in the application of assessment items related to palliative care.

When intents to educate can misinform: Inadvertent paltering through violations of communicative norms

Paltering is a form of deception whereby true statements are used to mislead and is widely employed in negotiations, marketing, espionage, and ordinary communications where speakers hold ulterior motives. We argue that paltering is accomplished through strategic violations of communicative norms such as the Gricean cooperative principles of relevance, quantity, quality and manner. We further argue that, just as genuine paltering deceives by deliberately violating communicative norms, inadvertent violations of these norms may be just as misleading. In this work, we demonstrated that educational information presented prominently on the American Diabetes Association website violated the Gricean communicative principles and disrupted readers' performance on a test of diabetes knowledge. To establish the effects of these communicative violations, we revised the ADA's information to preserve the original content while better adhering to pragmatic principles. When these ADA explanations were judiciously revised to minimize pragmatic violations, they were transformed from misleading to educational.

'The Future is Probably Now': Understanding of illness, uncertainty and end-of-life discussions in older adults with heart failure and family caregivers

Background

Earlier end‐of‐life communication is critical for people with heart failure given the uncertainty and high‐risk of mortality in illness. Despite this, end‐of‐life communication is uncommon in heart failure. Left unaddressed, lack of end‐of‐life discussions can lead to discordant care at the end of life.

Objective

This study explores patients' and caregivers’ understanding of illness, experiences of uncertainty, and perceptions of end‐of‐life discussions in advanced illness.

Design

Interpretive descriptive qualitative study of older adults with heart failure and family caregivers. Fourteen semi‐structured interviews were conducted with 19 participants in Ontario, Canada. Interviews were transcribed verbatim and content analysis was used to analyse the data.

Main results

Understanding of illness was shaped by participants’ illness‐related experiences (e.g. symptoms, hospitalizations and self‐care routines) and the ability to adapt to challenges of illness. Participants were knowledgeable of heart failure management, and yet, were limited in their understanding of the consequences of illness. Participants adapted to the challenges of illness which appeared to influence their perception of overall health. Uncertainty reflected participants’ inability to connect manifestations of heart failure as part of the progression of illness towards the end of life. Most participants had not engaged in prior end‐of‐life discussions.

Conclusion

Detailed knowledge of heart failure management does not necessarily translate to an understanding of the consequences of illness. The ability to adapt to illness‐related challenges may delay older adults and family caregivers from engaging in end‐of‐life discussions. Future research is needed to examine the impact of addressing the consequences of illness in facilitating earlier end‐of‐life communication.

Communication between healthcare professionals and relatives of patients approaching the end-of-life: A systematic review of qualitative evidence

BACKGROUND

Effective communication between healthcare professionals and relatives of patients approaching the end-of-life is vital to ensure patients have a 'good death'. To improve communication, it is important to first identify how this is currently being accomplished.

AIM

To review qualitative evidence concerning characteristics of communication about prognosis and end-of-life care between healthcare professionals and relatives of patients approaching the end-of-life.

DESIGN

Qualitative systematic review (PROSPERO registration CRD42017065560) using thematic synthesis. Peer-reviewed, English language articles exploring the content of conversations and how participants communicated were included. No date restrictions were applied. Quality of included studies was appraised using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research.

DATA SOURCES

An electronic database search of CINAHL, MEDLINE, PsycINFO and EMBASE was performed.

RESULTS

Thirty-one papers were included. Seven themes were identified: highlighting deterioration; involvement in decision-making, post-decision interactional work, tailoring, honesty and clarity, specific techniques for information delivery and roles of different healthcare professionals. Varied levels of family involvement in decision-making were reported. Healthcare professionals used strategies to aid understanding and collaborative decision-making, such as highlighting the patient's deterioration, referring to patient wishes and tailoring information delivery. Doctors were regarded as responsible for discussing prognosis and decision-making, and nurses for providing individualized care.

CONCLUSION

Findings suggest training could provide healthcare professionals with these strategies to improve communication. Interventions such as question prompt lists could help relatives overcome barriers to involvement in decision-making. Further research is needed to understand communication with relatives in different settings and with different healthcare professionals.

End-of-life communication: a nationwide study of bereaved parents’ perceptions

Objective

To investigate bereaved parents’ perception of end-of-life communication with healthcare professionals after losing a child due to life-limiting diagnoses.

Methods

A national register identified the causes of death of 951 children aged 0–18 years during the period 2012–2014. A previously described classification of life-limiting diagnoses identified 402 children. A modified version of the self-administered questionnaire 'To Lose a Child' was distributed to the parents of these 402 children, capturing their perceptions of communication with the healthcare professionals throughout the child’s disease trajectory and imminent death.

Results

A total of 193 bereaved parents, representing 38% of the identified children, participated in the study. Overall, 98% of the parents expressed the view that physicians should immediately disclose when curatively intended treatment options were exhausted. Some 79% of parents reported that information about their child’s incurable illness was given in an appropriate manner; however, 42% said that information about the child's imminent death was given too late. Finally, 31% felt deprived of the option to say goodbye to their child in their preferred manner, and 56% said that their child’s death was “a shock”.

Conclusions

Parents request accurate and timely information. However, a substantial number of the parents surveyed reported that healthcare professionals communicated too late about palliative care and end-of-life issues. Even though healthcare professionals strive to communicate effectively with dying children and their parents, barriers were identified that may hinder even the best of intentions. National guidelines addressing communication issues and improved education of healthcare professionals should form part of any future agenda.

Towards appropriate information provision for and decision-making with patients with limited health literacy in hospital-based palliative care in Western countries: a scoping review into available communication strategies and tools for healthcare providers

BACKGROUND

Person-centred palliative care poses high demands on professionals and patients regarding appropriate and effective communication and informed decision-making. This is even more so for patients with limited health literacy, as they lack the necessary skills to find, understand and apply information about their health and healthcare. Recognizing patients with limited health literacy and adapting the communication, information provision and decision-making process to their skills and needs is essential to achieve desired person-centred palliative care. The aim of this study is to summarize available strategies and tools for healthcare providers towards successful communication, information provision and/or shared decision-making in supporting patients with limited health literacy in hospital-based palliative care in Western countries.

METHODS

A scoping review was conducted. First, databases PubMed, Embase, CINAHL, and PsycINFO were searched. Next, grey literature was examined using several online databases and by contacting national experts. In addition, all references of included studies were checked.

RESULTS

Five studies were included that showed that there are face-to-face, written as well as online strategies available for healthcare providers to support communication, information provision and, to a lesser extent, (shared) decision-making in palliative care for patients with limited health literacy. Strategies that were mentioned several times were: teach-back method, jargon-free communication and developing and testing materials with patients with limited health literacy, among others. Two supporting tools were found: patient decision aids and question prompt lists.

CONCLUSIONS

To guarantee high quality person-centred palliative care, the role of health literacy should be considered. Although there are several strategies available for healthcare providers to facilitate such communication, only few tools are offered. Moreover, the strategies and tools appear not specific for the setting of palliative care, but seem helpful for providers to support the communication, information provision and decision making with patients with limited health literacy in general. Future research should focus on which strategies or tools are (most) effective in supporting patients with limited health literacy in palliative care, and the implementation of these strategies and tools in practice.

Understanding the Barriers to Introducing Early Palliative Care for Patients with Advanced Cancer: A Qualitative Study

Background: Palliative care is often underutilized or initiated late in the course of life-threatening illness. Randomized clinical Early Palliative Care (EPC) trials provide an opportunity for changing oncologists' perceptions of palliative care and their attitudes to referring patients to palliative care services. Aim: To describe French oncologists' perceptions of EPC and their effects on referral practices before a clinical EPC trial was launched. Design: A qualitative study involving semistructured face-to-face interviews. The data were analyzed using the Grounded Theory coding method. Setting/Participants: Thirteen oncologists and 19 palliative care specialists (PCSs) working at 10 hospitals all over France were interviewed. Most of them were involved in clinical EPC trials. Results: The findings suggest that referral to PCSs shortly after the diagnosis of advanced cancer increases the terminological barriers, induces avoidance patterns, and makes early disclosure of poor prognosis harder for oncologists. This situation is attributable to the widespread idea that palliative care means terminal care. In addition, the fact that the EPC concept is poorly understood increases the confusion between EPC and supportive care. Conclusion: Defining the EPC concept more clearly and explaining to health professionals and patients what EPC consists of and what role it is intended to play, and the potential benefits of palliative care services could help to overcome the wording barriers rooted in the traditional picture of palliative care. In addition, training French oncologists how to disclose "bad news" could help them cope with the emotional issues involved in referring patients to specialized palliative care.

Examining the transitions between living and dying roles at end-of-life

Improvements in the diagnosis and disclosure of dying mean that nowadays dying people typically live with an awareness of their status for longer than they have previously. However, little is known regarding how transitions between living and dying roles occur during this time. In this grounded theory study, we investigated role transitions at end-of-life. We found that dying people periodically foreground and background living and dying selfhoods, focus on living day-by-day and goal-by-goal and reframe dying roles with an orientation to living. We argue that with better understanding of role transitions at end-of-life more compassionate and responsive care becomes possible.

Agreement between patients' and radiation oncologists' cancer diagnosis and prognosis perceptions: A cross sectional study in Japan

This study assessed agreement between radiation oncologist- and cancer patient-reported perceptions about cancer diagnosis, time since diagnosis, treatment purpose, and whether life expectancy had been discussed; and described preferences for prognosis discussions. Adult cancer patients receiving radiotherapy at a Japanese hospital were invited to complete a touchscreen tablet survey. Patient survey responses were linked and comparisons made with a survey completed by their radiation oncologist. Among 146 cancer patient-oncologist dyads, there was almost perfect agreement on cancer diagnosis (ĸ = 0.88, 95% CI: 0.82–0.94), substantial agreement on time since diagnosis (ĸ = 0.70, 95% CI: 0.57–0.83) and moderate agreement on whether treatment goal was curative or palliative (ĸ = 0.44, 95% CI: 0.28–0.57; all p’s < 0.0001). Agreement about whether a life expectancy discussion had occurred was less than expected by chance (κ = -0.06, p = 0.9). Radiation oncologists reported that they had spoken to over two thirds of patients about this, whilst less than one third of patients stated that this discussion had occurred with their radiation oncologist. Over half of the patients who had not discussed life expectancy wanted to. Patients had variable preferences for whether they (80%), their radiation oncologist (78%) or their partner/family (52%) should decide whether they discuss their life expectancy. Although patient self-reported information about diagnosis and time since diagnosis appears to be reasonably accurate (compared with clinician-reported information), limitations of self-reported data about prognostic discussions were highlighted by poor agreement between patient- and clinician-reported information about whether prognostic discussions have occurred. Additional support is needed to improve prognosis communication and understanding in radiation oncology settings.

Truth-telling to a cancer patient about poor prognosis: A clinical case report in cross-cultural communication

Ethical principles are not mere abstract concepts of academic interest. They have to be applied by care providers in the real world under complex, challenging and often perplexing conditions. This paper discusses, through the case of an ethnic minority patient with metastasis of bowel cancer, the ethical dilemma of truth-telling and withholding information about poor prognosis. It highlights the complexities of applying ethical principles in a different cultural milieu, reflecting on different ethical frameworks and justifications. The paper also discusses some of the wider implications of the practices, issues and controversies of truth-telling about prognosis in cross-cultural communication relevant to clinical practice.

How should we talk about palliative care, death and dying? A qualitative study exploring perspectives from caregivers of people with advanced cancer

BACKGROUND

Health professionals commonly underestimate caregiver needs for information about palliative care, death and dying and may feel poorly prepared to discuss these issues. Few studies have sought caregiver perspectives of these communication practices.

AIM

To explore caregiver perspectives on communication about death, dying and the introduction to palliative care, with a view towards a series of caregiver-informed recommendations for use in clinical practice.

DESIGN

Cross-sectional, prospective, exploratory qualitative design, involving narrative-style interviews and underpinned by an interpretative phenomenological framework.

SETTING/PARTICIPANTS

Purposively sampled, English-speaking, adult caregivers of people with advanced cancer ( n = 25) recruited from cancer services at a tertiary metropolitan hospital in Melbourne, Australia.

RESULTS

Caregivers reported wanting routinely available written resources about palliative care, supplemented by conversations that are ideally staged overtime. Education about the tasks of palliative care should be separated from referral process, allowing time for gradual adjustment, and re-visiting discussion to enable patients and families to take some control in the process of transition. Once death is imminent, carers wanted health professionals to clarify how much they want to know about the dying process; provide spoken acknowledgement when death is close; include the words 'death' and 'dying'; use direct language, avoiding euphemisms; and communicate about death with patient present.

CONCLUSION

This study is among the first to directly address caregiver perspectives of communication about death, dying and the introduction to palliative care. The recommendations derived from caregiver perspectives build upon existing guidelines and offer health professionals some preliminary considerations around how to undertake these important communication tasks in future.

Caregiver informational support in different patient care settings at end of life

Caregivers of the terminally ill face many complicated tasks including providing direct patient care, communicating with clinicians, and managing the logistical demands of daily activities. They require instructive information at all points in the illness process and across several settings where patients receive end-of-life care. This study examines how the setting where a patient receives end-of-life care affects caregivers' informational support needs by thematically analyzing data from caregiver interviews and clinical observations. Caregivers providing care for patients at home received informational support related to meeting patients' mobility, medication, and nutritional needs. Caregivers who provided care remotely received informational support to navigate transitions between patient care settings or long-term care arrangements, including financial considerations and insurance logistics. The findings document that interventions designed to enhance information for caregivers should account for caregiving context and that health care providers should proactively and repeatedly assess caregiver information needs related to end-of-life patient care.

The Nexus Between the Documentation of End-of-Life Wishes and Awareness of Dying: A Model for Research, Education and Care

The convergence of medical treatment that can extend life with written medical orders that make it possible to refuse such treatment brings the differential dynamics of contemporary end-of-life decision making into sharp focus. Communication between families and clinicians can be confusing, uncertain, and pressured when death is imminent. These situations create distress that ultimately influences the end-of-life experience for people who are dying and those who care for them. This article presents the analysis of the decisional dynamics that emerge from the intersection of the patient-family-provider awareness that death is near with the presence or absence of documentation of expressed wishes for end-of-life care. A heuristic analysis was conducted with data from three studies about urgent decision making at the end of life. Original study data included 395 surveys, in-depth interviews with 91 prehospital (paramedics and emergency medical technicians), and content analysis of 100 Medical Orders for Life Sustaining Treatment forms that led to the development of an overarching conceptual model of decision making. Four decisional contexts emerged from the intersection of awareness of dying and documentation of wishes: 1) Aware Documented, 2) Aware Undocumented, 3) Unaware Documented, and 4) Unaware Undocumented. This generalizable model, which is agnostic of setting, can help clinicians more astutely recognize the clinical situation when death is imminent, assess patients and caregivers, and intervene to help focus conversation and direct decision making. The model can also inform research, education, and care for people in some of the most vulnerable moments of life.

End-of-Life Caregiver Social Support Activation: The Roles of Hospice Clinicians and Professionals

Caregivers of those with life-limiting illness face many complicated tasks, including providing direct patient care, communicating with professionals, and managing the logistical demands of daily activities. To assist with caregiving responsibilities, caregivers require social support from social network members at all points in the illness process. This study analyzes themes from interviews with 61 caregivers of patients enrolled in hospice services to identify the types of support caregivers mobilize from new social network members for social support during the end-of-life care process. Themes indicate that caregivers receive accessible, immediate, caregiver-centered emotional support from hospice health care professionals, and situationally tailored, understandable informational support from other types of professionals. In addition, caregivers received overlapping emotional and informational support from hospice health care professionals. Findings enhance the understanding of how caregivers receive tailored emotional and informational support.

Current status of accurate prognostic awareness in advanced/terminally ill cancer patients: Systematic review and meta-regression analysis

BACKGROUND

No systematic meta-analysis is available on the prevalence of cancer patients' accurate prognostic awareness and differences in accurate prognostic awareness by publication year, region, assessment method, and service received.

AIM

To examine the prevalence of advanced/terminal cancer patients' accurate prognostic awareness and differences in accurate prognostic awareness by publication year, region, assessment method, and service received.

DESIGN

Systematic review and meta-analysis.

METHODS

MEDLINE, Embase, The Cochrane Library, CINAHL, and PsycINFO were systematically searched on accurate prognostic awareness in adult patients with advanced/terminal cancer (1990-2014). Pooled prevalences were calculated for accurate prognostic awareness by a random-effects model. Differences in weighted estimates of accurate prognostic awareness were compared by meta-regression.

RESULTS

In total, 34 articles were retrieved for systematic review and meta-analysis. At best, only about half of advanced/terminal cancer patients accurately understood their prognosis (49.1%; 95% confidence interval: 42.7%-55.5%; range: 5.4%-85.7%). Accurate prognostic awareness was independent of service received and publication year, but highest in Australia, followed by East Asia, North America, and southern Europe and the United Kingdom (67.7%, 60.7%, 52.8%, and 36.0%, respectively; p = 0.019). Accurate prognostic awareness was higher by clinician assessment than by patient report (63.2% vs 44.5%, p < 0.001).

CONCLUSION

Less than half of advanced/terminal cancer patients accurately understood their prognosis, with significant variations by region and assessment method. Healthcare professionals should thoroughly assess advanced/terminal cancer patients' preferences for prognostic information and engage them in prognostic discussion early in the cancer trajectory, thus facilitating their accurate prognostic awareness and the quality of end-of-life care decision-making.

[Quality of diagnosis information given to terminal cancer patients]

AIM

To determine the information that terminal cancer patients have about their diagnosis, identifying key words used, and quantifying the conspiracy of silence.

METHOD

A cross-sectional, analytical study was conducted by reviewing the hospice support team data base which contains the medical history and a semi-structured interview with terminal cancer patients in the first visit to the hospice. Demographic and socioeconomic data was collected, as well as relevant clinical information (diagnosis, prevalent symptoms, number of symptoms, patient functionality, QoL, information given, and words used).

RESULTS

Out of total of sample of 723 records, 77.87% (95% CI: 74.70-80.74) of the patients were properly informed about their diagnosis. The most used words were cancer in 26% of the patients, tumour in 51.59%, and for the remaining 10.65%, the word inflammation was used. Statistically significant differences of information were found between sexes, age, types of cancer, and hospital ward.

CONCLUSIONS

Terminal cancer patients have knowledge on their diagnosis, suggesting that the conspiracy of silence is present to a lesser extent. This knowledge is transmitted using different words and with euphemisms.

Life expectancy discussions in a multisite sample of Australian medical oncology outpatients

OBJECTIVES

The study examined: 1) the proportion of patients who received their preferred level of information about life expectancy; and 2) sociodemographic, clinical and psychological factors associated with patients' perceptions of whether they received too little, too much, or the right amount of information about life expectancy.

DESIGN

Cross-sectional survey.

SETTING

Eleven large Australian medical oncology treatment centres.

PARTICIPANTS

A total of 1431 medical oncology outpatients participated (81% consent rate). Eligible patients were approached between September 2012 and May 2014.

MAIN OUTCOME MEASURES

Patients indicated whether the information about life expectancy they received aligned with their preferences.

RESULTS

Almost one in four patients (24%) received too little information, 4% received too much, and 50% received all the information they wanted; 22% of patients neither wanted nor received information about life expectancy. Patients were more likely to receive too little information if they were not in remission (odds ratio [OR], 1.77), did not know their cancer stage at diagnosis (OR, 3.64), or were anxious (OR, 1.48) or depressed (OR, 1.48). Patients had greater odds of receiving too much information if they were younger (OR, 1.45), had more advanced cancer (OR, 2.01) or did not know their cancer stage at diagnosis (OR, 4.42).

CONCLUSIONS

That fact that 28% of cancer patients did not receive their desired level of information about life expectancy highlights the difficulties associated with discussing this sensitive topic. To ensure that life expectancy discussions correspond with patient preferences, clinicians should routinely ask patients whether they want to know this information, in what format, and at which level of detail.

Exploring Health Care Providers' Views About Initiating End-of-Life Care Communication

Numerous factors impede effective and timely end-of-life (EOL) care communication. These factors include delays in communication until patients are seriously ill and/or close to death. Gaps in patient-provider communication negatively affect advance care planning and limit referrals to palliative and hospice care. Confusion about the roles of various health care providers also limits communication, especially when providers do not coordinate care with other health care providers in various disciplines. Although providers receive education regarding EOL communication and care coordination, little is known about the roles of all health care providers, including nonphysician support staff working with physicians to discuss the possibility of dying and help patients prepare for death. This study explores the perspectives of physicians, nurses, social workers, and chaplains on engaging seriously ill patients and families in EOL care communication. Qualitative data were from 79 (medical and nonmedical) providers practicing at 2 medical centers in Central Los Angeles. Three themes that describe providers' perceptions of their roles and responsibility in talking with seriously ill patients emerged: (1) providers' roles for engaging in EOL discussions, (2) responsibility of physicians for initiating and leading discussions, and (3) need for team co-management patient care. Providers highlighted the importance of beginning discussions early by having physicians lead them, specifically due to their medical training and need to clarify medical information regarding patients' prognosis. Although physicians are a vital part of leading EOL communication, and are at the center of communication of medical information, an interdisciplinary approach that involves nurses, social workers, and chaplains could significantly improve patient care.

Nurses' role and care practices in decision-making regarding artificial ventilation in late stage pulmonary disease

BACKGROUND

Decisions regarding whether or not to institute mechanical ventilation during the later stages of chronic obstructive pulmonary disease is challenging both ethically, emotionally and medically. Caring for these patients is a multifaceted process where nurses play a crucial role. Research question and design: We have investigated how nurses experienced their own role in decision-making processes regarding mechanical ventilation in later stages of chronic obstructive pulmonary disease and how they consider the patients' role in these processes. We applied a qualitative approach, with six focus-group interviews of nurses (n = 26). Ethical considerations: The Regional Committees for Medical and Health Research Ethics approved the study. Voluntary informed consent was obtained.

FINDINGS

The nurses found themselves operating within a cure-directed treatment culture wherein they were unable to stand up for the caring values. They perceived their roles and responsibilities in decision-making processes regarding mechanical ventilation to patients as unclear and unsatisfactory. They also experienced inadequate interdisciplinary cooperation.

DISCUSSION

Lack of communication skills, the traditional hierarchical hospital culture together with operating in a medical-orientated treatment culture where caring values is rated as less important might explain the nurses' absence in participation in the decision about mechanical ventilation.

CONCLUSION

To be able to advocate for the patients' and their own right to be included in decision-making processes, nurses need an awareness of their own responsibilities. This requires personal courage, leadership who are capable of organising common interpersonal meetings and willingness on the part of the physicians to include and value the nurses' participation in decision-making processes.

How do nursing home doctors involve patients and next of kin in end-of-life decisions? A qualitative study from Norway

BACKGROUND

Ethically challenging critical events and decisions are common in nursing homes. This paper presents nursing home doctors' descriptions of how they include the patient and next of kin in end-of-life decisions.

METHODS

We performed ten focus groups with 30 nursing home doctors. Advance care planning; aspects of decisions on life-prolonging treatment, and conflict with next of kin were subject to in-depth analysis and condensation.

RESULTS

The doctors described large variations in attitudes and practices in all aspects of end-of-life decisions. In conflict situations, many doctors were more concerned about the opinion of next of kin than ensuring the patient's best interest.

CONCLUSIONS

Many end-of-life decisions appear arbitrary or influenced by factors independent of the individual patient's values and interests and are not based on systematic ethical reflections. To protect patient autonomy in nursing homes, stronger emphasis on legal and ethical knowledge among nursing home doctors is needed.

Advance Directives and Communication Skills of Prehospital Physicians Involved in the Care of Cardiovascular Patients

Advance directives (AD) were developed to respect patient autonomy. However, very few patients have AD, even in cases when major cardiovascular surgery is to follow. To understand the reasons behind the low prevalence of AD and to help decision making when patients are incompetent, it is necessary to focus on the impact of prehospital practitioners, who may contribute to an increase in AD by discussing them with patients. The purpose of this study was to investigate self-rated communication skills and the attitudes of physicians potentially involved in the care of cardiovascular patients toward AD.Self-administered questionnaires were sent to general practitioners, cardiologists, internists, and intensivists, including the Quality of Communication Score, divided into a General Communication score (QOCgen 6 items) and an End-of-life Communication score (QOCeol 7 items), as well as questions regarding opinions and practices in terms of AD.One hundred sixty-four responses were received. QOCgen (mean (±SD)): 9.0/10 (1.0); QOCeol: 7.2/10 (1.7). General practitioners most frequently start discussions about AD (74/149 [47%]) and are more prone to designate their own specialty (30/49 [61%], P < 0.0001). Overall, only 57/159 (36%) physicians designated their own specialty; 130/158 (82%) physicians ask potential cardiovascular patients if they have AD and 61/118 (52%) physicians who care for cardiovascular patients talk about AD with some of them.The characteristics of physicians who do not talk about AD with patients were those who did not personally have AD and those who work in private practices.One hundred thirty-three (83%) physicians rated the systematic mention of patients' AD in the correspondence between physicians as good, while 114 (71%) at the patients' first registration in the private practice.Prehospital physicians rated their communication skills as good, whereas end-of-life communication was rated much lower. Only half of those surveyed speak about AD with cardiovascular patients. The majority would prefer that physicians of another specialty, most frequently general practitioners, initiate conversation about AD. In order to increase prehospital AD incidence, efforts must be centered on improving practitioners' communication skills regarding death, by providing trainings to allow physicians to feel more at ease when speaking about end-of-life issues.