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van der Velden NCA, Smets EMA, van Vliet LM, Brom L, van Laarhoven HWM, Henselmans I. Effects of Prognostic Communication Strategies on Prognostic Perceptions, Treatment Decisions and End-Of-Life Anticipation in Advanced Cancer: An Experimental Study among Analogue Patients. J Pain Symptom Manage 2024; 67:478-489.e13. [PMID: 38428696 DOI: 10.1016/j.jpainsymman.2024.02.563] [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] [Received: 09/01/2023] [Revised: 02/15/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
CONTEXT Evidence-based guidance for oncologists on how to communicate prognosis is scarce. OBJECTIVES To investigate the effects of prognostic communication strategies (prognostic disclosure vs. communication of unpredictability vs. non-disclosure; standard vs. standard and best-case vs. standard, best- and worst-case survival scenarios; numerical vs. word-based estimates) on prognostic perceptions, treatment decision-making and end-of-life anticipation in advanced cancer. METHODS This experimental study used eight videos of a scripted oncological consultation, varying only in prognostic communication strategies. Cancer-naive individuals, who imagined being the depicted patient, completed surveys before and after watching one video (n = 1036). RESULTS Individuals generally perceived dying within 1 year as more likely after prognostic disclosure, compared to communication of unpredictability or non-disclosure (P < 0.001), and after numerical versus word-based estimates (P < 0.001). Individuals felt better informed about prognosis to decide about treatment after prognostic disclosure, compared to communication of unpredictability or non-disclosure (P < 0.001); after communication of unpredictability versus non-disclosure (P < 0.001); and after numerical versus word-based estimates (P = 0.017). Chemotherapy was more often favored after prognostic disclosure versus non-disclosure (P = 0.010), but less often after numerical versus word-based estimates (P < 0.001). Individuals felt more certain about the treatment decision after prognostic disclosure, compared to communication of unpredictability or non-disclosure (P < 0.001). Effects of different survival scenarios were absent. No effects on end-of-life anticipation were observed. Evidence for moderating individual characteristics was limited. CONCLUSION If and how oncologists discuss prognosis can influence how individuals perceive prognosis, which treatment they prefer, and how they feel about treatment decisions. Communicating numerical estimates may stimulate prognostic understanding and informed treatment decision-making.
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Affiliation(s)
- Naomi C A van der Velden
- Department of Medical Psychology (N.C.A.V., E.M.A.S., I.H.), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health (N.C.A.V., E.M.A.S., I.H.), Quality of Care, Amsterdam, The Netherlands; Cancer Center Amsterdam (N.C.A.V., E.M.A.S., I.H., H.W.M.L.), Cancer Treatment and Quality of Life, Amsterdam, The Netherlands.
| | - Ellen M A Smets
- Department of Medical Psychology (N.C.A.V., E.M.A.S., I.H.), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health (N.C.A.V., E.M.A.S., I.H.), Quality of Care, Amsterdam, The Netherlands; Cancer Center Amsterdam (N.C.A.V., E.M.A.S., I.H., H.W.M.L.), Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Liesbeth M van Vliet
- Department of Health, Medical and Neuropsychology (L.M.V.), University of Leiden, Leiden, The Netherlands
| | - Linda Brom
- Department of Research and Development (L.B.), Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands; Netherlands Association for Palliative Care (PZNL) (L.B.), Utrecht, The Netherlands
| | - Hanneke W M van Laarhoven
- Cancer Center Amsterdam (N.C.A.V., E.M.A.S., I.H., H.W.M.L.), Cancer Treatment and Quality of Life, Amsterdam, The Netherlands; Department of Medical Oncology (H.W.M.L.), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Inge Henselmans
- Department of Medical Psychology (N.C.A.V., E.M.A.S., I.H.), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health (N.C.A.V., E.M.A.S., I.H.), Quality of Care, Amsterdam, The Netherlands; Cancer Center Amsterdam (N.C.A.V., E.M.A.S., I.H., H.W.M.L.), Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
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Yu TH, Lu FL, Wei CJ, Wu WW. The impacts of the scope of benefits expansion on hospice care among adult decedents: a nationwide longitudinal observational study. BMC Palliat Care 2023; 22:29. [PMID: 36978057 PMCID: PMC10053103 DOI: 10.1186/s12904-023-01146-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/09/2023] [Indexed: 03/30/2023] Open
Abstract
OBJECTIVES Compared to aggressive treatment for patients at the end stage of life, hospice care might be more likely to satisfy such patients' need and benefits and improve their dignity and quality of life. Whether the reimbursement policy expansion affect the use of hospice care among various demographics characteristics and health status was unknown. Therefore, the purpose of this study was to explore the impacts of reimbursement policy expansion on hospice care use, and to investigate the effects on people with various demographics characteristics and health status. METHODS We used the 2001-2017 Taiwan NHI claims data, Death Registry, and Cancer Registry in this study, and we included people who died between 2002 and 2017. The study period was divided into 4 sub-periods. hospice care use and the initiation time of 1st hospice care use were used as dependent variables; demographic characteristics and health status were also collected. RESULTS There were 2,445,781 people who died in Taiwan during the study period. The results show that the trend of hospice care use increased over time, going steeply upward after the scope of benefits expansion, but the initiation time of 1st hospice care use did not increase after the scope of benefits expansion. The results also show that the effects of expansion varied among patients by demographic characteristics. CONCLUSION The scope of benefits expansion might induce people's needs in hospice care, but the effects varied by demographic characteristics. Understanding the reasons for the variations in all populations would be the next step for Taiwan's health authorities.
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Affiliation(s)
- Tsung-Hsien Yu
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Frank Leigh Lu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
- School of Medicine, National Taiwan University, No.1 Jen-Ai Road section 1 Taipei 100, Taipei, Taiwan
| | - Chung-Jen Wei
- Department of Public Health, Fu-Jen Catholic University, New Taipei, Taiwan
| | - Wei-Wen Wu
- School of Medicine, National Taiwan University, No.1 Jen-Ai Road section 1 Taipei 100, Taipei, Taiwan.
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan.
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
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Uyeda AM, Lee RY, Pollack LR, Paul SR, Downey L, Brumback LC, Engelberg RA, Sibley J, Lober WB, Cohen T, Torrence J, Kross EK, Curtis JR. Predictors of Documented Goals-of-Care Discussion for Hospitalized Patients With Chronic Illness. J Pain Symptom Manage 2023; 65:233-241. [PMID: 36423800 PMCID: PMC9928787 DOI: 10.1016/j.jpainsymman.2022.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 11/04/2022] [Accepted: 11/13/2022] [Indexed: 11/23/2022]
Abstract
CONTEXT Goals-of-care discussions are important for patient-centered care among hospitalized patients with serious illness. However, there are little data on the occurrence, predictors, and timing of these discussions. OBJECTIVES To examine the occurrence, predictors, and timing of electronic health record (EHR)-documented goals-of-care discussions for hospitalized patients. METHODS This retrospective cohort study used natural language processing (NLP) to examine EHR-documented goals-of-care discussions for adults with chronic life-limiting illness or age ≥80 hospitalized 2015-2019. The primary outcome was NLP-identified documentation of a goals-of-care discussion during the index hospitalization. We used multivariable logistic regression to evaluate associations with baseline characteristics. RESULTS Of 16,262 consecutive, eligible patients without missing data, 5,918 (36.4%) had a documented goals-of-care discussion during hospitalization; approximately 57% of these discussions occurred within 24 hours of admission. In multivariable analysis, documented goals-of-care discussions were more common for women (OR=1.26, 95%CI 1.18-1.36), older patients (OR=1.04 per year, 95%CI 1.03-1.04), and patients with more comorbidities (OR=1.11 per Deyo-Charlson point, 95%CI 1.10-1.13), cancer (OR=1.88, 95%CI 1.72-2.06), dementia (OR=2.60, 95%CI 2.29-2.94), higher acute illness severity (OR=1.12 per National Early Warning Score point, 95%CI 1.11-1.14), or prior advance care planning documents (OR=1.18, 95%CI 1.08-1.30). Documentation of these discussions was less common for racially or ethnically minoritized patients (OR=0.823, 95%CI 0.75-0.90). CONCLUSION Among hospitalized patients with serious illness, documented goals-of-care discussions identified by NLP were more common among patients with older age and increased burden of acute or chronic illness, and less common among racially or ethnically minoritized patients. This suggests important disparities in goals-of-care discussions.
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Affiliation(s)
- Alison M Uyeda
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Robert Y Lee
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Lauren R Pollack
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Sudiptho R Paul
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Lois Downey
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Lyndia C Brumback
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Department of Biostatistics, University of Washington (L.C.B.), Seattle, Washington, USA
| | - Ruth A Engelberg
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - James Sibley
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Department of Biomedical Informatics and Medical Education, University of Washington (J.S., W.B.L., T.C.), Seattle, Washington, USA
| | - William B Lober
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Department of Biomedical Informatics and Medical Education, University of Washington (J.S., W.B.L., T.C.), Seattle, Washington, USA; Department of Biobehavioral Nursing and Health Informatics, University of Washington (W.B.L.), Seattle, Washington, USA
| | - Trevor Cohen
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Department of Biomedical Informatics and Medical Education, University of Washington (J.S., W.B.L., T.C.), Seattle, Washington, USA
| | - Janaki Torrence
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Erin K Kross
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - J Randall Curtis
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA.
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Rohlfing AB, Kelly AE, Flint LA. Make the Call: Engaging Family as a Critical Intervention. J Gen Intern Med 2023; 38:523-524. [PMID: 36376624 PMCID: PMC9905348 DOI: 10.1007/s11606-022-07913-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Anne B. Rohlfing
- Extended Care & Palliative Medicine Service, VA Palo Alto Health Care System, Palo Alto, CA USA
- Division of Primary Care & Population Health, Stanford Medicine, Stanford, CA USA
| | - Anne E. Kelly
- Geriatrics, Palliative, and Extended Care, San Francisco VA Medical Center, San Francisco, CA USA
| | - Lynn A. Flint
- Geriatrics, Palliative, and Extended Care, San Francisco VA Medical Center, San Francisco, CA USA
- Division of Geriatrics, University of California San Francisco, San Francisco, CA USA
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Marcewicz L, Kunihiro SK, Curseen KA, Johnson K, Kavalieratos D. Application of Critical Race Theory in Palliative Care Research: A Scoping Review. J Pain Symptom Manage 2022; 63:e667-e684. [PMID: 35231591 DOI: 10.1016/j.jpainsymman.2022.02.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/13/2022] [Accepted: 02/14/2022] [Indexed: 11/29/2022]
Abstract
CONTEXT Structural racism negatively impacts individuals and populations. In the medical literature, including that of palliative care, structural racism's influence on interracial differences in outcomes remains poorly examined. Examining the contribution of structural racism to outcomes is paramount to promoting equity. OBJECTIVES We examined portrayals of race and racial differences in outcomes in the palliative care literature and created a framework using critical race theory (CRT) to aid in this examination. METHODS We reviewed the CRT literature and iteratively developed a rubric to examine when and how differences between races are described. Research articles published in The Journal of Pain and Symptom Management presenting empiric data specifically including findings about racial differences were examined independently by three reviewers using the rubric. RESULTS Fifty-seven articles met inclusion criteria. Articles that specifically described racial differences were common in the topic areas of quality (75% of articles), hospice (53%), palliative care services (40%) and spirituality/religion (40%). The top three reasons posited for racial differences were patient preference (26%), physician bias (23%), and cultural barriers (21%). Using the CRT rubric we found that 65% of articles posited that a racial difference was something that needed to be rectified, while articles rarely provided narrative (5%) or other data on perspectives of people of color (11%) to explain assumptions about differences. CONCLUSION Palliative care research frequently highlights racial differences in outcomes. Articles that examine racial differences often assume that differences need to be fixed but posit reasons for differences without the narratives of those most affected by them.
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Affiliation(s)
- Lawson Marcewicz
- Division of Palliative Medicine (L.M., S.K.K., K.A.C., D.K.), Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA; Atlanta VA Health Care System (L.M.), Decatur, Georgia, USA.
| | - Susan K Kunihiro
- Division of Palliative Medicine (L.M., S.K.K., K.A.C., D.K.), Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Kimberly A Curseen
- Division of Palliative Medicine (L.M., S.K.K., K.A.C., D.K.), Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Khaliah Johnson
- Division of Pediatric Palliative Medicine (K.J.), Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine (L.M., S.K.K., K.A.C., D.K.), Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
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Janett-Pellegri C, Eychmüller AS. 'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication? PRAXIS 2021; 110:914-924. [PMID: 34814721 DOI: 10.1024/1661-8157/a003785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
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.'
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Affiliation(s)
- Camilla Janett-Pellegri
- Service de Médicine Interne, Hôpital Cantonal Fribourg, Fribourg
- Universitäres Zentrum für Palliative Care, Inselspital, Universitätsspital Bern, Bern
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Understanding how people with Parkinson's disease and their relatives approach advance care planning. Eur Geriatr Med 2021; 13:109-117. [PMID: 34398428 DOI: 10.1007/s41999-021-00548-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Advance care planning gives individuals with capacity the option of planning for their future, and anticipating future decision-making about their treatment or care should they then lose capacity. People with Parkinson's disease (PD) may develop significant physical and cognitive problems as the disease progresses, which creates a great need for, but significant challenges to, advance care planning. As a result, we set out to explore the views of people with PD and relatives on planning for the future and advance care planning. METHODS Qualitative study with semi-structured interviews of thirty-three people with PD and their relatives in the North-East of England. RESULTS Interviewees with PD were generally not keen to engage with advance care planning in the present, in comparison to the future. Three main themes arose from the data in identifying why this may be the case: (1) 'Awareness'-which included the limited awareness on purpose of advance care planning and Parkinson's disease; (2) 'Uncertainty'-the uncertainty of living with PD and of life; and (3) 'Salience'-the complex decision-making processes that interviewees engaged in, which were highly variable. CONCLUSION The use of advance care planning in PD is influenced by its perception amongst people with PD and their relatives. Health professionals have an important role in raising the salience of health care planning.
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Suthumphong C, Tran DB, Ruiz M. Perceptions and Misperceptions of Early Palliative Care Interventions for Patients With Hematologic Malignancies Undergoing Bone Marrow Transplantation. Cureus 2021; 13:e13876. [PMID: 33868840 PMCID: PMC8043049 DOI: 10.7759/cureus.13876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hematopoietic stem cell or bone marrow transplantation (BMT) is one of the most promising and potentially curative therapeutic options available for eligible patients with hematologic malignancies (HMs) or leukemias. However, the nature and clinical course of HMs, specifically for patients undergoing BMT, are associated with significant morbidity, symptomatology, healthcare service utilization, psychosocial and end of life issues, and overall decreased quality of life. Early palliative care (PC) consultations and utilization for patients with HMs have been shown to improve patient outcomes, satisfaction, and autonomy as well as caregiver burden, shared-decision making, and holistic care management. Despite the complexity of care and complications for patients with HM undergoing BMT, early PC interventions are systematically underutilized and understudied in this population compared to patients with solid tumors or non-HMs. Herein, the authors reviewed the current literature and knowledge to assess and report the perceptions and barriers to early PC utilization in the care of patients with HMs undergoing BMT. Clinical and cultural aspects of PC perceptions as well as current PC care models and potential directions for PC implementation were reviewed to inform future research studies and clinical practice guidelines necessary for the improvement of care and quality of life for HM patients undergoing BMT.
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Affiliation(s)
- Corey Suthumphong
- Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Dan B Tran
- Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Marco Ruiz
- Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA.,Miami Cancer Institute, Baptist Health South Florida, Miami, USA
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Davies JM, Maddocks M, Chua KC, Demakakos P, Sleeman KE, Murtagh FEM. Socioeconomic position and use of hospital-based care towards the end of life: a mediation analysis using the English Longitudinal Study of Ageing. Lancet Public Health 2021; 6:e155-e163. [PMID: 33571459 PMCID: PMC7910274 DOI: 10.1016/s2468-2667(20)30292-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/26/2020] [Accepted: 12/08/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Many patients prefer to avoid hospital-based care towards the end of life, yet hospitalisation is common and more likely for people with low socioeconomic position. The reasons underlying this socioeconomic inequality are not well understood. This study investigated health, service access, and social support as potential mediating pathways between socioeconomic position and receipt of hospital-based care towards the end of life. METHODS For this observational cohort study, we included deceased participants from the nationally representative English Longitudinal Study of Ageing of people aged 50 years or older in England. We used a multiple mediation model with age-adjusted and gender-adjusted probit regression to estimate the direct effect of socioeconomic position (measured by wealth and education) on death in hospital and three or more hospital admissions in the last 2 years of life, and the indirect effects of socioeconomic position via three mediators: health and function, access to health-care services, and social support. FINDINGS 737 participants were included (314 [42·6%] female, 423 [57·4%] male), with a median age at death of 78 years (IQR 71-85). For death in hospital, higher wealth had a direct negative effect (probit coefficient -0·16, 95% CI -0·25 to -0·06), which was not mediated by any of the pathways tested. For frequent hospital admissions, health and function mediated the effect of wealth (-0·04, -0·08 to -0·01), accounting for 34·6% of the total negative effect of higher wealth (-0·13, -0·23 to -0·02). Higher wealth was associated with better health and function (0·25, 0·18 to 0·33). Education was associated with the outcomes only indirectly via wealth. INTERPRETATION Our findings suggest that worse health and function could partly explain why people with lower wealth have more hospital admissions, highlighting the importance of socioeconomically driven health differences in explaining patterns of hospital use towards the end of life. The findings should raise awareness about the related risk factors of low wealth and worse health for patients approaching the end of life, and strengthen calls for resource allocation to be made on the basis of health need and socioeconomic profile. FUNDING Dunhill Medical Trust Fellowship Grant (RTF74/0116).
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Affiliation(s)
- Joanna M Davies
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Kia-Chong Chua
- Centre for Implementation Science, Health Service & Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Panayotes Demakakos
- Department of Epidemiology & Public Health, University College London, London, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Fliss E M Murtagh
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK; Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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10
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Maxwell CA, Rothman R, Wolever R, Simmons S, Dietrich MS, Miller R, Patel M, Karlekar MB, Ridner S. Development and testing of a frailty-focused communication (FCOM) aid for older adults. Geriatr Nurs 2020; 41:936-941. [PMID: 32709372 PMCID: PMC7738367 DOI: 10.1016/j.gerinurse.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/03/2020] [Accepted: 07/07/2020] [Indexed: 01/16/2023]
Abstract
The concept of frailty as it pertains to aging, health and well-being is poorly understood by older adults and the public-at-large. We developed an aging and frailty education tool designed to improve layperson understanding of frailty and promote behavior change to prevent and/or delay frailty. We subsequently tested the education tool among adults who attended education sessions at 16 community sites. Specific aims were to: 1) determine acceptability (likeability, understandability) of content, and 2) assess the likelihood of behavior change after exposure to education tool content. Results: Over 90% of participants "liked" or "loved" the content and found it understandable. Eighty-five percent of participants indicated that the content triggered a desire to "probably" or "definitely" change behavior. The desire to change was particularly motivated by information about aging, frailty and energy production. Eight focus areas for proactive planning were rated as important or extremely important by over 90% of participants.
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Affiliation(s)
- Cathy A Maxwell
- Vanderbilt University School of Nursing (VUSN), 461 21st Ave. South, Godchaux Hall 420, Nashville 37240, TN, United States.
| | - Russell Rothman
- Vanderbilt University Medical Center (VUMC), Nashville, TN, United States.
| | - Ruth Wolever
- Vanderbilt University Medical Center (VUMC), Nashville, TN, United States.
| | - Sandra Simmons
- Vanderbilt University Medical Center (VUMC), Nashville, TN, United States.
| | - Mary S Dietrich
- Vanderbilt University School of Nursing (VUSN), 461 21st Ave. South, Godchaux Hall 420, Nashville 37240, TN, United States.
| | - Richard Miller
- Vanderbilt University Medical Center (VUMC), Nashville, TN, United States.
| | - Mayur Patel
- Vanderbilt University Medical Center (VUMC), Nashville, TN, United States.
| | - Mohana B Karlekar
- Vanderbilt University Medical Center (VUMC), Nashville, TN, United States.
| | - Sheila Ridner
- Vanderbilt University School of Nursing (VUSN), 461 21st Ave. South, Godchaux Hall 420, Nashville 37240, TN, United States.
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11
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Maxwell CA, Mixon AS, Conner E, Phillippi JC. Receptivity of Hospitalized Older Adults and Family Caregivers to Prognostic Information about Aging, Injury, and Frailty: A Qualitative Study. Int J Nurs Stud 2020; 109:103602. [PMID: 32534291 DOI: 10.1016/j.ijnurstu.2020.103602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/20/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Frailty is the leading prognosticator for poor outcomes and palliative care among older adults. Delivery of negative prognostic information entails potentially difficult conversations about decline and death. OBJECTIVE The study aims were to: 1) examine hospitalized older adults' and family caregivers' receptivity to general (vs. individualized) prognostic information about frailty, injury, and one-year outcomes; and 2) determine information needs based on prognostic information. DESIGN Provision of general prognostic information followed by semi-structured interview questions. We deductively analyzed qualitative data within the context of problematic integration theory. SETTING An academic medical center in the Southeast region of the U.S. PARTICIPANTS Purposive sampling was utilized to obtain a distribution of patients across the frailty continuum (non-frail [N=10], pre-frail [N=9], frail [9=6]). Twenty-five older adults (≥ age 65) hospitalized for a primary injury (e.g. fall) and 15 family caregivers of hospitalized patients were enrolled. METHODS Hospitalized older patients and family caregivers were shown prognostic information about one-year outcomes of injured older adults in the form of simple pictographs. Semi-structured interview questions were administered immediately afterwards. The interviews were audio-recorded, transcribed, and analyzed using qualitative content analysis. Demographic and medical information data were used to contextualize the responses during analysis. RESULTS Overall, participants (patients [56%], caregivers [73%]) were open to receiving prognostic information. A small number of family caregivers (N=3) expressed reservations about the frankness of the information and suggested delivery through a softer approach or not at all. Qualitative data was coded using categories and constructs of problematic integration theory. Four codes (personalizing the evidence, vivid understanding, downhill spiral, realities of aging) reflected probabilistic and evaluative orientation categories of problematic integration theory. One code (fatalism vs. hope) represented manifestations of ambivalence and ambiguity in the theory; and another code (exceptionalism) represented divergence and impossibility. Two codes (role of thought processes, importance of faith) reflected forms of resolutions as described in problematic integration theory. Information needs based on prognostic information revealed four additional codes: give it to me straight, what can I do? what can I expect? and how can I prevent decline? A consistently reported desire of both patients and caregivers was for honesty and hope from providers. CONCLUSION This study supports the use of general prognostic information in conversations about aging, injury, frailty and patient outcomes. Incorporating prognostic information into communication aids can facilitate shared decision making before end-of-life is imminent.
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Affiliation(s)
- Cathy A Maxwell
- Vanderbilt University School of Nursing, 461 21st Ave. South, Nashville, TN 37240.
| | - Amanda S Mixon
- Section of Hospital Medicine, Vanderbilt University Medical Center and Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System.
| | - Elizabeth Conner
- University of Tennessee Health Science Center, College of Medicine, 910 Madison Ave. Suite 1031, Memphis, TN 38163.
| | - Julia C Phillippi
- Vanderbilt University School of Nursing, 461 21st Ave. South, Nashville, TN 37240.
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The Effect of Prognostic Communication on Patient Outcomes in Palliative Cancer Care: a Systematic Review. Curr Treat Options Oncol 2020; 21:40. [PMID: 32328821 PMCID: PMC7181418 DOI: 10.1007/s11864-020-00742-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND While prognostic information is considered important for treatment decision-making, physicians struggle to communicate prognosis to advanced cancer patients. This systematic review aimed to offer up-to-date, evidence-based guidance on prognostic communication in palliative oncology. METHODS PubMed and PsycInfo were searched until September 2019 for literature on the association between prognostic disclosure (strategies) and patient outcomes in palliative cancer care, and its moderators. Methodological quality was reported. RESULTS Eighteen studies were included. Concerning prognostic disclosure, results revealed a positive association with patients' prognostic awareness. Findings showed no or positive associations between prognostic disclosure and the physician-patient relationship or the discussion of care preferences. Evidence for an association with the documentation of care preferences or physical outcomes was lacking. Findings on the emotional consequences of prognostic disclosure were multifaceted. Concerning disclosure strategies, affective communication seemingly reduced patients' physiological arousal and improved perceived physician's support. Affective and explicit communication showed no or beneficial effects on patients' psychological well-being and satisfaction. Communicating multiple survival scenarios improved prognostic understanding. Physicians displaying expertise, positivity and collaboration fostered hope. Evidence on demographic, clinical and personality factors moderating the effect of prognostic communication was weak. CONCLUSION If preferred by patients, physicians could disclose prognosis using sensible strategies. The combination of explicit and affective communication, multiple survival scenarios and expert, positive, collaborative behaviour likely benefits most patients. Still, more evidence is needed, and tailoring communication to individual patients is warranted. IMPLICATIONS Future research should examine the effect of prognostic communication on psychological well-being over time and treatment decision-making, and focus on individualising care.
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13
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Vlckova K, Tuckova A, Polakova K, Loucka M. Factors associated with prognostic awareness in patients with cancer: A systematic review. Psychooncology 2020; 29:990-1003. [DOI: 10.1002/pon.5385] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Karolina Vlckova
- Center for Palliative Care Prague Czech Republic
- First Faculty of MedicineCharles University Prague Czech Republic
| | - Anna Tuckova
- Center for Palliative Care Prague Czech Republic
- Faculty of Social SciencesCharles University Prague Czech Republic
| | | | - Martin Loucka
- Center for Palliative Care Prague Czech Republic
- Third Faculty of MedicineCharles University Prague Czech Republic
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Gray TF, Temel JS, El-Jawahri A. Illness and prognostic understanding in patients with hematologic malignancies. Blood Rev 2020; 45:100692. [PMID: 32284227 DOI: 10.1016/j.blre.2020.100692] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/04/2020] [Accepted: 04/02/2020] [Indexed: 12/25/2022]
Abstract
It is critical for patients with hematologic malignancies to have an accurate understanding of their illness and prognosis to make informed treatment decisions. Illness and prognostic understanding have primarily been studied in patients with solid tumors, however, data in patients with hematologic malignancies are rapidly growing. Patients with hematologic malignancies often face a unique and unpredictable illness trajectory with the possibility of cure persisting even in relapsed and refractory settings. These patients often require intensive therapies such as high-dose chemotherapy, hematopoietic stem cell transplantation (HCT), or CAR T-cell therapy, which carry with them significant risk of morbidity, mortality, and prognostic uncertainty. In this review article, we first described the current literature on illness and prognostic understanding in patients with hematologic malignancies including 1) patients' varying desire for prognostic information; (2) patients' prognostic misperceptions, (3) the association between patients' prognostic understanding and their psychological outcomes; and (4) barriers to prognostic understanding. Next, we examined insights gained from the literature about illness and prognostic understanding in patients with solid tumors to guide our understanding of the research gaps in hematologic malignancies. Future studies are needed to better delineate the longitudinal relationship between prognostic understanding, psychological distress, and coping in patients with hematologic malignancies. Strategies such as communicating effectively about prognosis, cultivating adaptive coping in the face of a terminal prognosis, and integrating specialty palliative care for patients with hematologic malignancies have the potential to improve patients' prognostic understanding and their quality of life and care.
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Affiliation(s)
- Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jennifer S Temel
- Massachusetts General Hospital Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Areej El-Jawahri
- Massachusetts General Hospital Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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15
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Halpern SD, Small DS, Troxel AB, Cooney E, Bayes B, Chowdhury M, Tomko HE, Angus DC, Arnold RM, Loewenstein G, Volpp KG, White DB, Bryce CL. Effect of Default Options in Advance Directives on Hospital-Free Days and Care Choices Among Seriously Ill Patients: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e201742. [PMID: 32227179 PMCID: PMC7315782 DOI: 10.1001/jamanetworkopen.2020.1742] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE There is limited evidence regarding how patients make choices in advance directives (ADs) or whether these choices influence subsequent care. OBJECTIVE To examine whether default options in ADs influence care choices and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial included 515 patients who met criteria for having serious illness and agreed to participate. Patients were enrolled at 20 outpatient clinics affiliated with the University of Pennsylvania Health System and the University of Pittsburgh Medical Center from February 2014 to April 2016 and had a median follow-up of 18 months. Data analysis was conducted from November 2018 to April 2019. INTERVENTIONS Patients were randomly assigned to complete 1 of the 3 following ADs: (1) a comfort-promoting plan of care and nonreceipt of potentially life-sustaining therapies were selected by default (comfort AD), (2) a life-extending plan of care and receipt of potentially life-sustaining therapies were selected by default (life-extending AD), or (3) no choices were preselected (standard AD). MAIN OUTCOMES AND MEASURES This trial was powered to rule out a reduction in hospital-free days in the intervention groups. Secondary outcomes included choices in ADs for an overall comfort-oriented approach to care, choices to forgo 4 forms of life support, patients' quality of life, decision conflict, place of death, admissions to hospitals and intensive care units, and costs of inpatient care. RESULTS Among 515 patients randomized, 10 withdrew consent and 13 were later found to be ineligible, leaving 492 (95.5%) in the modified intention-to-treat (mITT) sample (median [interquartile range] age, 63 [56-70] years; 279 [56.7%] men; 122 [24.8%] black; 363 [73.8%] with cancer). Of these, 264 (53.7%) returned legally valid ADs and were debriefed about their assigned intervention. Among these, patients completing comfort ADs were more likely to choose comfort care (54 of 85 [63.5%]) than those returning standard ADs (45 of 91 [49.5%]) or life-extending ADs (33 of 88 [37.5%]) (P = .001). Among 492 patients in the mITT sample, 57 of 168 patients [33.9%] who completed the comfort AD, 47 of 165 patients [28.5%] who completed the standard AD, and 35 of 159 patients [22.0%] who completed the life-extending AD chose comfort care (P = .02), with patients not returning ADs coded as not selecting comfort care. In mITT analyses, median (interquartile range) hospital-free days among 168 patients assigned to comfort ADs and 159 patients assigned to life-extending default ADs were each noninferior to those among 165 patients assigned to standard ADs (standard AD: 486 [306-717] days; comfort AD: 554 [296-833] days; rate ratio, 1.05; 95% CI, 0.90-1.23; P < .001; life-extending AD: 550 [325-783] days; rate ratio, 1.03; 95% CI, 0.88-1.20; P < .001). There were no differences among groups in other secondary outcomes. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, default options in ADs altered the choices seriously ill patients made regarding their future care without changing clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02017548.
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Affiliation(s)
- Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
| | - Dylan S Small
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Statistics Department, the Wharton School, the University of Pennsylvania, Philadelphia
| | - Andrea B Troxel
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Division of Biostatistics, New York University School of Medicine, New York
- Department of Population Health, New York University School of Medicine, New York
| | - Elizabeth Cooney
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
| | - Brian Bayes
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
| | - Heather E Tomko
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Institute for Doctor-Patient Communication, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Palliative and Supportive Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - George Loewenstein
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Carnegie Mellon University, Department of Social and Decision Sciences, Pittsburgh, Pennsylvania
| | - Kevin G Volpp
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- The Wharton School, Health Care Management Department, the University of Pennsylvania, Philadelphia
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Program of Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Cindy L Bryce
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Ermers DJM, van Bussel KJH, Perry M, Engels Y, Schers HJ. Advance care planning for patients with cancer in the palliative phase in Dutch general practices. Fam Pract 2019; 36:587-593. [PMID: 30535044 DOI: 10.1093/fampra/cmy124] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is a crucial element of palliative care. It improves the quality of end-of-life care and reduces aggressive and needless life-prolonging medical interventions. However, little is known about its application in daily practice. This study aims to examine the application of ACP for patients with cancer in general practice. METHODS We performed a retrospective cohort study in 11 general practices in the Netherlands. Electronic patient records (EPRs) of deceased patients with colorectal or lung cancer were analysed. Data on ACP documentation, correspondence between medical specialist and GP, and health care use in the last year of life were extracted. RESULTS Records of 163 deceased patients were analysed. In 74% of the records, one or more ACP items were registered. GPs especially documented patients' preferences for euthanasia (58%), palliative sedation (46%) and preferred place of death (26%). Per patient, GPs received on average six letters from medical specialists. These letters mainly contained information regarding medical treatment and rarely ACP items. In the last year of life, patients contacted the GP over 30 times, and 51% visited the emergency department at least once, of whom 54% in the last month. CONCLUSIONS Registration of ACP items in GPs' EPRs appeared to be limited. ACP elements were rarely subject of communication between primary and secondary care, which may impact the continuity of patient care during the last year of life. More emphasis on registration of ACP items and better exchange of information regarding patients' preferences are needed.
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Affiliation(s)
- Daisy J M Ermers
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Karin J H van Bussel
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marieke Perry
- Department of Geriatrics, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Yvonne Engels
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Henk J Schers
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands
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Chen CH, Chen JS, Wen FH, Chang WC, Chou WC, Hsieh CH, Hou MM, Tang ST. An Individualized, Interactive Intervention Promotes Terminally Ill Cancer Patients' Prognostic Awareness and Reduces Cardiopulmonary Resuscitation Received in the Last Month of Life: Secondary Analysis of a Randomized Clinical Trial. J Pain Symptom Manage 2019; 57:705-714.e7. [PMID: 30639758 DOI: 10.1016/j.jpainsymman.2019.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 01/01/2019] [Accepted: 01/02/2019] [Indexed: 02/07/2023]
Abstract
CONTEXT/OBJECTIVE Half of advanced cancer patients do not have accurate prognostic awareness (PA). However, few randomized clinical trials (RCTs) have focused on facilitating patients' PA to reduce their life-sustaining treatments at end of life (EOL). To address these issues, we conducted a double-blinded RCT on terminally ill cancer patients. METHODS Experimental-arm participants received an individualized, interactive intervention tailored to their readiness for advanced care planning and prognostic information. Control-arm participants received a symptom-management educational treatment. Effectiveness of our intervention in facilitating accurate PA and reducing life-sustaining treatments received, two secondary RCT outcomes, was evaluated by intention-to-treat analysis using multivariate logistic regression. RESULTS Participants (N = 460) were randomly assigned 1:1 to experimental and control arms, each with 215 participants in the final sample. Referring to 151-180 days before death, experimental-arm participants had significantly higher odds of accurate PA than control-arm participants 61-90, 91-120, and 121-150 days before death (adjusted odds ratio [95% CI]: 2.04 [1.16-3.61], 1.94 [1.09-3.45], and 1.93 [1.16-3.21], respectively), but not one to 60 days before death. Experimental-arm participants with accurate PA were significantly less likely than control-arm participants without accurate PA to receive cardiopulmonary resuscitation (CPR) (0.16 [0.03-0.73]), but not less likely to receive intensive care unit care and mechanical ventilation in their last month. CONCLUSION Our intervention facilitated cancer patients' accurate PA early in their dying trajectory, reducing the risk of receiving CPR in the last month. Health care professionals should cultivate cancer patients' accurate PA early in the terminal-illness trajectory to allow them sufficient time to make informed EOL-care decisions to reduce CPR at EOL.
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Affiliation(s)
- Chen Hsiu Chen
- College of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Ming-Mo Hou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan.
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Rogers J, Goldsmith C, Sinclair C, Auret K. The advance care planning nurse facilitator: describing the role and identifying factors associated with successful implementation. Aust J Prim Health 2019; 25:564-569. [DOI: 10.1071/py19010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 07/11/2019] [Indexed: 11/23/2022]
Abstract
Advance care planning (ACP) has been shown to improve end-of-life care, yet uptake remains limited. Interventions aimed at increasing ACP uptake have often used a ‘specialist ACP facilitator’ model. The present qualitative study appraised the components of an ACP facilitator intervention comprising nurse-led patient screening and ACP discussions, as well as factors associated with the successful implementation of this model in primary care and acute hospital settings across rural and metropolitan Western Australia. Semistructured interviews were undertaken with 17 health professionals who were directly or indirectly involved in the facilitator ACP intervention among patients with severe respiratory disease. Additional process data (nurse facilitator role description, agreements with participating sites) were used to describe the nurse facilitator role. The interview data identified factors associated with successful implementation, including patient factors, health professional factors, ACP facilitator characteristics and the optimal settings for the intervention. The primary care setting was seen as most appropriate, and time limitations were a key consideration. Factors associated with successful implementation included trusting relationships between the nurse facilitator and referring doctor, as well as opportunities for meaningful encounters with patients. This study suggests a model of ACP nurse facilitation based in primary care may be an acceptable and effective method of increasing ACP uptake.
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Maxwell CA, Patel MB, Suarez-Rodriguez LC, Miller RS. Frailty and Prognostication in Geriatric Surgery and Trauma. Clin Geriatr Med 2018; 35:13-26. [PMID: 30390979 DOI: 10.1016/j.cger.2018.08.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Frailty is a predominant predictor of poor outcomes in older populations. This article presents a review of the concept of frailty and its role for prognostication among geriatric trauma and surgery patients. We discuss models of frailty defined in the scientific literature, emphasizing that frailty is a process of biologic aging. We emphasize the importance of screening, assessment, and inclusion of frailty indices for the development and use of prognostication instruments/tools in the population of interest. Finally, we discuss best practices for the delivery of prognostic information in acute care settings and specific recommendations for trauma and surgical care settings.
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Affiliation(s)
- Cathy A Maxwell
- Vanderbilt University School of Nursing, 461 21st Avenue South, GH 420, Nashville, TN 37240, USA.
| | - Mayur B Patel
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, 1211 21st Avenue South, Nashville, TN 37212-1750, USA
| | - Luis C Suarez-Rodriguez
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, 1211 21st Avenue South, Nashville, TN 37212-1750, USA
| | - Richard S Miller
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, 1211 21st Avenue South, Nashville, TN 37212-1750, USA
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Cain CL, Surbone A, Elk R, Kagawa-Singer M. Culture and Palliative Care: Preferences, Communication, Meaning, and Mutual Decision Making. J Pain Symptom Manage 2018; 55:1408-1419. [PMID: 29366913 DOI: 10.1016/j.jpainsymman.2018.01.007] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 01/11/2023]
Abstract
Palliative care is gaining acceptance across the world. However, even when palliative care resources exist, both the delivery and distribution of services too often are neither equitably nor acceptably provided to diverse population groups. The goal of this study was to illustrate tensions in the delivery of palliative care for diverse patient populations to help clinicians to improve care for all. We begin by defining and differentiating culture, race, and ethnicity, so that these terms-often used interchangeably-are not conflated and are more effectively used in caring for diverse populations. We then present examples from an integrative literature review of recent research on culture and palliative care to illustrate both how and why varied responses to pain and suffering occur in different patterns, focusing on four areas of palliative care: the formation of care preferences, communication patterns, different meanings of suffering, and decision-making processes about care. For each area, we provide international and multiethnic examples of variations that emphasize the need for personalization of care and the avoidance of stereotyping beliefs and practices without considering individual circumstances and life histories. We conclude with recommendations for improving palliative care research and practice with cultural perspectives, emphasizing the need to work in partnerships with patients, their family members, and communities to identify and negotiate culturally meaningful care, promote quality of life, and ensure the highest quality palliative care for all, both domestically and internationally.
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Affiliation(s)
- Cindy L Cain
- Department of Health Policy and Management, University of California-Los Angeles, Los Angeles, California.
| | - Antonella Surbone
- Department of Medicine, Division of Haematology and Medical Oncology, New York University Medical School, New York, New York
| | - Ronit Elk
- College of Nursing, University of South Carolina, Columbia, South Carolina
| | - Marjorie Kagawa-Singer
- Department of Community Health Sciences and Asian American Studies Center, University of California-Los Angeles, Los Angeles, California
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Tang ST, Chen CH, Wen FH, Chen JS, Chang WC, Hsieh CH, Chou WC, Hou MM. Accurate Prognostic Awareness Facilitates, Whereas Better Quality of Life and More Anxiety Symptoms Hinder End-of-Life Care Discussions: A Longitudinal Survey Study in Terminally Ill Cancer Patients' Last Six Months of Life. J Pain Symptom Manage 2018; 55:1068-1076. [PMID: 29289656 DOI: 10.1016/j.jpainsymman.2017.12.485] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 12/20/2017] [Accepted: 12/20/2017] [Indexed: 11/17/2022]
Abstract
CONTEXT Terminally ill cancer patients do not engage in end-of-life (EOL) care discussions or do so only when death is imminent, despite guidelines for EOL care discussions early in their disease trajectory. Most studies on patient-reported EOL care discussions are cross sectional without exploring the evolution of EOL care discussions as death approaches. Cross-sectional studies cannot determine the direction of association between EOL care discussions and patients' prognostic awareness, psychological well-being, and quality of life (QOL). OBJECTIVES/METHODS We examined the evolution and associations of accurate prognostic awareness, functional dependence, physical and psychological symptom distress, and QOL with patient-physician EOL care discussions among 256 terminally ill cancer patients in their last six months by hierarchical generalized linear modeling with logistic regression and by arranging time-varying modifiable variables and EOL care discussions in a distinct time sequence. RESULTS The prevalence of physician-patient EOL care discussions increased as death approached (9.2%, 11.8%, and 18.3% for 91-180, 31-90, and 1-30 days before death, respectively) but only reached significance in the last month. Accurate prognostic awareness facilitated subsequent physician-patient EOL care discussions, whereas better patient-reported QOL and more anxiety symptoms hindered such discussions. The likelihood of EOL care discussions was not associated with levels of physical symptom distress, functional dependence, or depressive symptoms. CONCLUSION Physician-patient EOL care discussions for terminally ill Taiwanese cancer patients remain uncommon even when death approaches. Physicians should facilitate EOL care discussions by cultivating patients' accurate prognostic awareness early in their cancer trajectory when they are physically and psychologically competent, with better QOL, thus promoting informed and value-based EOL care decision making.
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Affiliation(s)
- Siew Tzuh Tang
- Chang Gung University, School of Nursing, Kwei-Shan, Tao-Yuan, Taiwan, ROC; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, ROC; Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, ROC.
| | - Chen Hsiu Chen
- Department of Nursing, University of Kang Ning, Tainan, Taiwan, ROC
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, ROC
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, ROC; Chang Gung University College of Medicine, Taoyuan, Taiwan, ROC
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, ROC; Chang Gung University College of Medicine, Taoyuan, Taiwan, ROC
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, ROC; Chang Gung University College of Medicine, Taoyuan, Taiwan, ROC
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, ROC; Chang Gung University College of Medicine, Taoyuan, Taiwan, ROC
| | - Ming-Mo Hou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, ROC; Chang Gung University College of Medicine, Taoyuan, Taiwan, ROC
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Preferences for Aggressive End-of-life Care and Their Determinants Among Taiwanese Terminally Ill Cancer Patients. Cancer Nurs 2016; 38:E9-E18. [PMID: 24915466 DOI: 10.1097/ncc.0000000000000155] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Studies on factors influencing preferences for aggressive end-of-life (EOL) care have focused predominantly on preferred goals of EOL and seldom comprehensively incorporate patients' predisposing, enabling, and need factors into their analyses. OBJECTIVE The aim of this study was to investigate the determinants of preferences for a wide range of aggressive EOL care from the aforementioned factors. METHODS A cross-sectional survey was conducted using a convenience sample of 2329 terminally ill cancer patients recruited from 23 hospitals throughout Taiwan. RESULTS Among these Taiwanese terminally ill cancer patients, 8.2% preferred prolonging life as their goal for EOL care. When combining those who wanted and those who were undecided as wanting that specific treatment, 27.9% preferred cardiopulmonary resuscitation when their life was in danger, and 36.0%, 27.3%, 24.3%, and 26.7% preferred to receive care at intensive care unit, cardiac massage, intubation, and mechanical ventilation support, respectively. Those at risk of preferring aggressive EOL care were men, younger than 45 years, married, diagnosed within 6 months, and with comorbidity and their physician had not accurately disclosed their prognosis or discussed EOL care issues to/with them. CONCLUSIONS Few Taiwanese terminally ill cancer patients preferred to prolong life as their goal for EOL care, cardiopulmonary resuscitation when their life was in danger, and life-sustaining treatments at EOL. Preferences for aggressive EOL care are determined by patients' predisposing, enabling, and need factors. IMPLICATIONS FOR PRACTICE Terminally ill cancer patients at risk of preferring aggressive EOL care should receive interventions to help them appropriately weigh the burdens and benefits of such aggressive treatments.
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Fredricks TR, Nakazawa M. Perceptions of physicians in civilian medical practice on veterans' issues related to health care. J Osteopath Med 2016; 115:360-8. [PMID: 26024329 DOI: 10.7556/jaoa.2015.076] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
CONTEXT The percentage of total US residents in the military is lower than ever before. Many civilians, including civilian physicians, have little knowledge of US military actions or the day-to-day experiences and working environments of veterans. OBJECTIVE To assess civilian physician knowledge of veterans' issues using a survey. METHODS A 10-item survey was distributed to physicians at 2 primary care-focused medical conferences in Ohio to determine self-reported levels of comfort and familiarity with veteran-oriented topics. RESULTS Of 350 surveys that were distributed, 141 surveys were returned. Of the 141 respondents, 101 practiced primary care, 19 practiced internal medicine, 16 practiced other specialties, and 5 did not report a specialty affiliation and were excluded from final analysis. A single respondent reported pediatrics as a specialty but indicated "not applicable" for all answers. This individual was excluded from final analysis. Overall, physicians reported feeling moderately comfortable with military terminology and uncomfortable with the diagnosis and management of traumatic brain injury. More than half of the respondents indicated that they were not comfortable discussing health-related exposures and associated risks that veterans might experience and that they were unfamiliar with referral and consultation services for veterans. The data collected had a high degree of reliability (Cronbach α=0.88). Respondents of both primary care and internal medicine specialties scored statistically significantly higher than the other respondents in questions on veterans' medical conditions, military terminology, and military health risks (P<.05), although these 2 groups scored similarly (P>.05). Specialty orientation did not affect responses for questions on other topics (P>.05). CONCLUSION The data indicated an overall moderate level of familiarity among civilian physicians with veterans' issues. The results did not reveal an overall high level of comfort with any issues included in the survey. More research is needed to determine reasons behind the findings and methods to improve civilian physician comfort with various veterans' issues.
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McDonald JC, du Manoir JM, Kevork N, Le LW, Zimmermann C. Advance directives in patients with advanced cancer receiving active treatment: attitudes, prevalence, and barriers. Support Care Cancer 2016; 25:523-531. [DOI: 10.1007/s00520-016-3433-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 09/26/2016] [Indexed: 11/25/2022]
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Sanders JJ, Robinson MT, Block SD. Factors Impacting Advance Care Planning among African Americans: Results of a Systematic Integrated Review. J Palliat Med 2016; 19:202-27. [DOI: 10.1089/jpm.2015.0325] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Justin J. Sanders
- Division of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Ariadne Labs, Boston, Massachusetts
| | - Maisha T. Robinson
- Department of Neurology, University of California Los Angeles, Los Angeles, California
| | - Susan D. Block
- Division of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Ariadne Labs, Boston, Massachusetts
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Tang ST, Liu TW, Liu LN, Chiu CF, Hsieh RK, Tsai CM. Physician-patient end-of-life care discussions: correlates and associations with end-of-life care preferences of cancer patients-a cross-sectional survey study. Palliat Med 2014; 28:1222-30. [PMID: 24965755 DOI: 10.1177/0269216314540974] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Honoring patients' treatment preferences is a key component of high-quality end-of-life care. Connecting clinical practices to patients' preferences requires effective communication. However, few cancer patients reported discussing end-of-life-care preferences with their physicians. AIM To identify correlates of physician-patient end-of-life-care discussions and to investigate associations of physician-patient end-of-life-care discussions with patient end-of-life-care preferences. DESIGN A cross-sectional survey from April 2011 through November 2012. SETTING/PARTICIPANTS A convenience sample of 2467 cancer patients (89.3% participation rate) whose disease was diagnosed as terminal and unresponsive to current curative cancer treatment was recruited from 23 teaching hospitals throughout Taiwan. RESULTS Only 7.8% of respondents reported discussing end-of-life-care preferences with their physicians. Physicians were more likely to discuss end-of-life-care preferences with cancer patients who accurately understood their prognosis but less likely to do so if patients were married or received care in a hospital with an inpatient hospice unit. Furthermore, physician-patient end-of-life-care discussions were significantly, positively associated with the likelihood of preferring comfort-oriented care and hospice care, but negatively associated with preferences for receiving cardiopulmonary resuscitation when life is in danger and aggressive life-sustaining treatments at end of life, including intensive care unit admission, cardiac massage, intubation, and mechanical ventilation support. CONCLUSION Physician-patient end-of-life-care discussions are correlated with accurate prognostic awareness, marital status, and institutional characteristics and negatively associated with terminally ill cancer patients' preferences for aggressive end-of-life care. Interventions should be developed to facilitate timely end-of-life-care discussions between at-risk patients and their physicians, thus honoring patients' end-of-life-care preferences and possibly avoiding futile life-sustaining treatments.
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Affiliation(s)
- Siew Tzuh Tang
- School of Nursing, Chang Gung University, Tao-Yuan, Taiwan
| | - Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Taipei, Taiwan
| | - Li Ni Liu
- Department of Nursing, Fu Jen Catholic University, Taipei, Taiwan
| | - Chang-Fang Chiu
- Division of Hematology-Oncology and Comprehensive Cancer Center, China Medical University Hospital, Taichung, Taiwan
| | - Ruey-Kuen Hsieh
- Division of Hematology and Oncology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chun-Ming Tsai
- Chest Department, Taipei Veterans General Hospital, Taipei, Taiwan
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Lovell A, Yates P. Advance Care Planning in palliative care: a systematic literature review of the contextual factors influencing its uptake 2008-2012. Palliat Med 2014; 28:1026-35. [PMID: 24821708 DOI: 10.1177/0269216314531313] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advance Care Planning is an iterative process of discussion, decision-making and documentation about end-of-life care. Advance Care Planning is highly relevant in palliative care due to intersecting clinical needs. To enhance the implementation of Advance Care Planning, the contextual factors influencing its uptake need to be better understood. AIM To identify the contextual factors influencing the uptake of Advance Care Planning in palliative care as published between January 2008 and December 2012. METHODS Databases were systematically searched for studies about Advance Care Planning in palliative care published between January 2008 and December 2012. This yielded 27 eligible studies, which were appraised using National Institute of Health and Care Excellence Quality Appraisal Checklists. Iterative thematic synthesis was used to group results. RESULTS Factors associated with greater uptake included older age, a college degree, a diagnosis of cancer, greater functional impairment, being white, greater understanding of poor prognosis and receiving or working in specialist palliative care. Barriers included having non-malignant diagnoses, having dependent children, being African American, and uncertainty about Advance Care Planning and its legal status. Individuals' previous illness experiences, preferences and attitudes also influenced their participation. CONCLUSION Factors influencing the uptake of Advance Care Planning in palliative care are complex and multifaceted reflecting the diverse and often competing needs of patients, health professionals, legislature and health systems. Large population-based studies of palliative care patients are required to develop the sound theoretical and empirical foundation needed to improve uptake of Advance Care Planning in this setting.
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Affiliation(s)
- Allison Lovell
- Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia Specialist Palliative Care Service, Division of Internal Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Patsy Yates
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
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Chang A, Datta-Barua I, McLaughlin B, Daly B. A survey of prognosis discussions held by health-care providers who request palliative care consultation. Palliat Med 2014; 28:312-7. [PMID: 24327660 DOI: 10.1177/0269216313514126] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patient misunderstandings about prognosis may be related to lack of communication. AIM This study aimed to examine prognosis discussions held with hospitalized patients for whom palliative care consultations were requested, and if prognosis discussions did not occur, to explore why not. DESIGN This was a survey conducted over the telephone from a convenience sample of health-care providers who requested palliative care consultations. Respondents were asked about whether prognosis had been discussed with the patient and the topics addressed. PARTICIPANTS A total of 65 health-care providers who called to request a consultation from the palliative care team in a large academic medical center in the United States. RESULTS Of the 65 responses, 45 (69.2%) subjects reported that a prognosis discussion had occurred, while 15 (23.1%) reported that a prognosis discussion had not taken place. Among the surveys reporting a prognosis discussion, a majority of providers responded that most aspects of prognosis were discussed, with the exceptions of life expectancy, survival rates/statistics, and psychosocial concerns. When the prognosis discussion had not occurred, the most common reasons for omitting the prognosis discussion included difficulty in determining prognosis, the perception that the patient already knew his or her prognosis, and the belief that the prognosis discussion was better suited for a different specialty. CONCLUSIONS The results of this study highlight the uncertainty that primary team providers in the academic hospital environment have with prognostication, which is a complex process for which this set of providers, composed primarily of medical trainees and nurses, may not have had sufficient training.
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Affiliation(s)
- Amy Chang
- 1Previously at School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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Laguna J, Goldstein R, Braun W, Enguídanos S. Racial and ethnic variation in pain following inpatient palliative care consultations. J Am Geriatr Soc 2014; 62:546-52. [PMID: 24575714 DOI: 10.1111/jgs.12709] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Studies have documented high levels of pain in hospitalized individuals at the end of life, with minorities reporting higher levels of pain than whites. In response, inpatient palliative care (IPC) teams have grown rapidly to improve care of seriously ill individuals. Although research indicates that IPC teams effectively reduce and maintain control of pain, racial and ethnic differences in pain following IPC consultation remain unclear. This study investigated racial and ethnic pain differences after an IPC intervention in 385 seriously ill white, black, and Latino individuals aged 65 and older. Using the 11-point Numeric Rating Scale for pain, individuals were asked to rate their pain intensity at four points during hospitalization (before IPC consultation, 2 and 24 hours after the consultation, and at hospital discharge). Results indicate that whites (F1.657, 173.998 = 16.528, P < .001), blacks (F1.800, 95.410 = 7.103, P = .002), and Latinos (F1.388, 73.584 = 10.902, P < .001) all experienced significant reductions in pain after the intervention. Adjusted multivariate models testing between-group racial and ethnic differences revealed that Latinos were 62% more likely than whites to report experiencing pain at hospital discharge (relative risk = 0.38, 95% confidence interval = 0.15-0.97). Regardless of race or ethnicity, IPC effectively reduces and controls pain after consultation. Despite pain decreases, Latinos remain more likely than whites to report pain at follow-up. Further research is needed to determine the mechanisms in operation and to better understand and address the needs of this population.
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Affiliation(s)
- Jeff Laguna
- Davis School of Gerontology, University of Southern California, Los Angeles, California
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Tang ST, Liu TW, Chow JM, Chiu CF, Hsieh RK, Chen CH, Liu LN, Feng WL. Associations between accurate prognostic understanding and end-of-life care preferences and its correlates among Taiwanese terminally ill cancer patients surveyed in 2011-2012. Psychooncology 2014; 23:780-7. [DOI: 10.1002/pon.3482] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 12/15/2013] [Accepted: 12/17/2013] [Indexed: 01/03/2023]
Affiliation(s)
- Siew Tzuh Tang
- School of Nursing; Chang Gung University; Tao-Yuan Taiwan
| | - Tsang-Wu Liu
- National Health Research Institutes; National Institute of Cancer Research; Taipei Taiwan
| | - Jyh-Ming Chow
- Section of Hematology and Medical Oncology; Wan-Fang Hospital; Taipei Taiwan
| | - Chang-Fang Chiu
- Division of Hematology-Oncology and Comprehensive Cancer Center; China Medical University Hospital; Taichung Taiwan
| | - Ruey-Kuen Hsieh
- Division of Hematology and Oncology, Department of Internal Medicine; Mackay Memorial Hospital; Taipei Taiwan
| | - Chen H. Chen
- School of Nursing; Kang-Ning Junior College of Medical Care and Management; Taipei Taiwan
| | - Li Ni Liu
- Department of Nursing; Fu Jen Catholic University; Taipei Taiwan
| | - Wei-Lien Feng
- National Health Research Institutes; National Institute of Cancer Research; Taipei Taiwan
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van Gurp J, Hasselaar J, van Leeuwen E, Hoek P, Vissers K, van Selm M. Connecting with patients and instilling realism in an era of emerging communication possibilities: a review on palliative care communication heading to telecare practice. PATIENT EDUCATION AND COUNSELING 2013; 93:504-514. [PMID: 23906650 DOI: 10.1016/j.pec.2013.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 06/28/2013] [Accepted: 07/01/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Appropriate palliative care communication is pivotal to optimizing the quality of life in dying patients and their families. This review aims at describing communication patterns in palliative care and discussing potential relations between communication patterns and upcoming telecare in the practice of palliative care. METHODS This review builds on a systematic five-step qualitative analysis of the selected articles: 1. Development of a 'descriptive table of studies reviewed' based on the concept of genre, 2. Open coding of table content and first broad clustering of codes, 3. Intracluster categorization of inductive codes into substantive categories, 4. Constant inter- and intracluster comparison results in identification of genres, and 5. Labeling of genres. RESULTS This review includes 71 articles. In the analysis, two communication genres in palliative care proved to be dominant: the conversation to connect, about creating and maintaining a professional-patient/family relationship, and the conversation to instill realism, about telling a clinical truth without diminishing hope. CONCLUSION The abovementioned two genres clarify a logical intertwinement between communicative purposes, the socio-ethical background underlying palliative care practice and elements of form. PRACTICE IMPLICATIONS Our study supports understanding of current communication in palliative care and anticipates future communicative actions in an era of new communication technologies.
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Affiliation(s)
- Jelle van Gurp
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands.
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Simpson AC. An opportunity to care? Preliminary insights from a qualitative study on advance care planning in advanced COPD. PROGRESS IN PALLIATIVE CARE 2013. [DOI: 10.1179/1743291x11y.0000000007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Advance directives in an intensive care unit: experiences and recommendations of critical care nurses and physicians. Crit Care Nurs Q 2013; 35:396-409. [PMID: 22948374 DOI: 10.1097/cnq.0b013e318268fe35] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM OF STUDY This study explored the experiences of critical care nurses and physicians with advance directives (ADs) in an intensive care unit (ICU) to identify the benefits and limitations of ADs and recommendations for improvement. METHODS, SETTING, AND SUBJECTS This descriptive study, obtained by ethnographic means, was implemented in a 22-bed adult medical-surgical ICU in a large community hospital in the Midwestern United States. Subjects included 14 critical care nurses, 7 attending, and 3 fellow critical care physicians. Subjects were interviewed informally and formally. Patient medical records were reviewed for ADs. RESULTS AND CONCLUSIONS Results supported numerous problems with ADs described previously and identified additional problems, including inability of ADs to prevent unwanted aggressive treatments outside of health care facilities, and patient reluctance to share ADs for fear of physicians "throwing in the towel" too early. Although most subjects described ADs as "useless," one helpful aspect was using ADs to shift perceptions of responsibility for end-of-life decision making and outcomes from the family/providers to the patient by reframing "pulling the plug" to "honoring patient wishes." Recommendations are described, including evolving the current emphasis of increasing completion of ADs to encourage patient-family discussions focused on quality of life to increase the likelihood of discussions occurring.
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Anderson WG, Kools S, Lyndon A. Dancing around death: hospitalist-patient communication about serious illness. QUALITATIVE HEALTH RESEARCH 2013; 23:3-13. [PMID: 23034778 PMCID: PMC3502664 DOI: 10.1177/1049732312461728] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Hospital physicians care for most seriously ill patients in the United States. We employed dimensional analysis to describe communication about death and dying in audio-recorded admission encounters between seriously ill patients and hospitalists. Acknowledging or not acknowledging the possibility of dying emerged as a key process. Acknowledgment was rare, and depended on synergistic communication behaviors between patient and physician. Facilitators included patients cuing for information and disclosing emotional distress, and physicians exploring the patient's understanding of his or her illness and emotional distress. When hospitalists focused on acute issues, stated that they were awaiting test results, and deferred to other physicians, discussion moved away from acknowledgment. Meaningful discussion of end-of-life issues, including goals and values, fears about death and dying, prognosis, and options for palliative care followed open acknowledgment. This acknowledgment process can serve as a guide for providers to sensitively and honestly discuss essential end-of-life issues.
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Affiliation(s)
- Wendy G Anderson
- University of California, San Francisco, California 94143-0903, USA.
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35
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Abstract
Chronic obstructive pulmonary disease (COPD) in advanced stages runs an unpredictable downward course with increasingly frequent, ultimately fatal exacerbations. Worldwide financial and human costs are huge. Responsibility for initiating advance care planning in COPD has usually fallen to the physicians. The tendency has been to avoid this aspect of care, which can result in inadequate, rushed, reactive, crisis decision-making in the form of a “code status” discussion. In this article, I review the relevant literature and report findings from a qualitative study designed within my doctoral program to explore the question, “What is required for meaningful and effective advance care planning in the context of advanced COPD?” I describe the “collaborative care” approach to advance care planning I used with eight patients and carers living with advanced COPD. Along with a skilled clinician facilitator, user-friendly education elements, and attention to readiness, unique aspects of the approach included a focus on caring, engaging hope, facilitator reflective praxis, and contextual sensitivity. This approach has significant potential for enhancing decision making and goal setting, efficiency of resource utilization, and satisfaction with outcomes. Done well, it may reclaim the care element in advance care planning as it addresses barriers cited by physicians and patients/families.
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Affiliation(s)
- Catherine Simpson
- Division of Respirology, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
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Gay EB, Weiss SP, Nelson JE. Integrating palliative care with intensive care for critically ill patients with lung cancer. Ann Intensive Care 2012; 2:3. [PMID: 22339793 PMCID: PMC3306209 DOI: 10.1186/2110-5820-2-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 02/16/2012] [Indexed: 01/22/2023] Open
Abstract
With newer information indicating more favorable outcomes of intensive care therapy for lung cancer patients, intensivists increasingly are willing to initiate an aggressive trial of this therapy. Concerns remain, however, that the experience of the intensive care unit for patients with lung cancer and their families often may be distressing. Regardless of prognosis, all patients with critical illness should receive high-quality palliative care, including symptom control, communication about appropriate care goals, and support for both patient and family throughout the illness trajectory. In this article, we suggest strategies for integrating palliative care with intensive care for critically ill lung cancer patients. We address assessment and management of symptoms, knowledge and skill needed for effective communication, and interdisciplinary collaboration for patient and family support. We review the role of expert consultants in providing palliative care in the intensive care unit, while highlighting the responsibility of all critical care clinicians to address basic palliative care needs of patients and their families.
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Affiliation(s)
- Elizabeth B Gay
- Department of Pulmonary and Critical Care Medicine, University of Virginia Health Systems, Charlottesville, VA
| | - Stefanie P Weiss
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai School of Medicine, New York, NY
| | - Judith E Nelson
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai School of Medicine, New York, NY
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Waldrop DP, Meeker MA, Kerr C, Skretny J, Tangeman J, Milch R. The nature and timing of family-provider communication in late-stage cancer: a qualitative study of caregivers' experiences. J Pain Symptom Manage 2012; 43:182-94. [PMID: 22248787 DOI: 10.1016/j.jpainsymman.2011.04.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 03/29/2011] [Accepted: 04/12/2011] [Indexed: 10/14/2022]
Abstract
CONTEXT Family members of people with advanced cancer can experience intensified distress and uncertainty during the final stages of their loved one's illness. Enhanced comprehension about disease progression, symptom management, and options for care can help families adapt, cope, and plan for the future. OBJECTIVES Guided by concepts from the Sense of Coherence Theory, which illuminates factors that contribute to adaptation in stressful situations, the objective of this study was to explore and describe family caregivers' accounts of the nature and timing of communication they had with a loved one's health care provider(s) during the advanced stages of cancer and before hospice enrollment. METHODS Retrospective in-depth interviews were conducted with caregivers of 46 people who died of cancer. Interviews were audiotaped, transcribed, and submitted to an iterative process of qualitative data analysis that included 1) systematic coding, 2) the use of data matrices to display summarized results and collapse the codes into themes, 3) and axial coding to characterize the nature of the themes. RESULTS Overall, communication with providers was found to be either 1) satisfactory or 2) unsatisfactory. Satisfactory communication was 1) compassionate, 2) responsive, and/or 3) dedicated. Unsatisfactory communication was described as 1) sparse, 2) conflicted, 3) contradictory, and/or 4) brink of death. CONCLUSION Communication with health care providers is critical for helping family caregivers understand and manage the changes that accompany a life-limiting illness. Timely communication with information and meaningful discussion about disease progression can help families prepare for the advanced stages of an illness and approaching death.
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Affiliation(s)
- Deborah P Waldrop
- University at Buffalo School of Social Work, Buffalo, New York 14260, USA.
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Higton A, Collins S, Bilton D. Gastroesophageal reflux causing nutritional failure and vomiting in a teenager with cystic fibrosis and respiratory failure. J R Soc Med 2011; 104 Suppl 1:S44-8. [PMID: 21719893 DOI: 10.1258/jrsm.2011.s11108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Alexandra Higton
- Department of Respiratory Medicine, Frimley Park Hospital, Frimley, Surrey, UK.
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Wentlandt K, Burman D, Swami N, Hales S, Rydall A, Rodin G, Lo C, Zimmermann C. Preparation for the end of life in patients with advanced cancer and association with communication with professional caregivers. Psychooncology 2011; 21:868-76. [DOI: 10.1002/pon.1995] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 04/09/2011] [Accepted: 04/13/2011] [Indexed: 11/08/2022]
Affiliation(s)
- Kirsten Wentlandt
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
| | - Debika Burman
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Campbell Family Cancer Research Institute, Ontario Cancer Institute; Princess Margaret Hospital, University Health Network; Toronto Canada
| | - Nadia Swami
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Campbell Family Cancer Research Institute, Ontario Cancer Institute; Princess Margaret Hospital, University Health Network; Toronto Canada
| | - Sarah Hales
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Department of Psychiatry; University of Toronto; Toronto Canada
| | - Anne Rydall
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Campbell Family Cancer Research Institute, Ontario Cancer Institute; Princess Margaret Hospital, University Health Network; Toronto Canada
| | - Gary Rodin
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Campbell Family Cancer Research Institute, Ontario Cancer Institute; Princess Margaret Hospital, University Health Network; Toronto Canada
- Department of Psychiatry; University of Toronto; Toronto Canada
| | - Christopher Lo
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Department of Psychiatry; University of Toronto; Toronto Canada
| | - Camilla Zimmermann
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Hospital, University Health Network; Toronto Canada
- Campbell Family Cancer Research Institute, Ontario Cancer Institute; Princess Margaret Hospital, University Health Network; Toronto Canada
- Department of Psychiatry; University of Toronto; Toronto Canada
- Division of Medical Oncology and Haematology, Department of Medicine; University of Toronto; Toronto Canada
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Nelson JE, Gay EB, Berman AR, Powell CA, Salazar-Schicchi J, Wisnivesky JP. Patients rate physician communication about lung cancer. Cancer 2011; 117:5212-20. [PMID: 21495028 DOI: 10.1002/cncr.26152] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 03/02/2011] [Accepted: 03/03/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND High-quality lung cancer care includes physician-patient communication about the disease and treatment, patient needs/preferences, and care goals. In this study, the authors evaluated communication with patients at all stages across multiple topics. METHODS A standardized questionnaire asked patients with lung cancer to rate (on 5-point, verbal descriptor scale) the extent of communication with physicians on symptoms, spiritual concerns, practical needs, proxy appointment, living will preparation, prognosis, care goals, potential complications of therapy, life support preferences, and hospice. Communication was defined as inadequate if the patient reported discussing ≥5 of 11 questionnaire topics "not at all" or "a little bit." Multivariate logistic regression was used to evaluate the factors associated with inadequate communication. RESULTS In total, 276 of 348 (79%) eligible patients were enrolled (mean age [±standard deviation], 65 ± 10 years; 55% white, 21% black, and 19% Hispanic; all disease stages). For most topics, the majority of respondents reported that physicians communicated "not at all" or "a little bit." Low ratings were frequent for discussion of emotional symptoms (56%; 95% confidence interval [CI], 49%-62%), practical needs (71%; 95% CI, 65%-76%), spiritual concerns (80%; 95% CI, 75%-85%), proxy appointment (63%; 95% CI, 57%-69%), living will preparation (90%; 95% CI, 85%-93%), life support preferences (80%; 95% CI, 75%-84%), and hospice (88%; 95% CI, 86%-94%). Communication was inadequate for patients of different ages, stages, and races, although Hispanics were less likely than non-Hispanic whites and blacks to report inadequate communication (odds ratio, 0.31; 95% CI, 0.15-0.65). CONCLUSIONS Across all stages, patients with lung cancer reported low rates of physician-patient communication on key topics, which may increase patient distress, impair decision-making, and compromise clinical outcomes and use patterns.
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Affiliation(s)
- Judith E Nelson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, New York, USA
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