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Mastropolo R, Altschuler A, Brock KE, Casperson M, Chao CR, Fisher L, Greenzang KA, Kushi LH, Lakin JR, Lefebvre A, Schwartz CM, Shalman DM, Wall CB, Wiener L, Mack JW. Patient, Caregiver, and Clinician Perspectives on Core Components of Therapeutic Alliance for Adolescents and Young Adults With Advanced Cancer: A Qualitative Study. JAMA Netw Open 2023; 6:e2328153. [PMID: 37556137 PMCID: PMC10413170 DOI: 10.1001/jamanetworkopen.2023.28153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/29/2023] [Indexed: 08/10/2023] Open
Abstract
Importance The patient-clinician therapeutic alliance is an important aspect of high-quality cancer care. However, components of the therapeutic alliance in adolescents and young adults (AYAs, aged 12-39 years) with cancer have not been defined. Objective To identify components of and barriers to the therapeutic alliance between AYAs, caregivers, and clinicians from the perspective of all key stakeholders. Design, Setting, and Participants In this qualitative study, semistructured in-depth interviews with patients, caregivers, and clinicians were conducted from 2018 to 2021 with no additional follow-up, with content analysis of resulting transcripts. Participants were recruited from Dana-Farber Cancer Institute, Kaiser Permanente Northern California, Kaiser Permanente Southern California, and an online cancer support community (Cactus Cancer Society). Eligible participants were English- or Spanish-speaking. Eligible patients were aged 12 to 39 years with stage IV or recurrent cancer. Eligible caregivers cared for an AYA living with advanced cancer or one who had died within 5 years. Eligible clinicians routinely provided care for AYAs with cancer. Main Outcomes and Measures Perspectives on therapeutic alliance. Results Interviews were conducted with 80 participants: 23 were patients (48% were female; 78% were White), 28 were caregivers (82% were female; 50% were White), and 29 were clinicians (69% were female; 45% were White). The mean (SD) age of patients was 29 (7.3) years. Interviews identified 6 components of therapeutic alliance: (1) compassion; (2) sense of connection; (3) clinician presence; (4) information sharing; (5) shared goals; and (6) individualization of care. While some domains were represented in prior models of therapeutic alliance, a unique domain was identified related to the need for individualization of the approach to care for AYA patients and their caregivers. Interviews also identified potential barriers to building the therapeutic alliance specific to the AYA population, including managing discordant needs between patients and caregivers and communication challenges at the end of life. Conclusions and Relevance This study identified core components and barriers to building therapeutic alliance in the AYA advanced cancer population from the perspective of all the key stakeholders in the relationship. A novel component highlighting the need for individualization was identified. This model enables a deeper understanding of how to build therapeutic alliance in the AYA advanced cancer population, which may guide clinician training and facilitate improved care for this vulnerable population.
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Affiliation(s)
- Rosemarie Mastropolo
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Katharine E. Brock
- Department of Pediatric Oncology, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mallory Casperson
- Divisions of Pediatric Oncology and Palliative Care, Cactus Cancer Society, Oakland, California
| | - Chun R. Chao
- Department of Research and Evaluation (C.R.C.), Kaiser Permanente Southern California, Pasadena
| | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Katie A. Greenzang
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lawrence H. Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Joshua R. Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anna Lefebvre
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Corey M. Schwartz
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland
| | - Dov M. Shalman
- Department of Palliative Care, Kaiser Permanente Southern California, Pasadena
| | - Catherine B. Wall
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lori Wiener
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, Maryland
| | - Jennifer W. Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
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Baker JN, Friebert S, Needle J, Jiang J, Wang J, Lyon ME. An Intervention in Congruence for End-of-Life Treatment Preference: A Randomized Trial. Pediatrics 2022; 149:e2021054796. [PMID: 35425986 PMCID: PMC9648108 DOI: 10.1542/peds.2021-054796] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There is a gap in family knowledge of their adolescents' end-of-life (EOL) treatment preferences. We tested the efficacy of Family Centered Advance Care Planning for Teens with Cancer (FACE-TC) pediatric advance care planning (to increase congruence in EOL treatment preferences. METHODS Adolescents with cancer/family dyads were randomized into a clinical trial from July 2016 to April 2019 at a 2:1 ratio: intervention (n = 83); control (n = 43) to either 3 weekly sessions of FACE-TC (Lyon Advance Care Planning Survey; Next Steps: Respecting Choices Interview; Five Wishes, advance directive) or treatment as usual (TAU). Statement of Treatment Preferences measured congruence. RESULTS Adolescents' (n = 126) mean age was 16.9 years; 57% were female and 79% were White. FACE-TC dyads had greater overall agreement than TAU: high 34% vs 2%, moderate 52% vs 45%, low 14% vs 52%, and P < .0001. Significantly greater odds of congruence were found for FACE-TC dyads than TAU for 3 of 4 disease-specific scenarios: for example, "a long hospitalization with low chance of survival," 78% (57 of 73) vs 45% (19 of 42); odds ratio, 4.31 (95% confidence interval, 1.89-9.82). FACE-TC families were more likely to agree to stop some treatments. Intervention adolescents, 67% (48 of 73), wanted their families to do what is best at the time, whereas fewer TAU adolescents, 43% (18 of 42), gave families this leeway (P = .01). CONCLUSIONS High-quality pediatric advance care planning enabled families to know their adolescents' EOL treatment preferences.
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Affiliation(s)
- Justin N. Baker
- Division of Quality of Life and Palliative Care, St. Jude
Children’s Research Hospital, Memphis, Tennessee
| | - Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center
- Rebecca D. Considine Research Institute, Akron
Children’s Hospital, Akron, Ohio
| | - Jennifer Needle
- Department of Pediatrics and Center for Bioethics,
University of Minnesota, Minneapolis, Minnesota
| | - JiJi Jiang
- Henry M. Jackson Foundation for the Advancement of
Military Medicine, Bethesda, Maryland
| | - Jichuan Wang
- Divisions of Biostatistics and Study Methodology
- Center for Translational Research/Children’s
National Research Institute, Children’s National Hospital, Washington,
DC
| | - Maureen E. Lyon
- Adolescent and Young Adult Medicine
- Center for Translational Research/Children’s
National Research Institute, Children’s National Hospital, Washington,
DC
- Department of Pediatrics, George Washington University
School of Medicine and Health Sciences, Washington, DC
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Grill KB, Wang J, Scott RK, Benator D, D'Angelo LJ, Lyon ME. What Do Adults With HIV Want? End-of-Life Care Goals, Values and Beliefs by Gender, Race, Sexual Orientation. Am J Hosp Palliat Care 2021; 38:610-617. [PMID: 33464114 DOI: 10.1177/1049909120988282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE We examined factors influencing end-of-life care preferences among persons living with HIV (PLWH). METHODS 223 PLWH were enrolled from 5 hospital-based clinics in Washington, DC. They completed an end-of-life care survey at baseline of the FACE™-HIV Advance Care Planning clinical trial. FINDINGS The average age of patients was 51 years. 56% were male, 66% heterosexual, and 86% African American. Two distinct groups of patients were identified with respect to end-of-life care preferences: (1) a Relational class (75%) who prioritized family and friends, comfort from church services, and comfort from persons at the end-of-life; and (2) a Transactional/Self-Determination class (25%) who prioritized honest answers from their doctors, and advance care plans over relationships. African Americans had 3x the odds of being in the Relational class versus the Transactional/Self-determination class, Odds ratio = 3.30 (95% CI, 1.09, 10.03), p = 0.035. Males were significantly less likely to be in the relational latent class, Odds ratio = 0.38 (CI, 0.15, 0.98), p = 0.045. Compared to non-African-Americans, African-American PLWH rated the following as important: only taking pain medicines when pain is severe, p = 0.0113; saving larger doses for worse pain, p = 0.0067; and dying in the hospital, p = 0.0285. PLWH who were sexual minorities were more afraid of dying alone, p = 0.0397, and less likely to only take pain medicines when pain is severe, p = 0.0091. CONCLUSION Integrating culturally-sensitive palliative care services as a component of the HIV care continuum may improve health equity and person-centered care.
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Affiliation(s)
| | - Jichuan Wang
- Division of Biostatistics and Study Methodology, Center for Translational Research at Children's National Hospital, Washington, DC, USA.,George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Rachel K Scott
- MedStar Health Research Institute and Washington Hospital Center, Washington, DC, USA
| | - Debra Benator
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Washington DC Veterans Affairs Medical Center, Washington, DC, USA
| | - Lawrence J D'Angelo
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Division of Adolescent and Young Adult Medicine, 571630Children's National Hospital, Washington, DC, USA
| | - Maureen E Lyon
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Division of Adolescent and Young Adult Medicine, 571630Children's National Hospital, Washington, DC, USA.,Center for Translational Research/Children's National Research Institute at 571630Children's National Hospital, Washington, DC, USA
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Lyon ME, Dallas RH, Garvie PA, Wilkins ML, Garcia A, Cheng YI, Wang J. Paediatric advance care planning survey: a cross-sectional examination of congruence and discordance between adolescents with HIV/AIDS and their families. BMJ Support Palliat Care 2019; 9:e22. [PMID: 28935629 PMCID: PMC5862773 DOI: 10.1136/bmjspcare-2016-001224] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 05/19/2017] [Accepted: 08/07/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To identify patient-reported paediatric advance care planning (pACP) needs of adolescents living with HIV and to examine the congruence with their family's perception of their needs. METHODS A cross-sectional survey among six paediatric hospital-based outpatient HIV specialty clinics. Participants included 48 adolescent/family dyads (n=96 participants) within a larger study facilitating pACP. The main outcome measure was the Lyon Advance Care Planning Survey - Adolescent and Surrogate Versions-Revised. RESULTS Adolescents' mean age was 18 years (range ≥14-<21); 54% male; 92% African-American; 27% with prior AIDS diagnosis. If dying, 92% believed in completing an advance directive; 85% preferred to die at home;88% knowing how to say good bye; 71% being off machines that extend life and 77% dying a natural death. Best timing for end-of-life (EOL) decisions was while healthy (38%), when first diagnosed (17%), when first sick from a life-threatening illness (4%), when first hospitalised (8%), if dying (4%) and all of the above (19%). Prevalence-adjusted bias-adjusted Kappa (PABAK) measured congruence in pACP needs within adolescent/family dyads. There was substantial congruence in that being free from pain (PABAK=0.83), and understanding your treatment choices (PABAK=0.92) were very important or important. There was discordance about being off machines that extend life (PABAK=0.08) and when is the best time to bring up EOL decisions (PABAK=0.32). CONCLUSIONS Areas of discordance were associated with life-sustaining choices and when to have the EOL conversation. Targeted, adolescent/family-centred, evidence-based pACP interventions are needed to improve family understanding of youth's EOL wishes. TRIAL REGISTRATION NUMBER NCT01289444; Results.
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Affiliation(s)
- Maureen E Lyon
- Center for Translational Science/Children’s Research Institute/Children’s National Medical Center, Washington, District of Columbia, USA
| | - Ronald H Dallas
- Department of Infectious Disease, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Patricia A Garvie
- Research Department, Children’s Diagnostic & Treatment Center, Lauderdale, Florida, USA
| | - Megan L Wilkins
- Department of Infectious Disease, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Ana Garcia
- Division of Infectious Disease, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Yao Iris Cheng
- Center for Translational Science/Children’s Research Institute/Children’s National Medical Center, Washington, District of Columbia, USA
| | - Jichuan Wang
- Center for Translational Science/Children’s Research Institute/Children’s National Medical Center, Washington, District of Columbia, USA
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Namisango E, Bristowe K, Allsop MJ, Murtagh FEM, Abas M, Higginson IJ, Downing J, Harding R. Symptoms and Concerns Among Children and Young People with Life-Limiting and Life-Threatening Conditions: A Systematic Review Highlighting Meaningful Health Outcomes. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2018; 12:15-55. [DOI: 10.1007/s40271-018-0333-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hughes B, O'Brien MR, Flynn A, Knighting K. The engagement of young people in their own advance care planning process: A systematic narrative synthesis. Palliat Med 2018; 32:1147-1166. [PMID: 29720032 DOI: 10.1177/0269216318772749] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND An increasing number of young people are living with life-limiting conditions. Current research about advance care planning for young people indicates differing experiences for those involved. Understanding how far young people are engaged in their own advance care plan is important to shape future practice and facilitate young people's wishes. AIM To identify and assess the current evidence to determine the barriers and facilitators to the engagement of young people in their own advance care planning process. DESIGN A systematic narrative synthesis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using a quality assessment framework previously used in similar research. DATA SOURCES CINAHL Complete, MEDLINE, PubMed and PsycINFO were searched for articles published between 1 January 1990 and 31 October 2017. Grey literature was searched using Google Scholar and Open Grey. RESULTS Most studies related to the engagement of young people were conducted in hospitals or other institutions. Research reported not only the aim to include young people in their own advance care planning but also potential barriers to engagement. Barriers include poor communication, conflict within relationships of those in the planning process and patchy education and training for healthcare professionals. Some existing studies are characterised by a lack of rigorous, high-quality research, limiting their impact. CONCLUSION Irrespective of setting, engagement of young people would benefit their advance care planning. More detailed, high-quality research is needed to understand the extent of the barriers to young people's engagement in their own advance care plan and how to facilitate their involvement.
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Affiliation(s)
- Ben Hughes
- Faculty of Health and Social Care, Edge Hill University, Lancashire, UK
| | - Mary R O'Brien
- Faculty of Health and Social Care, Edge Hill University, Lancashire, UK
| | - Anita Flynn
- Faculty of Health and Social Care, Edge Hill University, Lancashire, UK
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7
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Robinson EL, Hart B, Sanders S. It's okay to talk about death: Exploring the end-of-life wishes of healthy young adults. DEATH STUDIES 2018; 43:389-396. [PMID: 29913114 DOI: 10.1080/07481187.2018.1478913] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 03/15/2018] [Accepted: 04/08/2018] [Indexed: 06/08/2023]
Abstract
Young adults (N = 80) participated in advance care planning (ACP) as part of a death and dying course and submitted reflection papers on their experiences. These papers were analyzed using directed qualitative content analysis methods. Among the findings, participants almost exclusively chose a parent or other family member as a Health Care Agent. Twenty-five percent expressed concern about placing burden on their agent, but felt their advance directives (AD) would ease that burden. For many, previous experiences with death helped shape their wishes. This research has practice implications for recruiting more healthy young adults in completing their AD.
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Affiliation(s)
- Erin L Robinson
- a University of Missouri School of Social Work , Columbia , MO , USA
| | - Becky Hart
- a University of Missouri School of Social Work , Columbia , MO , USA
| | - Sara Sanders
- b University of Iowa School of Social Work , Iowa City , IA , USA
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8
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Lyon ME, D’Angelo LJ, Dallas RH, Hinds PS, Garvie PA, Wilkins ML, Garcia A, Briggs L, Flynn PM, Rana SR, Cheng YI, Wang J. A randomized clinical trial of adolescents with HIV/AIDS: pediatric advance care planning. AIDS Care 2017; 29:1287-1296. [PMID: 28359212 PMCID: PMC5846623 DOI: 10.1080/09540121.2017.1308463] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The objective of this study is to determine if pediatric advance care planning (pACP) increases adolescent/family congruence in end-of-life (EOL) treatment preferences longitudinally. Adolescents aged 14-21 years with HIV/AIDS and their families were randomized (N = 105 dyads) to three-60-minute sessions scheduled one week apart: either the pACP intervention (survey administered independently, facilitated conversation with adolescent and family present, completion of legal advance directive document with adolescent and family present) or an active control (developmental history, safety tips, nutrition and exercise education). This longitudinal, single-blinded, multi-site, randomized controlled trial was conducted in six pediatric hospital-based HIV-clinics, located in high HIV mortality cities. The Statement of Treatment Preferences measured adolescent/family congruence in EOL treatment preferences at immediately following the facilitated pACP conversation (Session 2), and at 3-month post-intervention. The mean age of adolescent participants was 18 years (range 14-21 years); 54% were male; and 93% were African-American. One-third had an AIDS diagnosis. Immediately post-intervention the Prevalence Adjusted Bias Adjusted Kappa showed substantial treatment preference agreement for pACP dyads compared to controls (High burden/low chance of survival, PABAK = 0.688 vs. 0.335; Functional impairment, PABAK = 0.687 vs. PABAK= 0.34; Mental impairment, PABKA = 0.717 vs. 0.341). Agreement to limit treatments was greater among intervention dyads than controls (High burden: 14.6% vs. 0%; Functional impairment = 22.9% vs. 4.4%; and Mental impairment: 12.5% vs. 4.4%). Overall treatment preference agreement among pACP dyads was high immediately post-intervention, but decreased over time. In contrast, treatment agreement among control dyads was low and remained low over time. As goals of care change over time with real experiences, additional pACP conversations are needed.
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Affiliation(s)
- Maureen E. Lyon
- Department of Pediatrics, Children’s National, Children’s Research Institute, Center for Translational Science and George Washington University School of Medicine and Health Sciences, Washington, USA
- Department of Pediatrics, Children’s National, Division of Adolescent & Young Adult Medicine, George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Lawrence J. D’Angelo
- Department of Pediatrics, Children’s National, Division of Adolescent & Young Adult Medicine, George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Ronald H. Dallas
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, USA
| | - Pamela S. Hinds
- Department of Pediatrics, Children’s National, Children’s Research Institute, Center for Translational Science and George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Patricia A. Garvie
- Research Department, Children’s Diagnostic & Treatment Center, Fort Lauderdale, USA
| | - Megan L. Wilkins
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, USA
| | - Ana Garcia
- Pediatric Infectious Disease & Immunology, University of Miami Miller School of Medicine, Miami, USA
| | - Linda Briggs
- Gundersen Lutheran Medical Foundation, Inc., La Crosse, USA
| | - Patricia M. Flynn
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, USA
| | - Sohail R. Rana
- Department of Pediatrics and Child Health, Howard University Hospital, Washington, USA
| | - Yao Iris Cheng
- Division of Biostatistics and Study Methodology, Children’s National, Children’s Research Institute, Center for Translational Science, Washington, USA
| | - Jichuan Wang
- Division of Biostatistics and Study Methodology, Children’s National, Children’s Research Institute, Center for Translational Science, Washington, USA
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Hudson BF, Oostendorp LJM, Candy B, Vickerstaff V, Jones L, Lakhanpaul M, Bluebond-Langner M, Stone P. The under reporting of recruitment strategies in research with children with life-threatening illnesses: A systematic review. Palliat Med 2017; 31:419-436. [PMID: 27609607 PMCID: PMC5405809 DOI: 10.1177/0269216316663856] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Researchers report difficulties in conducting research with children and young people with life-limiting conditions or life-threatening illnesses and their families. Recruitment is challenged by barriers including ethical, logistical and clinical considerations. AIM To explore how children and young people (aged 0-25 years) with life-limiting conditions or life-threatening illnesses and their families were identified, invited and consented to research published in the last 5 years. DESIGN Systematic review. DATA SOURCES MEDLINE, PsycINFO, Web of Science, Sciences Citation Index and SCOPUS were searched for original English language research published between 2009 and 2014, recruiting children and young people with life-limiting conditions or life-threatening illness and their families. RESULTS A total of 215 studies - 152 qualitative, 54 quantitative and 9 mixed methods - were included. Limited recruitment information but a range of strategies and difficulties were provided. The proportion of eligible participants from those screened could not be calculated in 80% of studies. Recruitment rates could not be calculated in 77%. A total of 31% of studies recruited less than 50% of eligible participants. Reasons given for non-invitation included missing clinical or contact data, or clinician judgements of participant unsuitability. Reasons for non-participation included lack of interest and participants' perceptions of potential burdens. CONCLUSION All stages of recruitment were under reported. Transparency in reporting of participant identification, invitation and consent is needed to enable researchers to understand research implications, bias risk and to whom results apply. Research is needed to explore why consenting participants decide to take part or not and their experiences of research recruitment.
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Affiliation(s)
- Briony F Hudson
- Louis Dundas Centre for Children’s Palliative Care, UCL Institute of Child Health, London, UK
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, London, UK
| | - Linda JM Oostendorp
- Louis Dundas Centre for Children’s Palliative Care, UCL Institute of Child Health, London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, London, UK
| | - Louise Jones
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, London, UK
| | - Monica Lakhanpaul
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Myra Bluebond-Langner
- Louis Dundas Centre for Children’s Palliative Care, UCL Institute of Child Health, London, UK
| | - Paddy Stone
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, London, UK
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Dallas RH, Kimmel A, Wilkins ML, Rana S, Garcia A, Cheng YI, Wang J, Lyon ME. Acceptability of Family-Centered Advanced Care Planning for Adolescents With HIV. Pediatrics 2016; 138:peds.2016-1854. [PMID: 27940700 PMCID: PMC5127070 DOI: 10.1542/peds.2016-1854] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Small pilot studies support the appropriateness of engaging adolescents with chronic or life-limiting illnesses in pediatric advance care planning (pACP). We do not yet know if pACP is acceptable, feasible, and worthwhile, even if emotionally intense, in a fully powered randomized controlled trial. METHODS We conducted a prospective 2-arm randomized controlled trial at 6 US urban hospitals. Adolescent/family member dyads were randomized to receive the 1-session-a-week 3-session FAmily-CEntered Advance Care Planning (FACE) pACP intervention (1, ACP Survey; 2, Goals of Care Conversation/Treatment Preferences; 3, Completion of Advance Directive) or active comparator (1, Developmental History; 2, Safety Tips; 3, Nutrition/Exercise). The Satisfaction Questionnaire was administered to participants independently after each session by a blinded research assistant. RESULTS We enrolled 53% of eligible participants and intervened with 97 adolescent/family dyads. Adolescents ranged in age from 14 to 21 years; 54% were male individuals; 93% African American; and 73% perinatally infected. Attendance was 99% for all 3 sessions in each arm. At session 3, FACE adolescents and family dyad members, respectively, found the session useful (98%, 98%) and helpful (98%, 100%), despite feelings of sadness (25%, 17%). FACE adolescents' improvement in the total subscale A score (useful, helpful, like a load off my mind, satisfied, something I needed to do, courageous, worthwhile) was better than control adolescents at session 3 (β = 1.16, P = .02). There were no adverse events. CONCLUSIONS FACE enabled worthwhile conversations, while simultaneously eliciting intense emotions. No participants withdrew, 99% of those enrolled completed each session, and there were no adverse events, evidence of pACP's feasibility, acceptability, and safety.
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Affiliation(s)
- Ronald H. Dallas
- Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Allison Kimmel
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia
| | - Megan L. Wilkins
- Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Sohail Rana
- Howard University College of Medicine, Washington, District of Columbia
| | - Ana Garcia
- The University of Miami Miller School of Medicine, Miami, Florida; and
| | - Yao I. Cheng
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia
| | - Jichuan Wang
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia;,The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Maureen E. Lyon
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia;,The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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11
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Keim-Malpass J, Stegenga K, Loudin B, Kennedy C, Kools S. “It’s Back! My Remission Is Over”. J Pediatr Oncol Nurs 2015; 33:209-17. [DOI: 10.1177/1043454215600424] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cancer in adolescence presents unique challenges to patients and families due to the dramatic physical and psychological vulnerabilities that occur during a time of identity development. Additionally, adolescents who experience progression of their cancer, or failure of first-line therapies, represent an understudied group within pediatric oncology. Illness blogs offer a unique opportunity to understand the experience of a chronic or serious illness through a naturalistic and longitudinal perspective that is inherently patient centered. The purpose of this exploratory qualitative study was to describe the experiences of adolescents with cancer who experienced disease progression through analysis of their online illness blogs. Seven illness blogs written by adolescents with cancer diagnosed between the ages of 13 and 18 years were analyzed using thematic analysis. Several key themes were described among the adolescents, including normalizing the news, facing treatment failure, and reconciling chronos—the finite concept of time. These findings provide vital descriptive evidence for the experience of disease progression as described by adolescents, as well as identifying key points of further study and intervention development for nurse researchers and nurses who care for this vulnerable patient population.
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Affiliation(s)
| | | | - Beth Loudin
- University of Virginia School of Nursing, Charlottesville, VA, USA
| | | | - Susan Kools
- University of Virginia School of Nursing, Charlottesville, VA, USA
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Hutson SP. Climbing Back Up the Mountain: Reflections From an Exploration of End-of-Life Needs of Persons Living With HIV/AIDS in Appalachian Tennessee. Am J Hosp Palliat Care 2015; 33:972-976. [PMID: 26290520 DOI: 10.1177/1049909115600857] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Little is known about the health access and end-of-life (EOL) concerns of persons living with HIV/AIDS (PLWHA) in Appalachia, where religious and cultural values are largely traditional. A qualitative, descriptive study with 9 participants was undertaken to assess EOL care needs among those from South Central Appalachian PLWHA. The focus of the study was to examine subjective data regarding EOL needs assessment related to advanced care planning. Five men and 4 women self-acknowledged a diagnosis of HIV/AIDS and completed a 2-hour face-to-face interview with the nurse researcher. Data were analyzed using qualitative descriptive content analysis methods, including data coding for emergent themes and metaphors. A common metaphor tied content to both struggle and triumph as well as the beauty and ruggedness of the Appalachian region: "Climbing Back up the Mountain." Rich descriptions of the significance of the metaphor match with stigma as the greatest hurdle to overcome in planning and interacting with others, including health care providers and significant others, about EOL care needs and advanced planning preferences. Further, the metaphor was derived directly from quotes offered by participants. Sources of stigma were often intersecting: the disease itself, associations with "promiscuity," sexual minority status, illicit drug use, and so on. Strong spiritual images were contrasted with a common avoidance and disdain of organized religion. Findings were used in refining plans for a larger study of EOL care needs and concerns on the population of PLWHA in 2 Southern Appalachian states. Comparison with other research and insights for providers is included.
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Affiliation(s)
- Sadie P Hutson
- College of Nursing, University of Tennessee, Knoxville, TN, USA
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Jacobs S, Perez J, Cheng YI, Sill A, Wang J, Lyon ME. Adolescent end of life preferences and congruence with their parents' preferences: results of a survey of adolescents with cancer. Pediatr Blood Cancer 2015; 62:710-4. [PMID: 25545105 DOI: 10.1002/pbc.25358] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 10/20/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Little is known about how well family members accurately represent adolescents when making EOL decisions on their behalf. This study reports on surveys given to adolescents with cancer and their parents as part of a larger study facilitating advanced care discussions, as well as the results of a survey for health care providers. PROCEDURE Trained facilitators administered surveys orally to adolescents and families in the intervention arm of the FAmily CEntered Advance Care Planning (ACP) for Teens with Cancer (FACE-TC) study. In addition, a post-hoc survey was sent to oncology providers. RESULTS Seventeen adolescent/family dyads completed this survey. Seventy five percent of adolescents believed it was appropriate to discuss EOL decisions early and only 12% were not comfortable discussing death. Most preferred to be at home if dying. There were substantial areas of congruence between adolescents and their surrogates, but lower agreement on the importance of dying a natural death, dying at home and "wanting to know if I were dying." Among providers, 83% felt their patients' participation in the study was helpful to the patients and 78% felt it was helpful to them as providers. CONCLUSIONS Adolescents with cancer were comfortable discussing EOL, and the majority preferred to talk about EOL issues before they are facing EOL. There were substantive areas of agreement between adolescents and their surrogates, but important facets of adolescents' EOL wishes were not known by their families, reinforcing the importance of eliciting individual preferences and engaging dyads so parents can understand their children's wishes.
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Affiliation(s)
- Shana Jacobs
- Children's National Medical Center/Division of Oncology/Children's Research Institute/Center for Cancer and Immunology Research and George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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14
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Kavalieratos D, Ernecoff NC, Keim-Malpass J, Degenholtz HB. Knowledge, attitudes, and preferences of healthy young adults regarding advance care planning: a focus group study of university students in Pittsburgh, USA. BMC Public Health 2015; 15:197. [PMID: 25885778 PMCID: PMC4349677 DOI: 10.1186/s12889-015-1575-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 02/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To date, research and promotion regarding advance care planning (ACP) has targeted those with serious illness or the elderly, thereby ignoring healthy young adults. The purpose of this study was to explore young adults' knowledge, attitudes, and preferences regarding advance care planning (ACP) and medical decision-making. Further, we aimed to understand the potential role of public health to encourage population-based promotion of ACP. METHODS Between February 2007 and April 2007, we conducted six focus groups comprising 56 young adults ages 18-30. Topics explored included (1) baseline knowledge regarding ACP, (2) preferences for ACP, (3) characteristics of preferred surrogates, and (4) barriers and facilitators to completing ACP specific to age and individuation. We used a qualitative thematic approach to analyze transcripts. RESULTS All participants desired more information regarding ACP. In addition, participants expressed (1) heterogeneous attitudes regarding triggers to perform ACP, (2) the opinion that ACP is a marker of individuation, (3) the belief that prior exposure to illness plays a role in prompting ACP, and (4) an appreciation that ACP is flexible to changes in preferences and circumstances throughout the life-course. CONCLUSION Young adults perceive ACP as a worthwhile health behavior and view a lack of information as a major barrier to discussion and adoption. Our data emphasize the need for strategies to increase ACP knowledge, while encouraging population-level, patient-centered, healthcare decision-making.
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Affiliation(s)
- Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA.
| | - Natalie C Ernecoff
- Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
| | | | - Howard B Degenholtz
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
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Lyon ME, Garvie P, He J, Malow R, McCarter R, D'Angelo LJ. Spiritual well-being among HIV-infected adolescents and their families. JOURNAL OF RELIGION AND HEALTH 2014; 53:637-53. [PMID: 23104266 PMCID: PMC3568454 DOI: 10.1007/s10943-012-9657-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Congruence in spirituality between HIV+ adolescent (n = 40)/family (n = 40) dyads and psychological adjustment and quality of life were assessed, using the Spiritual Well-Being Scale of the Functional Assessment of Chronic Illness Therapy, Beck Depression Inventory-II, Beck Anxiety Inventory and Pediatric Quality of Life Inventory at baseline and 3-month post-intervention. Adolescents were 60 % female and 92 % African American. Congruence in spirituality between adolescent/surrogate dyads remained unchanged at 3 months. High congruence existed for "having a reason for living"; rejection of "life lacks meaning/purpose" and "HIV is a punishment from God." Adolescents were less likely to forgive the harm others caused them than their families.
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Affiliation(s)
- Maureen E Lyon
- Center for Translational Research, Children's Research Institute, Children's National Medical Center, Room M7658, 111 Michigan Avenue, N.W., Washington, DC, 20010-2970, USA,
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A longitudinal, randomized, controlled trial of advance care planning for teens with cancer: anxiety, depression, quality of life, advance directives, spirituality. J Adolesc Health 2014; 54:710-7. [PMID: 24411819 DOI: 10.1016/j.jadohealth.2013.10.206] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 10/11/2013] [Accepted: 10/28/2013] [Indexed: 11/23/2022]
Abstract
PURPOSE To test the feasibility, acceptability and safety of a pediatric advance care planning intervention, Family-Centered Advance Care Planning for Teens With Cancer (FACE-TC). METHODS Adolescent (age 14-20 years)/family dyads (N = 30) with a cancer diagnosis participated in a two-armed, randomized, controlled trial. Exclusion criteria included severe depression and impaired mental status. Acceptability was measured by the Satisfaction Questionnaire. General Estimating Equations models assessed the impact of FACE-TC on 3-month post-intervention outcomes as measured by the Pediatric Quality of Life Inventory 4.0 Generic Core Scale, the Pediatric Quality of Life Inventory 4.0 Cancer-Specific Module, the Beck Depression and Anxiety Inventories, the Spiritual Well-Being Scale of the Functional Assessment of Chronic Illness Therapy-IV, and advance directive completion. RESULTS Acceptability was demonstrated with enrollment of 72% of eligible families, 100% attendance at all three sessions, 93% retention at 3-month post-intervention, and 100% data completion. Intervention families rated FACE-TC worthwhile (100%), whereas adolescents' ratings increased over time (65%-82%). Adolescents' anxiety decreased significantly from baseline to 3 months post-intervention in both groups (β = -5.6; p = .0212). Low depressive symptom scores and high quality of life scores were maintained by adolescents in both groups. Advance directives were located easily in medical records (100% of FACE-TC adolescents vs. no controls). Oncologists received electronic copies. Total Spirituality scores (β = 8.1; p = .0296) were significantly higher among FACE-TC adolescents versus controls. The FACE-TC adolescents endorsed the best time to bring up end-of-life decisions: 19% before being sick, 19% at diagnosis, none when first ill or hospitalized, 25% when dying, and 38% for all of the above. CONCLUSIONS Family-Centered Advance Care Planning for Teens With Cancer demonstrated feasibility and acceptability. Courageous adolescents willingly participated in highly structured, in-depth pediatric advance care planning conversations safely.
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