Distinct Patterns of Conjoint Symptom Distress and Functional Impairment in the Last Year of Life Predict Terminally Ill Cancer Patients' Survival

Patient-caregiver concordance on death preparedness over Taiwanese cancer patients' last 6 months

BACKGROUND

Worldwide patient-caregiver concordance on cognitive prognostic awareness (PA) has been extensively examined, but concordance on sufficient (ie, cognitive and emotional) death preparedness is unexplored. We comprehensively examine the evolution of patient-caregiver concordance on death preparedness over the patient's last 6 months.

MATERIALS/METHODS

This study re-examined data from 2 cohort studies on 694 dyads of cancer patients and their caregivers recruited from a single medical center in Taiwan. Patient and caregiver death-preparedness states were individually identified by latent transition analysis. Patient-caregiver concordance was examined by percentages and kappa coefficients.

RESULTS

No-, cognitive-, emotional-, and sufficient-death-preparedness states were identified for both groups. The no-death-preparedness state reflects neither accurate PA nor adequate emotional preparedness for death. The sufficient-death-preparedness state reflects accurate PA and adequate emotional preparedness for death. In the cognitive- and emotional-death-preparedness states, participants had only accurate PA or adequate emotional-death preparedness, respectively. Prevalence of the sufficient-death-preparedness state increased substantially for patients but decreased slightly for caregivers. Membership in the no- and emotional-preparedness states declined throughout the last 6 months with substantially lower prevalence for caregivers than for patients, whereas the prevalence of the cognitive-death-preparedness state increased. Concordance was poor throughout the patient's last 6 months (percent concordance: 31.6% [95% CI, 24.7%, 38.5%]-43.5% [39.2%, 47.9%], kappa: 0.077 [-0.009, 0.162]-0.115 [0.054, 0.176]) with significant improvement in the last month only.

CONCLUSION

Poor patient-caregiver concordance on death-preparedness states likely reflects the cultural practice of family-consent prognostic disclosure, patients' adjustment for death, and difficulties in patient-caregiver communication on end-of-life (EOL) issues, indicating targets for improving EOL care.

Associations of preloss and postloss factors with severe depressive symptoms and quality of life over the first 2 years of bereavement for family caregivers of terminally ill cancer patients

BACKGROUND

Family caregivers carry heavy end-of-life (EOL) caregiving burdens, with their physical and psychological well-being threatened from caregiving to bereavement. However, caregiving burden has rarely been examined as a risk factor for bereavement adjustment to disentangle the wear-and-tear vs relief models of bereavement. Objective/Methods Preloss and postloss variables associated with severe depressive symptoms and quality of life (QOL) for 201 terminally ill cancer patients' caregivers over their first 2 years of bereavement were simultaneously evaluated using multivariate hierarchical linear modeling. Severe depressive symptoms (Center for Epidemiological Studies Depression Scale score > 16) and QOL (physical and mental component summaries of the Medical Outcomes Study Short-Form Health Survey) were measured 1, 3, 6, 13, 18, and 24 months postloss.

RESULTS

Caregivers' likelihood of severe depressive symptoms and mental health-related QOL improved significantly from the second year and throughout the first 2 years of bereavement, respectively, whereas physical health-related QOL remained steady over time. Higher subjective caregiving burden and postloss concurrent greater social support and better QOL were associated with bereaved caregivers' lower likelihood of severe depressive symptoms. Bereaved caregivers' mental health-related QOL was facilitated and impeded by concurrent greater perceived social support and severe depressive symptoms, respectively.

CONCLUSION

Severe depressive symptoms and mental health-related QOL improved substantially, whereas physical health-related QOL remained steady over the first 2 years of bereavement for cancer patients' caregivers. Timely referrals to adequate bereavement services should be promoted for at-risk bereaved caregivers, thus addressing their support needs and facilitating their bereavement adjustment.

Factors Predisposing Terminally Ill Cancer Patients' Preferences for Distinct Patterns/States of Life-Sustaining Treatments Over Their Last Six Months

CONTEXT

High-quality end-of-life (EOL) care depends on thoroughly assessing terminally ill patients' preferences for EOL care and tailoring care to individual needs. Studies on predictors of EOL-care preferences were primarily cross-sectional and assessed preferences for multiple life-sustaining treatments (LSTs), making clinical applications difficult.

OBJECTIVE/METHODS

We examined factors predisposing cancer patients (N = 303) to specific LST-preference states (life-sustaining preferring, comfort preferring, uncertain, and nutrition preferring) derived from six LSTs (cardiopulmonary resuscitation, intensive care unit care, chest compression, intubation with mechanical ventilation, intravenous nutrition, and tube feeding) in patients' last six months by multilevel multinomial logistic regression.

RESULTS

Participants with accurate prognostic awareness and physician-patient EOL-care discussions were less likely to be in life-sustaining-preferring, uncertain, and nutrition-preferring states than in the comfort-preferring state. Better quality of life (QOL) and more depressive symptoms predisposed participants to be less likely to be in the uncertain than in the comfort-preferring state. Membership in the nutrition-preferring rather than the comfort-preferring state was significantly higher for participants in the state of moderate symptom distress with severe functional impairment than in the state of mild symptom distress with high functioning.

CONCLUSION

Accurate prognostic awareness, physician-patient EOL-care discussions, QOL, depressive symptoms, and symptom-functional states predisposed terminally ill cancer patients to distinct LST-preference states. Clinicians should cultivate patients' accurate prognostic awareness and facilitate EOL-care discussions to foster realistic expectations of LST efficacy at EOL. Clinicians should enhance patients' QOL to reduce uncertainty in EOL-care decision making and provide adequate psychological support to those with more depressive symptoms who prefer comfort care only.

Family Caregivers' Subjective Caregiving Burden, Quality of Life, and Depressive Symptoms Are Associated With Terminally Ill Cancer Patients' Distinct Patterns of Conjoint Symptom Distress and Functional Impairment in Their Last Six Months of Life

CONTEXT

Family caregivers constitute a critical component of the end-of-life care system with considerable cost to themselves. However, the joint association of terminally ill cancer patients' symptom distress and functional impairment with caregivers' subjective caregiving burden, quality of life (QOL), and depressive symptoms remains unknown.

OBJECTIVES/METHODS

We used multivariate hierarchical linear modeling to simultaneously evaluate associations between five distinct patterns of conjoint symptom distress and functional impairment (symptom-functional states) and subjective caregiving burden, QOL, and depressive symptoms in a convenience sample of 215 family caregiver-patient dyads. Data were collected every 2 to 4 weeks over patients' last 6 months.

RESULTS

Caregivers of patients in the worst symptom-functional states (States 3-5) reported worse subjective caregiving burden and depressive symptoms than those in the best two states, but the three outcomes did not differ between caregivers of patients in State 3 and States 4-5. Caregivers of patients in State 5 endured worse subjective caregiving burden and QOL than those in State 4. Caregivers of patients in State 4 suffered worse subjective caregiving burden and depressive symptoms but comparable QOL to those in State 2.

CONCLUSION

Patients' five distinct, conjoint symptom-functional states were significantly and differentially associated with their caregivers' worse subjective caregiving burden, QOL, and depressive symptoms while caring for patients over their last 6 months.