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McClelland S. Accuracy of Medical Oncology Prognosis for Metastatic Cancer Patients Evaluated for Enrollment Onto an Ongoing Randomized Clinical Trial. Am J Clin Oncol 2024:00000421-990000000-00218. [PMID: 38992872 DOI: 10.1097/coc.0000000000001122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
OBJECTIVES For patients with metastatic cancer, a key aspect of interdisciplinary care has involved the overall prognosis provided by Medical Oncology. This study represents prospective evaluation of Medical Oncology prognosis accuracy for patients considered for enrollment onto an ongoing randomized controlled trial. METHODS The Spine Patient Optimal Radiosurgery Treatment for Symptomatic Metastatic Neoplasms (SPORTSMEN) phase 2 randomized clinical trial examines optimal radiation therapy treatment of symptomatic spinal metastases with a primary end point of pain freedom at 3 months post-treatment. A key eligibility criterion for trial enrollment is overall prognosis exceeding 3 months, typically provided by Medical Oncology. During the first year of trial enrollment, Medical Oncology prognosis for patients considered for SPORTSMEN inclusion was prospectively assessed for accuracy. RESULTS Twenty-seven patients with documented Medical Oncology prognosis were considered for SPORTSMEN enrollment. The prognosis administered by Medical Oncology exceeded 3 months in 26 patients, and <3 months in 1 patient. The overall accuracy of Medical Oncology prognosis was correct for 15 of 27 patients (56%), significantly worse for inpatients than outpatients (P=0.0381). CONCLUSIONS In patients with metastatic spine disease, the estimated prognosis provided by Medical Oncology is often optimistic, as nearly half of patients assigned a prognosis of >3 months failed to reach this threshold before experiencing death or hospice. These findings indicate that a more heuristic approach to assessing patient prognosis may be necessary to avoid unwarranted prognostic optimism, particularly for inpatients. Such an approach could potentially provide a more compassionate and cost-effective management of these patients' remaining lifespan thereby optimizing quality of life.
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Affiliation(s)
- Shearwood McClelland
- Departments of Radiation Oncology
- Neurological Surgery, University Hospitals Seidman Cancer Center Case Western Reserve University School of Medicine, Cleveland, OH
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Kupf I, Thanner G, Gerken M, Crispin A, Braess J. How accurate is clinical prognostication by oncologists during routine practice in a general hospital and can it be improved by a specific prognosis training programme: a prospective interventional study. BMJ Open 2024; 14:e081661. [PMID: 38890134 PMCID: PMC11191806 DOI: 10.1136/bmjopen-2023-081661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVES Oncologists need competence in clinical prognostication to deliver appropriate care to patients with cancer. Most studies on prognostication have been restricted to patients in palliative care settings. This paper investigates (1) the prognostic accuracy of physicians regarding a broad cohort of patients with cancer with a median life expectancy of >2 years and (2) whether a prognosis training can improve prognostication. DESIGN Prospective single-centre study comprising 3 phases, each lasting 1 month. SETTING Large teaching hospital, department of oncology and haematology, Germany. PARTICIPANTS 18 physicians with a professional experience from entry level to 34 years. 736 patients with oncological and malignant haematological diseases. INTERVENTIONS Baseline prognostication abilities were recorded during an 'untrained' phase 1. As an intervention, a specific prognosis-training programme was implemented prior to phases 2 and 3. In phase 3, physicians had to provide additional estimates with the inclusion of electronic prognostic tools. OUTCOME MEASURES Prognostic estimates (PE) were collected using 'standard' surprise question (SQ), 'probabilistic' SQ (both for short-term prognostication up to 6 months) and clinician prediction of survival (CPS) (for long-term prognostication). Estimated prognoses were compared with observed survival. Phase 1 was compared with phases 2 and 3. RESULTS We included 2427 PE for SQ, 1506 for CPS and 800 for probabilistic SQ. Median OS was 2.5 years. SQ accuracy improved significantly (p<0.001) from 72.6% in phase 1 to 84.3% in phase 3. Probabilistic SQ in phase 3 showed 83.1% accuracy. CPS accuracy was 25.9% and could not be significantly improved. (Electronic) prognostic tools-used alone-performed significantly worse (p<0.0005) than physicians and-used by the clinicians-did not improve their performance. CONCLUSION A specific prognosis-training programme could improve short-term and intermediate-term prognostication. Improvement of long-term prognostication was not possible. Inexperienced residents as well as experienced oncologists benefited from training.
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Affiliation(s)
- Irma Kupf
- Department of Dermatology and Allergy, Ludwig-Maximilians-Universität München, München, Germany
| | - Gabriele Thanner
- Pepig Gabriele Thanner MS Office and project management consulting, Neutraubling, Germany
| | - Michael Gerken
- Tumor Center, Centre for Quality Management and Health Services Research, University of Regensburg, Regensburg, Germany
| | - Alexander Crispin
- Institute for Medical Information Processing, Biometry, and Epidemiology, Pettenkofer School of Public Health, Medical Faculty, Ludwig-Maximilians-Universität München, München, Germany
| | - Jan Braess
- Department of Oncology and Hematology, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
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Yoong SQ, Bhowmik P, Kapparath S, Porock D. Palliative prognostic scores for survival prediction of cancer patients: a systematic review and meta-analysis. J Natl Cancer Inst 2024; 116:829-857. [PMID: 38366659 DOI: 10.1093/jnci/djae036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/05/2024] [Accepted: 02/13/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND The palliative prognostic score is the most widely validated prognostic tool for cancer survival prediction, with modified versions available. A systematic evaluation of palliative prognostic score tools is lacking. This systematic review and meta-analysis aimed to evaluate the performance and prognostic utility of palliative prognostic score, delirium-palliative prognostic score, and palliative prognostic score without clinician prediction in predicting 30-day survival of cancer patients and to compare their performance. METHODS Six databases were searched for peer-reviewed studies and grey literature published from inception to June 2, 2023. English studies must assess palliative prognostic score, delirium-palliative prognostic score, or palliative prognostic score without clinician-predicted survival for 30-day survival in adults aged 18 years and older with any stage or type of cancer. Outcomes were pooled using the random effects model or summarized narratively when meta-analysis was not possible. RESULTS A total of 39 studies (n = 10 617 patients) were included. Palliative prognostic score is an accurate prognostic tool (pooled area under the curve [AUC] = 0.82, 95% confidence interval [CI] = 0.79 to 0.84) and outperforms palliative prognostic score without clinician-predicted survival (pooled AUC = 0.74, 95% CI = 0.71 to 0.78), suggesting that the original palliative prognostic score should be preferred. The meta-analysis found palliative prognostic score and delirium-palliative prognostic score performance to be comparable. Most studies reported survival probabilities corresponding to the palliative prognostic score risk groups, and higher risk groups were statistically significantly associated with shorter survival. CONCLUSIONS Palliative prognostic score is a validated prognostic tool for cancer patients that can enhance clinicians' confidence and accuracy in predicting survival. Future studies should investigate if accuracy differs depending on clinician characteristics. Reporting of validation studies must be improved, as most studies were at high risk of bias, primarily because calibration was not assessed.
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Affiliation(s)
- Si Qi Yoong
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Priyanka Bhowmik
- Maharaja Jitendra Narayan Medical College and Hospital, Coochbehar, West Bengal, India
| | | | - Davina Porock
- Centre for Research in Aged Care, Edith Cowan University, Australia
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Lee D, Lim B, Nguyen TT, Choi SY. Identifying Suitable Patients for Overcoming Androgen Deprivation Monotherapy in De Novo Metastatic Hormone-Sensitive Prostate Cancer. J Pers Med 2024; 14:517. [PMID: 38793099 PMCID: PMC11122339 DOI: 10.3390/jpm14050517] [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: 04/12/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Although metastatic hormone-sensitive prostate cancer (mHSPC) treatments have evolved, androgen deprivation therapy (ADT) remains a widely used regimen. Therefore, this study sought patients who did not progress to castration-resistant prostate cancer (CRPC) but received ADT monotherapy and factors affecting overall survival (OS) in de novo mHSPC. METHODS De novo mHSPC patients who received ADT treatment were included. ADT included luteinizing hormone-releasing hormone agonists with or without anti-androgen. The total cohort was divided into two groups relative to CRPC progression within two years. Logistic analysis was used to identify factors that did not progress CRPC within two years. Cox regression was used to assess the independent predictors for OS. RESULTS The total cohort was divided into the no-CRPC within two years group (n = 135) and the CRPC within two years group (n = 126). Through multivariate logistic analysis, the life expectancy (odds ratio [OR] 0.95, 95% CI 0.91-0.99, p = 0.014) and Gleason scores (≥9 vs. ≤8; OR 0.43, 95% CI 0.24-0.75, p = 0.003) were associated with the group without castration-resistant prostate cancer progression within two years. The multivariate Cox model revealed that life expectancy (hazard ratio [HR] 0.951, 95% CI 0.904-0.999, p = 0.0491), BMI (HR 0.870, 95% CI 0.783-0.967, p = 0.0101), and CCI (≥2 vs. <2; HR 2.018, 95% CI 1.103-3.693, p = 0.0227) were significant predictive factors for OS. CONCLUSIONS Patients with long life expectancy and a Gleason score of 9 or more were more likely to develop mCRPC while alive. Patients with short life expectancy, low BMI, and worsening comorbidity were more likely to die before progressing to CRPC. Although intensified treatment is essential for oncologic outcomes in mHSPC, shared decision making is integral for patients who may not benefit from this treatment.
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Affiliation(s)
- Donghyun Lee
- Department of Urology, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea;
| | - Bumjin Lim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea;
| | - Tuan Thanh Nguyen
- Department of Urology, Cho Ray Hospital, University of Medicine and Pharmacy, Ho Chi Minh City 700000, Vietnam;
| | - Se Young Choi
- Department of Urology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul 06973, Republic of Korea
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Swiderski D, Taniguchi RN, Chuang E. Are Safety-Net Primary Care Physicians Prepared to Engage in Serious Illness Conversations? Am J Hosp Palliat Care 2024; 41:486-491. [PMID: 37533362 DOI: 10.1177/10499091231190354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Advance Care Planning (ACP) has not reliably improved care for patients at end-of-life. Serious Illness Conversations when patients are in the late stages of chronic illness might be more effective to address patients' goals. The Serious Illness Conversation (SIC) Guide has been helpful but was not developed for use in safety-net settings serving racial and ethnic minority populations. METHODS Physicians were recruited to complete a needs assessment survey prior to training in the use of the SIC Guide. RESULTS Of the 44 physician participants, most were female (82%) and white, non-Hispanic (62%). Less than half of respondents rated themselves as skilled or very skilled in basic serious illness communication related tasks such as setting up goals of care discussions (44%), assessing informational preferences (42%), sharing prognosis (38%), exploring goals for future care (49%) and managing family dynamics (44%). Respondents reported lower skill levels in conducting goals of care conversations via telehealth and establishing trust in racially discordant provider/patient pairs. CONCLUSIONS Most participants expressed the need for further training in critical end-of-life communications skills, including help with encounters with racial and/or language discordance. This may help to explain the failure of ACP discussions to reliably result in appropriate end-of-life care.
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Affiliation(s)
| | | | - Elizabeth Chuang
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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Fernández-Fradejas J, Martínez-Barros H, Rexach-Cano L, Álvarez-Díaz AM, Delgado-Silveira E. Deprescribing in older patients with advanced cancer referred to palliative care. BMJ Support Palliat Care 2024:spcare-2024-004849. [PMID: 38453405 DOI: 10.1136/spcare-2024-004849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVES This study aimed to explore the prevalence of potentially inappropriate medications (PIMs) in a cohort of older adults with advanced cancer referred to palliative care. Secondary objectives were to describe the categories of identified PIMs and assess risk factors associated with their presence in this population. METHODS This retrospective, observational study evaluated patients with advanced cancer admitted to a tertiary university hospital in Madrid, Spain and referred to palliative care between 1 January 2020 and 30 June 2020. Demographic, clinical, and pharmacotherapeutic data were obtained from the electronic medical records and regional databases. PIMs were assessed using the Screening Tool of Older Persons Prescriptions in Frail adults (STOPPFrail) criteria, V1. RESULTS Among 123 patients (median age 80 years (IQR 73.5-87), 64.2% male), 74% presented at least one PIM according to the STOPPFrail criteria. The most common categories of inappropriate medications were lipid-lowering therapies, proton pump inhibitors, calcium supplements, and oral antidiabetics. The number of chronic comedications was significantly associated with PIM presence. CONCLUSIONS Our study found a high prevalence of PIM among a cohort of older adults with advanced cancer and short life expectancy. This underlines the need for a comprehensive medication review to optimise pharmacotherapy in this population.
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Affiliation(s)
| | | | - Lourdes Rexach-Cano
- Unidad de Cuidados Paliativos, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | | | - Eva Delgado-Silveira
- Servicio de Farmacia, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
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Goutam S, Ghosh S, Stosky J, Tam A, Quirk S, Fairchild A, Wu J, Kerba M. An Analysis of Clinical and Systemic Factors Associated with Palliative Radiotherapy Delivery and Completion at the End of Life in Alberta, Canada. Curr Oncol 2023; 30:10043-10056. [PMID: 38132364 PMCID: PMC10742975 DOI: 10.3390/curroncol30120730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/12/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023] Open
Abstract
Radiotherapy (RT) is often utilized for symptom control at the end of life. Palliative RT (pRT) may not be taken to completion by patients, thus decreasing clinical benefits and adversely impacting resource allocation. We determined rates of incomplete pRT and examined predictors of non-completion using an electronic questionnaire. Methods: A questionnaire was embedded within the RT electronic prescribing system for all five cancer centers of Alberta, Canada, between 2017 and 2020. Prescribing radiation oncologists (ROs) were tasked with completing the questionnaire. Treatment variables were collected for 2040 patients prescribed pRT. Details on pRT courses delivered and completed were used to determine rates of incomplete RT. Electronic medical records of a subset of 367 patients randomly selected from the 2040 patients were then analyzed to examine for association of non-completion of RT with patient, disease, and therapy-related factors. Results: Overall, 10% of patients did not complete pRT. The rate of single fractions prescribed as a proportion of all RT fractions increased from 18% (pre-2017: pre-study era) to 29% (2017-2020: study era) (p < 0.0001). After conducting multivariate analysis on the overall group, multiple lifetime malignancies (OR:0.64) or increasing the number of pRT fractions (OR:0.08-0.17) were associated with non-completion. Being selected for stereotactic RT (OR:3.75) or survival > 30 days post-RT prescription (OR:2.20-5.02) were associated with greater rates of RT completion. The ROs' estimates of life expectancy at the time of RT prescription were not predictive of RT completion. In the multivariate analysis of the 367-patient subset, the presence of hepatic metastases (OR 2.59), survival 30-59 days (OR 6.61) and survival 90+ days (OR 8.18) post-RT prescription were associated with pRT completion. Only increasing pRT fractionation (OR:0.05-0.2) was associated with non-completion. Conclusion: One in ten patients prescribed pRT did not complete their treatment course. Decreasing pRT fractionation and improving prognostication in patients near the end of life may decrease rates of incomplete RT courses.
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Affiliation(s)
- Siddhartha Goutam
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R7, Canada
| | - Sunita Ghosh
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R7, Canada
- Cross Cancer Institute, Edmonton, AB T6G 1Z2, Canada
| | - Jordan Stosky
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
| | - Alexander Tam
- Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
| | - Sarah Quirk
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
- Department of Physics and Astronomy, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Alysa Fairchild
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R7, Canada
- Cross Cancer Institute, Edmonton, AB T6G 1Z2, Canada
| | - Jackson Wu
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
| | - Marc Kerba
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
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Gerber K, Bloomer MJ, Hayes B, Lee CY, Lock K, Bodna K, Yates P. Facing uncertainty - Pilot testing of a palliative prognostic index training with hospital aged care assessment teams. Geriatr Nurs 2023; 54:211-218. [PMID: 37839368 DOI: 10.1016/j.gerinurse.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Prognostic avoidance can delay discussions about older hospital patients' life expectancy. This pilot study examined the effects of a prognostic training program on hospital clinicians' knowledge and confidence in identifying older patients at risk of dying. METHODS Fifty-seven clinicians from aged care assessment teams at two Australian hospitals were introduced to the Palliative Prognostic Index, a 5-item checklist indicating prognoses between 3 and 6 weeks. Mixed-methods training evaluation included pre-post-training surveys and semi-structured interviews, conducted three months post-training. RESULTS Clinicians used a combination of experience, knowledge, and intuition as strategies to generate prognoses. Allied health staff relied on intuition more often than medical and nursing staff. Prognostic tools were rarely used. Pre-post-training comparisons showed significant improvements in clinicians' knowledge and confidence in identifying signs of dying, particularly amongst allied health. Follow-up interviews highlighted advantages and challenges of using prognostic tools. Recommendations are made for addressing these.
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Affiliation(s)
- Katrin Gerber
- Melbourne School of Psychological Science, The University of Melbourne, Parkville VIC, 3010 Australia; Melbourne Ageing Research Collaboration, National Ageing Research Institute, Parkville VIC, 3052 Australia; School of Media and Communication, RMIT, Melbourne VIC, 3000 Australia; The Royal Melbourne Hospital, Parkville VIC, 3052 Australia.
| | - Melissa J Bloomer
- School of Nursing and Midwifery, Griffith University, Nathan QLD, 4111, Australia; Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, QLD 4102, Australia; Menzies Health Institute Queensland, Southport 4222 QLD, Australia
| | - Barbara Hayes
- Cancer Services, Northern Health, Bundoora VIC, 3083 Australia; Northern Clinical School, University of Melbourne, Bundoora VIC, 3083 Australia
| | - Cik Yin Lee
- Centre for Medicine Use and Safety, Monash University, Parkville VIC, 3052 Australia; Department of Nursing, University of Melbourne, Parkville VIC, 3052 Australia
| | - Kayla Lock
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Parkville VIC, 3052 Australia; School of Medicine, The University of Melbourne, Parkville VIC, 3010 Australia
| | - Karen Bodna
- Community Advisory Group, Melbourne Ageing Research Collaboration, National Ageing Research Institute, Parkville VIC, 3052 Australia
| | - Paul Yates
- Department of Geriatric Medicine, Austin Health, Heidelberg VIC, 3084 Australia; School of Medicine, The University of Melbourne, Parkville VIC, 3010 Australia
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Spooner C, Vivat B, White N, Bruun A, Rohde G, Kwek PX, Stone P. What outcomes do studies use to measure the impact of prognostication on people with advanced cancer? Findings from a systematic review of quantitative and qualitative studies. Palliat Med 2023; 37:1345-1364. [PMID: 37586031 PMCID: PMC10548779 DOI: 10.1177/02692163231191148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
BACKGROUND Studies evaluating the impact of prognostication in advanced cancer patients vary in the outcomes they measure, and there is a lack of consensus about which outcomes are most important. AIM To identify outcomes previously reported in prognostic research with people with advanced cancer, as a first step towards constructing a core outcome set for prognostic impact studies. DESIGN A systematic review was conducted and analysed in two subsets: one qualitative and one quantitative. (PROSPERO ID: CRD42022320117; 29/03/2022). DATA SOURCES Six databases were searched from inception to September 2022. We extracted data describing (1) outcomes used to measure the impact of prognostication and (2) patients' and informal caregivers' experiences and perceptions of prognostication in advanced cancer. We classified findings using the Core Outcome Measures in Effectiveness Trials (COMET) initiative taxonomy, along with a narrative description. We appraised retrieved studies for quality, but quality was not a basis for exclusion. RESULTS We identified 42 eligible studies: 32 quantitative, 6 qualitative, 4 mixed methods. We extracted 70 outcomes of prognostication in advanced cancer and organised them into 12 domains: (1) survival; (2) psychiatric outcomes; (3) general outcomes; (4) spiritual/religious/existential functioning/wellbeing, (5) emotional functioning/wellbeing; (6) cognitive functioning; (7) social functioning; (8) global quality of life; (9) delivery of care; (10) perceived health status; (11) personal circumstances; and (12) hospital/hospice use. CONCLUSION Outcome reporting and measurement varied markedly across the studies. A standardised approach to outcome reporting in studies of prognosis is necessary to enhance data synthesis, improve clinical practice and better align with stakeholders' priorities.
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Affiliation(s)
- Caitlin Spooner
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Bella Vivat
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Nicola White
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Andrea Bruun
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Gudrun Rohde
- Marie Curie Palliative Care Research Department, University College London, London, UK
- Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
| | - Pei Xing Kwek
- University College Dublin School of Medicine, University College Dublin, Dublin, Ireland
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, University College London, London, UK
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Horning MA, Bowen ME. Characterizing end-of-life communication in families. Palliat Care Soc Pract 2023; 17:26323524231193033. [PMID: 37674618 PMCID: PMC10478557 DOI: 10.1177/26323524231193033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 07/21/2023] [Indexed: 09/08/2023] Open
Abstract
Background The chronic disease course can be uncertain, contributing to delayed end-of-life discussion within families resulting in missed opportunity to articulate wishes, increased decisional uncertainty, and delayed hospice care. Consistent with the Family Communication Patterns Theory (FCPT), family communication patterns may affect the quality and timing of end-of-life discussion, hospice utilization, and the experience of 'a good death.' Objective To assess how families' conversation and conformity orientation (spontaneity of conversation and hierarchical rigidity) form four family communication patterns (consensual, pluralistic, protective, and laissez-faire) and may be associated with the number and timing of end-of-life discussions. Design A cross-sectional study. Methods Family members of loved ones who died from chronic illnesses while in hospice (n = 56) completed online surveys including a modified Revised Family Communication Pattern instrument (RFCP) and the Chronic Illness Rating Scale (CIRS). Additional survey questions assessed the number and timing of end-of-life discussions and timing of hospice enrollment. IBM SPSS version 26 was used for descriptive analysis. Results Most families (42.9%) were pluralistic, reporting communication styles with high conversation and low conformity orientation; (39.29%) were protective, reporting low conversation and high conformity orientation. Pluralistic families had more end-of-life conversations than did protective families. Conclusion Study findings suggest that there may be a relationship between family communication pattern type and inclination toward end-of-life discussion. This first step supports future research regarding whether the FCPT can be used to predict which families may be at increased risk for ineffective or delayed end-of-life discussion. Additional variables to consider include the timing of hospice enrollment and the quality of the dying experience. Clinicians may ultimately use findings to facilitate earlier identification of and intervention for families who are at risk for poor end-of-life communication and outcomes.
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Affiliation(s)
- Melanie A. Horning
- Department of Nursing, Towson University, 8000 York Road, Towson, MD 21252, USA
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Deng X, Gao W, Zhao R. Perspectives of prognosis and end-of-life care in patients with progressive cancer: A single-center analysis. Asian J Surg 2023; 46:3969-3970. [PMID: 37117063 DOI: 10.1016/j.asjsur.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 04/03/2023] [Indexed: 04/30/2023] Open
Affiliation(s)
- Xiaomeng Deng
- Department of Digestive System, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, 3 Workers' New Street, Taiyuan, 030013, Shanxi Province, China.
| | - Wei Gao
- Department of Thoracic Surgery, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, 3 Workers' New Street, Taiyuan, 030013, Shanxi Province, China.
| | - Runli Zhao
- Department of Respiratory, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, 3 Workers' New Stree, Taiyuan, 030013, Shanxi Province, China.
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Yoong SQ, Porock D, Whitty D, Tam WWS, Zhang H. Performance of the Palliative Prognostic Index for cancer patients: A systematic review and meta-analysis. Palliat Med 2023; 37:1144-1167. [PMID: 37310019 DOI: 10.1177/02692163231180657] [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] [Indexed: 06/14/2023]
Abstract
BACKGROUND Clinician predicted survival for cancer patients is often inaccurate, and prognostic tools may be helpful, such as the Palliative Prognostic Index (PPI). The PPI development study reported that when PPI score is greater than 6, it predicted survival of less than 3 weeks with a sensitivity of 83% and specificity of 85%. When PPI score is greater than 4, it predicts survival of less than 6 weeks with a sensitivity of 79% and specificity of 77%. However, subsequent PPI validation studies have evaluated various thresholds and survival durations, and it is unclear which is most appropriate for use in clinical practice. With the development of numerous prognostic tools, it is also unclear which is most accurate and feasible for use in multiple care settings. AIM We evaluated PPI model performance in predicting survival of adult cancer patients based on different thresholds and survival durations and compared it to other prognostic tools. DESIGN This systematic review and meta-analysis was registered in PROSPERO (CRD42022302679). We calculated the pooled sensitivity and specificity of each threshold using bivariate random-effects meta-analysis and pooled diagnostic odds ratio of each survival duration using hierarchical summary receiver operating characteristic model. Meta-regression and subgroup analysis were used to compare PPI performance with clinician predicted survival and other prognostic tools. Findings which could not be included in meta-analyses were summarised narratively. DATA SOURCES PubMed, ScienceDirect, Web of Science, CINAHL, ProQuest and Google Scholar were searched for articles published from inception till 7 January 2022. Both retrospective and prospective observational studies evaluating PPI performance in predicting survival of adult cancer patients in any setting were included. The Prediction Model Risk of Bias Assessment Tool was used for quality appraisal. RESULTS Thirty-nine studies evaluating PPI performance in predicting survival of adult cancer patients were included (n = 19,714 patients). Across meta-analyses of 12 PPI score thresholds and survival durations, we found that PPI was most accurate for predicting survival of <3 weeks and <6 weeks. Survival prediction of <3 weeks was most accurate when PPI score>6 (pooled sensitivity = 0.68, 95% CI 0.60-0.75, specificity = 0.80, 95% CI 0.75-0.85). Survival prediction of <6 weeks was most accurate when PPI score>4 (pooled sensitivity = 0.72, 95% CI 0.65-0.78, specificity = 0.74, 95% CI 0.66-0.80). Comparative meta-analyses found that PPI performed similarly to Delirium-Palliative Prognostic Score and Palliative Prognostic Score in predicting <3-week survival, but less accurately in <30-day survival prediction. However, Delirium-Palliative Prognostic Score and Palliative Prognostic Score only provide <30-day survival probabilities, and it is uncertain how this would be helpful for patients and clinicians. PPI also performed similarly to clinician predicted survival in predicting <30-day survival. However, these findings should be interpreted with caution as limited studies were available for comparative meta-analyses. Risk of bias was high for all studies, mainly due to poor reporting of statistical analyses. while there were low applicability concerns for most (38/39) studies. CONCLUSIONS PPI score>6 should be used for <3-week survival prediction, and PPI score>4 for <6-week survival. PPI is easily scored and does not require invasive tests, and thus would be easily implemented in multiple care settings. Given the acceptable accuracy of PPI in predicting <3- and <6-week survival and its objective nature, it could be used to cross-check clinician predicted survival especially when clinicians have doubts about their own judgement, or when clinician estimates seem to be less reliable. Future studies should adhere to the reporting guidelines and provide comprehensive analyses of PPI model performance.
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Affiliation(s)
- Si Qi Yoong
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Davina Porock
- School of Nursing and Midwifery, Edith Cowan University, Perth, WA, Australia
| | - Dee Whitty
- School of Nursing and Midwifery, Edith Cowan University, Perth, WA, Australia
| | - Wilson Wai San Tam
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hui Zhang
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- St. Andrew's Community Hospital, Singapore
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13
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Kapoor I, Prabhakar H, Mahajan C, Zirpe KG, Tripathy S, Wanchoo J, Kakkar G, Sapra H, Gupta N, Singhal V, Chaturvedi A. A Nationwide Survey on the Practice of End-of-life Care Issues in Critical Care Units in India. Indian J Crit Care Med 2023; 27:305-314. [PMID: 37214124 PMCID: PMC10196640 DOI: 10.5005/jp-journals-10071-24446] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 05/24/2023] Open
Abstract
Background End-of-life (EOL) care is the care of terminally ill patients who are nearing their end. It includes important components like palliative care, supportive care, hospice care, patient's right to choose, and choice of medical intervention, including continuation of routine medical interventions. The aim of this survey was to assess the practices of EOL care in various critical care units in India. Methods The participants included clinicians involved in EOL care of patients with advanced diseases in different hospital across India. We sent blast emails and posted links on social media for inviting participants to take the survey. Study data were collected and managed by using Google Forms. The collected information was automatically entered into a spread sheet and stored in a secure database. Results In total, 91 clinicians took the survey. The years of experience, practice area, and setting had significant effect on the palliative care, terminal strategy, and prognostication in terminally ill patients (p < 0.05). Statistical analysis was done using software STATA. Descriptive statistics were performed, and results were presented as number (percentage). Conclusion The years of work experience, the practice area, and the practice setting have a strong impact on EOL care management of terminally ill patients. There are a lot of gaps in providing EOL care for these patients. Many reforms are needed in the Indian health care system to make EOL care better. How to cite this article Kapoor I, Prabhakar H, Mahajan C, Zirpe KG, Tripathy S, Wanchoo J, et al. A Nationwide Survey on the Practice of End-of-life Care Issues in Critical Care Units in India. Indian J Crit Care Med 2023;27(5):305-314.
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Affiliation(s)
- Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | | | - Swagata Tripathy
- Department of Anesthesia and Intensive Care, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Jaya Wanchoo
- Department of Neuroanaesthesia and Neurocritical Care, Medanta The Medicity, Gurgaon, Haryana, India
| | - Gaurav Kakkar
- Department of Neuroanaesthesia and Neurocritical Care, Amrita Hospital, Faridabad, India
| | - Harsh Sapra
- Department of Neuroanaesthesia and Neurocritical Care, Medanta The Medicity, Gurgaon, Haryana, India
| | - Nidhi Gupta
- Department of Neuroanaesthesia, Indraprastha Apollo Hospital, New Delhi, India
| | - Vasudha Singhal
- Department of Neuroanaesthesia and Neurocritical Care, Medanta The Medicity, Gurgaon, Haryana, India
| | - Arvind Chaturvedi
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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14
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Stone P, Buckle P, Dolan R, Feliu J, Hui D, Laird BJA, Maltoni M, Moine S, Morita T, Nabal M, Vickerstaff V, White N, Santini D, Ripamonti CI. Prognostic evaluation in patients with advanced cancer in the last months of life: ESMO Clinical Practice Guideline. ESMO Open 2023; 8:101195. [PMID: 37087198 PMCID: PMC10242351 DOI: 10.1016/j.esmoop.2023.101195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/08/2023] [Accepted: 02/16/2023] [Indexed: 04/24/2023] Open
Abstract
•This ESMO Clinical Practice Guideline provides key recommendations for using prognostic estimates in advanced cancer. •The guideline covers recommendations for patients with cancer and an expected survival of months or less. •An algorithm for use of clinical predictions, prognostic factors and multivariable risk prediction models is presented. •The author group encompasses a multidisciplinary group of experts from different institutions in Europe, USA and Asia. •Recommendations are based on available scientific data and the authors’ collective expert opinion.
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Affiliation(s)
- P Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK; Palliative Care Team, Central and North West London NHS Trust, London, UK
| | | | - R Dolan
- Academic Unit of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - J Feliu
- Department of Medical Oncology, La Paz University Hospital, IdiPAZ, CIBERONC, Cátedra UAM-AMGEN, Madrid, Spain
| | - D Hui
- Departments of Palliative Care, Rehabilitation and Integrative Medicine, Houston, USA; General Oncology, University of Texas MD Anderson Cancer Center, Houston, USA
| | - B J A Laird
- Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK; St Columba's Hospice Care, Edinburgh, UK
| | - M Maltoni
- Medical Oncology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Specialised, Experimental and Diagnostic Medicine, University of Bologna, Bologna, Italy
| | - S Moine
- Health Education and Practices Laboratory (LEPS EA3412), University Paris Sorbonne Paris Cité, Bobigny, Paris, France
| | - T Morita
- Department of Palliative and Supportive Care, Palliative Care Team and Seirei Hospice, Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - M Nabal
- Palliative Care Supportive Team, Hospital Universitario Arnau de Vilanova, Lleida, Spain
| | - V Vickerstaff
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - N White
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - D Santini
- UOC Oncologia Medica Territoriale, La Sapienza University of Rome, Polo Pontino, Rome, Italy
| | - C I Ripamonti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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15
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Dark-Freudeman A, Bensadon BA. Advance care planning: End-of-life hopes and fears among community dwelling adults. J Health Psychol 2022; 27:3177-3189. [PMID: 35445612 DOI: 10.1177/13591053221089726] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
End-of-life (EOL) medical care in the United States often does not align with patients' goals and preferences. This study explored EOL hopes and fears among 86 community-dwelling adults and examined medical and psychological predictors of death anxiety. Common EOL hopes included absence of suffering, closure, and personal fulfillment. Common EOL fears included suffering, lack of competence, and specific types of death. Fear of the dying process was greater than fear of death itself. Health predicted death anxiety; age alone, did not. Advance care planning and clinical decision making should include these psychological insights and explicitly address EOL hopes and fears.
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16
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Jøhnk C, Laigaard HH, Pedersen AK, Bauer EH, Brandt F, Bollig G, Wolff DL. Time to End-of-Life of Patients Starting Specialised Palliative Care in Denmark: A Descriptive Register-Based Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13017. [PMID: 36293593 PMCID: PMC9602996 DOI: 10.3390/ijerph192013017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
Increasing numbers of patients are being referred to specialised palliative care (SPC) which, in order to be beneficial, is recommended to last more than three months. This cohort study aimed to describe time to end-of-life after initiating SPC treatment and to explore potential regional variations. We used national register data from all Danish hospital SPC teams. We included patients who started SPC treatment from 2015-2018 to explore if time to end-of-life was longer than three months. Descriptive statistics were used to summarise the data and a generalised linear model was used to assess variations among the five Danish regions. A total of 27,724 patients were included, of whom 36.7% (95% CI 36.2-37.1%) had over three months to end-of-life. In the Capital Region of Denmark, 40.1% (95% CI 39.0-41.3%) had over three months to end-of-life versus 32.5% (95% CI 30.9-34.0%) in North Denmark Region. We conclude that most patients live for a shorter period of time than the recommended three months after initiating SPC treatment. This is neither optimal for patient care, nor the healthcare system. A geographical variation between regions was shown indicating different practices, patient groups or resources. These results warrant further investigation to promote optimal SPC treatment.
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Affiliation(s)
- Camilla Jøhnk
- Department of Internal Medicine, Hospital Sønderjylland, University Hospital of Southern Denmark, Sydvang 1, 6400 Sønderborg, Denmark
| | - Helene Holm Laigaard
- Department of Internal Medicine, Hospital Sønderjylland, University Hospital of Southern Denmark, Sydvang 1, 6400 Sønderborg, Denmark
| | - Andreas Kristian Pedersen
- Department of Regional Health Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense, Denmark
- Department of Clinical Research, Hospital Sønderjylland, University Hospital of Southern Denmark, Kresten Philipsens Vej 15, 6200 Aabenraa, Denmark
| | - Eithne Hayes Bauer
- Department of Regional Health Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense, Denmark
- Internal Medicine Research Unit, Hospital Sønderjylland, University Hospital of Southern Denmark, Kresten Philipsens Vej 15, 6200 Aabenraa, Denmark
| | - Frans Brandt
- Department of Internal Medicine, Hospital Sønderjylland, University Hospital of Southern Denmark, Sydvang 1, 6400 Sønderborg, Denmark
- Department of Regional Health Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense, Denmark
- Internal Medicine Research Unit, Hospital Sønderjylland, University Hospital of Southern Denmark, Kresten Philipsens Vej 15, 6200 Aabenraa, Denmark
| | - Georg Bollig
- Department of Internal Medicine, Hospital Sønderjylland, University Hospital of Southern Denmark, Sydvang 1, 6400 Sønderborg, Denmark
- Department of Regional Health Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense, Denmark
- Internal Medicine Research Unit, Hospital Sønderjylland, University Hospital of Southern Denmark, Kresten Philipsens Vej 15, 6200 Aabenraa, Denmark
- Department of Anesthesiology, Intensive Care, Palliative Medicine and Pain Therapy, HELIOS Klinikum, 24837 Schleswig, Germany
| | - Donna Lykke Wolff
- Department of Regional Health Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense, Denmark
- Internal Medicine Research Unit, Hospital Sønderjylland, University Hospital of Southern Denmark, Kresten Philipsens Vej 15, 6200 Aabenraa, Denmark
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Gilmore N, Culakova E, Mohile S. In Reply to the Comment on "The Relationship Between Frailty and Emotional Health in Older Patients With Advanced Cancer". Oncologist 2022; 27:e820-e821. [PMID: 35947999 PMCID: PMC9526486 DOI: 10.1093/oncolo/oyac153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/28/2022] [Indexed: 11/13/2022] Open
Abstract
This letter to the editor responds to comments on an article that reported on the prevalence of frailty, anxiety, depression, and distress and the relationships between frailty and emotional health in older patients with advanced cancer.
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Affiliation(s)
- Nikesha Gilmore
- Department of Surgery, Division of Supportive Care in Cancer, University of Rochester Medical Center, Rochester, NY, USA
| | - Eva Culakova
- Department of Surgery, Division of Supportive Care in Cancer, University of Rochester Medical Center, Rochester, NY, USA
| | - Supriya Mohile
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
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18
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Chuang E, Yu S, Georgia A, Nymeyer J, Williams J. A Decade of Studying Drivers of Disparities in End-of-Life Care for Black Americans: Using the NIMHD Framework for Health Disparities Research to Map the Path Ahead. J Pain Symptom Manage 2022; 64:e43-e52. [PMID: 35381316 PMCID: PMC9189009 DOI: 10.1016/j.jpainsymman.2022.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 03/02/2022] [Accepted: 03/24/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of this paper is to provide a review of the existing literature on racial disparities in quality of palliative and end-of-life care and to demonstrate gaps in the exploration of underlying mechanisms that produce these disparities. BACKGROUND Countless studies over several decades have revealed that our healthcare system in the United States consistently produces poorer quality end-of-life care for Black compared with White patients. Effective interventions to reduce these disparities are sparse and hindered by a limited understanding of the root causes of these disparities. METHODS We searched PubMed, CINAHL and PsychInfo for research manuscripts that tested hypotheses about causal mechanisms for disparities in end-of-life care for Black patients. These studies were categorized by domains outlined in the National Institute of Minority Health and Health Disparities (NIMHD) framework, which are biological, behavioral, physical/built environment, sociocultural and health care systems domains. Within these domains, studies were further categorized as focusing on the individual, interpersonal, community or societal level of influence. RESULTS The majority of the studies focused on the Healthcare System and Sociocultural domains. Within the Health Care System domain, studies were evenly distributed among the individual, interpersonal, and community level of influence, but less attention was paid to the societal level of influence. In the Sociocultural domain, most studies focused on the individual level of influence. Those focusing on the individual level of influence tended to be of poorer quality. CONCLUSIONS The sociocultural environment, physical/built environment, behavioral and biological domains remain understudied areas of potential causal mechanisms for racial disparities in end-of-life care. In the Healthcare System domain, social influences including healthcare policy and law are understudied. In the sociocultural domain, the majority of the studies still focused on the individual level of influence, missing key areas of research in interpersonal discrimination and local and societal structural discrimination. Studies that focus on individual factors should be better screened to ensure that they are of high quality and avoid stigmatizing Black communities.
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Affiliation(s)
- Elizabeth Chuang
- Department of Family and Social Medicine (E.C.), Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Sandra Yu
- Columbia Mailman School of Public Health (S.Y.), New York, NY, USA
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19
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Lund JL, Duberstein PR, Loh KP, Gilmore N, Plumb S, Lei L, Keil AP, Islam JY, Hanson LC, Giguere JK, Vogel VG, Burnette BL, Mohile SG. Life expectancy in older adults with advanced cancer: Evaluation of a geriatric assessment-based prognostic model. J Geriatr Oncol 2022; 13:176-181. [PMID: 34483079 PMCID: PMC8882125 DOI: 10.1016/j.jgo.2021.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 08/06/2021] [Accepted: 08/25/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Oncologists estimate patients' prognosis to guide care. Evidence suggests oncologists tend to overestimate life expectancy, which can lead to care with questionable benefits. Information obtained from geriatric assessment may improve prognostication for older adults. In this study, we created a geriatric assessment-based prognostic model for older adults with advanced cancer and compared its performance to alternative models. MATERIALS AND METHODS We conducted a secondary analysis of a trial (URCC 13070; PI: Mohile) capturing geriatric assessment and vital status up to one year for adults age ≥ 70 years with advanced cancer. Oncologists estimated life expectancy as 0-6 months, 7-12 months, and > 1 year. Three statistical models were developed: (1) a model including age, sex, cancer type, and stage (basic model), (2) basic model + Karnofsky Performance Status (≤50, 60-70, and 80+) (KPS model), and (3) basic model +16 binary indicators of geriatric assessment impairments (GA model). Cox regression was used to model one-year survival; c-indices and time-dependent c-statistics assessed model discrimination and stratified survival curves assessed model calibration. RESULTS We included 484 participants; mean age was 75; 48% had gastrointestinal or lung cancer. Overall, 43% of patients died within one year. Oncologists classified prognosis accurately for 55% of patients, overestimated for 35%, and underestimated for 10%. C-indices were 0.61 (basic model), 0.62 (KPS model), and 0.63 (GA model). The GA model was well-calibrated. CONCLUSIONS The GA model showed moderate discrimination for survival, similar to alternative models, but calibration was improved. Further research is needed to optimize geriatric assessment-based prognostic models for use in older adults with advanced cancer.
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Affiliation(s)
- Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Paul R Duberstein
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Kah Poh Loh
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Nikesha Gilmore
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Sandy Plumb
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Lianlian Lei
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Alexander P Keil
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jessica Y Islam
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jeffrey K Giguere
- NCORP of the Carolinas (Greenville Health System NCORP), Greenville, SC, USA
| | | | - Brian L Burnette
- Cancer Research of Wisconsin and Northern Michigan (CROWN) NCORP, Grand Rapids, MI, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY, USA
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20
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Ivey GD, Johnston FM. Barriers to Equitable Palliative Care Utilization Among Patients with Cancer. Surg Oncol Clin N Am 2021; 31:9-20. [PMID: 34776067 DOI: 10.1016/j.soc.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Over the past half century, palliative care has grown to become a pillar of clinical oncology. Its practice revolves around relieving suffering and optimizing quality of life, not just dealing with end-of-life decisions. Despite evidence that palliative care has the potential to reduce health care utilization and improve advance care planning without affecting mortality, palliative care remains inequitably accessible and underutilized. Furthermore, it is still too often introduced late in the care of patients receiving surgical intervention. This article summarizes the numerous and complex barriers to equitable palliative care utilization among patients with cancer. Potential strategies for dismantling these barriers are also discussed.
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Affiliation(s)
- Gabriel D Ivey
- Department of Surgery, Division of Surgical Oncology, The Johns Hopkins University, 600 North Wolfe Street, Blalock 611, Baltimore, MD 21287, USA
| | - Fabian M Johnston
- Department of Surgery, Division of Surgical Oncology, The Johns Hopkins University, 600 North Wolfe Street, Blalock 606, Baltimore, MD 21287, USA.
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21
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Epstein RM. Facing epistemic and complex uncertainty in serious illness: The role of mindfulness and shared mind. PATIENT EDUCATION AND COUNSELING 2021; 104:2635-2642. [PMID: 34334265 DOI: 10.1016/j.pec.2021.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Epistemic uncertainty refers to situations in which available evidence is insufficient or unreliable, often accompanied by complexity due to novel contexts, multifactorial causation, and emerging options (the "unknowable unknown"). It stands in contrast to aleatory uncertainty where probabilities are known, and potential benefits and harms can be calculated and presented graphically (the "knowable unknown"). DISCUSSION Epistemic uncertainty is common, and encompasses uncertainty about the nature of the illness, whom to entrust with one's care, and one's ability to adapt and cope. Communication about the "unknowable unknown" occurs infrequently and ineffectively, and there is little research on improving communication in the face of epistemic and complex uncertainty. Terror Management Theory (TMT) predicts that in encountering serious illness, people engage in "worldview defense" - suppressing death-related thoughts, affiliating with like-minded others, and developing cognitive rigidity and intolerance of information that challenges their worldview. Mindfulness is associated with diminished defensive worldview reactions and cognitive rigidity, and greater tolerance of ambiguity. Shared mind encompasses shared understanding and affective attunement. CONCLUSION For clinicians and seriously ill patients facing epistemic uncertainty, psychologically-informed interventions that promote mindfulness and shared mind offer promise in promoting open discussions regarding prognostic uncertainty, advance care planning, and treatment decision-making.
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Affiliation(s)
- Ronald M Epstein
- Center for Communication and Disparities Research, Department of Family Medicine, and Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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22
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Bazargan M, Cobb S, Assari S, Bazargan-Hejazi S. Preparedness for Serious Illnesses: Impact of Ethnicity, Mistrust, Perceived Discrimination, and Health Communication. Am J Hosp Palliat Care 2021; 39:461-471. [PMID: 34476995 PMCID: PMC10173884 DOI: 10.1177/10499091211036885] [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] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Increasing severity of serious illness requires individuals to prepare and make decisions to mitigate adverse consequences of their illness. In a racial and ethnically diverse sample, the current study examined preparedness for serious illness among adults in California. METHODS This cross-sectional study used data from the Survey of California Adults on Serious Illness and End-of-Life 2019. Participants included 542 non-Hispanic White (52%), non-Hispanic Black (28%), and Hispanic (20%) adults who reported at least one chronic medical condition that they perceived to be a serious illness. Race/ethnicity, socio-demographic factors, health status, discrimination, mistrust, and communication with provider were measured. To perform data analysis, we used logistic regression models. RESULTS Our findings revealed that 19%, 24%, and 34% of non-Hispanic White, non-Hispanic Blacks, and Hispanic believed they were not prepared if their medical condition gets worse, respectively. Over 60% indicated that their healthcare providers never engaged them in discussions of their feelings of fear, stress, or sadness related to their illnesses. Results of bivariate analyses showed that race/ethnicity was associated with serious illness preparedness. However, multivariate analysis uncovered that serious illness preparedness was only lower in the presence of medical mistrust in healthcare providers, perceived discrimination, less communication with providers, and poorer quality of self-rated health. CONCLUSION This study draws attention to the need for healthcare systems and primary care providers to engage in effective discussions and education regarding serious illness preparedness with their patients, which can be beneficial for both individuals and family members and increase quality of care.
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Affiliation(s)
- Mohsen Bazargan
- Department of Family Medicine, Charles R. Drew University of Medicine and Science & University of California at Los Angeles (UCLA), Los Angeles, CA, USA.,Department of Public Health, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA.,Physician Assistant Program, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA.,Department of Family Medicine, UCLA, Los Angeles, CA, USA
| | - Sharon Cobb
- School of Nursing, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Shervin Assari
- Department of Family Medicine, Charles R. Drew University of Medicine and Science & University of California at Los Angeles (UCLA), Los Angeles, CA, USA.,Department of Public Health, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Shahrzad Bazargan-Hejazi
- Department of Psychiatry, Charles R. Drew University of Medicine and Science & University of California at Los Angeles (UCLA), Los Angeles, CA, USA
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Bazargan M, Bazargan-Hejazi S. Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature. Am J Hosp Palliat Care 2021; 38:688-718. [PMID: 33287561 PMCID: PMC8083078 DOI: 10.1177/1049909120966585] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Published research in disparities in advance care planning, palliative, and end-of-life care is limited. However, available data points to significant barriers to palliative and end-of-life care among minority adults. The main objective of this scoping review was to summarize the current published research and literature on disparities in palliative and hospice care and completion of advance care planning and directives among non-Hispanc Blacks. METHODS The scoping review method was used because currently published research in disparities in palliative and hospice cares as well as advance care planning are limited. Nine electronic databases and websites were searched to identify English-language peer-reviewed publications published within last 20 years. A total of 147 studies that addressed palliative care, hospice care, and advance care planning and included non-Hispanic Blacks were incorporated in this study. The literature review include manuscripts that discuss the intersection of social determinants of health and end-of-life care for non-Hispanic Blacks. We examined the potential role and impact of several factors, including knowledge regarding palliative and hospice care; healthcare literacy; communication with providers and family; perceived or experienced discrimination with healthcare systems; mistrust in healthcare providers; health care coverage, religious-related activities and beliefs on palliative and hospice care utilization and completion of advance directives among non-Hispanic Blacks. DISCUSSION Cross-sectional and longitudinal national surveys, as well as local community- and clinic-based data, unequivocally point to major disparities in palliative and hospice care in the United States. Results suggest that national and community-based, multi-faceted, multi-disciplinary, theoretical-based, resourceful, culturally-sensitive interventions are urgently needed. A number of practical investigational interventions are offered. Additionally, we identify several research questions which need to be addressed in future research.
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Affiliation(s)
- Mohsen Bazargan
- Department of Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shahrzad Bazargan-Hejazi
- Department of Psychiatry, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA
- Department of Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Fernandes M, Branco TP, Fernandez MCN, Paparelli C, Braz MS, Kishimoto CS, de Freitas Medeiros HM, Ebina K, Cabral LRB, Nagashima S, de Avó Cortizo SA, Borges F, Monteiro MR, Abrahao ABK, Moreira RB, dos Santos Tavares AP, Aguiar PN. Palliative Prognostic Index accuracy of survival prediction in an inpatient palliative care service at a Brazilian tertiary hospital. Ecancermedicalscience 2021; 15:1228. [PMID: 34158832 PMCID: PMC8183653 DOI: 10.3332/ecancer.2021.1228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Indexed: 11/06/2022] Open
Abstract
PURPOSE The Palliative Prognostic Index (PPI) was developed to improve survival prediction for advanced cancer patients. However, there is limited data about the PPI application in a real-world scenario. This study aimed to assess the accuracy of PPI > 6 in predicting survival of cancer inpatients. METHODS A prospective observational cohort in an inpatient palliative care service at a tertiary hospital in São Paulo-SP, Brazil, between May 2011 and December 2018. RESULTS We included 1,376 critically ill cancer inpatients. Patients were divided into three PPI subgroups: PPI ≤ 4, PPI 4-6, and PPI ≥ 6. Their respective medium overall survival values were 44 days (95% confidence interval [CI] 35.52-52.47), 20 days (95% CI 15.40-24.59), and 8 days (95% CI 7.02-8.98), (p < 0.001). PPI ≥ 6 predicted survival of <3 weeks with a positive predictive value (PPV) of 72% and an negative predictive value (NPV) of 68% (sensitivity 67%, specificity 72%). PPI > 4 predicted survival of <6 weeks with a PPV of 88% and an NPV of 36% (sensitivity 74%, specificity 59%). When PPI was <4, the mortality rate over 3 weeks was 39% with a relative risk (RR) of 0.15 (95% CI 0.11-0.20; p < 0.001), and the 6-week mortality rate was 63% with a RR of 0.18 (95% CI 0.13-0.25; p < 0.001) compared to PPI ≥ 4. CONCLUSIONS PPI was a good discriminator of survival among critically ill cancer inpatients and could assist in hospital discharge decision. PPI may help healthcare policymakers and professionals in offering high-quality palliative care to patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Karen Ebina
- Americas Centro de Oncologia Integrado, São Paulo 01321-001, Brazil
| | | | - Simone Nagashima
- Americas Centro de Oncologia Integrado, São Paulo 01321-001, Brazil
| | | | - Fabíola Borges
- Americas Centro de Oncologia Integrado, São Paulo 01321-001, Brazil
| | | | | | | | | | - Pedro Nazareth Aguiar
- Americas Centro de Oncologia Integrado, São Paulo 01321-001, Brazil
- Faculdade de Medicina do ABC, Santo André 09060-870, Brazil
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25
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Abstract
Traditional healthcare services have demonstrated structural shortcomings in the delivery of patient care and enforced numerous elements of integration in the delivery of healthcare services. Integrated healthcare aims at providing all healthcare that makes humans healthy. However, with mainly chronically ill people and seniors, typically suffering from numerous comorbidities and diseases, being recruited for care, there is a need for a change in the healthcare service structure beyond direct-patient care to be compatible in peacetime and during public health emergencies. This article’s objective is to discuss the opportunities and obstacles for increasing the effectiveness of healthcare through improved integration. A rapid evidence review approach was used by performing a systematic followed by a non-systematic literature review and content analysis. The results confirmed that integrated healthcare systems play an increasingly important role in healthcare system reforms undertaken in European Union countries. The essence of these changes is the transition from the episodic treatment of acute diseases to the provision of coordinated medical services, focused on chronic cases, prevention, and ensuring patient continuity. However, integrated healthcare, at a level not yet fully defined, will be necessary if we are to both define and attain the integrated practice of both global health and global public health emergencies. This paper attains the necessary global challenges to integrate healthcare effectively at every level of society. There is a need for more knowledge to effectively develop, support, and disseminate initiatives related to coordinated healthcare in the individual healthcare systems.
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26
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Binder F, Ungaro CM, Bonella MB, Cafferata CM, Giunta DH, Ferreyro BL. Timing of palliative care referral in patients with advanced Non-Small Cell Lung Cancer: a retrospective cohort study. PROGRESS IN PALLIATIVE CARE 2021. [DOI: 10.1080/09699260.2021.1890914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Fernando Binder
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Health Data Science Area, Health Informatics Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - María Belén Bonella
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carlos Maria Cafferata
- Palliative Care Division, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Diego Hernán Giunta
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Internal Medicine Research Area, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Bruno Leonel Ferreyro
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada
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27
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Winkfield KM, Regnante JM, Miller-Sonet E, González ET, Freund KM, Doykos PM. Development of an Actionable Framework to Address Cancer Care Disparities in Medically Underserved Populations in the United States: Expert Roundtable Recommendations. JCO Oncol Pract 2021; 17:e278-e293. [PMID: 33464925 PMCID: PMC8202060 DOI: 10.1200/op.20.00630] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/09/2020] [Accepted: 11/06/2020] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Cancer disparities persist among medically underserved populations despite widespread efforts to address them. We describe the development of a framework for addressing cancer care disparities across the cancer care continuum (CCC), guided by the CCC domains established by the Institute of Medicine/National Academies of Sciences, Engineering, and Medicine (IOM/NAS). MATERIALS AND METHODS An environmental scan was conducted to identify strategies and associated experts who are providing or have successfully provided community- and/or patient-centric IOM/NAS-defined domain standards to our target populations. A multistakeholder expert roundtable working group was convened for framework development. A premeeting survey informed agenda development, documented expert practices for target populations, and identified priority areas for meeting focus. RESULTS The environmental scan identified 84 unique experts across 8 stakeholder groups and 44 patient organizations; 50 were invited to the roundtable and 33 participated. They broadly represented disease sites, geography, and experience with target populations and all CCC domains. The premeeting survey (16 responses) identified coordination of care or patient navigation (66.7%), community engagement (60.0%), and healthcare system changes (53.3%) as priority focus areas. The experts identified access and treatment barriers or gaps within and between CCC domains, specified key notable practices to address these, and developed an actionable framework and recommendations for each priority focus area. CONCLUSION The framework and recommendations are intended to guide researchers, healthcare leaders, advocates, community- and patient-focused service organizations, and policy leaders to address and promote health equity in cancer care access and treatment outcomes.
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Affiliation(s)
- Karen M. Winkfield
- Meharry-Vanderbilt Alliance, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Evelyn T. González
- Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA
| | - Karen M. Freund
- Sara Murray Jordan Professor of Medicine, Tufts University School of Medicine, Boston, MA
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28
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Zaorsky NG, Liang M, Patel R, Lin C, Tchelebi LT, Newport KB, Fox EJ, Wang M. Survival after palliative radiation therapy for cancer: The METSSS model. Radiother Oncol 2021; 158:104-111. [PMID: 33610623 DOI: 10.1016/j.radonc.2021.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND We propose a predictive model that identifies patients at greatest risk of death after palliative radiotherapy, and subsequently, can help medical professionals choose treatments that better align with patient choice and prognosis. METHODS The National Cancer Database was queried for recipients of palliative radiotherapy during first course of treatment. Cox regression models and adjusted hazard ratios with 95% confidence intervals were used to evaluate survival predictors. The mortality risk index was calculated using predictors from the estimated Cox regression model, with higher values indicating higher mortality risk. Based on tertile cutpoints, patients were divided into low, medium, and high risk groups. RESULTS A total of 68,505 patients were included from 2010-2014, median age 65.7 years. Several risk factors were found to predict survival: (1) location of metastases (liver, bone, lung, and brain); (2) age; (3) tumor primary (prostate, breast, lung, other); (4) gender; (5) Charlson-Deyo comorbidity score; and (6) radiotherapy site. The median survival times were 11.66 months, 5.09 months, and 3.28 months in the low (n=22,621), medium (n=22,638), and high risk groups (n=22,611), respectively. A nomogram was created and validated to predict survival, available online, https://tinyurl.com/METSSSmodel. Harrel's C-index was 0.71 and receiver operator characteristic area under the curve was 0.76 at 4 years. CONCLUSION We created a predictive nomogram for survival of patients receiving palliative radiotherapy during their first course of treatment (named METSSS), based on Metastases location, Elderly (age), Tumor primary, Sex, Sickness/comorbidity, and Site of radiotherapy.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, USA; Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA.
| | - Menglu Liang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA
| | - Rutu Patel
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, USA
| | - Christine Lin
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, USA
| | - Leila T Tchelebi
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, USA
| | - Kristina B Newport
- Department of Medicine, Section of Palliative Care, Penn State College of Medicine, Hershey, USA
| | - Edward J Fox
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Hershey, USA
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA
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29
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Patel MN, Nicolla JM, Friedman FAP, Ritz MR, Kamal AH. Hospice Use Among Patients With Cancer: Trends, Barriers, and Future Directions. JCO Oncol Pract 2020; 16:803-809. [PMID: 33186083 DOI: 10.1200/op.20.00309] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Patients with advanced cancer and their families frequently encounter clinical and logistical challenges related to end-of-life care. Hospice provides interdisciplinary and holistic care to meet patients' biomedical, psychosocial, and spiritual needs in the last phases of life. Despite increasing general acceptance and use among patients with cancer, hospice remains underused. Underuse stems from ongoing misconceptions regarding hospice and its purpose, coupled with the rapid development of novel anticancer treatments, such as immunotherapies and targeted therapies, that have changed the landscape of possibilities. Furthermore, rapid evolutions in how end-of-life care is structured and reimbursed for will affect how oncology patients will intersect with hospice care. In this review, we explore the current and future challenges to greater integration of hospice care in the care of patients with advanced cancer and propose five recommendations as part of the path forward.
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Affiliation(s)
- Mihir N Patel
- Trinity College of Arts and Sciences, Duke University, Durham, NC
| | | | | | - Michala R Ritz
- Duke Cancer Institute, Duke University Medical Center, Durham, NC
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, NC.,Duke Fuqua School of Business, Durham, NC
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30
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Goebel JR, Bird MN, Martinez IL. Empowering the Latino Community Related to Palliative Care and Chronic Disease Management through Promotores de Salud (Community Health Workers). J Palliat Med 2020; 24:423-427. [PMID: 32833526 DOI: 10.1089/jpm.2020.0332] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Latinos are the largest minority group in the United States and when compared with non-Latino whites suffer from higher rates of certain chronic diseases. Latino community health workers (promotores de salud) are successful in improving the health of their communities. However, evidence of their effectiveness in increasing awareness of palliative care (PC) is limited. Objective: To evaluate the feasibility of applying a promotores de salud model to improve PC awareness among Latinos within the context of chronic disease management. Methods: Bilingual promotores from Familias en Acción trained 76 southern California promotores on PC and chronic disease management. Promotores agreed to disseminate the information learned to 10+ Latino community members. The strengths of the curriculum and the community's needs were identified during phone interviews six months post-training. Results: In 406 diverse settings, 69 promotores trained 2734 community members. Interviews with promotores at follow-up established four themes: (1) holistic health in chronic disease management; (2) communication with doctors; (3) shared decision making, patients' rights, and control; and (4) need for PC information (awareness, access, and support groups). Conclusion: Promotores proved effective at disseminating information related to PC within chronic disease management to Latino community members. Future training should include information on support groups and where caregivers can seek help while caring for those with a terminal disease.
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Affiliation(s)
- Joy R Goebel
- School of Nursing, College of Health and Human Services, California State University, Long Beach, California, USA
| | - Mara N Bird
- Center for Latino Community Health, Evaluation and Leadership Training, College of Health and Human Services, California State University, Long Beach, California, USA
| | - Iveris L Martinez
- Center for Successful Aging, College of Health and Human Services, California State University, Long Beach, California, USA
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31
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Torensma M, Suurmond JL, van der Heide A, Onwuteaka-Philipsen BD. Care and Decision-Making at the End of Life for Patients With a Non-Western Migration Background Living in The Netherlands: A Nationwide Mortality Follow-Back Study. J Pain Symptom Manage 2020; 59:990-1000.e5. [PMID: 31837456 DOI: 10.1016/j.jpainsymman.2019.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/20/2019] [Accepted: 11/26/2019] [Indexed: 12/30/2022]
Abstract
CONTEXT Migrant populations across Europe are aging and will increasingly need end-of-life care. OBJECTIVE The objectives of this study were to gain insight into end-of-life care and decision-making for patients with a non-western migration background and assess differences compared to patients with a Dutch or western migration background. METHODS A mortality follow-back study was conducted using a stratified sample of death certificates of persons who died between August and December 2015, obtained from the central death registry of Statistics Netherlands. Questionnaires were sent to the attending physician (n = 9351; response 78%). Patients aged ≥18 years who died a nonsudden death were included in this study (n = 5327). RESULTS Patients with a non-western migration background are more likely than patients with a Dutch or western migration background to be admitted to and die in hospital (51.6% vs. 33.9% [OR 1.74; 95% CI 1.26-2.41]; 39.1% vs. 20.1% [OR 1.96; 95% CI 1.39-2.78]); less likely to receive morphine or morphine-like medication and continuous deep sedation (72.8% vs. 80.1% [OR 0.62; 95% CI 0.43-0.89]; 16.8% vs. 25.2% [OR 0.52; 95% CI 0.34-0.80]); and more likely to receive end-of-life care that, according to physicians, is directed at curation for too long (6.8% vs. 1.7% [OR 3.61; 95% CI 1.83-7.12]). End-of-life decisions are made less frequently for patients with a non-western migration background (71.6% vs. 79.2% [OR 0.64; 95% CI 0.45-0.91]). Characteristics of decision-making are similar. CONCLUSION End-of-life care for patients with a non-western migration background focuses more, or longer on maximum, curative treatment and end-of-life decisions are made less often.
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Affiliation(s)
- Marieke Torensma
- Department of Public Health, Amsterdam UMC Expertise center for Palliative Care and Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Jeanine L Suurmond
- Department of Public Health, Amsterdam UMC Expertise center for Palliative Care and Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam UMC Expertise center for Palliative Care and Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Chu C, Anderson R, White N, Stone P. Prognosticating for Adult Patients With Advanced Incurable Cancer: a Needed Oncologist Skill. Curr Treat Options Oncol 2020; 21:5. [PMID: 31950387 PMCID: PMC6965075 DOI: 10.1007/s11864-019-0698-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patients with advanced cancer and their families commonly seek information about prognosis to aid decision-making in medical (e.g. surrounding treatment), psychological (e.g. saying goodbye), and social (e.g. getting affairs in order) domains. Oncologists therefore have a responsibility to identify and address these requests by formulating and sensitively communicating information about prognosis. Current evidence suggests that clinician predictions are correlated with actual survival but tend to be overestimations. In an attempt to cultivate prognostic skills, it is recommended that clinicians practice formulating and recording subjective estimates of prognosis in advanced cancer patient’s medical notes. When possible, a multi-professional prognostic estimate should be sought as these may be more accurate than individual predictions alone. Clinicians may consider auditing the accuracy of their predictions periodically and using feedback from this process to improve their prognostic skills. Clinicians may also consider using validated prognostic tools to complement their clinical judgements. However, there is currently only limited evidence about the comparative accuracy of different prognostic tools or the extent to which these measures are superior to clinical judgement. Oncologists and palliative care physicians should ensure that they receive adequate training in advanced communication skills, which builds upon their pre-existing skills, to sensitively deliver information on prognosis. In particular, clinicians should acknowledge their own prognostic uncertainty and should emphasise the supportive care that can continue to be provided after stopping cancer-directed therapies.
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Affiliation(s)
- Christina Chu
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Rebecca Anderson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Nicola White
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
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Ingersoll LT, Alexander SC, Ladwig S, Anderson W, Norton SA, Gramling R. The contagion of optimism: The relationship between patient optimism and palliative care clinician overestimation of survival among hospitalized patients with advanced cancer. Psychooncology 2019; 28:1286-1292. [PMID: 31020758 DOI: 10.1002/pon.5080] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/28/2019] [Accepted: 04/01/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Clinicians frequently overestimate survival time among seriously ill patients, and this can result in medical treatment at end of life that does not reflect the patient's preferences. Little is known, however, about the sources of clinicians' optimistic bias in survival estimation. Related work in social networks and experimental psychology demonstrates that psychological states-such as optimism-can transfer from one person to another. METHODS We directly observed and audio recorded 189 initial inpatient palliative care consultations among hospitalized patients with advanced cancer. Patients self-reported their level of trait optimism and expectations for survival prognosis prior to the palliative care consultation, and the palliative care clinicians rated their expectations for the patient's survival time following the initial conversation with the patient. We followed patient mortality for 6 months. RESULTS Patient optimism was associated with clinician overestimation of their survival in a dose-response relationship. Clinicians were approximately three times as likely to overestimate the survival of patients endorsing both high trait optimism and optimistic ratings of their survival time compared with neither (OR: 2.95; 95% CI: 1.24-7.02). This association was not attenuated by adjustment for age, gender, race, ethnicity, education, income, cancer type, functional status, quality of life, or white blood cell count (ORadj : 3.45; 95% CI: 1.24-9.66). CONCLUSION Patients' optimism may have some influence over their clinicians' prognostic judgments.
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Affiliation(s)
- Luke T Ingersoll
- Department of Consumer Science, Purdue University, West Lafayette, IN
| | | | - Susan Ladwig
- Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | - Wendy Anderson
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Sally A Norton
- School of Nursing, University of Rochester Medical Center, Rochester, NW
| | - Robert Gramling
- Palliative Medicine Division, University of Vermont Medical Center, Burlington, VT
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