Assessment of the Decision-Making Capacity for Clinical Research Participation in Patients With Advanced Cancer in the Last Weeks of Life

Factors Associated With Family Surrogate Decisional-Regret Trajectories

CONTEXT/OBJECTIVES

The scarce research on factors associated with surrogate decisional regret overlooks longitudinal, heterogenous decisional-regret experiences and fractionally examines factors from the three decision-process framework stages: decision antecedents, decision-making process, and decision outcomes. This study aimed to fill these knowledge gaps by focusing on factors modifiable by high-quality end-of-life (EOL) care.

METHODS

This observational study used a prior cohort of 377 family surrogates of terminal-cancer patients to examine factors associated with their membership in the four preidentified distinct decisional-regret trajectories: resilient, delayed-recovery, late-emerging, and increasing-prolonged trajectories from EOL-care decision making through the first two bereavement years by multinomial logistic regression modeling using the resilient trajectory as reference.

RESULTS

Decision antecedent factors: Financial sufficiency and heavier caregiving burden increased odds for the delayed-recovery trajectory. Spousal loss, higher perceived social support during an EOL-care decision, and more postloss depressive symptoms increased odds for the late-emerging trajectory. More pre- and postloss depressive symptoms increased odds for the increasing-prolonged trajectory. Decision-making process factors: Making an anticancer treatment decision and higher decision conflict increased odds for the delayed-recovery and increasing-prolonged trajectories. Making a life-sustaining-treatment decision increased membership in the three more profound trajectories. Decision outcome factors: Greater surrogate appraisal of quality of dying and death lowered odds for the three more profound trajectories. Patient receipt of anticancer or life-sustaining treatments increased odds for the late-emerging trajectory.

CONCLUSION

Surrogate membership in decisional-regret trajectories was associated with decision antecedent, decision-making process, and decision outcome factors. Effective interventions should target identified modifiable factors to address surrogate decisional regret.

Methodological and ethical challenges in designing and conducting research at the end of life: A systematic review of qualitative and textual evidence

AIM

This systematic review aims to identify methodological and ethical challenges in designing and conducting research at the end of life from the perspective of researchers and provide a set of recommendations.

BACKGROUND

Conducting research with patients and family carers facing end-of-life issues is ethically and methodologically complex.

DESIGN

A systematic review was conducted.

DATA SOURCES

Four databases (MEDLINE, EMBASE, CINAHL, PsycInfo) were searched from inception until the end of 2021 in February 2022.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews was followed, and the JBI Approach to qualitative synthesis was used for analysis.

RESULTS

Seventeen of 1983 studies met inclusion criteria. Data were distilled to six main themes. These included (1) the need for flexibility at all stages of the research process; (2) careful attention to timing; (3) sensitivity in approach; (4) the importance of stakeholder collaboration; (5) the need for unique researcher skills; and (6) the need to deal with the issue of missing data.

CONCLUSION

The findings illuminate several considerations that can inform training programmes, ethical review processes and research designs when embarking on research in this field.

Decisional-Regret Trajectories From End-of-Life Decision Making Through Bereavement

CONTEXT

Regret plays a central role in surrogate decision making. Research on decisional regret in family surrogates is scarce and lacks longitudinal studies to illustrate the heterogenous, dynamic evolution of decisional regret.

OBJECTIVES

To identify distinct decisional-regret trajectories from end-of-life (EOL) decision making through the first two bereavement years among surrogates of cancer patients.

METHODS

A prospective, longitudinal, observational study was conducted on a convenience sample of 377 surrogates of terminally ill cancer patients. Decisional regret was measured by the five-item Decision Regret Scale monthly during the patient's last six months and 1, 3, 6, 13, 18, and 24 months post loss. Decisional-regret trajectories were identified using latent-class growth analysis.

RESULTS

Surrogates reported substantially high decisional regret (pre- and postloss mean [SD] as 32.20 [11.47] and 29.90 [12.47], respectively). Four decisional-regret trajectories were identified. The resilient trajectory (prevalence: 25.6%) showed a general low decisional-regret level with mild and transient perturbations around the time of patient death only. Decisional regret for the delayed-recovery trajectory (56.3%) accelerated before the patient's death and decreased slowly throughout bereavement. Surrogates in the late-emerging (10.2%) trajectory reported a low decisional-regret level before loss but their decisional regret increased gradually thereafter. The increasing-prolonged trajectory (6.9%) rapidly increased in decisional-regret levels during EOL decision making, peaked one-month post loss, then declined steadily but without a complete resolution.

CONCLUSION

Surrogates heterogeneously suffered decisional regret from EOL decision making through bereavement as evident by four identified distinct decisional-regret trajectories. Early identification and prevention of increasing/prolonged decisional-regret trajectories is warranted.

A model for the uptake of advance care planning in older cancer adults: a scoping review

BACKGROUND AND AIMS

Advance care planning (ACP) might assist older cancer patients in expressing their goals, values, and care preferences; yet, the ACP uptake rates in this group are low. The goal of this study is to discover factors that influence ACP uptake in older cancer adults and to construct a model that integrates these factors.

METHODS

Using Arksey and O' Malley's methodology, we systematically searched seven electronic databases of ACP literature in older cancer adults from inception to March 2022. To identify factors linked to ACP uptake in elderly cancer patients, researchers used a pre-piloted extraction form. There were two phases to the thematic analysis of the labeled factors. First, factors were grouped into one of three categories using a directed content analysis approach: patient context, provider context, or mechanism. Second, we took both a deductive and inductive thematic approach to identifying and coding contributing factors in each category to identify themes and subthemes. Deductive coding was undertaken using the Andersen's Behavioral Model of Health Services Utilization. Finally, results were visualized into a conceptual model.

RESULTS

In the including 37 articles, 131 factors were extracted. Thematic analysis of patient context factors (n = 72) showed that ACP uptake in older cancer adults is associated with predisposing characteristics, enabling resources and need. Factors attributed to provider context (n = 28) concerned predisposing characteristics and enabling resources. Mechanism factors (n = 31) are related to perceived value and patient trust, and the C-ACP uptake model was created.

CONCLUSION

ACP uptake in older cancer patients is commonly influenced by patient-provider-related contextual factors, and highlights the fact that ACP uptake is more likely to be mediated through both perceived value and patient trust. This review serves as a resource for providers exploring ACP implementation options in older cancer adults.

Development and validation of the Terminal Delirium-Related Distress Scale to assess irreversible terminal delirium

OBJECTIVE

There is no tool to appropriately assess terminal delirium, including the natural terminal course. The objective of this study was to develop an evaluation scale to assess distress from irreversible terminal delirium and to examine the validity of the scale.

METHOD

Based on previous qualitative analysis and systematic literature searches, we carried out a survey regarding the views of bereaved families and developed a questionnaire. We extracted items that bereaved families regarded as important and constructed an evaluation scale of terminal delirium. Then, we applied the questionnaire in a cross-sectional questionnaire survey of bereaved relatives of cancer patients who were admitted to a hospice or a palliative care unit.

RESULTS

We developed the Terminal Delirium-Related Distress Scale (TDDS), a 24 item questionnaire consisting of five subscales (support for families and respect for a patient, ability to communicate, hallucinations and delusions, adequate information about the treatment of delirium, and agitation and restlessness). Two hundred and eighty-one bereaved relatives participated in the validation phase. The construct validity was shown to be good by repeated factor analysis. Convergent validity, confirmed by the correlation between the TDDS and the Care Evaluation Scale (r = 0.651, P < 0.001), was also good. The TDDS had good internal consistency (Cronbach's alpha coefficient for all 24 items = 0.84).

SIGNIFICANCE OF RESULTS

This study showed that the TDDS is a valid and feasible measure of irreversible terminal delirium.