Relationships between personal attitudes about death and communication with terminally ill patients: How oncology clinicians grapple with mortality

How to talk about dying? The development of an evidence-based model for communication with patients in their last days of life and their family caregivers

Objective

To help healthcare professionals (HCP) act with more confidence when communicating about approaching death, we sought to develop a communication model for HCP to facilitate conversations with dying patients and family caregivers (FC) in nonemergency situations.

Methods

We used a four-phase integrative approach: (1) creation of a preliminary model based on a systematic literature review and expert knowledge, (2) review of the model draft by international palliative care experts, (3) review by key stakeholders, and (4) final appraisal by communication experts.

Results

After the clinical recognition of dying, the communication model provides a structure and practical communication aids for navigating the conversation based on three phases. It describes the content and relational level as core dimensions of effective conversations about approaching death and highlights the importance of HCP self-awareness and self-care when caring for the dying.

Conclusion

Based on systematic involvement of key stakeholders, the model supports clinicians navigating challenging conversations about approaching death with dying patients and their FC successfully and with more confidence.

Innovation

This study expands the theoretical basis for communication about approaching death and offers a pragmatic model for educational interventions and clinical use.

The role of psychologists in supporting illness-related dying and death: A systematic mixed studies review

Psychologists remain underrepresented in end-of-life care, and there is limited understanding of their role among healthcare professionals, patients, and caregivers. This systematic mixed-studies review, prospectively registered on PROSPERO (CRD42020215775), explored the role of psychologists, and the facilitators and barriers they experience, in supporting clients with illness-related dying and death. A search of six research databases was conducted in October 2023. Fifty-one studies, mainly qualitative and from the perspectives of psychologists, met inclusion criteria. Thematic synthesis highlighted how psychologists provided expertise across various contexts. They supported clients with preparing for death, and adjusting to dying, provided professional consultancy and support, and undertook leadership in enhancing psychological end-of-life care. Results illustrated the sustaining factors and ongoing challenges working in end-of-life care, namely, the unique nature of navigating the death space, recognition and awareness of psychologists' contribution, and the support, training and development required. Given the universality of dying and death, this review is relevant to psychologists working within and beyond more traditional end-of-life care contexts, such as employee assistance programs, private practice, schools, and other psychological services. Policy, clinical and research implications are discussed, including the need for greater engagement and training of psychologists in the dying and death space.

Communication Strategies of Transplant Hematologists in High-Risk Decision-Making Conversations

PURPOSE

Shared decision making (SDM) is essential to empower patients with blood cancers to make goal-concordant decisions about allogeneic hematopoietic cell transplantation. This study characterizes communication strategies used by hematologists to discuss treatment options and facilitate SDM with patients in this high-risk, high-reward setting.

METHODS AND MATERIALS

We recruited US hematologists who routinely perform allogeneic hematopoietic cell transplant through email. Participants conducted up to an hour-long video-recorded encounter with an actor portraying a 67-year-old man with recently diagnosed high-risk myelodysplastic syndrome. We transcribed and qualitatively analyzed video-recorded data.

RESULTS

The mean age of participants (N = 37) was 44 years, 65% male, and 68% White. Many hematologists included similar key points in this initial consultation, although varied in how much detail they provided. Their discussion of treatment options included transplant and chemotherapy and less commonly supportive care or clinical trials. They often emphasized transplant's potential for cure, discussed transplant chronologically from pretransplant considerations through the post-transplant course, and outlined risks, complications, and major outcomes. Hematologists referred to several elements that formed the basis of treatment decision making. The strength of their treatment recommendations ranged from strong recommendations for transplant or chemotherapy to deferrals pending more information. Hematologists also varied in the extent to which they indicated the decision was physician-driven, patient-led, or shared.

CONCLUSION

The transplant decision-making discussion is complex. Identification of similar content areas used by hematologists can be used as the basis for a communication tool to help hematologists discuss allogeneic hematopoietic cell transplant with patients.

Oncology clinicians' feelings towards patients presented in supervision: A pre-post assessment using the feeling word checklist

OBJECTIVE

Clinical supervision of oncology clinicians by psycho-oncologists is an important means of psychosocial competence transfer and support. Research on this essential liaison activity remains scarce. The aim of this study was to assess the impact of supervision on oncology clinicians' feelings towards patients presented in supervision.

METHODS

Oncology clinicians' (n = 23) feelings towards patients presented in supervision were assessed with the Feeling Word Checklist (FWC). The FWC was filled in by supervisees prior and after their supervision sessions (n = 91), which were conducted by experienced supervisors (n = 6). Pre- post-modification of feelings was evaluated based on a selection of FWC items, which were beforehand considered as likely to change in a beneficial supervision. Items were evaluated on session level using t-tests for dependent groups. Composite scores were calculated for feelings expected to raise and feelings expected to decrease and analysed on the level of supervisees.

RESULTS

Feelings related to threats, loss of orientation or hostility such as "anxious", "overwhelmed", "impotent", "confused", "angry", "depreciated" and "guilty" decreased significantly after supervision, while feelings related to the resume of the relationship ("attentive", "happy"), a better understanding of the patient ("empathic"), a regain of control ("confident") and being "useful" significantly increased. Feeling "interested" and "calm" remained unchanged. Significant increase or decrease in the composite scores for supervisees confirmed these results.

CONCLUSIONS

This study demonstrates modification of feelings towards patients presented in supervision. This modification corresponds to the normative, formative, and especially restorative function (support of the clinician) of supervision.

Integrated dual training in palliative care and oncology

Fellowship training in Hospice and Palliative Medicine (HPM) and Hematology/Oncology (Hem/Onc) share common themes and roots in the holistic care of people living with cancer. As of 2021, approximately 630 physicians in the United States were board-certified in both HPM and Hem/Onc. There is increasing demand for an integrated fellowship pathway, and the inaugural integrated fellowship Match took place in 2022. We present the historical context of the overlap in HPM and Hem/Onc fellowship training, limitations of the standard training paradigm, and an overview of the recently developed integrated training pathway accredited by the Accreditation Council for Graduate Medical Education (ACGME). We explore applications of dual training in clinical care, program development, and research at the intersection of HPM and Hem/Onc. Finally, we consider challenges to the success and how best to assess the outcomes of this program. Integrated fellowship training in HPM and Hem/Onc is 1 avenue to develop a cohort of dual-trained physicians poised to effect broad cultural change in this important and evolving space. A subset of physicians with dual training has the potential to fill unmet needs by promoting enhanced patient-centered care, developing infrastructure for heightened collaboration between these distinct but closely related fields, and prioritizing research focused on advanced communication skills and symptom management for patients with cancer.

Breaking bad news in medical services: a comprehensive systematic review

Objective

This study was performed with the aims of screening the previous studies on breaking bad news in all medical wards.

Methods

Eligible observational studies were selected. The quality of the studies was assessed using the STROBE checklist. The findings were reported using Garrard's table. All the stages of the present study were performed in terms of the PRISMA statement.

Results

Totally, 40 articles were included in the study and 96 items were extracted. The results show that breaking bad news is a recipient-centered process. Respect, empathy, and support were reported. The news presenters are better to use guidelines based on evidence-based findings. It is suggested that the presenter should use simple and understandable content. Moreover, suitable time and space are important to present the news. The results show the importance of paying enough attention to the emotions of the recipient and the need to provide support after breaking bad news.

Conclusion

The recipient must be the center of the programs. It is necessary to pay attention to the characteristics of the news presenter, the news content, and finally the support.Practice Implication: Understand the recipient, trained presenter, and use of the evidence-based results, improve the breaking bad news outcome.

Investigating the Relationship between Fear of Failure and the Delivery of End-of-Life Care: A Questionnaire Study

OBJECTIVE

To investigate whether fear of failure (FOF) influences a clinician's perception of how confident and comfortable they are in their delivery of end-of-life (EOL) care.

METHODS

Cross-sectional questionnaire study with recruitment of physicians and nurses across two large NHS hospital trusts in the UK and national UK professional networks. A total of 104 physicians and 101 specialist nurses across 20 hospital specialities provided data that were analysed using a two-step hierarchical regression.

RESULTS

The study validated the PFAI measure for use in medical contexts. Number of EOL conversations, gender, and role were shown to impact confidence and comfortableness with EOL care. Four FOF subscales did show a significant relationship with perceived delivery of EOL care.

CONCLUSION

Aspects of FOF can be shown to negatively impact the clinician experience of delivering EOL care.

CLINICAL IMPLICATIONS

Further study should explore how FOF develops, populations that are more susceptible, sustaining factors, and its impact on clinical care. Techniques developed to manage FOF in other populations can now be investigated in a medical population.

The TRIBE model: How socioemotional processes fuel end-of-life treatment in the United States

Prior interventions have repeatedly failed to decrease the prescription and receipt of treatments and procedures that confer more harm than benefit at the End-of-Life (EoL); new approaches to intervention are needed. Ideally, future interventions would be informed by a social-ecological conceptual model that explains EoL healthcare utilization patterns, but current models ignore two facts: (1) healthcare is an inherently social activity, involving clinical teams and patients' social networks, and (2) emotions influence social activity. To address these omissions, we scaffolded Terror Management Theory and Socioemotional Selectivity Theory to create the Transtheoretical Model of Irrational Biomedical Exuberance (TRIBE). Based on Terror Management Theory, TRIBE suggests that the prospect of patient death motivates healthcare teams to conform to a biomedical norm of care, even when clinicians believe that biomedical interventions will likely be unhelpful. Based on Socioemotional Selectivity Theory, TRIBE suggests that the prospect of dwindling time motivates families to prioritize emotional goals, and leads patients to consent to disease-directed treatments they know will likely be unhelpful, as moral emotions motivate deference to the perceived emotional needs of their loved ones. TRIBE is unique among models of healthcare utilization in its acknowledgement that moral emotions and processes (e.g., shame, compassion, regret-avoidance) influence healthcare delivery, patients' interactions with family members, and patients' outcomes. TRIBE is especially relevant to potentially harmful EoL care in the United States, and it also offers insights into the epidemics of overtreatment in healthcare settings worldwide. By outlining the role of socioemotional processes in the care of persons with serious conditions, TRIBE underscores the critical need for psychological innovation in interventions, health policy and research on healthcare utilization.

"You'll need to settle your affairs": How the subject of death is approached by oncologists and advanced cancer patients in follow-up consultations

OBJECTIVES

This qualitative study aimed to investigate communication about death in consultations with patients undergoing chemotherapy with no curative intent. Specifically, we examined (i) how the topic of death was approached, who raised it, in what way, and which responses were elicited, (ii) how the topic unfolded during consultations, and (iii) whether interaction patterns or distinguishing ways of communicating can be identified.

METHODS

The data consisted of 134 audio-recorded follow-up consultations. A framework of sensitizing concepts was developed, and interaction patterns were looked for when death was discussed.

RESULTS

The subject of death and dying was most often initiated by patients, and they raised it in various ways. In most consultations, direct talk about death was initiated only once. We identified 4 interaction patterns. The most frequent consists of indirect references to death by patients, followed by a direct mention of the death of a loved one, and a statement of the oncologists aiming to skip the subject.

SIGNIFICANCE OF RESULTS

Patients and oncologists have multiple ways of raising, pursuing, addressing and evacuating the subject of death. Being attentive and recognizing these ways and associated interaction patterns can help oncologists to think and elaborate on this topic and to facilitate discussions.

'It needs experience and courage': Awareness towards end of life communication practices in oncologists: A mixed methods study

OBJECTIVE

End of life communication (EOLC) is generally regarded as a challenging aspect of the medical profession, with high influences of culture, the physician's experience and awareness. The aim of the current study was to assess the awareness of Austrian oncologists towards EOLC practices in their daily clinical routine and to identify limiting and supporting factors of these conversations.

METHODS

Overall, 45 oncologists participated in the assessment in this cross-sectional, mixed-method design using semi-structured interviews and questionnaire.

RESULTS

Themes that occurred during the interviews included the initiation of EOLC, EOLC in practice, strategies for EOLC, limiting and supporting factors and consequences of EOLC. There were several variations in the EOLC approach, that is, the use of time frames, timing, initiation and the amount of details given to the patient.

CONCLUSION

Oncologists agreed that EOLC is important in their daily clinical routine and for their patients. Nevertheless, there seems to be an underlying variation in approaches chosen by Austrian oncologists. This variation might be reduced by asking patients about their information preferences in advance and by routine implementation of communication guidelines, nomograms and prognostic calculators to reduce uncertainty.

Chinese physicians' perceptions of palliative care integration for advanced cancer patients: a qualitative analysis at a tertiary hospital in Changsha, China

Background

Little previous research has been conducted outside of major cities in China to examine how physicians currently perceive palliative care, and to identify specific goals for training as palliative care access expands. This study explored physicians’ perceptions of palliative care integration for advanced cancer patients in Changsha, China.

Methods

We conducted semi-structured qualitative interviews with physicians (n = 24) specializing in hematology or oncology at a tertiary hospital.

Results

Most physicians viewed palliative care as equivalent to end-of-life care, while a minority considered it possible to integrate palliative care with active treatment. Almost all physicians maintained separate conversations about palliative care with family members and patients, communicating more directly with family members than with patients about prognosis and goals of care. Physicians described experiencing ethical tension between the desire of family members to protect the patient from knowing they have advanced cancer, and the patient’s “right to decide” about palliative treatment. Physicians varied overall regarding perceptions of the role they should have in discussions about goals of care.

Conclusions

As palliative care access expands in China, medical training should encourage earlier integration of palliative care for advanced cancer, address ethical issues faced by physicians communicating about palliative care, and establish guidance on the role of the physician in discussions about goals of care.

Personal fear of their own death and determination of philosophy of life affects the breaking of bad news by internal medicine and palliative care clinicians

INTRODUCTION

Patients with life-threatening disease should be informed about the diagnosis and prognosis of life-expectancy. Breaking bad news (BBN) by a clinician may be affected not only by their lack of communication skills but also their philosophy of life, beliefs, fear of their own death, their length of tenure, and their exposure to dying and death.

MATERIAL AND METHODS

This questionnaire-based study aimed to investigate the impact of these factors on BBN in internal medicine practitioners (INT) versus palliative care physicians (PCP), and to detect the possible impediments to the proper communication process and the clinicians' needs regarding their preparation for such a conversation.

RESULTS

Thirty-eight PCPs and 64 INTs responded. Determination of philosophy of life, but not religiousness, positively correlated with the number of working years in palliative care. Two-thirds of the respondents declared fear of death, and it diminishes along with working years, especially in palliative care. For most physicians, BBN appeared difficult; however, less so for PCPs, persons with a high level of determination of philosophy of life, and men. The most frequent impediment was insufficient communication skills. Consistently, the respondents expressed the need for closing the gap in communication skills, especially by mentoring or training on communication.

CONCLUSIONS

Fear of death may restrain inexperienced medical professionals from BBN to patients and makes it difficult. Working in palliative care augments the determination of philosophy of life and diminishes fear of death. The higher the determination of philosophy of life, the more likely BBN is to be performed. Philosophy of life, spirituality, and communication skills should be addressed in postgraduate education.

Facing epistemic and complex uncertainty in serious illness: The role of mindfulness and shared mind

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.

Assessing Medical Students' Confidence towards Provision of Palliative Care: A Cross-Sectional Study

Under a surging demand for palliative care, medical students generally still show a lack of confidence in the provision in abroad studies. This cross-sectional study aims to investigate the confidence and its association with knowledge, attitude and exposure on providing palliative care among medical undergraduates with a self-administered questionnaire to improve the international phenomenon. Full-time local medical undergraduates were recruited to obtain information regarding the demographics, confidence, knowledge, attitude and exposure on palliative care; the information was collected from July 2020 to October 2020. Questions on confidence (10-items), knowledge (20-items), attitude (10-items) and exposure were referenced from validated indexes and designed from literature review. Confidence level was categorized into “Confident” and “Non-confident” as suggested by studies to facilitate data analysis and comparison. Of the 303 participants, 59.4% were “Non-confident” (95% C.I.: 53.8% to 65.0%) in providing palliative care on average. Among medical students, knowledge (p = 0.010) and attitude (p = 0.003) are significantly positively associated with the confidence to provide palliative care, while exposure to death of family/friends (p = 0.024) is negatively associated. This study begins an investigation on the research area in Hong Kong primarily. The confidence of local medical students should be enhanced to provide palliative care in their future. It thus highlights the importance of the medical curriculum and provides insights to remove barriers responsively to improve the overall confidence and the quality of palliative care.

Archaeology and contemporary death: Using the past to provoke, challenge and engage

While death is universal, reactions to death and ways of dealing with the dead body are hugely diverse, and archaeological research reveals numerous ways of dealing with the dead through time and across the world. In this paper, findings are presented which not only demonstrate the power of archaeology to promote and aid discussion around this difficult and challenging topic, but also how our approach resulted in personal growth and professional development impacts for participants. In this interdisciplinary pilot study, archaeological case studies were used in 31 structured workshops with 187 participants from health and social care backgrounds in the UK, to explore their reactions to a diverse range of materials which documented wide and varied approaches to death and the dead. Our study supports the hypothesis that the past is a powerful instigator of conversation around challenging aspects of death, and after death care and practices: 93% of participants agreed with this. That exposure to archaeological case studies and artefacts stimulates multifaceted discourse, some of it difficult, is a theme that also emerges in our data from pre, post and follow-up questionnaires, and semi-structured interviews. The material prompted participants to reflect on their biases, expectations and norms around both treatment of the dead, and of bereavement, impacting on their values, attitudes and beliefs. Moreover, 87% of participants believed the workshop would have a personal effect through thinking differently about death and bereavement, and 57% thought it would impact on how they approached death and bereavement in their professional practice. This has huge implications today, where talk of death remains troublesome, and for some, has a near-taboo status-'taboo' being a theme evident in some participants' own words. The findings have an important role to play in facilitating and normalising discussions around dying and bereavement and in equipping professionals in their work with people with advanced illness.

Attitudes toward death and death acceptance among hemato-oncologists: An Israeli sample

OBJECTIVE

Hemato-oncologists are highly exposed to patients' death and suffering during their daily work. The current exploratory and cross-sectional study examined death acceptance attitudes, in order to explore whether death acceptance attitudes are associated with fear of death.

METHOD

A convenience sample of 50 Israeli hemato-oncologists currently working in a clinical setting participated in the study. They completed the Death Attitudes Profile revised questionnaire (DAP-R), which examines levels of fear of death, death avoidance, approach acceptance, neutral acceptance, and escape acceptance. In addition, the hemato-oncologists reported on levels of exposure to patients' death and suffering.

RESULTS

A repeated measures MANOVA revealed significantly lower levels of neutral acceptance, compared with approach and escape acceptance. Path analysis for predicting fear of death by the other study variables revealed that death avoidance fully mediated the relationship between approach acceptance and fear of death as well as revealing a negative correlation between neutral acceptance and fear of death (higher neutral acceptance was related to lower fear of death). No associations were found between exposure to death and suffering and attitudes toward death.

SIGNIFICANCE OF RESULTS

In contrast to previous conceptualizations, the ability to adaptively cope with fear of death differed in accordance with death acceptance attitudes. Whereas neutral acceptance adaptively defended from fear of death, approach acceptance was associated with increased fear of death through death avoidance. As hemato-oncologists are highly exposed to patients' death and suffering, and are required to make critical medical decisions on daily basis, these findings may have substantial implications for end-of-life care and the process of medical decision-making regarding the choice of treatment goals: cure, quality of life, and life prolongment. Further research is needed to investigate the role of death acceptance attitudes among hemato-oncologists.

Dialysis Regret: Prevalence and Correlates

BACKGROUND AND OBJECTIVES

Although some patients regret the decision to start dialysis, modifiable factors associated with regret have rarely been studied. We aimed to identify factors associated with patients' regret to initiate dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A 41-item questionnaire was administered to adult patients receiving maintenance dialysis in seven dialysis units located in Cleveland, Ohio, and its suburbs. Of the 450 patients asked to participate in the study, 423 agreed and 397 provided data on decisional regret. We used multivariable logistic regression to identify predictors of regret, which was assessed using a single item, "Do you regret your decision to start dialysis?" We report adjusted odd ratios (ORs) and 95% confidence intervals (95% CIs) for the following candidate predictors: knowledge of CKD, attitudes toward CKD treatment, and preference for end-of-life care.

RESULTS

Eighty-two of 397 respondents (21%) reported decisional regret. There were no significant demographic correlates of regret. Regret was more common when patients reported choosing dialysis to please doctors or family members (OR, 2.34; 95% CI, 1.27 to 4.31; P<0.001). Patients who reported having a prognostic discussion about life expectancy with their doctors (OR, 0.42; 95% CI, 0.18 to 0.98; P=0.03) and those who had completed a living will (OR, 0.48; 95% CI, 0.25 to 0.95; P=0.03) were less likely to report regret with dialysis initiation.

CONCLUSIONS

Dialysis regret was common in this sample. Demographic factors (age, sex, marital status, race, or educational attainment) were not significantly associated with regret, but modifiable care processes were.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_06_09_CJN13781119.mp3.

Definition of a Good Death, Attitudes Toward Death, and Feelings of Interconnectedness Among People Taking Care of Terminally ill Patients With Cancer: An Exploratory Study

The concept of a good death is crucial in palliative care, but its relationship with attitudes toward death and feelings of interconnectedness needs to be further deepened. The first aim of this study was to explore the concept of good death, attitudes toward death, and feelings of interconnectedness among family caregivers (FCs) and health-care providers (HCPs) of terminally ill patients with cancer. The second aim was to analyze associations of good death concept with attitudes toward death and feelings of interconnectedness. Participants were asked to assess the importance of features that characterize a good death. To explore each person’s attitude toward death and feelings of interconnectedness, 3 open questions were used. The sample consisted of 49 participants: 24 (48.98%) FCs and 25 (51.02%) HCPs. Nine good death features were considered essential by more than 70% of participants. These referred to the physical (eg, symptoms control), social (eg, loved ones’ presence), emotional (eg, sharing emotions), and spiritual (eg, inner peace) dimensions. Importance attributed to components of a good death such as patient’s awareness and acceptance of death, meaning, respect for the patient’s wishes, and inner peace were found to be associated with lack of avoidance and acceptance toward death and feelings of interconnectedness. Given the importance of FCs and HCPs in providing care and their impact on the patients’ dying process, it is necessary to reflect upon how their personal attitudes and previous experiences influence the care of dying patients.

Moving toward the next generation of communication training in oncology: The relevance of findings from qualitative research

OBJECTIVE

The critics and recommendations for communication training in oncology call for new ideas, which may contribute to designing the next generation of training. The aim of this work was to search the literature on communication in oncology for empirically grounded observations that might be useful for the development of training approaches.

METHODS

The approach consists of identifying findings that might serve as cues for the design of the next generation of training. The literature search strategy allowed the inclusion of 68 articles.

RESULTS

Findings of the articles showed that multiple factors shape clinical communication: the functions and effects of information provision, the relational and interactional aspects of communication, its patient- and context-related dimensions, and the intrapsychic and context-related barriers hampering the patient encounter that clinicians are facing.

CONCLUSION

A way to reach all oncologists and to provide training centred on the singular needs of participants is a shift in the focus of training from communication tasks or communication-related situations to the clinician.

PRACTICE IMPLICATIONS

Training should focus on the competencies and qualities to be developed by clinicians, such as being flexible, able to adapt to the singular patient, sensitive to interactional aspects of communication, which influence the clinical encounter.

Physician and Patient Characteristics Associated With More Intensive End-of-Life Care

CONTEXT

Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties.

OBJECTIVE

To test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL.

METHODS

We report secondary analyses of data collected prospectively from physicians (n = 38) and patients with advanced cancer (n = 265) in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15-31 days before death [scored 1], and >31 days [scored 0]) and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0]) in the last month of life.

RESULTS

Chemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95% CI = 0.047-0.429) or reported an unfavorable attitude toward palliative care (0.247 points, 95% CI = 0.047-0.450). A two-standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95% CI = 0.03-0.66) for chemotherapy and 0.33 (95% CI = 0.04-0.61) for emergency department visits/inpatient admissions. There was no evidence of effect modification.

CONCLUSION

Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.

When chemotherapy fails: Emotionally charged experiences faced by family caregivers of patients with advanced cancer

OBJECTIVE

To explore family caregivers' emotional experiences while caring for patients with advanced cancer and navigating distressing information, awareness of dying, and difficult decisions.

METHODS

Qualitative descriptive study of semi-structured interviews with 92 bereaved caregivers of patients with advanced cancer. Interviews explored caregivers' experiences as patients transitioned out of active cancer treatment and neared the end of life.

RESULTS

Included in caregivers' characterization of this transition time were three particularly emotionally charged experiences. The first occurred when caregivers felt jolted into awareness that patients were dying.They were startled to realize that patients would die sooner than expected; some expressed frustration that they had not been adequately warned. In the second, caregivers felt conflicted when involved in decisions that pitted patients' preferences against what caregivers felt patients needed, resulting in ambivalence, guilt, and grief. Thirdly, caregivers who felt they did their best for patients expressed fulfillment and gratitude.

CONCLUSION

Caregivers of patients with advanced cancer face unique, emotionally charged experiences that can lead to distress and affect care at the end of life.

PRACTICE IMPLICATIONS

Awareness of these situations may help oncology teams to provide sufficient guidance and support, partner with caregivers to clarify patients' needs, and deliver higher quality care.

Relationship between physicians' death anxiety and medical communication and decision-making: A systematic review

OBJECTIVE

To examine the relationship between physicians' death anxiety and medical communication and decision-making. It was hypothesized that physicians' death anxiety may lead to the avoidance of end-of-life conversations and a preference for life-prolonging treatments.

METHODS

PubMed and PsycInfo were systematically searched for empirical studies on the relation between physicians' death anxiety and medical communication and decision-making.

RESULTS

This review included five quantitative and two qualitative studies (N = 7). Over 38 relations between death anxiety and communication were investigated, five were in line with and one contradicted our hypothesis. Physicians' death anxiety seemes to make end-of-life communication more difficult. Over 40 relations between death anxiety and decision-making were investigated, three were in line with and two contradicted the hypothesis. Death anxiety seemes related to physicians' guilt or doubt after a patient's death.

CONCLUSIONS

There was insufficient evidence to confirm that death anxiety is related to more avoidant communication or decision-making. However, death anxiety does seem to make end-of-life communication and decision-making more difficult for physicians.

PRACTICE IMPLICATIONS

Education focused on death and dying and physicians' emotions in medical practice may improve the perceived ease with which physicians care for patients at the end of life.

'Treat them into the grave': cancer physicians' attitudes towards the use of high-cost cancer medicines at the end of life

The prescribing of high-cost cancer medicines at the end of life has become a focus of criticism, due primarily to concerns about the safety, efficacy and cost-effectiveness of these medicines in this clinical context. In response to these concerns, a number of interventions have been proposed - frequently focused on improving physician-patient communication at the end of life. Underpinning these strategies is the assumption that the prescribing of high-cost cancer medicines at the end of life is primarily the result of poor communication on the part of cancer physicians. In this paper, we explore the factors perceived by cancer physicians to be driving the use of high-cost cancer medicines at the end of life. Drawing on semi-structured interviews with 16 Australian oncologists and haematologists, we demonstrate that these physicians believe that the use of high-cost medicines at the end of life is driven by multiple factors - including individual, interpersonal, socio-cultural and public policy influences. We conclude that these factors, and their interactions, need to be taken into account in the development of public policy and clinical interventions to address the use of high-cost medicines at the end of life.

Profissionais de saúde e o processo de morte e morrer dos pacientes: uma revisão integrativa

Objetivo: conocer la producción científica sobre la relación entre los profesionales de salud y la muerte del paciente. Metodología: revisión integradora de la literatura mediante análisis de proximidad temática. Resultados: se elaboraron cuatro categorías: profesionales de salud no preparados para enfrentar la muerte; desafíos para lidiar con el proceso de muerte y morir en diferentes escenarios; tipos de muerte y sus interpretaciones, y profesionales de salud; y aspectos personales sobre cómo enfrentar la muerte. Concluciones: los profesionales de salud no están preparados para enfrentar el proceso del final de la vida; más allá de eso, sienten una falta de atención al tema, especialmente en relación con las estrategias de afrontamiento.

Is Annual Income a Predictor of Completion of Advance Directives (ADs) in Patients With Cancer

CONTEXT:

Completion of advance directives (ADs) enhances the likelihood of receiving goal-concordant treatments near the end of life. Previous research on community samples have shown that completion of ADs is less common in lower socioeconomic status demographic group; there is a paucity of such research in patients with cancer.

OBJECTIVES:

To study the effect of income and education on the completion of ADs.

HYPOTHESIS:

Patients with cancer having lower incomes and education levels would be less likely to report completing ADs.

METHODS:

We conducted cross-sectional analyses of data provided by patients (n = 265) enrolled in the Values and Options in Cancer Care clinical trial. Patients with advanced cancer reported whether they had (1) completed a living will or (2) designated a health-care proxy. Response options for both questions were yes (scored 1), no (scored 0), and unsure (scored 0). We studied the association of lower household income (≤US$20 000) and education level (never attended college) with AD scores.

RESULTS:

Patients with lower annual incomes had lower AD scores (estimate -0.44; confidence intervals [CI]: -0.71 to -0.16, P = .001); the association between higher educational attainment (some college or more) and completion of ADs was not statistically significant (estimate 0.04, CI: -0.16 to 0.24, P = .70).

CONCLUSION:

Interventions to promote completion of ADs among lower income patients with serious illnesses are needed.

Fatalism and educational disparities in beliefs about the curability of advanced cancer

OBJECTIVE

Understanding socioeconomic disparities in the care of patients with incurable cancer is a high priority. We hypothesized that patients without a high school education are more likely to believe that they could be cured and we explored the role of fatalism.

METHODS

We studied 977 patients with advanced, incurable cancer. Two logistic regression analyses were conducted. Model One examined the effect of education on beliefs about curability. Model Two added fatalism.

RESULTS

The significant association between having less than a high school education and the belief that advanced cancer can be cured (OR=2.55; 95% CI: 1.09-5.96) in Model One was attenuated by 39% and rendered nonsignificant in Model Two. Fatalism was associated with the belief that advanced cancer can be cured. Whites were less likely to believe they could be cured than Blacks and Asians/Pacific Islanders. Beliefs about curability were not associated with income or insurance status.

CONCLUSIONS

People who do not complete high school are more likely to believe that their advanced cancer is curable, in part because they are more likely to hold fatalistic worldviews.

PRACTICE IMPLICATIONS

Interventions to help oncologists care for patients with fatalistic beliefs could mitigate socioeconomic disparities in end-of-life care.

Effect of a Patient-Centered Communication Intervention on Oncologist-Patient Communication, Quality of Life, and Health Care Utilization in Advanced Cancer: The VOICE Randomized Clinical Trial

IMPORTANCE

Observational studies demonstrate links between patient-centered communication, quality of life (QOL), and aggressive treatments in advanced cancer, yet few randomized clinical trials (RCTs) of communication interventions have been reported.

OBJECTIVE

To determine whether a combined intervention involving oncologists, patients with advanced cancer, and caregivers would promote patient-centered communication, and to estimate intervention effects on shared understanding, patient-physician relationships, QOL, and aggressive treatments in the last 30 days of life.

DESIGN, SETTING, AND PARTICIPANTS

Cluster RCT at community- and hospital-based cancer clinics in Western New York and Northern California; 38 medical oncologists (mean age 44.6 years; 11 (29%) female) and 265 community-dwelling adult patients with advanced nonhematologic cancer participated (mean age, 64.4 years, 146 [55.0%] female, 235 [89%] white; enrolled August 2012 to June 2014; followed for 3 years); 194 patients had participating caregivers.

INTERVENTIONS

Oncologists received individualized communication training using standardized patient instructors while patients received question prompt lists and individualized communication coaching to identify issues to address during an upcoming oncologist visit. Both interventions focused on engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information. Control participants received no training.

MAIN OUTCOMES AND MEASURES

The prespecified primary outcome was a composite measure of patient-centered communication coded from audio recordings of the first oncologist visit following patient coaching (intervention group) or enrollment (control). Secondary outcomes included the patient-physician relationship, shared understanding of prognosis, QOL, and aggressive treatments and hospice use in the last 30 days of life.

RESULTS

Data from 38 oncologists (19 randomized to intervention) and 265 patients (130 intervention) were analyzed. In fully adjusted models, the intervention resulted in clinically and statistically significant improvements in the primary physician-patient communication end point (adjusted intervention effect, 0.34; 95% CI, 0.06-0.62; P = .02). Differences in secondary outcomes were not statistically significant.

CONCLUSIONS AND RELEVANCE

A combined intervention that included oncologist communication training and coaching for patients with advanced cancer was effective in improving patient-centered communication but did not affect secondary outcomes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01485627.

[The special requirements of old age in terms of dying]

It is expected that the rising average life expectancy will leave ever more people with chronic progressive diseases of the body and brain. This then means not only having to deal with increasingly longer periods of care, but also possibly distinct neurocognitive disorders in the years prior to death and dying. The aim of this study is to report epidemiological data on the causes of death, as well as on the places of death. In addition, the attitudes and behaviour towards death and dying, as well as the different places of death will be discussed. Expecting support in the process of dying, as well as factors that have a more conducive effect on the internal processing of dying, are mentioned. At the same time, the attitudes and behaviours in respect of the accompaniment of dying people, which can be seen in the staff in clinical inpatient facilities, are addressed. Personal intense grappling with dying and death actually has a positive effect on these behaviours and attitudes. Finally, the contribution turns to the question of to what extent the theory of compression of morbidity may be perceived as valid, especially in view of the rising average life expectancy. It is emphasised that chronic diseases, even when no functional loss is present, place not only great demands on the patient, but also on the care system and financial resources. Furthermore, it is demonstrated that frailty can often cause mental disorders. Specific requirements with a view to the care of people with dementia are given.