How and when do patients request life-expectancy estimates? Evidence from hospice medical consultations and insights for practice

Haptic Resources in Pain Communication: New Amputees Redirecting Doctors' Professional Touch at the Prosthetic Clinic

Pain assessment is key in deciding whether amputee patients are fit to receive a prosthesis, but its interactional accomplishment is still underexplored. This study adopts multimodal conversation analysis to investigate how pain assessment is carried out during medical visits at an Italian prosthetic clinic involving 77 patients and 24 health professionals. In the analyzed data, doctors carry out pain assessment by asking patients whether they feel pain during palpation of the stump, and patients respond by elaborating on their sensations and using touch in turn. The analysis focuses on a collection of 10 cases in which patients use response expansions and self-touch to reorient doctors' ongoing inquiry by specifying the type of sensation they experience and its location or to correct doctors' previous inquiry. The analysis illuminates how the patient's body becomes a resource for tactile practices that are shared between doctors and patients in the service of a common understanding of patients' pain. This analysis provides new knowledge of a practice patients use to redirect doctors' attention and understandings.

Inviting the Patient to Talk About a Conversation They Had with Another Healthcare Practitioner: A Way of Promoting Discussion About Disease Progression and End of Life in Palliative Care Interactions

Discussing disease progression is a core task in palliative care. This is especially important when there are indications that a patient considers their death as less imminent than the clinical team does. This article examines a communicative action that palliative medicine doctors use to address such discrepancies in knowledge and understanding of the patient's prognosis: inviting the patient to talk about the contents of a conversation they had with another healthcare practitioner. The study used conversation analysis to examine five consultations in which this action was identified. These were part of a larger data set of 37 consultations recorded in a large UK hospice and involving patients with palliative care needs, sometimes accompanied by family or friends, and palliative medicine doctors. Findings are that the action of inviting the patient to talk about a previous conversation creates an opportunity for patients to articulate what they know and understand about their disease progression - but without requiring them to do so. Discussing such sensitive matters is thus made a matter of 'opting in' (rather than 'opting out'). Doctors thereby avoid being interactionally accountable for directly initiating a potentially distressing topic. The article shows how the task of discussing disease progression and end of life is intertwined with the delicate management of patients' displayed states of awareness regarding their disease progression. The study thus has practical implications by documenting ways in which clinicians can help patients realign their expectations about such delicate matters.

Managing understandings of palliative care as more than care immediately before death: Evidence from observational analysis of consultations

BACKGROUND

Evidence suggests that public, and some professional, understandings of palliative care are limited to care provided immediately before death, which contrasts palliative care's scope as care provided across a range of illness stages.

OBJECTIVE

To examine how clinicians manage patients' understandings of palliative care during initial consultations.

DESIGN

Initial palliative care consultations were video-recorded and analysed using conversation analytic methods.

SETTING/PARTICIPANTS

Consultations were recorded in a specialist palliative care outpatient unit within an Australian public hospital. Participants included 20 newly referred patients and their families, and three palliative care clinicians.

RESULTS

During initial consultations, it was observed that specialist palliative care clinicians frequently managed the possibility that patients may understand palliative care as limited to care provided immediately before death. Clinicians used recurrent practices that seemed designed to pre-empt and contradict patients' possible narrow understandings. When discussing the palliative care inpatient unit, clinicians recurrently explained inpatient care could include active treatment and referred to the possibility of being discharged. These practices contradict possible understandings that future admission to the inpatient unit would be solely for care immediately before death.

DISCUSSION

The findings demonstrate that palliative care clinicians are aware of possible narrow understandings of their discipline among members of the public. The practices identified show how clinicians pre-emptively manage these understandings to patients newly referred to palliative care.

CONCLUSIONS

These findings highlight scope for greater partnership with teams referring patients to palliative care, to assist patients in understanding the range of reasons for their referral.

PATIENT OR PUBLIC CONTRIBUTION

The observational method of conversation analysis provides direct insight into matters that are relevant for patients, as raised in their consultations with clinicians. This direct evidence enables analysis of their lived experience, as it occurs, and grounds analysis in observable details of participants' conduct, rather than interpretations of subjective experiences. The patients' contributions, therefore, were to allow observation into their initial palliative care consultations.

Examining Conversation Analysis in Palliative Care: A Systematic Review

Communication is an integral component in palliative care. A number of studies have used conversation analysis (CA) to examine communication between healthcare professionals (HCPs) and patients/companions in palliative care. To the best of our knowledge, however, no work has been done to synthesize these studies. Thus, the review aimed to synthesize these conversation analytic studies in the setting of palliative care. The review included peer-reviewed studies that focused on communication between HCPs and patients/companions and that were published in English before September 10 2022. The database and manual search produced 16 eligible studies. The thematic analysis generated five themes: (1) promoting patient agency and autonomy; (2) practices for gathering pain-related information and navigating pain concerns (practices for gathering pain-related information and practices for navigating patients' pain concerns); (3) initiating and managing end-of-life discussions; (4) facilitating shared decision making in palliative care; and (5) navigating sensitive topics and uncertainty in prognostic talk. The review highlighted the potential of CA for research in palliative care and had implications for communication practice.

Companion responses to diagnosis in Chinese outpatient clinical interaction

Patients regularly attend clinical consultations with companions in Chinese outpatient clinics. Despite companions' significant influence on clinical consultations, how companions respond to diagnosis and their contributions to the activity of diagnosis in Chinese outpatient clinical interaction remain under-researched. The present study, by adopting the method of conversation analysis, investigated clinicians' diagnostic deliveries and companions' subsequent responses in Chinese outpatient clinical interaction. The data for this study consisted of 79 video recordings of clinical consultations in the Chinese orthopedic outpatient clinic, approximately lasting 12 h and involving three male clinicians, 79 patients (37 male/42 female), and 91 companions (51 male/40 female). Three basic categories of companion responses to diagnosis were identified: minimal verbal responses, embodied responses, and extended responses. It was demonstrated that these distinct responses allowed companions to challenge clinicians' medical authority in the activity of diagnosis by delivering their own diagnostic judgments, resisting clinicians' diagnoses, and orienting to clinicians' accounts for their diagnostic statements and reasoning, thus displaying companion agency in the Chinese outpatient clinical decision-making and indicating a transition from a paternalistic model to a family-centered model of the doctor-patient relationship in the Chinese orthopedic outpatient interaction. This study furthers current knowledge of companion involvement across healthcare contexts and contributes to raising clinicians' awareness of the significance of companions' contributions in Chinese outpatient clinical interaction.

The Role of Health Care Communication in Treatment Outcomes

The physician-patient relationship has evolved significantly in the past century. Physician authority has been reduced while patients have been empowered. This review focuses on face-to-face clinical care and argues that current physician-patient relations range from partnerships between social actors who each play critical roles in negotiating care to a more adversarial duel in which both participants advocate for goals that are not necessarily shared. While the former is the hope of increased patient involvement, the latter is increasingly common. Through our discussion of existing studies, we document that while high levels of patient participation are beneficial to treatment outcomes, this engagement also has a dark side that threatens treatment outcomes. We discuss some communication resources patients use that affect treatment outcomes, exemplify how patient engagement affects physician communication, and discuss some strategies that current research finds effective for communicating about treatment with today's engaged patients.

An online randomised controlled trial of prognosticating imminent death in advanced cancer patients: Clinicians give greater weight to advice from a prognostic algorithm than from another clinician with a different profession

BACKGROUND

A second opinion or a prognostic algorithm may increase prognostic accuracy. This study assessed the level to which clinicians integrate advice perceived to be coming from another clinician or a prognostic algorithm into their prognostic estimates, and how participant characteristics and nature of advice received affect this.

METHODS

An online double-blind randomised controlled trial was conducted. Palliative doctors, nurses and other types of healthcare professionals were randomised into study arms differing by perceived source of advice (algorithm or another clinician). In fact, the advice was the same in both arms (emanating from the PiPS-B14 prognostic model). Each participant reviewed five patient summaries. For each summary, participants: (1) provided an initial probability estimate of two-week survival (0% 'certain death'-100% 'certain survival'); (2) received advice (another estimate); (3) provided a final estimate. Weight of Advice (WOA) was calculated for each summary (0 '100% advice discounting' - 1 '0% discounting') and multilevel linear regression analyses were conducted.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04568629.

RESULTS

A total of 283 clinicians were included in the analysis. Clinicians integrated advice from the algorithm more than advice from another clinician (WOA difference = -0.12 [95% CI -0.18, -0.07], p < 0.001). There was no interaction between study arm and participant profession, years of palliative care or overall experience. Advice of intermediate strength (75%) was given a lower WOA (0.31) than advice received at either the 50% (WOA 0.40) or 90% level (WOA 0.43). The overall interaction between strength of advice and study arm on WOA was significant (p < 0.001).

CONCLUSION

Clinicians adjusted their prognostic estimates more when advice was perceived to come from a prognostic algorithm than from another clinician. Research is needed to understand how clinicians make prognostic decisions and how algorithms are used in clinical practice.

Knowledge and Attitudes of Allied Health Professionals Towards End-Of-Life and Advance Care Planning Discussions With People With COPD: A Cross-Sectional Survey Study

Chronic obstructive pulmonary disease (COPD) is a progressive, life-limiting condition. End-of-life (EOL) and Advance Care Planning (ACP) discussions are essential, yet access and support remain inadequate. Allied health professionals (AHPs) commonly have ongoing relationships with patients and opportunities to discuss care outside acute crises as is considered best practice. Australian and New Zealand AHPs were invited to complete an anonymous, online, cross-sectional survey that aimed to explore knowledge, attitudes and practices, and associated perceived triggers and barriers to EOL and ACP discussions with patients with COPD. Closed survey responses were summarized descriptively and free-text thematically analysed. One hundred and one AHPs (physiotherapists, social workers and occupational therapists) participated. Many held positive attitudes towards ACP but lacked procedural knowledge. Half (50%) of participants routinely discussed EOL care with patients when perceiving this to be appropriate but only 21% actually discussed ACP with the majority of their patients. Many cited lack of training to engage in sensitive EOL discussions, with barriers including: 1) clinician lack of confidence/fear of distressing patients (75%); 2) perceived patient and family reluctance (51%); 3) organizational challenges (28%); and 4) lack of role clarity (39%). AHPs commonly have ongoing relationships with patients with chronic conditions but lack the confidence and role clarity to utilise this position to engage ongoing EOL and ACP discussions. While AHPs may not traditionally consider EOL and ACP discussions as part of their role, it is crucial that they feel prepared to respond if patients broach the topic.

RealTalk evidence-based communication training resources: development of conversation analysis-based materials to support training in end-of-life-related health and social care conversations

Training to enhance healthcare practitioners' capabilities in engaging people in sensitive and end-of life-related conversations is in demand. However, evaluations have either not measured, or found very limited impact on actual practice and patient experience. Training effectiveness is improved when it is based on in-depth evidence, reflects the complexity of real-life interactions, and instils principles adaptable to everyday practice. A relatively new source of in-depth evidence and practice-relevant insights on healthcare interactions is conversation analytic research, a form of observational analysis of real-life interactions. However, conversation analytic research findings have largely been disseminated by and for scientists, rather than clinicians and trainers. We used conversation analytic evidence to develop resources for use by healthcare trainers. The aim was to increase training's evidence-base and authenticity. We further aimed to develop resources applicable to working with learners ranging from novices to advanced practitioners.

METHODS

 Using an intervention development approach, we created online video-clips and supplementary written materials for professionals who deliver training, supervision, and support in healthcare communication for staff and students. The materials were reviewed by an advisory group comprising clinicians, lay consultees, educators, and researchers, and piloted by trainers in UK universities, NHS organisations and independent hospices. We refined materials based on their feedback.

RESULTS

 The resulting 'RealTalk' resources focus on practices for communicating with patients and their companions about end-of-life and prognosis. Two core training modules were developed, each comprising several patient case studies featuring video-clips from real-life healthcare consultations. The clips featured practices that patients and experienced practitioners use in approaching end-of-life matters. The case studies also included evidence-based descriptions of observable practices and the principles underlying these, alongside transcripts and case synopses.

CONCLUSIONS

 RealTalk training resources aim to facilitate evidence-based, experiential and reflective learning, focusing on communication challenges, practices and principles for end-of-life-related interactions. The resources are designed for use by trainers for delivering all levels of training, from introductory to advanced, in both formal and informal training settings. Our development process may serve as a blueprint for the production of future evidence-based training resources based on conversation analytic research.

A direct observation of pain scale use in five video-recorded palliative care consultations: Using conversation analysis to show how practitioners support patients to describe pain

OBJECTIVE

Assessing pain intensity is an important palliative care task. Self-report pain intensity scales are frequently used within assessment. In contrast to formal studies of validity and reliability, we examine administration of, and responses to these scales in everyday palliative care.

METHODS

We searched episodes of pain scale use in a dataset of (video/audio-recorded) UK palliative care consultations involving five doctors, 37 terminally ill patients and their companions. We found five, and applied the techniques and tools of conversation analysis to characterise scales' administration and functioning.

RESULTS

Generally, the patients responded to scales by reporting multiple aspects of pain; the doctors supported and encouraged this. In two episodes, the scales generated misunderstandings. The doctors worked to resolve these in ways that avoided implying the patient was at fault.

CONCLUSION

Pain intensity scales can yield richer information than just intensity. They can also generate misunderstandings and social friction which take skill and effort to resolve.

PRACTICE IMPLICATIONS

Patients tend to respond to pain intensity scales by reporting on multiple aspects of pain, professionals should support them in this. These scales sometimes generate misunderstandings. To preserve the therapeutic relationship, professionals should work to resolve these without implying the patient is to blame.

"Do you want us to try to resuscitate?": Conversational practices generating patient decisions regarding cardiopulmonary resuscitation

OBJECTIVE

To explore how physicians elicit patients' preferences about cardio-pulmonary resuscitation (CPR) during hospital admission interviews.

METHODS

Conversation analysis of 37 audio-recorded CPR patient-physician discussions at admission to a geriatric hospital.

RESULTS

The most encountered practice is when physicians submit an option to the patient's validation ("do you want us to resuscitate"). Through it, physicians display presuppositions about the patient's preference, which is not elicited as an autonomous contribution. Through open elicitors ("what would you wish"), physicians treat patients as knowledgeable about options and autonomous in determining their preference. A third practice is related to patients delivering their preference in anticipation of the request and is encountered only for choices against CPR. These decisions are revealed as informed and autonomous, and the patient as collaborative.

CONCLUSION

The way that physicians elicit patients' preferences about CPR influences the delivery of autonomous and informed decisions. Our findings point to an asymmetry in ways of initiating talk about the possibility of not attempting CPR, potentially exacerbated by the context of admission interviews.

PRACTICE IMPLICATIONS

Decisions about the relevancy life-sustaining interventions need an adequate setting in order to allow for patient participation. Our findings have implications for communication training in regard to involving patients in conversations about goals of care.

What happens when patients say "no" to offers of referral for weight loss? - Results and recommendations from a conversation analysis of primary care interactions

OBJECTIVE

Guidelines recommend that clinicians should offer patients with obesity referrals to weight management services. However, clinicians and patients worry that such conversations will generate friction, and the risk of this is greatest when patients say no. We examined how doctors actually respond to patient refusals, and how patients reacted to clinicians in turn.

METHODS

Conversation analysis of 226 GP-patient interactions recorded during a clinical trial of weight management referrals in UK primary care.

RESULTS

Some clinicians responded to refusals by delivering further information or offering referral again. These actions treated patient refusals as unwelcome, and acted to pursue acceptance instead. However, pursuit did not lead to acceptance. Rather, pursuing acceptance lengthened consultations and led to frustration, offence, or anger. Clinicians who accepted refusals and closed the consultation avoided friction and negative emotional displays.

CONCLUSION

Patient refusals have the potential to create negative consequences in the consultation and clinician responses were key in avoiding these. When clinicians acknowledged the legitimacy of patient refusals, negative consequences were avoided, and the conversation was briefer and smoother.

PRACTICE IMPLICATIONS

When patients refuse the offer of a free weight management referral, GPs should accept this refusal, rather than trying to persuade patients to accept.

Communicating with patients and families about illness progression and end of life: a review of studies using direct observation of clinical practice

BACKGROUND

There is growing recognition that a diverse range of healthcare professionals need competence in palliative approaches to care. Effective communication is a core component of such practice. This article informs evidence-based communication about illness progression and end of life through a rapid review of studies that directly observe how experienced clinicians manage such discussions.

METHODS

The current rapid review updates findings of a 2014 systematic review, focussing more specifically on evidence related to illness progression and end-of-life conversations. Literature searches were conducted in nine bibliographic databases. Studies using conversation analysis or discourse analysis to examine recordings of actual conversations about illness progression or end of life were eligible for inclusion in the review. An aggregative approach was used to synthesise the findings of included studies.

RESULTS

Following screening, 26 sources were deemed to meet eligibility criteria. Synthesis of study findings identified the structure and functioning of ten communication practices used in discussions about illness progression and end-of-life.

CONCLUSION

The ten practices identified underpin five evidence-based recommendations for communicating with patients or family members about illness progression and end of life.

Life Expectancy After Liver Transplantation for Alcoholic Cirrhosis

BACKGROUND

Alcohol-associated liver disease is the leading cause of liver transplantation in the western world. For these patients we calculated life expectancies both at time of transplant and several years later, stratified by key risk factors, and determined if survival has improved in recent years.

METHODS

Data on 14 962 patients with alcohol-associated liver disease who underwent liver transplantation in the MELD era (2002-2018) from the United States Organ Procurement and Transplantation Network database were analyzed using the Cox proportional hazards regression model and life table methods.

RESULTS

Demographic and past medical history factors related to survival were patient age, presence of diabetes or severe hepatic encephalopathy, and length of hospital stay. Survival improved over the study period, at roughly 3% per calendar year during the first 5 years posttransplant and 1% per year thereafter.

CONCLUSIONS

Life expectancy in transplanted patients with alcohol-associated liver disease was much reduced from normal, and varied according to age, medical risk factors, and functional status. Survival improved modestly over the study period. Information on patient longevity can be helpful in making treatment decisions.

'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication?

Uncertainty, fear to harm the patient, discomfort handling the discussion and lack of time are the most cited barriers to prognostic disclosure. Physicians can be reassured that patients desire the truth about prognosis and can manage the discussion without harm, including the uncertainty of the information, if approached in a sensitive manner. Conversational guides could provide support in preparing such difficult conversations. Communicating 'with realism and hope' is possible, and anxiety is normal for both patients and clinicians during prognostic disclosure. As a clinician pointed out: 'I had asked a mentor once if it ever got easier. - No. But you get better at it.'

Respiratory Nurses Have Positive Attitudes But Lack Confidence in Advance Care Planning for Chronic Obstructive Pulmonary Disease: Online Survey

Chronic obstructive pulmonary disease (COPD) is a progressive, life-limiting illness. Despite significant symptom burden, access to advance care planning (ACP) and palliative care are limited. Early initiation of ACP enables patients to articulate the values that underpin the decisions they would make if, in the future, they are unable to speak for themselves. Nurses constitute the majority of health care workforce and are well placed to initiate these discussions. This study explored knowledge, attitudes, and practice regarding ACP for patients with COPD among Australian and New Zealand respiratory nurses. A cross-sectional online survey tested knowledge about ACP and canvassed attitudes about current practice. Data were analyzed using descriptive statistics and content analysis of text data. The 112 participating respiratory nurses had substantial knowledge and positive attitudes regarding ACP in COPD; however, they lacked confidence and clarity regarding their role. Despite advances in end-of-life care provision for chronic disease, well-established barriers remained (inadequate training, fear of distressing patients, and time), and discussion triggers were still linked to acute deterioration, diagnosis of severe disease, and patient initiation. Better articulating the role of the respiratory nurse in ACP and building capacity and confidence within this workforce may improve ACP access for people living with COPD.

Development of a life expectancy table for individuals with type 1 diabetes

AIMS/HYPOTHESIS

Tables reporting life expectancies by common risk factors are available for individuals with type 2 diabetes; however, there is currently no published equivalent for individuals with type 1 diabetes. We aimed to develop a life expectancy table using a recently published simulation model for individuals with type 1 diabetes.

METHODS

The simulation model was developed using data from a real-world population of patients with type 1 diabetes selected from the Swedish National Diabetes Register. The following six important risk factors were included in the life table: sex; age; current smoking status; BMI; eGFR; and HbA_1c. For each of 1024 cells in the life expectancy table, a synthetic cohort containing 1000 individuals was created, with other risk factors assigned values representative of the real-world population. The simulations were executed for all synthetic cohorts and life expectancy for each cell was calculated as mean survival time of the individuals in the respective cohort.

RESULTS

There was a substantial variation in life expectancy across patients with different risk factor levels. Life expectancy of 20-year-old men varied from 29.3 years to 50.6 years, constituting a gap of 21.3 years between those with worst and best risk factor levels. In 20-year-old women, this gap was 18.9 years (life expectancy range 35.0-53.9 years). The variation in life expectancy was a function of the combination of risk factor values, with HbA_1c and eGFR consistently showing a negative and positive correlation, respectively, with life expectancy at any level combination of other risk factors. Individuals with the lowest level (20 kg/m²) and highest level of BMI (35 kg/m²) had a lower life expectancy compared with those with a BMI of 25 kg/m². Non-smokers and women had a higher life expectancy than smokers and men, respectively, with the difference in life expectancy ranging from 0.4 years to 2.7 years between non-smokers and smokers, and from 1.9 years to 5.9 years between women and men, depending on levels of other risk factors.

CONCLUSIONS/INTERPRETATION

The life expectancy table generated in this study shows a substantial variation in life expectancy across individuals with different modifiable risk factors. The table allows for rapid communications of risk in an easily understood format between healthcare professionals, health economists, researchers, policy makers and patients. Particularly, it supports clinicians in their discussion with patients about the benefits of improving risk factors.

A scoping review of practice recommendations for clinicians' communication of uncertainty

BACKGROUND

Health-care providers increasingly have to discuss uncertainty with patients. Awareness of uncertainty can affect patients variably, depending on how it is communicated. To date, no overview existed for health-care professionals on how to discuss uncertainty.

OBJECTIVE

To generate an overview of available recommendations on how to communicate uncertainty with patients during clinical encounters.

SEARCH STRATEGY

A scoping review was conducted. Four databases were searched following the PRISMA-ScR statement. Independent screening by two researchers was performed of titles and abstracts, and subsequently full texts.

INCLUSION CRITERIA

Any (non-)empirical papers were included describing recommendations for any health-care provider on how to orally communicate uncertainty to patients.

DATA EXTRACTION

Data on provided recommendations and their characteristics (eg, target group and strength of evidence base) were extracted. Recommendations were narratively synthesized into a comprehensible overview for clinical practice.

RESULTS

Forty-seven publications were included. Recommendations were based on empirical findings in 23 publications. After narrative synthesis, 13 recommendations emerged pertaining to three overarching goals: (a) preparing for the discussion of uncertainty, (b) informing patients about uncertainty and (c) helping patients deal with uncertainty.

DISCUSSION AND CONCLUSIONS

A variety of recommendations on how to orally communicate uncertainty are available, but most lack an evidence base. More substantial research is needed to assess the effects of the suggested communicative approaches. Until then, health-care providers may use our overview of communication strategies as a toolbox to optimize communication about uncertainty with patients.

PATIENT OR PUBLIC CONTRIBUTION

Results were presented to stakeholders (physicians) to check and improve their practical applicability.

Being in Place: A Multimodal Analysis of the Contribution of the Patient's Companion to "First Time" Oncological Visits

Companions to medical visits have been alternatively viewed as members who “support” or “inhibit” and “interfere” with the doctor-patient interaction. One way of looking at the companions' contribution to medical visits is by coding roles or functions of their communicative behavior. Our paper aims at reconsidering these findings and analyzing how the companion participation is a local and sequential accomplishment, changing from time to time in the consultation. The paper relies upon an overall collection of 58 videorecordings of first oncological visits. Visits were conducted in two different hospitals, one of which a University hospital, and by different oncologists, including both senior professionals and (in the second setting) medical students in oncology. Visits were fully transcribed according to the Jeffersonian conventions and authors examined the transcripts and video according to the methodology of Conversation Analysis. The aim of the paper focused on how patient's companions orient and contribute to the accomplishment of the different aims and activities at different stages of the visit as an institutional speech event. The multimodal analysis of turns and actions (such as, gaze shifts, prosodic modulation, bodily arrangements), and the close examination of the sequential and temporal arrangements of companions' and their co-participants' turns revealed that companions finely attune to the multiparty framework of the encounter and the institutional constraints that govern the oncological first visit. Overall, results show two relevant features: that companions act as to preserve the doctor-patient interaction and to maintain the patient as the most responsible and legitimate agent in the interaction; that companions' contributions are relevant to the activities that sequentially unfold at different stages in the consultation (e.g., history taking, problem presentation, treatment recommendation etc.). The study complements earlier findings on the companion's roles, showing how these are highly mobile, multimodal and multiparty accomplishments, and they are tied to the specific contingencies of the visit. The results solicit to consider the value of multimodal analysis in understanding the complexity of multiparty communication in medical setting, and make it usable also in medical education.

Oncologists' Communication About Uncertain Information in Second Opinion Consultations: A Focused Qualitative Analysis

Introduction: Uncertainty is omnipresent in cancer care, including the ambiguity of diagnostic tests, efficacy and side effects of treatments, and/or patients' long-term prognosis. During second opinion consultations, uncertainty may be particularly tangible: doubts and uncertainty may drive patients to seek more information and request a second opinion, whereas the second opinion in turn may also affect patients' level of uncertainty. Providers are tasked to clearly discuss all of these uncertainties with patients who may feel overwhelmed by it. The aim of this study was to explore how oncologists communicate about uncertainty during second opinion consultations in medical oncology. Methods: We performed a secondary qualitative analysis of audio-recorded consultations collected in a prospective study among cancer patients (N = 69) who sought a second opinion in medical oncology. We purposively selected 12 audio-recorded second opinion consultations. Any communication about uncertainty by the oncologist was double coded by two researchers and an inductive analytic approach was chosen to allow for novel insights to arise. Results: Seven approaches in which oncologists conveyed or addressed uncertainty were identified: (1) specifying the degree of uncertainty, (2) explaining reasons of uncertainty, (3) providing personalized estimates of uncertainty to patients, (4) downplaying or magnifying uncertainty, (5) reducing or counterbalancing uncertainty, and (6) providing support to facilitate patients in coping with uncertainty. Moreover, oncologists varied in their (7) choice of words/language to convey uncertainty (i.e., "I" vs. "we"; level of explicitness). Discussion: This study identified various approaches of how oncologists communicated uncertain issues during second opinion consultations. These different approaches could affect patients' perception of uncertainty, emotions provoked by it, and possibly even patients' behavior. For example, by minimizing uncertainty, oncologists may (un)consciously steer patients toward specific medical decisions). Future research is needed to examine how these different ways of communicating about uncertainty affect patients. This could also facilitate a discussion about the desirability of certain communication strategies. Eventually, practical and evidence-based guidance needs to be developed for clinicians to optimally inform patients about uncertain issues and support patients in dealing with these.

Multi-disciplinary supportive end of life care in long-term care: an integrative approach to improving end of life

Background

Optimal supportive end of life care for frail, older adults in long term care (LTC) homes involves symptom management, family participation, advance care plans, and organizational support. This 2-phase study aimed to combine multi-disciplinary opinions, build group consensus, and identify the top interventions needed to develop a supportive end of life care strategy for LTC.

Methods

A consensus-building approach was undertaken in 2 Phases. The first phase deployed modified Delphi questionnaires to address and transform diverse opinions into group consensus. The second phase explored and prioritized the interventions needed to develop a supportive end of life care strategy for LTC. Development of the Delphi questionnaire was based on findings from published results of physician perspectives of barriers and facilitators to optimal supportive end of life care in LTC, a literature search of palliative care models in LTC, and published results of patient, family and nursing perspectives of supportive end of life care in long term care. The second phase involved World Café Style workshop discussions. A multi-disciplinary purposive sample of individuals inclusive of physicians; staff, administrators, residents, family members, and content experts in palliative care, and researchers in geriatrics and gerontology participated in round one of the modified Delphi questionnaire. A second purposive sample derived from round one participants completed the second round of the modified Delphi questionnaire. A third purposive sample (including participants from the Delphi panel) then convened to identify the top priorities needed to develop a supportive end-of-life care strategy for LTC.

Results

19 participants rated 75 statements on a 9-point Likert scale during the first round of the modified Delphi questionnaire. 11 participants (participation rate 58 %) completed the second round of the modified Delphi questionnaire and reached consensus on the inclusion of 71candidate statements. 35 multidisciplinary participants discussed the 71 statements remaining and prioritized the top clinical practice, communication, and policy interventions needed to develop a supportive end of life strategy for LTC.

Conclusions

Multi-disciplinary stakeholders identified and prioritized the top interventions needed to develop a 5-point supportive end of life care strategy for LTC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02271-1.

Barriers to Palliative Care Referral and Advance Care Planning (ACP) for Patients With COPD: A Cross-Sectional Survey of Palliative Care Nurses

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive, life-limiting illness that requires end-of-life care planning, yet remains under-served. Understanding barriers to advance care planning (ACP) from different specialties' perspectives will enable a co-ordinated, cross-disciplinary approach to improving ACP access.

METHODS

Australia and New Zealand palliative care nurses were invited to complete an anonymous online cross-sectional survey. Questions tested knowledge of validated ACP-related practice indicators and canvassed perspectives on barriers to ACP in COPD. Data are described and free-text thematically analyzed.

RESULTS

The 90 participants had high knowledge and positive attitudes to ACP in COPD, however, lacked consensus as to whether patients want to know their prognosis or discuss treatment options and end-of-life wishes. 59% discussed ACP in more than half their patients with COPD, and 77% and 73% routinely initiated or followed-up these discussions. Key barriers included: lack of confidence and training in COPD; reluctance to distress patients and families; referral late in the disease course; lack of consensus on referral timing; and lack of patient and clinician understanding of COPD prognoses. Many reported that lack of consensus in the treating team, paired with prognostic uncertainty, precluded timely ACP engagement.

CONCLUSIONS

Palliative care nurses have substantial knowledge and positive beliefs regarding ACP, however, some beliefs and practices lack alignment with qualitative data on patients' wishes in COPD. While palliative care nurses are well placed to facilitate early implementation for patients with advanced COPD, ACP training and practice guidelines specific to COPD may increase implementation in this life-limiting disease.

Transitioning out of prognostic talk in discussions with families of hospice patients at the end of life: A conversation analytic study

OBJECTIVE

To examine transitions out of prognostic talk in interactions between clinicians and the relatives and friends of imminently dying hospice patients.

METHODS

Conversation analysis of 20 conversations between specialist palliative care clinicians and the families of imminently dying patients in a hospice.

RESULTS

Following the provision and acknowledgement of a prognostic estimate, clinicians were able to transition gradually towards making assurances about actions that could be taken to ensure patient comfort. When families raised concerns or questions, this transition sequence was extended. Clinicians addressed these questions or concerns and then pivoted to action-oriented talk, most often relating to patient comfort.

CONCLUSION

In conversations at the end of life, families and clinicians used practices to transition from the uncertainty of prognosis to more certain, controllable topics including comfort care.

PRACTICE IMPLICATIONS

In a context in which there is a great deal of uncertainty, transitioning towards talk on comfort care can emphasise action and the continued care of the patient and their family.

Life Expectancy after Liver Transplantation for Non-Cirrhotic Hepatocellular Carcinoma

BACKGROUND

Hepatocelluar carcinoma typically occurs with underlying cirrhosis. However roughly 20% of cases arise in a non-cirrhotic liver. There is limited literature that addresses the long-term survival of the narrow subgroup who received transplantation. For such patients we sought to calculate life expectancies both at time of transplant and several years later, stratified by key risk factors, and to determine if survival has improved in recent years. Such information can be helpful in making treatment decisions.

METHODS

Data on 4,373 non-cirrhotic HCC patients who underwent liver transplantation in the MELD era (2002-2018) from the United States OPTN database were analyzed using the Cox proportional hazards regression model and life table methods.

RESULTS

Demographic and past medical history factors related to survival were patient age, donor age over 20, and the presence of ascites or severe hepatic encephalopathy. Survival did not vary by race or sex. HCC-specific factors significantly related to survival were the total number of tumors, extrahepatic spread, lymph node involvement, satellite lesions, micro- or macrovascular invasion, tumor differentiation (grade), and pre-transplant treatment. Survival improved over the study period, at 4% per calendar year during the first 5 years post transplant and 1% per year thereafter.

CONCLUSIONS

Life expectancy in non-cirrhotic HCC transplant patients is much reduced from normal, and varies according to age and tumor-related factors. Survival improved modestly over the study period.

Discussing Prognosis with Empathy to Cancer Patients

PURPOSE OF REVIEW

Our goal was to provide healthcare professionals (HCPs) with evidence-based data about what can be done to handle prognostic discussions with empathy.

RECENT FINDINGS

First, disclosing prognosis involves a good reason to do so and making sure that the patient will be able to process the discussion. Second, communication tips are given for the three dimensions of empathy: "establishing rapport with the patient," which should not be overlooked; the emotional dimension, which involves an accurate understanding of the patient and communication skills; and the "active/positive" dimension which is about giving hope, explaining things clearly and helping patients take control with shared decision-making and a planned future. Although communication tips are helpful, empathy training should be based more on the development of HCPs' emotional skills, in order to help them regulate their emotions and thus be more comfortable with those of patients and families. Furthermore, research into empathy toward minorities and relatives is needed.

Life Expectancy After Liver Transplantation for Hepatocellular Carcinoma With Cirrhosis

BACKGROUND

Hepatocelluar carcinoma, the most common primary liver cancer, has a historically dire prognosis. For hepatic cancer patients with cirrhosis who underwent liver transplantation, we sought to calculate life expectancies both at time of transplant and several years later, stratified by some key variables, and to determine if survival has improved in recent years.

METHODS

Data on 13,797 hepatic cancer patients with cirrhosis who underwent liver transplantation in the MELD era (2002-2018) from the US Organ Procurement and Transplantation Network database were analyzed using the Cox proportional hazards regression model and life table methods.

RESULTS

The major factors related to survival were age, donor age, transplant year, diabetes, functional status, and the presence of severe hepatic encephalopathy. Survival was significantly worse with increasing age and decreasing functional status level. There was no significant difference in survival between males and females. Survival improved over the study period, at 5% per calendar year during the first 5 years post transplant, and 1% per year thereafter.

CONCLUSIONS

Life expectancies were markedly reduced from normal, even among 5-year survivors with the most favorable characteristics. Survival improved modestly over the years 2002-2018.

Understanding Hospice Patients' Beliefs About Their Life Expectancy: A Qualitative Interview Study

BACKGROUND

Patients with advanced disease often overestimate their life expectancy, which potentially impacts decision making.

OBJECTIVE

To examine the nature and source of hospice patients' life expectancy estimates, about which little is known.

DESIGN

Using semi-structured interviews, patients were asked to estimate their life expectancy and elaborate on their response.

SETTING/SUBJECTS

Participants were hospice patients (n = 20, 55% male; 60% cancer).

MEASUREMENT

We conducted thematic analysis using open and focused coding.

RESULTS

Many participants had difficulty answering the life expectancy question and expressed uncertainty about when they would die. One-third overestimated their length of life relative to actual survival. The most common source of patients' prognostic beliefs was knowledge about their body, including physical symptoms and change over time. Half of patients reported that a provider had given them a prognostic estimate, and one-third agreed with, or gave estimates consistent with, the provider's estimate. Some patients said providers do not know prognosis or that time of death was unknowable.

CONCLUSIONS

Key findings were that 1) many hospice patients had difficulty estimating life expectancy, and 2) hospice patients' life expectancy estimates were frequently based on their body and not on information from medical providers. These findings have implications for measuring prognostic awareness, as valid assessment is a necessary component of determining whether prognostic awareness is beneficial for patients. Future research should examine how life expectancy estimates are associated with well-being and whether results extend to larger samples of patients with advanced disease not in hospice.

Managing uncertainty and references to time in prognostic conversations with family members at the end of life: A conversation analytic study

BACKGROUND

When patients are likely to die in the coming hours or days, families often want prognostic information. Prognostic uncertainty and a lack of end-of-life communication training make these conversations challenging.

AIM

The objective of this study is to understand how clinicians and the relatives/friends of patients at the very end of life manage uncertainty and reference time in prognostic conversations.

DESIGN

Conversation analysis of audio-recorded conversations between clinicians and the relatives/friends of hospice inpatients.

SETTING/PARTICIPANTS

Experienced palliative care clinicians and relatives/friends of imminently dying hospice inpatients. Twenty-three recorded conversations involved prognostic talk and were included in the analysis.

RESULTS

Requests for prognostic information were initiated by families in the majority of conversations. Clinicians responded using categorical time references such as 'days', allowing the provision of prognostic estimates without giving a precise time. Explicit terms such as 'dying' were rare during prognostic discussions. Instead, references to time were understood as relating to prognosis. Relatives displayed their awareness of prognostic uncertainty when requesting prognostic information, providing clinicians with 'permission' to be uncertain. In response, clinicians often stated their uncertainty explicitly, but presented evidence for their prognostic estimates, based on changes to the patient's function previously discussed with the family.

CONCLUSION

Prognostic uncertainty was managed collaboratively by clinicians and families. Clinicians were able to provide prognostic estimates while being honest about the related uncertainty, in part because relatives displayed their awareness of uncertainty within their requests. The conversation analytic method identified contributions of both clinicians and families, and identified strategies based on real interactions, which could inform communication training.

Preferences for life expectancy discussions following diagnosis with a life-threatening illness: a discrete choice experiment

PURPOSE

To explore in a sample of adult cancer patients: (1) the relative influence of initiation source, information format and consultation format on preferred approach to life expectancy disclosure using a discrete choice experiment (DCE); and (2) whether patient age, cancer type and perceived prognosis were associated with preferences within the three attributes.

METHODS

A DCE survey of adult solid tumour and haematological cancer patients. Participants chose between three hypothetical scenarios about life expectancy disclosure consisting of three attributes: initiation source (i.e. doctor versus patient-initiated discussion), information content (i.e. estimate presented as best-worst-typical length of life case scenario versus median survival time) and consultation format (i.e. two 20-min versus one 40-min consultation). Respondents selected their most preferred scenario within each question.

RESULTS

Three hundred and two patients completed the DCE (78% consent rate). Initiation source was the most influential predictor of patient choice. More preferred a doctor deliver life expectancy information as soon as it is available rather than waiting for the patient to ask (59% vs 41% z = - 7.396, p < 0.01). More patients preferred the two 20-min rather than the one 40-min consultation format (55% vs 45%, z = 4.284, p < 0.01). Information content did not influence choice. Age, cancer type, and patient-perceived prognosis were not associated with preferences.

CONCLUSION

Healthcare professionals should assess cancer patients' preferences for engaging in life expectancy discussions as soon as they have this information, and ensure patients have adequate time to consider the information they receive, seek additional information and involve others if they wish.

Prognosticating for Adult Patients With Advanced Incurable Cancer: a Needed Oncologist Skill

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.