Decisional control preferences of patients with advanced cancer receiving palliative care

Bridging the care gap: patients' needs and experiences regarding shared decision-making in radiotherapy

Background and purpose

Shared decision-making (SDM), a collaborative process in which patients and physicians jointly determine further treatment, has been associated with numerous positive effects. However, its implementation into routine clinical practice faces challenges. In radiotherapy (RT) it may have additional challenges, since patients are referred from another oncologist, often "to undergo RT". The aim of this study is to understand patients' preferences and experiences regarding SDM at an academic RT clinic, and to identify targets for SDM implementation in RT.

Materials and methods

We adapted an earlier survey sent out by the Dutch Cancer Patient Organizations Federation to fit the RT setting. The survey was distributed via letters and social media to (former) patients who had their intake between 2020 and 2022.

Results

1799 participants completed the survey, of whom 88,3% mentioned to always or often prefer SDM. 23,1% of participants reported experiencing a choice, and 50% of these participants experienced multiple options. The most commons reason for preferring SDM was bodily autonomy (n = 1114) and against SDM was wanting to decide themselves instead (n = 11). Participants with a higher educational attainment were more likely to prefer and experience SDM. Older participants were more likely to experience multiple options.

Conclusion

Our findings reaffirm that most cancer patients prefer SDM, and extend these findings to RT. However, we found a large gap between patients' desire for SDM, and the SDM experienced in our RT institute. SDM implementation strategies are needed and should focus on overcoming RT-specific and patient-reported barriers and opportunities.

A Joanna Briggs Institute Framework Approach to Shared Decision Making in End-of-Life

AIM

To implement shared decision-making (SDM) through a patient decision aid (PtDA) for the initiation of palliative care (PC) in end-of-life (EOL) cancer patients.

METHODOLOGY

A comprehensive Scoping Review was conducted on SDM in PubMed, CINAHL and PsycInfo. An evidence-based implementation of PtDAs was created using the Joanna Briggs Institute framework, which followed rigorous pillars: (1) context, (2) facilitation and (3) evaluation.

RESULTS

Fifteen studies were identified and categorised into (1) Implementation characteristics and (2) Strategies for implementing SDM in terminally ill cancer patients. SDM should consider the decision-making location, optimal timing, participants and decision type. Strategies include professional training, PtDAs and implementation programmes. A PtDA implementation protocol in video format for deciding to initiate PC is proposed, following International Patient Decision Aid Standards (IPDAS) and Clinical Practice Guidelines (CPG).

CONCLUSIONS

SDM implementation should be guided by evidence-based methodological models justifying and structuring its execution, especially in complex and interdisciplinary contexts. National or international frameworks facilitate the adoption of health innovations, such as PtDAs, benefiting patients and improving their usage.

PRACTICE IMPLICATIONS

SDM is not just a concept but an important approach to the Care of cancer patients at EOL, enhancing patient satisfaction and improving care quality. The success and sustainability of SDM hinge on the fundamental aspects of staff training, interdisciplinary collaboration and ongoing evaluation. The lack of specific aid in Spanish underscores the immediate need for local development. Further research is needed in this area, as most reviewed studies did not measure SDM effectiveness in diverse hospital settings.

PATIENT OR PUBLIC CONTRIBUTION

This proposal was developed based on the experience and input of the nursing staff from the healthcare service where it is intended to be implemented.

How do Patients With Advanced Cancer and Family Caregivers Accommodate One Another in Decision-Making? Findings From a Qualitative Study in Specialist Palliative Care

BACKGROUND

Patients with advanced cancer commonly involve family caregivers in decision-making for palliative care. However, how patients with advanced cancer and family caregivers accommodate each other in decision-making is unclear.

METHODS

A qualitative study in advanced cancer was conducted with 14 patients and 19 family caregivers recruited from two hospices comprising a large regional specialist palliative care service in Ireland. Data comprised semi-structured interviews with participants. The data were analyzed using grounded theory coding procedures.

RESULTS

Most patients preferred to make care decisions with their family caregiver or at least involve their family caregiver in care discussions. Patients engaged in shared decision-making because they felt they benefited from caregiver support. Patients accommodated family caregiver preferences out of concern for that person and because they trusted them. Family caregivers accommodated patient preferences because they wanted to honor the patient's wishes and felt a responsibility to protect patient autonomy when they had a close relationship with the patient. Prior conflict between the patient and family caregiver was a barrier to mutual accommodation. Although concealment was used as a mechanism to support accommodation between the patient and family caregiver, both sought to communicate openly with other family members to negate potential conflict between each other and the wider family.

CONCLUSION

Patients with advanced cancer and family caregivers in specialist palliative care support one another by accommodating each other's preferences for patient care. Patients with advanced cancer and family caregivers accommodate one another in decision-making out of a sense of responsibility to one another.

Advanced directives' knowledge among Portuguese palliative patients and caregivers: do the sociodemographic factors influence it? A cross-sectional survey

BACKGROUND

The influence of demographic factors on the completion and knowledge of the Portuguese Advance Directives (PAD) and the Health Care Proxy's (HCP) role is still not clear.

OBJECTIVES

To identify sociodemographic features associated with knowledge and adherence to PAD and HCP in palliative care.

DESIGN

Cross-Sectional analysis of the sociodemographic data, PAD and HCP role knowledge, and PAD Register from a group of Portuguese palliative patients and their caregivers enrolled on the DAVPAL trial to test the PAD efficacy in promoting better concordance between patients and caregivers.

PARTICIPANTS

One hundred twenty participants (60 palliative patients and 60 caregivers).

METHODS

After enrollment, the participants' sociodemographic data was acquired, their knowledge of PAD and the role of an HCP was questioned, and their prior register of the PAD was asked.

RESULTS

60 patients and 60 caregivers were included (n=120), with differences among them regarding age (p<.001), gender (p=.003), education (p<.001), job (p<.001), marital status (p=.043), and access to the internet (p=.003), but not regarding religion (p=.21). Only 13.3% of the participants were aware of PAD, 15.0% were aware of the HCP role, and 5.0% had previously filled a PAD. Religious beliefs (Non-Catholic) were the only sociodemographic factor significantly related to these three topics.

CONCLUSIONS

There is low awareness of PAD and the HCP's role in palliative care, and there is higher knowledge on these topics among non-Catholic individuals. End-of-life decisions seem to be influenced by similarities in religious beliefs between patients and HCP. Improving education is necessary, namely in palliative care.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT05090072 . Retrospectively registered on 22/10/2021.

Patients' preferences in therapeutic decision-making in digestive oncology: a single centre cross-sectional observational study

Considering the preferences in Shared Decision Making (SDM) of patients with Digestive Cancer (DC) is crucial to ensure the quality of care. To date, there is limited information on preferences in SDM of patients with DC. The objectives of this study were to describe digestive cancer patients' preference for involvement in therapeutic decision-making and to identify variables associated with these preferences. An observational prospective study in a French university cancer center has been conducted. Patients completed two questionnaires to qualify and quantify their preference for involvement in therapeutic decision-making: the Control Preference Scale (CPS) and the Autonomy Preference Index (API), which is composed of the Decision Making (DM) score and the Information Seeking (IS) score. Associations between these scores and socio-demographic data, disease-related data, coping strategies (Brief-COPE), physical (QLQ-C30) and psychological (HADS) quality of life were tested. One-hundred fifteen patients returned the questionnaires. The majority of patients reported a passive (49.1%) or a collaborative (43.0%) CPS status. The mean DM score was 39.4 Variables associated with decision-making preferences were occupational status and time since diagnosis. The identification of variables associated with patients' preferences for involvement in decision-making can help make clinicians aware of patients' needs and wishes. However, it can only be determined by interviewing the patient individually.

Decision-Making Preferences among Advanced Cancer Patients in a Palliative Setting in Jordan

Understanding patients' decision-making preferences is crucial for enhancing patients' outcomes. The current study aims to identify Jordanian advanced cancer patients' preferred decision-making and to explore the associated variables of the passive decision-making preference. We used a cross-sectional survey design. Patients with advanced cancer referred to the palliative care clinic at a tertiary cancer center were recruited. We measured patients' decision-making preferences using the Control Preference Scale. Patients' satisfaction with decision-making was assessed with the Satisfaction with Decision Scale. Cohen's kappa statistic was used to assess the agreement between decision-control preferences and actual decision-making, and the bivariate analysis with 95% CI and the univariate and multivariate logistic regression were used to examine the association and predictors of the demographical and clinical characteristics of the participants and the participants' decision-control preferences, respectively. A total of 200 patients completed the survey. The patients' median age was 49.8 years, and 115 (57.5%) were female. Of them, 81 (40.5%) preferred passive decision control, and 70 (35%) and 49 (24.5%) preferred shared and active decision control, respectively. Less educated participants, females, and Muslim patients were found to have a statistically significant association with passive decision-control preferences. Univariate logistic regression analysis showed that, being a male (p = 0.003), highly educated (p = 0.018), and a Christian (p = 0.006) were statistically significant correlates of active decision-control preferences. Meanwhile, the multivariate logistic regression analysis showed that being a male or a Christian were the only statistically significant predictors of active participants' decision-control preferences. Around 168 (84%) of participants were satisfied with the way decisions were made, 164 (82%) of patients were satisfied with the actual decisions made, and 143 (71.5%) were satisfied with the shared information. The agreement level between decision-making preferences and actual decision practices was significant (ⱪ coefficient = 0.69; 95% CI = 0.59 to 0.79). The study's results demonstrate that a passive decision-control preference was prominent among patients with advanced cancer in Jordan. Further studies are needed to evaluate decision-control preference for additional variables, such as patients' psychosocial and spiritual factors, communication, and information sharing preferences, throughout the cancer trajectory so as to inform policies and improve practice.

Patients' Preference for Participation in Medical Decision-Making: Secondary Analysis of the BEDSIDE-OUTSIDE Trial

BACKGROUND

Patients may prefer different levels of involvement in decision-making regarding their medical care which may influence their medical knowledge.

OBJECTIVE

We investigated associations of patients' decisional control preference (DCP) with their medical knowledge, ward round performance measures (e.g., duration, occurrence of sensitive topics), and perceived quality of care measures (e.g., trust in the healthcare team, satisfaction with hospital stay).

DESIGN

This is a secondary analysis of a randomized controlled multicenter trial conducted between 2017 and 2019 at 3 Swiss teaching hospitals.

PARTICIPANTS

Adult patients that were hospitalized for inpatient care.

MAIN MEASURES

The primary outcome was patients' subjective average knowledge of their medical care (rated on a visual analog scale from 0 to 100). We classified patients as active, collaborative, and passive according to the Control Preference Scale. Data collection was performed before, during, and after the ward round.

KEY RESULTS

Among the 761 included patients, those with a passive DCP had a similar subjective average (mean ± SD) knowledge (81.3 ± 19.4 points) compared to patients with a collaborative DCP (78.7 ± 20.3 points) and active DCP (81.3 ± 21.5 points), p = 0.25. Regarding patients' trust in physicians and nurses, we found that patients with an active vs. passive DCP reported significantly less trust in physicians (adjusted difference, - 5.08 [95% CI, - 8.69 to - 1.48 points], p = 0.006) and in nurses (adjusted difference, - 3.41 [95% CI, - 6.51 to - 0.31 points], p = 0.031). Also, patients with an active vs. passive DCP were significantly less satisfied with their hospital stay (adjusted difference, - 7.17 [95% CI, - 11.01 to - 3.34 points], p < 0.001).

CONCLUSION

Patients with active DCP have lower trust in the healthcare team and lower overall satisfaction despite similar perceived medical knowledge. The knowledge of a patient's DCP may help to individualize patient-centered care. A personalized approach may improve the patient-physician relationship and increase patients' satisfaction with medical care.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03210987).

Effects of the Heart to Heart Card Game for Patients with Advanced Cancer Receiving Home-Based Palliative Care: A Clinical Randomized Controlled Trial

The Heart to Heart Card Game improves psychological health outcomes in hospitalized patients with advanced cancer, but effectiveness studies for patients at home are rare. This randomized controlled study was conducted to determine the effectiveness of the Heart to Heart Card Game on patients with advanced cancer receiving home-based palliative care. Sixty-six participants were randomly assigned to the intervention group (n = 34) and control group (n = 32). The quality of life, dignity, and psychological distress were considered as outcomes, which were assessed pre-intervention and six weeks after the intervention. There was a statistical difference in the quality of life (global health statues) between the intervention group and the control group after intervention (z = 2.017, p < 0.05). A significant difference was found in the quality of life (emotional, social function), dignity (symptom distress dimension), and psychological distress in the intervention group through intragroup comparison before and after the intervention. This randomized trial showed that the Heart to Heart Card Game likely alleviates barriers to end-of-life conversations and helps patients with advanced cancer maintain a more stable mental state. This trial has been registered at the Chinese Clinical Trial Registry (registration number: ChiCTR2100049933).

Priorities and preferences of advanced soft tissue sarcoma patients starting palliative chemotherapy: baseline results from the HOLISTIC study

INTRODUCTION

Palliative chemotherapy is the principal treatment of patients with advanced soft tissue sarcomas (STS); however prognosis is limited (median overall survival 12-19 months). In this setting, patient values and priorities are central to personalised treatment decisions.

PATIENTS AND METHODS

The prospective HOLISTIC study was conducted in the UK and the Netherlands assessing health-related quality of life in STS patients receiving palliative chemotherapy. Participants completed a questionnaire before starting chemotherapy, including attitudes towards quality of life (QoL) versus length of life (LoL), decisional control preferences, and decisional conflict. Chi-square and Fisher's exact tests were used to evaluate associations between patient characteristics and preferences.

RESULTS

One hundred and thirty-seven patients with advanced STS participated (UK: n = 72, the Netherlands: n = 65). Median age was 62 (27-79) years. Preference for extended LoL (n = 66, 48%) was slightly more common than preference for QoL (n = 56, 41%); 12 patients (9%) valued LoL and QoL equally (missing: n = 3). Younger patients (age <40 years) prioritised LoL, whereas two-thirds of older patients (aged ≥65 years) felt that QoL was equally or more important than LoL (P = 0.020). Decisional conflict was most common in patients who prioritised QoL (P = 0.024). Most patients preferred an active (n = 45, 33%) or collaborative (n = 59, 44%) role in treatment decisions. Gender, performance status, and country were significantly associated with preferred role. Concordance between preferred and actual role in chemotherapy decision was high (n = 104, 76%).

CONCLUSIONS

Heterogeneous priorities and preferences among advanced STS patients support personalised decisions about palliative treatment. Considering individual differences during treatment discussions may enhance communication and optimise patient-centred care.

A Qualitative Study on Nudging and Palliative Care: "An Attractive but Misleading Concept"

The debate about the ethical decision-making process in the healthcare context has been enriched with a theory called “nudging”, which has been defined as the framing of information that can significantly influence behaviour without restricting choice. The literature shows very limited data on the opinion and experience of palliative care healthcare professionals on the use of nudging techniques in their care setting. The aim of this study is to explore the beliefs of experienced palliative care professionals towards nudging. We performed a qualitative study using textual data collected through a focus group. It was audio-recorded, and the transcripts were subjected to a thematic analysis. It was performed within an oncological research hospital with a small and multidisciplinary group of healthcare professionals specialised in PC. Participants reported two overarching positions grounded in two main themes: (1) translating nudging in the PC setting and (2) towards a neutral space. The participants found few justifications for the use of nudging in the PC field, even if it can be very attractive and reassuring. Participants also expressed concerns about the excessive risk of developing pure paternalism.

Decisional control preference among Chinese patients with advanced kidney disease: the role of mastery, perceived social support and self-efficacy

Although previous studies have shown a correlation between mastery, self-efficacy, and perceived social support among Chinese patients with advanced kidney disease, few studies have examined their relationship pathways. This study aimed to examine decisional control preference and the relationship between mastery, perceived social support, and self-efficacy among patients with advanced chronic kidney disease. A cross-sectional survey was conducted, and 350 participants were investigated using Control Preference Scale, Personal Mastery Scale, Perceived Social Support Scale, and Self-efficacy Scale. The mediating relationships were determined via structural equation modeling. Results showed that education and economic status were demographic factors influencing patients' decisional control preference. The model showed that mastery and self-efficacy had a direct effect on decisional control preference while perceived social support had an indirect effect mediated via mastery and self-efficacy. Therefore, improving self-efficacy can increase patient willingness to involve in medical decision-making. This study provides new interventions and future directions for promoting decisional control preference.

Decision-making among the substitute decision makers in intensive care units: An investigation of decision control preferences and decisional conflicts

AIMS

To explore decision control preferences and decisional conflicts and to analyse their association among the surrogate decision makers in the intensive care unit.

DESIGN

The study carried out a cross-sectional survey among the surrogates.

METHODS

The participants were 115 surrogate decision makers of critical patients, from August to September 2019. A Chi-squared test and logistic regression were used to assess decision control preferences and decisional conflicts, and Spearman's rank correlation coefficient was employed to examine their association.

RESULTS

Of the 115 surrogate decision makers, 51.3% preferred a collaborative role, and 63.48% were somewhat unsure about making decisions. Logistic regression analysis identified decision control preferences was associated with surrogates' age, education level, and personality traits, while decisional conflicts was associated with surrogates' age, education level, character, medical expense burden, and Acute Physiology and Chronic Health Evaluation-II score. Cohen's kappa statistics showed a bad concordance of decision-making expectations and actuality, with kappa values of 0.158 (p < .05). Wherein surrogates who experienced discordance between their preferred and actual roles, have relatively higher decisional conflicts.

CONCLUSION

This study identified individual differences of surrogate decision makers in decision control preferences and decisional conflicts. These results imply that incorporation of the individual decision preferences and communication styles into care plans is an important first step to develop high quality decision support.

IMPACT

This research is a contribution to the limited study on decision control preferences and decisional conflicts among surrogate decision makers of critically ill patients. Moreover based on the investigation of understanding the status and related factors of decision preferences and decisional conflicts set the stage for developing effective decision support interventions.

A cross-sectional study investigating patients' preferences regarding shared decision-making in adult orthodontic patients

Introduction Shared decision-making (SDM) is a process by which patients and clinicians work collaboratively to make decisions about healthcare. Previously, research has shown that patients want to be more involved in decisions about their care, but more recent evidence suggests that some patients may not wish to have the level of involvement that is now expected of them.Aims This study therefore investigated adult orthodontic patients' preferred and perceived roles in treatment decision-making.Methods This cross-sectional study was carried out in a teaching hospital using the Control Preferences Scale (CPS). This involved asking patients to choose one of five cards relating, firstly, to their preferred role in orthodontic decision-making, and then their perceived role in their current orthodontic treatment decision-making, and these were compared.Results One hundred patients were recruited and perceived roles in decision-making tended to be more passive than those patients said they preferred. Males were significantly more likely to select a passive role than females (p = 0.018).Conclusions Adult orthodontic patients perceived a more passive role in their current treatment decisions than they would have preferred. This highlights the importance of clinicians asking patients about their preferred role in treatment decision-making from the outset.

Cancer Patients Numeracy and Preferences for Information Presentation-a Survey Among German Cancer Patients

Numeracy is highly relevant for therapy safety and effective self-management. Worse numeracy leads to poor health outcome. Most medical information is expressed in numbers. Considering the complexity of decisions, more information on the patient's ability to understand information is needed. We used a standardized questionnaire. Content was self-perception of numeracy, preferences regarding decision-making with respect to medical issues, and preferred content of information from four possible answers on side effect of cancer therapies (insomnia) within two scenarios. Overall, 301 participants answered the questionnaire. Presentation of facts in numbers was rated as helpful or very helpful (59.4%). Higher numeracy was associated with higher appreciation for presentation in numbers (p = 0.002). Although participants indicated presentation of facts in numbers as helpful in general, the favored answer in two concrete scenarios was verbal and descriptive instead of numerical. Numeracy is highly relevant for therapy safety and effective self-management. Health professionals need more knowledge about patient's ability and preferences with respect to presentation of health information. An individualized patient communication might be the best strategy to discuss treatment plans. We need to understand in which situations patients benefit from numerical presentation and how managing numerical data might influence decision processes.