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Lucas B, Friend B, Jarrell JA, Kentor R. "Just let me go"; When suicidal ideation and goals of care collide in adolescent cancer at the end of life. Pediatr Blood Cancer 2024; 71:e30893. [PMID: 38265262 DOI: 10.1002/pbc.30893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/10/2024] [Accepted: 01/16/2024] [Indexed: 01/25/2024]
Abstract
Cancer in adolescents and young adults is associated with an increased risk for suicidal ideation (SI). There are no reported pediatric oncology cases describing management of SI during end of life. We present the case of a 14-year-old male with relapsed, high-risk, B-cell acute lymphoblastic leukemia who received a haploidentical stem cell transplant and was suicidal at various points in his treatment. We discuss how to manage acute suicidality in this patient population, the importance of giving a voice to the adolescent patient, the impact of discordant goals of care, and potential preventive strategies for similar cases.
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Affiliation(s)
- Bryony Lucas
- Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Brian Friend
- Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Jill Ann Jarrell
- Baylor College of Medicine, Houston, Texas, USA
- Division of Palliative Care, Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Rachel Kentor
- Baylor College of Medicine, Houston, Texas, USA
- Division of Palliative Care, Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
- Division of Psychology, Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
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Golmohammadi M, Ebadi A, Ashrafizadeh H, Rassouli M, Barasteh S. Factors related to advance directives completion among cancer patients: a systematic review. BMC Palliat Care 2024; 23:3. [PMID: 38166983 PMCID: PMC10762918 DOI: 10.1186/s12904-023-01327-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person's future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients. METHODS A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior. RESULTS Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients' age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: "Lack of knowledge of the ADs concept" and "Previous experience of the disease", the subjective norm category includes three subcategories: "Social support and interaction with family", "Respecting the patient's wishes" and "EOL care choices". Also, the category of perceived control behavior was categorized into two sub-categories: "Decision-making" and "Access to the healthcare system", as well as external factors affecting the model, including "socio-demographic characteristics". CONCLUSION The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.
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Affiliation(s)
- Mobina Golmohammadi
- Student Research Committee, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Hadis Ashrafizadeh
- Student Research Committee, Faculty of Nursing, Dezful University of Medical Sciences, Dezful, Iran
| | - Maryam Rassouli
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Salman Barasteh
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran.
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
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Pennarola BW, Fry A, Prichett L, Beri AE, Shah NN, Wiener L. Mapping the Landscape of Advance Care Planning in Adolescents and Young Adults Receiving Allogeneic Hematopoietic Stem Cell Transplantation: A 5-Year Retrospective Review. Transplant Cell Ther 2022; 28:164.e1-164.e8. [PMID: 34936929 PMCID: PMC8923987 DOI: 10.1016/j.jtct.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/03/2021] [Accepted: 12/05/2021] [Indexed: 12/17/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) carries significant risks of morbidity and mortality. Participation in advance care planning (ACP) is crucial to promote patient-centered care and has been shown to have positive impacts on patients, caregivers, and providers. Historically, both HSCT recipients and adolescents and young adults (AYAs) are significantly less likely to engage in ACP. We sought to characterize ACP utilization in AYAs undergoing HSCT by evaluating the frequency of different types of ACP documentation over time and identifying demographic and clinical factors associated with documentation of each type of ACP. We conducted a single-center retrospective review of the electronic health record (EHR) of AYAs (age 15 to 39 years) who underwent allogeneic HSCT between 2015 and 2020. EHR documents were screened for 3 predefined categories of ACP: (1) advance directives (ADs) or medical orders (MOs), which included proof of signed paper directives, expressions of preferred code status, and identification of a healthcare proxy; (2) goals of care (GOC) conversations, which included discussions of medical care in a specific situation informed by patients' priorities; and (3) other ACP conversations, which included more general discussions of patients' values regarding their care or legacy wishes. Documents were coded by 2 researchers, and discrepant categorizations were reviewed by a third researcher. Patients age <18 years on the day of transplantation were excluded in the analyses of AD/MO documentation. Univariate and multivariate logistic regression were used to test for associations between patient factors and documentation of each type of ACP. For deceased patients, Kaplan-Meier curves were created to illustrate the time-to-event relationship between days before death and documentation of each type of ACP. Sixty-eight thousand documents associated with 219 patients were reviewed, and 666 ACP documents associated with 190 patients were identified. Few of the 219 patients had documented GOC (n = 29; 13%) or other ACP conversations (n = 81; 37%). A subset of patients (n = 28; 13%) had no documented ACP. Most of the 201 patients age ≥18 years had a documented AD/MO (n = 172; 86%). No tested factors were significantly associated with documentation of ADs/MOs. GOC and other ACP conversations were more likely to occur in patients with a palliative care consult, and patients with a malignant diagnosis were also more likely to engage in GOC conversations. More than 50% of the documentation occurred in the subset of 39 deceased patients, with one-half of AD/MO documentation in the last 67 days of life, one-half of other ACP documentation in the last 20 days of life, and one-half of GOC documentation in the final 2 days of life. Although the majority of AYA patients receiving HSCT did have documentation of ADs/MOs, few patients had documented GOC or other ACP conversations. The bulk of all ACP conversations occurred in patients that ultimately died and who were very close to the end of life. Our results support ongoing efforts to improve the implementation of ACP in this vulnerable population, particularly for those undergoing HSCT for nonmalignant conditions.
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Affiliation(s)
- Brian W. Pennarola
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD,Department of Pediatric Oncology, Johns Hopkins Hospital, Baltimore, MD
| | - Abigail Fry
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
| | - Laura Prichett
- Johns Hopkins School of Medicine, Department of Pediatrics, Biostatistics, Epidemiology, and Data Management (BEAD) Core, Baltimore, MD
| | - Andrea E. Beri
- NIH Biomedical Translational Research Information System (BTRIS), Bethesda, MD
| | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
| | - Lori Wiener
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
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Salazar MM, DeCook LJ, Butterfield RJ, Zhang N, Sen A, Wu KL, Vanness DJ, Khera N. End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation. J Palliat Med 2021; 25:97-105. [PMID: 34705545 DOI: 10.1089/jpm.2021.0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Patients receiving allogeneic hematopoietic cell transplantation (HCT) have high morbidity and mortality risk, but literature is limited on factors associated with end-of-life (EOL) care intensity. Objectives: Describe EOL care in patients after allogeneic HCT and examine association of patient and clinical characteristics with intense EOL care. Design: Retrospective chart review. Setting/Subjects: A total of 113 patients who received allogeneic HCT at Mayo Clinic Arizona between 2013 and 2017 and died before November 2019. Measurements: A composite EOL care intensity measure included five markers: (1) no hospice enrollment, (2) intensive care unit (ICU) stay in the last month, (3) hospitalization >14 days in last month, (4) chemotherapy use in the last two weeks, and (5) cardiopulmonary resuscitation, hemodialysis, or mechanical ventilation in the last week of life. Multivariable logistic regression modeling assessed associations of having ≥1 intensity marker with sociodemographic and disease characteristics, palliative care consultation, and advance directive documentation. Results: Seventy-six percent of patients in our cohort had ≥1 intensity marker, with 43% receiving ICU care in the last month of life. Median hospital stay in the last month of life was 15 days. Sixty-five percent of patients died in hospice; median enrollment was 4 days. Patients with higher education were less likely to have ≥1 intensity marker (odds ratio 0.28, p = 0.02). Patients who died >100 days after HCT were less likely to have ≥1 intensity marker than patients who died ≤100 days of HCT (p = 0.04). Conclusions: Death within 100 days of HCT and lower educational attainment were associated with higher likelihood of intense EOL care.
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Affiliation(s)
- Marisa M Salazar
- Mayo Clinic Alix School of Medicine, Mayo Clinic College of Science and Medicine, Scottsdale, Arizona, USA
| | - Lori J DeCook
- Division of Hematology and Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Nan Zhang
- Department of Biostatistics, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Kelly L Wu
- Division of General Internal Medicine, Center for Palliative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - David J Vanness
- Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania, USA
| | - Nandita Khera
- Division of Hematology and Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Prospective Randomized Study of Advance Directives in Allogeneic Hematopoietic Cell Transplantation Recipients. Transplant Cell Ther 2021; 27:615.e1-615.e7. [PMID: 33836311 DOI: 10.1016/j.jtct.2021.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/19/2021] [Accepted: 03/29/2021] [Indexed: 11/20/2022]
Abstract
Patients undergoing allogeneic hematopoietic cell transplantation (HCT) are at risk for high morbidity and mortality. Advance directives (AD) allow patients to express wishes regarding their care at the end of life, but these are not completed in the majority of patients undergoing HCT, with only 44% of deceased allogeneic HCT recipients at this institution completing an AD in the past decade. Increasing the AD completion rate can improve the quality of care for allogeneic HCT recipients. Our objective was to evaluate whether an alternative AD instrument can increase AD completion rate and patient satisfaction. We conducted a prospective, randomized controlled study of the traditional California AD versus a novel Letter AD, the Stanford What Matters Most Letter, in adult allogeneic HCT recipients. Patients age ≥18 years undergoing first allogeneic HCT at Stanford University were eligible. Prior to HCT conditioning, enrolled patients were assigned at random to complete either the traditional AD or the Letter AD. The primary endpoint was AD completion. The chi-square test was used to compare the AD completion rate between arms. The Wilcoxon rank-sum test was used to compare uncertainty, satisfaction with decision making, and satisfaction with the AD. Of the 212 patients who were eligible, 126 (59.4%) were enrolled and randomized. The mean age was 53.7 years, 57 (45.2%) were female, and 74 (58.7%) were non-Hispanic white. The overall AD completion rate was 71.4% and did not differ between the traditional and Letter AD arms (70.3% versus 72.6%; P = .78). Of those who completed the Letter AD, 66.7%, 42.2%, and 46.7% of patients wished to die gently/naturally, at home, and/or with hospice, respectively. In the traditional AD arm, 60.0% wished to not prolong life if recovery was unlikely. Opinion surveys did not find differences in levels of satisfaction between the traditional AD and Letter AD. Completion rates of AD on this study were high (71.4%) compared with historically reported completion rates and did not significantly differ based on AD version.
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6
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Suthumphong C, Tran DB, Ruiz M. Perceptions and Misperceptions of Early Palliative Care Interventions for Patients With Hematologic Malignancies Undergoing Bone Marrow Transplantation. Cureus 2021; 13:e13876. [PMID: 33868840 PMCID: PMC8043049 DOI: 10.7759/cureus.13876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hematopoietic stem cell or bone marrow transplantation (BMT) is one of the most promising and potentially curative therapeutic options available for eligible patients with hematologic malignancies (HMs) or leukemias. However, the nature and clinical course of HMs, specifically for patients undergoing BMT, are associated with significant morbidity, symptomatology, healthcare service utilization, psychosocial and end of life issues, and overall decreased quality of life. Early palliative care (PC) consultations and utilization for patients with HMs have been shown to improve patient outcomes, satisfaction, and autonomy as well as caregiver burden, shared-decision making, and holistic care management. Despite the complexity of care and complications for patients with HM undergoing BMT, early PC interventions are systematically underutilized and understudied in this population compared to patients with solid tumors or non-HMs. Herein, the authors reviewed the current literature and knowledge to assess and report the perceptions and barriers to early PC utilization in the care of patients with HMs undergoing BMT. Clinical and cultural aspects of PC perceptions as well as current PC care models and potential directions for PC implementation were reviewed to inform future research studies and clinical practice guidelines necessary for the improvement of care and quality of life for HM patients undergoing BMT.
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Affiliation(s)
- Corey Suthumphong
- Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Dan B Tran
- Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Marco Ruiz
- Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA.,Miami Cancer Institute, Baptist Health South Florida, Miami, USA
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Cooper A, Dains JE. Advanced Care Planning and End-of-life Outcomes in Hematopoietic Stem Cell Transplant Patients. Am J Hosp Palliat Care 2020; 38:995-1003. [PMID: 33161732 DOI: 10.1177/1049909120971566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIM/PURPOSE This integrative review addresses whether the presence and timing of advanced care planning (ACP) with or without a palliative care (PC) consultation affect place of death and use of high-intensity medical care at end-of-life (EOL) in adolescent and young adult and adult cancer patients receiving hematopoietic stem cell transplant (HSCT) therapy. METHODS AND RESULTS A literature search was completed in the Scopus and PubMed databases. The search was not restricted by date but was restricted to English language. A total of 1,616 articles were found, and after exclusion of duplicates and irrelevance, 79 articles were available to review. After reviewing inclusion and exclusion criteria, 9 articles related to ACP with HSCT were found, and 4 were eliminated after further review, resulting in 5 viable articles for review related to EOL outcomes. EOL outcomes reviewed were place of death and high-intensity medical care. Factors noted to influence these measures included the presence or absence of ACP, the timing of ACP, and PC consultation. Overall survival also emerged as an EOL outcome affected by ACP. CONCLUSION Although there have been many barriers identified to ACP discussions in the HSCT population, the findings from the integrative literature review support the use of early ACP with patients who have hematologic malignancies undergoing HSCT to address patient EOL goals and reduce healthcare utilization at the EOL. The data also suggest that identification of patients who would most benefit from early engagement in ACP may positively impact outcomes.
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Affiliation(s)
- Alexandra Cooper
- 4002The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joyce E Dains
- 4002The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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The Korean-Advance Directive Model and Factors Associated With Its Completion Among Patients With Hematologic Disorders. J Hosp Palliat Nurs 2020; 21:E10-E16. [PMID: 30845064 DOI: 10.1097/njh.0000000000000522] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of this pilot study was to examine factors associated with the completion of advance directives (ADs) among patients with hematologic disorders in Korea. Using a descriptive design, patients with largely hematologic malignancies completed the questionnaires, including the Korean-Advance Directive (K-AD) model, which pertains to values, treatment wishes, and proxy appointment. Of 45 patients (aged 48.7 ± 10.7 years, 51.1% men), two-thirds had leukemia (40.0%) and lymphoma (26.7%). "Dying comfortably" was the most frequently selected value (n = 20). Regarding treatment wishes, hospice care was the most desired type (n = 22), whereas aggressive treatments, such as cardiopulmonary resuscitation, were less preferred (n = 3). The patient's spouse was most frequently appointed as a proxy (n = 27). Patients who completed all the 3 components of the K-AD model (51.1%) were less depressed (t = -2.31; P = .028) and more likely to perceive the benefits of the K-AD model (t = 2.07; P = .045), compared with the noncompleters (48.9%). Further, being male (odds ratio [OR], 6.42; P = .031), having higher scores on depressive symptoms (OR, 1.28; P = .016), and perceived barriers (OR, 1.08; P = .040) were associated with lower tendency to complete the K-AD model. These findings support the need for earlier introduction of ADs in hematologic disorders, with consideration of modifiable factors such as depression or barriers to end-of-life care decisions.
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Kim J, Park J, Lee MO, Park EY, Heo S, Shim JL. Modifiable Factors Associated with the Completion of Advance Treatment Directives in Hematologic Malignancy: A Patient-Caregiver Dyadic Analysis. J Palliat Med 2019; 23:611-618. [PMID: 31855491 DOI: 10.1089/jpm.2019.0274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: The completion rates of advance treatment preferences in patients with hematologic malignancies are low. To improve these rates, the modifiable factors associated with completion need to be determined. This study aimed to examine the associations of patient attitudes toward, and knowledge about, advance directives (ADs) with the patient-caregiver dyadic completion of advance treatment directive surveys. Methods: Using a nonexperimental correlational design, 44 patient-caregiver dyads completed the questionnaires, including a Korean-Advance Directive model. Cohen's kappa coefficient and multiple logistic regression analyses examined the extent of dyadic agreement and patient factors for the dyadic completion of the advance treatment directive survey, respectively. Results: A minor group of patients (4.5%-11.4%) and caregivers (11.4%-18.2%) preferred aggressive end-of-life treatments, whereas more patients (47.7%) and caregivers (68.2%) supported hospice care. The only significant patient-caregiver dyadic concordance on treatment directives was for chemotherapy with a moderately high agreement (kappa = 0.60: 95% CI: 2.51-3.73). One score increase in AD knowledge and having a history of hematopoietic stem cell transplant (HSCT) increased the likelihood of dyadic completion of the treatment directive survey by 43% (p = 0.039) and 917% (p = 0.047), respectively. Conclusions: The patient-caregiver dyads in the setting of hematologic malignancy had a moderately high concordance with chemotherapy but were not associated with other treatment options. A higher level of AD knowledge and HSCT were associated with dyadic completion of the AD survey. Educational support is important to increase knowledge regarding ADs through ongoing palliative discussions among hematologic patients and their caregivers.
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Affiliation(s)
- JinShil Kim
- College of Nursing, Gachon University, Incheon, South Korea
| | - Jinny Park
- Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Mee Ok Lee
- Gachon University Gil Medical Center, Incheon, Korea
| | - Eun Young Park
- College of Nursing, Gachon University, Incheon, South Korea
| | - Seongkum Heo
- Georgia Baptist College of Nursing, Mercer University, Atlanta, Georgia, USA
| | - Jae Lan Shim
- Department of Nursing, College of Medicine, Dongguk University, Gyeongju-si, South Korea
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Kim J, Heo S, Kim MY, Park EY, Seo EJ, Lee MO, Jeong BY, Lee JA. Correlates of life-support treatment preferences among low-income home-based cancer management recipients. Eur J Oncol Nurs 2019; 43:101665. [PMID: 31590070 DOI: 10.1016/j.ejon.2019.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 09/09/2019] [Accepted: 09/11/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE To examine the correlates of life-support treatment (LST) preferences from attitudes toward advance directives (ADs), perceived susceptibility, symptom frequency, symptom burden, and global health among low-income community-dwelling cancer management recipients, controlling for age, sex, education, and duration after cancer diagnosis. METHODS A cross-sectional, correlational study design was used to assess LST preferences and correlates. Data were collected from low-income cancer survivors during nurses' home visits. RESULTS Survivors who had mostly solid cancer participated (N = 107, mean age = 67.39 ± 11.57 years, 32.7% males). Hospice care was the most desired (66.4%), while aggressive treatments were less preferred: cardiopulmonary resuscitation (15.9%), ventilation support (15.0%), hemodialysis (18.7%), or chemotherapy (12.1%). Higher symptom frequency was associated with a greater likelihood of preferring all aggressive treatments (odds ratios = 1.44-1.75). In addition, longer cancer duration was associated with a greater likelihood of preferring ventilation support; females had a lesser likelihood of preferring hemodialysis and chemotherapy. Higher education was associated with a lesser likelihood of preferring chemotherapy. More positive attitudes (B = 0.15, p = .001) were associated with a greater likelihood of preferring hospice care, and greater symptom burden of pain (B = -0.03, p = .047) was associated with a lesser likelihood. CONCLUSION Results support the feasibility of incorporating ADs into cancer management among community-dwelling cancer survivors, with consideration of AD attitudes and symptom monitoring. An integration of AD discussion into the home visiting service could be a liaison for the quality and continuity of cancer survivorship care that guides and manages patients' survivorship issues.
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Affiliation(s)
- JinShil Kim
- Gachon University, College of Nursing, 191 Hambakmeoro, Yeonsu-gu, Incheon, 21936, South Korea.
| | - Seongkum Heo
- Mercer University, Georgia Baptist College of Nursing, 3001 Mercer University Drive, Atlanta, 30341, USA.
| | - Mi Yeong Kim
- Gachon University Gil Medical Center, 21, Namdong-daero, 774beon-gil, Namdong-gu, Incheon, 21565, South Korea.
| | - Eun Young Park
- Gachon University, College of Nursing, 191 Hambakmeoro, Yeonsu-gu, Incheon, 21936, South Korea.
| | - Eun Ju Seo
- National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, South Korea.
| | - Mee Ok Lee
- Gachon University Gil Medical Center, 21, Namdong-daero, 774beon-gil, Namdong-gu, Incheon, 21565, South Korea.
| | - Bo Yoon Jeong
- National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, South Korea.
| | - Jung-Ah Lee
- University of California, Irvine, Sue and Bill Gross School of Nursing, Irvine, CA, 92697, USA.
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Healthcare Utilization is High in Adult Patients Relapsing after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:1659-1665. [DOI: 10.1016/j.bbmt.2019.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 02/26/2019] [Accepted: 04/01/2019] [Indexed: 01/01/2023]
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12
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Starr LT, Ulrich CM, Corey KL, Meghani SH. Associations Among End-of-Life Discussions, Health-Care Utilization, and Costs in Persons With Advanced Cancer: A Systematic Review. Am J Hosp Palliat Care 2019; 36:913-926. [PMID: 31072109 DOI: 10.1177/1049909119848148] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Aggressive end-of-life (EOL) care is associated with lower quality of life and greater regret about treatment decisions. Higher EOL costs are also associated with lower quality EOL care. Advance care planning and goals-of-care conversations ("EOL discussions") may influence EOL health-care utilization and costs among persons with cancer. OBJECTIVE To describe associations among EOL discussions, health-care utilization and place of death, and costs in persons with advanced cancer and explore variation in study measures. METHODS A systematic review was conducted using PubMed, Embase, and CINAHL. Twenty quantitative studies published between January 2012 and January 2019 were included. RESULTS End-of-life discussions are associated with lower health-care costs in the last 30 days of life (median US$1048 vs US$23482; P < .001); lower likelihood of acute care at EOL (odds ratio [(OR] ranging 0.43-0.69); lower likelihood of intensive care at EOL (ORs ranging 0.26-0.68); lower odds of chemotherapy near death (ORs 0.41, 0.57); lower odds of emergency department use and shorter length of hospital stay; greater use of hospice (ORs ranging 1.79 to 6.88); and greater likelihood of death outside the hospital. Earlier EOL discussions (30+ days before death) are more strongly associated with less aggressive care outcomes than conversations occurring near death. CONCLUSIONS End-of-life discussions are associated with less aggressive, less costly EOL care. Clinicians should initiate these discussions with patients having cancer earlier to better align care with preferences.
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Affiliation(s)
- Lauren T Starr
- 1 NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.,2 Penn Center for Bioethics, University of Pennsylvania, Philadelphia, PA, USA.,3 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,4 University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Connie M Ulrich
- 1 NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.,4 University of Pennsylvania School of Nursing, Philadelphia, PA, USA.,5 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristin L Corey
- 1 NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.,4 University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Salimah H Meghani
- 1 NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.,3 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,4 University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Levoy K, Salani DA, Buck H. A Systematic Review and Gap Analysis of Advance Care Planning Intervention Components and Outcomes Among Cancer Patients Using the Transtheoretical Model of Health Behavior Change. J Pain Symptom Manage 2019; 57:118-139.e6. [PMID: 30595148 DOI: 10.1016/j.jpainsymman.2018.10.502] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 10/19/2018] [Accepted: 10/19/2018] [Indexed: 12/11/2022]
Abstract
CONTEXT Despite the benefits of advance care planning (ACP), cancer patients rarely engage in ACP. ACP is a process that parallels health behavior change. This makes the Transtheoretical Model of Health Behavior Change (TTM) an important framework for understanding how to increase ACP among cancer patients. OBJECTIVES This study aimed to systematically review ACP interventions for cancer patients by 1) categorizing ACP intervention components according to the stages and processes of behavior change in the TTM, 2) conducting a gap analysis among the categorized components, and 3) identifying patterns between the categorized intervention components and the intervention outcomes. METHODS PubMed, CINAHL Plus, MEDLINE, Cochrane Library, and Web of Science databases were searched for articles related to ACP and cancer. ACP intervention components were abstracted, assessed for theoretical relevance, organized according to the stages and process of change in the TTM, and then synthesized. RESULTS The search produced 4604 articles, with 25 meeting criteria for review. Most intervention components targeted the precontemplation and contemplation stages of change, with fewer targeting preparation, action, or maintenance. Multiple processes of change were not addressed. Interventions that resulted in ACP engagement tended to take an interdisciplinary approach to implementation and consisted of multiple consultations staged over time. CONCLUSION ACP likely requires "high touch" interventions to induce behavior change. ACP interventions that are stage-matched, use diverse mechanisms to engage ACP (i.e., processes of change), address ACP as a process, and monitor engagement across the illness trajectory are needed for cancers patients and their caregivers.
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Affiliation(s)
- Kristin Levoy
- University of Miami School of Nursing and Health Studies, Coral Gables, Florida, USA.
| | - Deborah A Salani
- University of Miami School of Nursing and Health Studies, Coral Gables, Florida, USA
| | - Harleah Buck
- University of South Florida College of Nursing, Tampa, Florida, USA
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