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Bennett C, Beach S, Pacheco K, Hsu AT, Tanuseputro P, Manuel DG. Exploring perceptions of online calculators for identifying community-dwelling older people at risk of dying: A qualitative study. PEC INNOVATION 2024; 5:100313. [PMID: 39040661 PMCID: PMC11260570 DOI: 10.1016/j.pecinn.2024.100313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 05/31/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024]
Abstract
Objectives This study aimed to assess the acceptability, value, and perceived barriers of using electronic risk calculators for predicting and communicating the risk of death in community-dwelling older adults. Methods One focus group and eight interviews were conducted with 16 participants with experience caring for patients or family members at end of life. A prototype mortality risk tool was used to anchor discussions. Data were analysed using a qualitative content analysis approach. Results Five themes emerged: acceptability, communication, barriers to use, broadening the circle of care, and tool limitations. Participants found the tool helpful for preparation, planning, and providing care, but disagreed on its community availability. Personalized risk estimates were valued for facilitating early goals of care conversations and normalizing discussions about death. However, concerns were raised about the tool's interpretation for individuals with different language, cultural, or educational backgrounds. Conclusions While electronic risk calculators were found to be acceptable, balancing autonomy with varying preferences for receiving the information and potential need for support is crucial. Innovation Providing patient-oriented life-expectancy estimates can enhance decisional capacity and facilitate shared decision-making between patients, their families, and healthcare professionals. Further research is needed to explore effective communication of personalized risk tools and additional benefits, harms, and barriers to implementation.
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Affiliation(s)
- Carol Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Ottawa, Canada
| | - Sarah Beach
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Karen Pacheco
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Amy T. Hsu
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
- C.T. Lamont Primary Health Care Research Centre Program, Bruyère Research Institute, Ottawa, Canada
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Douglas G. Manuel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Health Analysis Division, Statistics Canada, Government of Canada, Ottawa, Canada
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2
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Blum M, Gelfman LP, Fried TR, McKendrick K, Schoenrath F, Goldstein NE. Desire for Prognostic Information Among Persons With Advanced Heart Failure. JACC. HEART FAILURE 2024:S2213-1779(24)00571-7. [PMID: 39207322 DOI: 10.1016/j.jchf.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 06/26/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Moritz Blum
- Icahn School of Medicine at Mount Sinai, New York, New York, USA; Deutsches Herzzentrum der Charité, Berlin, Germany; Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Laura P Gelfman
- Icahn School of Medicine at Mount Sinai, New York, New York, USA; Geriatric Research Education and Clinical Center, Bronx, New York, USA
| | - Terri R Fried
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Karen McKendrick
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Felix Schoenrath
- Deutsches Herzzentrum der Charité, Berlin, Germany; Charité-Universitätsmedizin Berlin, Berlin, Germany; German Centre for Cardiovascular Research, partner site Berlin, Berlin, Germany
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3
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Hoesseini A, Sewnaik A, van den Besselaar BN, Zhang J, van Leeuwen N, Hardillo JA, Baatenburg de Jong RJ, Offerman MPJ. Prognostic model for overall survival of head and neck cancer patients in the palliative phase. BMC Palliat Care 2024; 23:54. [PMID: 38395897 PMCID: PMC10893612 DOI: 10.1186/s12904-023-01325-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/08/2023] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Patients with head and neck squamous cell carcinoma (HNSCC) enter the palliative phase when cure is no longer possible or when they refuse curative treatment. The mean survival is five months, with a range of days until years. Realistic prognostic counseling enables patients to make well-considered end-of-life choices. However, physicians tend to overestimate survival. The aim of this study was to develop a prognostic model that calculates the overall survival (OS) probability of palliative HNSCC patients. METHODS Patients diagnosed with incurable HNSCC or patients who refused curative treatment for HNSCC between January 1st 2006 and June 3rd 2019 were included (n = 659). Three patients were lost to follow-up. Patients were considered to have incurable HNSCC due to tumor factors (e.g. inoperability with no other curative treatment options, distant metastasis) or patient factors (e.g. the presence of severe comorbidity and/or poor performance status).Tumor and patients factors accounted for 574 patients. An additional 82 patients refused curative treatment and were also considered palliative. The effect of 17 candidate predictors was estimated in the univariable cox proportional hazard regression model. Using backwards selection with a cut-off P-value < 0.10 resulted in a final multivariable prediction model. The C-statistic was calculated to determine the discriminative performance of the model. The final model was internally validated using bootstrapping techniques. RESULTS A total of 647 patients (98.6%) died during follow-up. Median OS time was 15.0 weeks (95% CI: 13.5;16.6). Of the 17 candidate predictors, seven were included in the final model: the reason for entering the palliative phase, the number of previous HNSCC, cT, cN, cM, weight loss in the 6 months before diagnosis, and the WHO performance status. The internally validated C-statistic was 0.66 indicating moderate discriminative ability. The model showed some optimism, with a shrinkage factor of 0.89. CONCLUSION This study enabled the development and internal validation of a prognostic model that predicts the OS probability in HNSCC patients in the palliative phase. This model facilitates personalized prognostic counseling in the palliative phase. External validation and qualitative research are necessary before widespread use in patient counseling and end-of-life care.
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Affiliation(s)
- Arta Hoesseini
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands.
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Boyd N van den Besselaar
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Jang Zhang
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Nikki van Leeuwen
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jose A Hardillo
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Robert Jan Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Marinella P J Offerman
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
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4
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Ambrosino N, Nava S. How to Speak to Patients. Arch Bronconeumol 2023; 59:712-713. [PMID: 37620185 DOI: 10.1016/j.arbres.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023]
Affiliation(s)
| | - Stefano Nava
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Italy
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5
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Miranda SP, Morris RS, Rabas M, Creutzfeldt CJ, Cooper Z. Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations. Neurocrit Care 2023; 39:284-293. [PMID: 37349599 DOI: 10.1007/s12028-023-01764-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/11/2023] [Indexed: 06/24/2023]
Abstract
Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.
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Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman Center for Advanced Medicine, 15 South Tower, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Rachel S Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mackenzie Rabas
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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6
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Sangeorzan I, Andriopoulou P, Davies BM, McNair A. The information needs of people with degenerative cervical myelopathy: A qualitative study to inform patient education in clinical practice. PLoS One 2023; 18:e0285334. [PMID: 37205664 PMCID: PMC10198551 DOI: 10.1371/journal.pone.0285334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 04/20/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Individuals with lifelong illnesses need access to adequate information about their condition to make optimal health decisions. Degenerative Cervical Myelopathy (DCM) is the most common form of spinal cord dysfunction in adults worldwide. Its chronic and debilitating nature, varied impact, clinical trajectory, and management options necessitate appropriate informational support to sustain effective clinical and self-directed care strategies. However, before clinicians can meet patients' information needs, they must first have an understanding of their baseline requirements. This study explores the information needs of people with DCM (PwCM). In doing so, it provides a starting point for the development of patient education and knowledge management strategies in clinical practice. METHODS Semi-structured interviews with PwCM were conducted using an interview guide. Interviews were audio-recorded and transcribed verbatim. Thematic analysis according to Braun and Clarke's six-phase approach was used to analyse the data. Findings were reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. RESULTS Twenty PwCM (65% female, 35% male), with ages ranging from 39 to 74 years old participated in the interviews. The findings indicated that the provision of information to PwCM during clinical interactions varies. Accordingly, PwCM's information needs were broad-ranging, as was the nature of the information they found useful. Three main themes were identified (1) Variation in the provision of information to PwCM during clinical interactions, (2) Variations in the information needs of PwCM, and (3) Information that PwCM find useful. CONCLUSION Efforts must turn to adequately educating patients at the time of the clinical encounter. A comprehensive and consistent patient-centered information exchange in DCM is necessary to achieve this.
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Affiliation(s)
| | | | - Benjamin M. Davies
- Myelopathy.org, Cambridge, Cambridgeshire, United Kingdom
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, Cambridge, Cambridgeshire, United Kingdom
| | - Angus McNair
- Centre for Surgical Research, Bristol Medical School, University of Bristol, United Kingdom
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7
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Tillmann BW, Hallet J, Sutradhar R, Guttman MP, Coburn N, Chesney TR, Zuckerman J, Mahar A, Chan WC, Haas B. The impact of unexpected intensive care unit admission after cancer surgery on long-term symptom burden among older adults: a population-based longitudinal analysis. Crit Care 2023; 27:162. [PMID: 37098625 PMCID: PMC10127328 DOI: 10.1186/s13054-023-04415-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/27/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Older adults are at high-risk for a post-operative intensive care unit (ICU) admission, yet little is known about the impact of these admissions on quality of life. The objective of this study was to evaluate the impact of an unexpected post-operative ICU admission on the burden of cancer symptoms among older adults who underwent high-intensity cancer surgery and survived to hospital discharge. METHODS We performed a population-based cohort study of older adults (age ≥ 70) who underwent high-intensity cancer surgery and survived to hospital discharge in Ontario, Canada (2007-2017). Using the Edmonton Symptom Assessment System (ESAS), a standardized tool that quantifies patient-reported physical, mental, and emotional symptoms, we described the burden of cancer symptoms during the year after surgery. Total symptom scores ≥ 40 indicated a moderate-to-severe symptom burden. Modified log-Poisson analysis was used to estimate the impact of an unexpected post-operative ICU admission (admission not related to routine monitoring) on the likelihood of experiencing a moderate-to-severe symptom burden during the year after surgery, accounting for potential confounders. We then used multivariable generalized linear mixed models to model symptom trajectories among patients with two or more ESAS assessments. A 10-point difference in total symptom scores was considered clinically significant. RESULTS Among 16,560 patients (mean age 76.5 years; 43.4% female), 1,503 (9.1%) had an unexpected ICU admission. After accounting for baseline characteristics, patients with an unexcepted ICU admission were more likely to experience a moderate-to-severe symptom burden relative to those without an unexpected ICU admission (RR 1.64, 95% CI 1.31-2.05). Specifically, among patients with an unexcepted ICU admission the average probability of experiencing moderate-to-severe symptoms ranged from 6.9% (95 CI 5.8-8.3%) during the first month after surgery to 3.2% (95% CI 0.9-11.7%) at the end of the year. Among the 11,229 (67.8%) patients with multiple ESAS assessments, adjusted differences in total scores between patients with and without an unexpected ICU admission ranged from 2.0 to 5.7-points throughout the year (p < 0.001). CONCLUSION While unexpected ICU admissions are associated with a small increase in the likelihood of experiencing a moderate-to-severe symptom burden, most patients do not experience a high overall symptom burden during the year after surgery. These findings support the role of aggressive therapy among older adults after major surgery.
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Affiliation(s)
- Bourke W Tillmann
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue - Room D108, Toronto, ON, M4N 3M5, Canada.
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - Julie Hallet
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Rinku Sutradhar
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Matthew P Guttman
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Natalie Coburn
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Tyler R Chesney
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Unity Health, Toronto, ON, Canada
| | - Jesse Zuckerman
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alyson Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | | | - Barbara Haas
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue - Room D108, Toronto, ON, M4N 3M5, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
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8
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Hallet J, Zuckerman J, Guttman MP, Chesney TR, Haas B, Mahar A, Eskander A, Chan WC, Hsu A, Barabash V, Coburn N. Patient-Reported Symptom Burden After Cancer Surgery in Older Adults: A Population-Level Analysis. Ann Surg Oncol 2023; 30:694-708. [PMID: 36068425 DOI: 10.1245/s10434-022-12486-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 07/06/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Older adults have unique needs for supportive care after surgery. We examined symptom trajectories and factors associated with high symptom burden after cancer surgery in older adults. PATIENTS AND METHODS We conducted a population-level study of patients ≥ 70 years old undergoing cancer surgery (2007-2018) using prospectively collected Edmonton Symptom Assessment System (ESAS) scores. The monthly prevalence of moderate to severe symptoms (ESAS ≥ 4) for anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and poor wellbeing was computed over 12 months after surgery. RESULTS Among 48,748 patients, 234,420 ESAS scores were recorded over 12 months after surgery. Moderate to severe tiredness (57.8%), poor wellbeing (51.9%), and lack of appetite (39.3%) were most common. The proportion of patients with moderate to severe symptoms was stable over the 1 month prior to and 12 months after surgery (< 5% variation for each symptom). There was no clinically significant change (< 5%) in symptom trajectory with the initiation of adjuvant therapy. CONCLUSIONS Patient-reported symptom burden was stable for up to 1 year after cancer surgery among older adults. Neither surgery nor adjuvant therapy coincided with a worsening in symptom burden. However, the persistence of symptoms at 1 year may suggest gaps in supportive care for older adults. This information on symptom trajectory and predictors of high symptom burden is important to set appropriate expectations and improve patient counseling, recovery care pathways, and proactive symptom management for older adults after cancer surgery.
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Affiliation(s)
- Julie Hallet
- Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada. .,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada. .,Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - Jesse Zuckerman
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Matthew P Guttman
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Tyler R Chesney
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Unity Health, Toronto, ON, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alyson Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Antoine Eskander
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Wing C Chan
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Amy Hsu
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Victoria Barabash
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Natalie Coburn
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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9
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van der Velden NCA, Smets EMA, Hagedoorn M, Applebaum AJ, Onwuteaka-Philipsen BD, van Laarhoven HWM, Henselmans I. Patient-Caregiver Dyads' Prognostic Information Preferences and Perceptions in Advanced Cancer. J Pain Symptom Manage 2023; 65:442-455.e2. [PMID: 36731806 DOI: 10.1016/j.jpainsymman.2023.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 02/04/2023]
Abstract
CONTEXT Prognostic information is considered important for advanced cancer patients and primary informal caregivers to prepare for the end of life. Little is known about discordance in patients' and caregivers' prognostic information preferences and prognostic perceptions, while such discordance complicates adaptive dyadic coping, clinical interactions and care plans. OBJECTIVES To investigate the extent of patient-caregiver discordance in prognostic information preferences and perceptions, and the factors associated with discordant prognostic perceptions. METHODS We conducted secondary analyses of a cross-sectional study (PROSPECT, 2019-2021). Advanced cancer patients (median overall survival ≤12 months) from seven Dutch hospitals and caregivers completed structured surveys (n = 412 dyads). RESULTS Seven percent of patient-caregiver dyads had discordant information preferences regarding the likelihood of cure; 24%-25% had discordant information preferences regarding mortality risk (5/2/1 year). Seventeen percent of dyads had discordant perceptions of the likelihood of cure; 12%-25% had discordant perceptions of mortality risk (5/2/1 year). Dyads with discordant prognostic information preferences (P < 0.05) and dyads in which patients reported better physical functioning (P < 0.01) were significantly more likely to perceive the one-year mortality risk discordantly. CONCLUSION Physicians should be sensitive to discordant prognostic information preferences and prognostic perceptions among patient-caregiver dyads in advanced cancer care.
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Affiliation(s)
- Naomi C A van der Velden
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam (N.C.A.V., E.M.A.S, I.H.), Amsterdam, The Netherlands; Quality of Care, Amsterdam Public Health (N.C.A.V, E.M.A.S, B.D.O-P, I.H.), Amsterdam, The Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam (N.C.A.V., E.M.A.S, H.W.M.L, I.H.), Amsterdam, The Netherlands.
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam (N.C.A.V., E.M.A.S, I.H.), Amsterdam, The Netherlands; Quality of Care, Amsterdam Public Health (N.C.A.V, E.M.A.S, B.D.O-P, I.H.), Amsterdam, The Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam (N.C.A.V., E.M.A.S, H.W.M.L, I.H.), Amsterdam, The Netherlands
| | - Mariët Hagedoorn
- Department of Health Psychology, University Medical Center Groningen, University of Groningen (M.H), The Netherlands
| | - Allison J Applebaum
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center (A.J.A), New York, New York, USA
| | - Bregje D Onwuteaka-Philipsen
- Quality of Care, Amsterdam Public Health (N.C.A.V, E.M.A.S, B.D.O-P, I.H.), Amsterdam, The Netherlands; Department of Public and Occupational Health, Expertise Center for Palliative Care, Amsterdam UMC location Vrije Universiteit Amsterdam (B.D.O-P, I.H.), Amsterdam, The Netherlands
| | - Hanneke W M van Laarhoven
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam (N.C.A.V., E.M.A.S, H.W.M.L, I.H.), Amsterdam, The Netherlands; Department of Medical Oncology, Amsterdam UMC location University of Amsterdam (H.W.M.L), Amsterdam, The Netherlands
| | - Inge Henselmans
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam (N.C.A.V., E.M.A.S, I.H.), Amsterdam, The Netherlands; Quality of Care, Amsterdam Public Health (N.C.A.V, E.M.A.S, B.D.O-P, I.H.), Amsterdam, The Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam (N.C.A.V., E.M.A.S, H.W.M.L, I.H.), Amsterdam, The Netherlands
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10
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Relevant Study: Patient and Clinician Perspectives on Clinically-Meaningful Outcomes in Advanced Pancreatic Cancer. Cancers (Basel) 2023; 15:cancers15030738. [PMID: 36765698 PMCID: PMC9913496 DOI: 10.3390/cancers15030738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/14/2023] [Accepted: 01/21/2023] [Indexed: 01/27/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer with a poor prognosis and significant symptom burden. This prospective observational study aimed to evaluate expectations and priorities of patients with advanced PDAC and their clinicians through a study survey and two quality of life (QoL) questionnaires (QLQ-C30 and PAN26) at three time-points: baseline (T1), before (T2) and after (T3) their 1st on-treatment CT scan. Over a 1-year period, 106 patients were approached, 71 patients and 12 clinicians were recruited. Choosing between treatment options, patients prioritised: 54% overall survival (OS), 26% balance between side-effects and OS, 15% could not choose and 5% favoured symptom control. These were significantly different from the clinician's answers (p < 0.001). Patients who prioritised OS had higher symptom burden (p = 0.03) and shorter OS compared to those who prioritised balance (p = 0.01). Most (86%) patients had personal goals they wanted to reach; clinicians knew of these in 12% of instances. Patient and clinicians' views regarding survival improvement from chemotherapy were significantly different: 81% of clinicians and 12% of patients thought 1-2 or 3-6 months extension, 58% of patients and 0% physicians thought 1-5 or >5 years (p < 0.001). At T1, patients had low QoL and worst symptoms were: 'Future worries', 'planning of activities', fatigue and pain. Patients were willing to accept significantly higher amounts of side-effects as a trade-off for extra time, than clinicians thought (p < 0.001). Overall, there are significant discrepancies between patient and clinicians' views about the aims, priorities and expected extension of life.
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11
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Hasdenteufel M, Quintard B. Psychosocial factors affecting the bereavement experience of relatives of palliative-stage cancer patients: a systematic review. Palliat Care 2022; 21:212. [PMID: 36451118 PMCID: PMC9713164 DOI: 10.1186/s12904-022-01096-y] [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: 04/21/2022] [Accepted: 11/07/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Cancer is one of the leading causes of death worldwide and a cancer death is a major risk factor for pathological bereavement. This systematic review of the literature aimed to identify biopsychosocial and existential determinants specific to the palliative phase of cancer that influence the grieving experience of the caregiving relative. METHOD A systematic review of the literature was conducted without language or time restrictions. The Cairn, Cochrane Library, PubMed, PsycArticle, PsychInfo, Psychology and Behavioral Sciences Collection databases were explored. All studies assessing pre- and post-death measures and focusing on friends and relatives caring for adults with cancer in palliative care services were included in the review. RESULTS Out of 645 articles identified, 18 full text studies were finally included in our systematic review of the literature. Many factors specific to the cancer palliative phase were identified as influencing the bereavement experience of caregivers, with factors relating to: 1) the caregiver (e.g. social support, psychological burden, preparation for loss, action and discussion related to death); 2) the patient (e.g. denial or acceptance); 3) the interactions between patient and their caregivers (e.g. tensions, communication difficulties, and presence at the time of death); and 4) the end-of-life context. The caregiver's grief experience can be described by the following terms: typical and pathological grief, anxiety, depression, guilt, psychological distress, post-traumatic stress disorder and post-traumatic growth, and life satisfaction. CONCLUSIONS Many contextual, sociodemographic, dispositional and transactional factors specific to the palliative cancer phase are involved in the caregiver's grieving experience. Avenues for reflection and recommendations are proposed including supporting communication and patient-relative relationships, evaluating the nature and degree of functionality of coping strategies, strengthening the robustness of methodologies, considering impact of COVID-19, and new lines of enquiry for research.
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Affiliation(s)
- Marie Hasdenteufel
- grid.412041.20000 0001 2106 639XLaboratoire de Psychologie EA 4139, Université de Bordeaux, Faculté de Psychologie, 3 Ter, Place de La Victoire, 33076 Bordeaux-Cedex, France
| | - Bruno Quintard
- grid.412041.20000 0001 2106 639XLaboratoire de Psychologie EA 4139, Université de Bordeaux, Faculté de Psychologie, 3 Ter, Place de La Victoire, 33076 Bordeaux-Cedex, France
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12
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Hallet J, Tillman B, Zuckerman J, Guttman MP, Chesney T, Mahar AL, Chan WC, Coburn N, Haas B. Association Between Frailty and Time Alive and At Home After Cancer Surgery Among Older Adults: A Population-Based Analysis. J Natl Compr Canc Netw 2022; 20:1223-1232.e9. [PMID: 36351336 DOI: 10.6004/jnccn.2022.7052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/06/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although frailty is known to impact short-term postoperative outcomes, its long-term impact is unknown. This study examined the association between frailty and remaining alive and at home after cancer surgery among older adults. METHODS Adults aged ≥70 years undergoing cancer resection were included in this population-based retrospective cohort study using linked administrative datasets in Ontario, Canada. The probability of remaining alive and at home in the 5 years after cancer resection was evaluated using Kaplan-Meier methods. Extended Cox regression with time-varying effects examined the association between frailty and remaining alive and at home. RESULTS Of 82,037 patients, 6,443 (7.9%) had preoperative frailty. With median follow-up of 47 months (interquartile range, 23-81 months), patients with frailty had a significantly lower probability of remaining alive and at home 5 years after cancer surgery compared with those without frailty (39.1% [95% CI, 37.8%-40.4%] vs 62.5% [95% CI, 62.1%-63.9%]). After adjusting for age, sex, rural living, material deprivation, immigration status, cancer type, surgical procedure intensity, year of surgery, and receipt of perioperative therapy, frailty remained associated with increased hazards of not remaining alive and at home. This increase was highest 31 to 90 days after surgery (hazard ratio [HR], 2.00 [95% CI, 1.78-2.24]) and remained significantly elevated beyond 1 year after surgery (HR, 1.56 [95% CI, 1.48-1.64]). This pattern was observed across cancer sites, including those requiring low-intensity surgery (breast and melanoma). CONCLUSIONS Preoperative frailty was independently associated with a decreased probability of remaining alive and at home after cancer surgery among older adults. This relationship persisted over time for all cancer types beyond short-term mortality and the initial postoperative period. Frailty assessment may be useful for all candidates for cancer surgery, and these data can be used when counseling, selecting, and preparing patients for surgery.
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Affiliation(s)
- Julie Hallet
- 1Department of Surgery, University of Toronto, Toronto, Ontario
- 2Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario
- 3ICES, Toronto, Ontario
- 4Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario
| | - Bourke Tillman
- 3ICES, Toronto, Ontario
- 5Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario; and
| | - Jesse Zuckerman
- 1Department of Surgery, University of Toronto, Toronto, Ontario
- 3ICES, Toronto, Ontario
| | - Matthew P Guttman
- 1Department of Surgery, University of Toronto, Toronto, Ontario
- 3ICES, Toronto, Ontario
| | - Tyler Chesney
- 1Department of Surgery, University of Toronto, Toronto, Ontario
| | - Alyson L Mahar
- 3ICES, Toronto, Ontario
- 6Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Natalie Coburn
- 1Department of Surgery, University of Toronto, Toronto, Ontario
- 2Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario
- 3ICES, Toronto, Ontario
- 4Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario
| | - Barbara Haas
- 1Department of Surgery, University of Toronto, Toronto, Ontario
- 3ICES, Toronto, Ontario
- 4Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario
- 6Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Patient Interaction Involving Older Adults: Provider vs. Caregiver Expectations. Geriatrics (Basel) 2022; 7:geriatrics7050101. [PMID: 36136810 PMCID: PMC9498497 DOI: 10.3390/geriatrics7050101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
This paper presents a study of the interaction between healthcare providers (HCPs) and older patients and their caregivers. The paper first presents results from a rapid review and narrative synthesis using PubMed and Google Scholar of HCP/patient/caregiver interactions involving older patients; these results then informed the design of a survey administered to HCPs and caregivers using a range of scenarios and their ratings of appropriateness of different responses, to explore where expectations align or differ between HCPs and caregivers. In analyzing ratings, the research found HCPs and caregivers generally approach the older adult encounter with similar expectations, but differences for specific situations are informative. HCPs appear to better recognize when there is a need to show empathy, as when a patient is frustrated or anxious. HCPs, overall, offer more calming responses, especially in embarrassing, upsetting, or worrying situations. For older patients of advanced age, HCPs value engagement with patients more than caregivers, but HCPs are more aligned with caregivers in their ratings of how to engage caregivers. Compared to caregivers, HCPs focus more on simplifying the description of treatment rather than using thorough explanations when a patient expresses hesitancy or avoidance. The results from this work suggest that having a fuller understanding of the different participants’ expectations may improve communication and identify potential pitfalls. A better understanding may also lead to changes in how students in the healthcare fields are trained; having better insight into this relationship will prepare them for interacting with older patients while addressing the needs of caregivers.
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14
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Discussing prognosis and the end of life with patients with advanced cancer or COPD: A qualitative study. PLoS One 2022; 17:e0274201. [PMID: 36084060 PMCID: PMC9462714 DOI: 10.1371/journal.pone.0274201] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 08/23/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives To explore patients’ experiences and recommendations for discussions about their prognosis and end of life with their physicians. Methods Patients with advanced cancer or advanced chronic obstructive pulmonary disease (COPD) were enrolled in qualitative interviews, which were analyzed with a phenomenological and thematic approach. Results During interviews with fourteen patients (median age 64 years), we identified the following themes for discussion about prognosis and the end of life: topics discussed, the timing, the setting, physician–patient relationship, responsibilities for clinicians, and recommendations. Patients preferred the physician to initiate such discussion, but wanted to decide about its continuation and content. The discussions were facilitated by an established physician–patient relationship or attendance of relatives. Patients with cancer had had discussions about prognosis at rather clear-cut moments of deterioration than patients with COPD. Patients with COPD did not consider end-of-life discussions a responsibility of the pulmonologist. Patients recommended an understandable message, involvement of relatives or other clinicians, sufficient time, and sensitive non-verbal communication. Conclusions Patients appreciated open, sensitive, and negotiable discussions about prognosis and the end of life. Practice implications Patients’ recommendations could be used for communication training. Possible differences in the need for such discussions between patients with cancer or COPD warrant further research.
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15
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Petrillo LA, Shimer SE, Zhou AZ, Sommer RK, Feldman JE, Hsu KE, Greer JA, Traeger LN, Temel JS. Prognostic communication about lung cancer in the precision oncology era: A multiple-perspective qualitative study. Cancer 2022; 128:3120-3128. [PMID: 35731234 DOI: 10.1002/cncr.34369] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/31/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although most patients with cancer prefer to know their prognosis, prognostic communication between oncologists and patients is often insufficient. Targeted therapies for lung cancer improve survival yet are not curative and produce variable responses. This study sought to describe how oncologists communicate about prognosis with patients receiving targeted therapies for lung cancer. METHODS This qualitative study included 39 patients with advanced lung cancer with targetable mutations, 14 caregivers, and 10 oncologists. Semistructured interviews with patients and caregivers and focus groups or interviews with oncologists were conducted to explore their experiences with prognostic communication. One oncology follow-up visit was audio-recorded per patient. A framework approach was used to analyze interview transcripts, and a content analysis of patient-oncologist dialogue was conducted. Themes were identified within each source and then integrated across sources to create a multidimensional description of prognostic communication. RESULTS Six themes in prognostic communication were identified: Patients with targetable mutations develop a distinct identity in the lung cancer community that affects their information-seeking and self-advocacy; oncologists set high expectations for targeted therapy; the uncertain availability of new therapies complicates prognostic discussions; patients and caregivers have variable information preferences; patients raise questions about progression by asking about physical symptoms or scan results; and patients' expectations of targeted therapy influence their medical decision-making. CONCLUSIONS Optimistic patient-oncologist communication shapes the expectations of patients receiving targeted therapy for lung cancer and affects their decision-making. Further research and clinical guidance are needed to help oncologists to communicate uncertain outcomes effectively.
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Affiliation(s)
- Laura A Petrillo
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sophia E Shimer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ashley Z Zhou
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert K Sommer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Kelly E Hsu
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lara N Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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16
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Daly J, Schmidt M, Thoma K, Xu Y, Levy B. How Well are Serious Illness Conversations Documented and What are Patient and Physician Perceptions of These Conversations? J Palliat Care 2022; 37:332-340. [PMID: 35341365 DOI: 10.1177/08258597221090387] [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: 11/15/2022]
Abstract
BACKGROUND The Serious Illness Care Program (SICP), developed in 2011 by Ariadne Labs, restructures care so that knowing and then honoring patients' wishes becomes part of routine care. OBJECTIVES 1) summarize patient perceptions of use of the Serious Illness Conversation Guide (SICG) components, 2) assess whether a serious illness conversation was documented in the electronic health record (EHR) and identify the SICG components that were included, 3) summarize clinician perceptions of use of the SICG components, and 4) assess the association of documented SICG components with the patient's perception of the SICG discussion. METHODS Clinicians at three family medicine offices were trained in serious illness conversations using the SICG. They documented their serious illness conversations in the medical record. Retrospective chart review for SICG components was conducted for patients. Patients and clinicians completed questionnaires about their experience with the SICG. Statistical analysis included the Pearson chi-square test for categorical variables and Cohen's kappa to determine agreement between clinician documentation and patient perception. RESULTS Eighty-nine patients consented and completed their baseline questionnaire. Mean age of the 89 patients was 72 years and 65 (73%) were female. Thirty (34%) medical records had one or more SICG components documented. Seventy-nine (89%) patients reported at least one individual component of the SICG being discussed. Clinicians reported they engaged in asking patients what is important to them at a mean of 5.9, with 7 being "all the time". There was slight agreement (kappa = .19) for patient perception and clinician documentation of discussing patient goals, but no agreement for any of the other SICG components. CONCLUSION Even among trained clinicians, only one-third of patients had documentation of at least one SICG component. Only slight agreement was found between clinician documentation of SICG in the medical record and patient perception of SICG discussion.
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Affiliation(s)
- Jeanette Daly
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
| | - Megan Schmidt
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
| | - Kate Thoma
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
| | - Yinghui Xu
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
| | - Barcey Levy
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
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17
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Cheng BBY, Ryan BJ, Copland DA, Wallace SJ. Prognostication in post-stroke aphasia: Perspectives of people with aphasia on receiving information about recovery. Neuropsychol Rehabil 2022; 33:871-902. [PMID: 35297737 DOI: 10.1080/09602011.2022.2051565] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Many people with aphasia (language impairment post-stroke) want to know their prognosis for recovery, yet current understanding of their experience of receiving prognoses is limited. Such insight is necessary to inform clinical practice in formulating and delivering aphasia prognoses, especially given the psycho-emotional distress and secondary adverse effects on recovery associated with conversations about prognosis. We sought an in-depth understanding of the perspectives of people with aphasia in relation to receiving prognoses post-stroke, with the aim of informing an evidence-based approach to aphasia prognostication in clinical practice. Semi-structured interviews, facilitated by communication support strategies, were conducted one-to-one with eight people with aphasia (ranging from mild to very severe) 3-12 months post-stroke. Reflexive thematic analysis was used to analyse the qualitative data, yielding two over-arching themes: (1) How would you know without knowing me?; (2) I need to know, but I don't want to know. Our findings illustrate issues of mistrust within the patient-clinician relationship, and complex emotions relating to hope and post-stroke adjustment. The present insight into the lived experience of receiving aphasia prognoses highlights the need for focused consideration of personal definitions of normalcy, measures for fostering trust, and the role of prognostic uncertainty.
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Affiliation(s)
- Bonnie B Y Cheng
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia.,Queensland Aphasia Research Centre, The University of Queensland, Herston, Australia
| | - Brooke J Ryan
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia.,Queensland Aphasia Research Centre, The University of Queensland, Herston, Australia.,NHMRC Centre of Research Excellence in Aphasia Recovery and Rehabilitation, Brisbane, Australia.,Discipline of Clinical Psychology, Graduate School of Health, University of Technology Sydney, Ultimo, Australia
| | - David A Copland
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia.,Queensland Aphasia Research Centre, The University of Queensland, Herston, Australia.,NHMRC Centre of Research Excellence in Aphasia Recovery and Rehabilitation, Brisbane, Australia
| | - Sarah J Wallace
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia.,Queensland Aphasia Research Centre, The University of Queensland, Herston, Australia.,NHMRC Centre of Research Excellence in Aphasia Recovery and Rehabilitation, Brisbane, Australia
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18
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Mitzel H, Brown D, Thomas M, Curl B, Wild M, Kelsch A, Muskrat J, Hossain A, Ryan K, Babalola O, Burgard M, Mehedi M. Patient-Centered Discussion on End-of-Life Care for Patients with Advanced COPD. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:254. [PMID: 35208578 PMCID: PMC8878082 DOI: 10.3390/medicina58020254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/30/2022] [Accepted: 02/01/2022] [Indexed: 11/16/2022]
Abstract
Exacerbations of chronic obstructive pulmonary disease (COPD) may lead to a rapid decline in health and subsequent death, an unfortunate tyranny of having COPD-an irreversible health condition of 16 million individuals in the USA totaling 60 million in the world. While COPD is the third largest leading cause of death, causing 3.23 million deaths worldwide in 2019 (according to the WHO), most patients with COPD do not receive adequate treatment at the end stages of life. Although death is inevitable, the trajectory towards end-of-life is less predictable in severe COPD. Thus, clinician-patient discussion for end-of-life and palliative care could bring a meaningful life-prospective to patients with advanced COPD. Here, we summarized the current understanding and treatment of COPD. This review also highlights the importance of patient-centered discussion and summarizes current status of managing patients with advanced COPD.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Masfique Mehedi
- School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND 58202, USA; (H.M.); (D.B.); (M.T.); (B.C.); (M.W.); (A.K.); (J.M.); (A.H.); (K.R.); (O.B.); (M.B.)
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19
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Abstract
Dementia is a progressive, irreversible illness and leading global cause of death defined by cognitive and subsequent functional decline. Current treatments have limited impact on mortality. In this chapter, we discuss the trajectory of dementia and its variability, markers associated with poorer prognosis (such as poor nutrition, pneumonia, comorbid conditions), the impact of hospitalization on prognosis, and current models of end-of-life palliative care/hospice eligibility (with the use of the Functional Assessment Staging tool and other markers). We then discuss strategies to discuss prognosis with patients and their healthcare proxies using a mental model (Ask, Discover, Anticipate, Provide, Track: ADAPT) and specific skills. Because of progression of dementia variability, prognosis is better discussed in terms of function. For patients with dementia, initiating advance care planning earlier in their disease course allows for more patient involvement (such as to identify a surrogate decision maker).
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Affiliation(s)
- Sinthana U Ramsey
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; Palliative and Supportive Institute, UPMC Health System, Pittsburgh, PA, United States
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20
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Shafir A, Ritchie CS, Garrett SB, Sideman AB, Naasan G, Merrilees J, Widera E, Flint L, Harrison KL. "Captive by the Uncertainty"-Experiences with Anticipatory Guidance for People Living with Dementia and Their Caregivers at a Specialty Dementia Clinic. J Alzheimers Dis 2022; 86:787-800. [PMID: 35124641 PMCID: PMC9717709 DOI: 10.3233/jad-215203] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND After a diagnosis of Alzheimer's disease and related disorders, people living with dementia (PWD) and caregivers wonder what disease trajectory to expect and how to plan for functional and cognitive decline. This qualitative study aimed to identify patient and caregiver experiences receiving anticipatory guidance about dementia from a specialty dementia clinic. OBJECTIVE To examine PWD and caregiver perspectives on receiving anticipatory guidance from a specialty dementia clinic. METHODS We conducted semi-structured interviews with PWD, and active and bereaved family caregivers, recruited from a specialty dementia clinic. Interviews were recorded, transcribed, and systematically summarized. Thematic analysis identified anticipatory guidance received from clinical or non-clinical sources and areas where respondents wanted additional guidance. RESULTS Of 40 participants, 9 were PWD, 16 were active caregivers, and 15 were bereaved caregivers. PWD had a mean age of 75 and were primarily male (n = 6/9); caregivers had a mean age of 67 and were primarily female (n = 21/31). Participants felt they received incomplete or "hesitant" guidance on prognosis and expected disease course via their clinicians and filled the gap with information they found via the internet, books, and support groups. They appreciated guidance on behavioral, safety, and communication issues from clinicians, but found more timely and advance guidance from other non-clinical sources. Guidance on legal and financial planning was primarily identified through non-clinical sources. CONCLUSION PWD and caregivers want more information about expected disease course, prognosis, and help planning after diagnosis. Clinicians have an opportunity to improve anticipatory guidance communication and subsequent care provision.
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Affiliation(s)
- Adi Shafir
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Department of Veterans Affairs Medical Center, San Francisco
- Division of General Internal Medicine and Geriatrics, Oregon Health and Sciences University, Portland, OR
| | - Christine S. Ritchie
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Division of Palliative Care and Geriatric Medicine and the Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital and Harvard Medical School, Boston
- Global Brain Health Institute, University of California, San Francisco
| | - Sarah B. Garrett
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Alissa Bernstein Sideman
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- UCSF Department of Humanities & Social Sciences
- Global Brain Health Institute, University of California, San Francisco
| | - Georges Naasan
- The Barbara and Maurice Deane Center for Wellness and Cognitive Health, Department of Neurology, Mount Sinai, Icahn School of Medicine, NY
- Global Brain Health Institute, University of California, San Francisco
| | | | - Eric Widera
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Department of Veterans Affairs Medical Center, San Francisco
| | - Lynn Flint
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Department of Veterans Affairs Medical Center, San Francisco
| | - Krista L. Harrison
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- Global Brain Health Institute, University of California, San Francisco
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21
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Keuper K, England AE, Shah RC, Quinn TV, Gerhart J, Greenberg JA. Surrogate and Physician Decision Making for Mechanically Ventilated Patients According to Expected Patient Outcome. J Palliat Med 2021; 25:907-914. [PMID: 34964669 DOI: 10.1089/jpm.2021.0348] [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: Surrogates and physicians may differ in their priorities and perspectives when making decisions for incapacitated, critically ill patients. Objectives: To determine the extent to which surrogate and physician decisions to sustain life support are associated with their expectations for patient outcomes. Setting/Subjects: Surrogates and physicians of 100 mechanically ventilated patients at an academic, tertiary care medical center in the United States were surveyed. Measurements: Linear regression was used to determine if participant expectations for patient survival, good quality of life, and confidence in these expectations were associated with their agreement that mechanical ventilation should be continued if required for patient survival. Results: Surrogates were more likely than physicians to expect that patients would be alive in three months (91% interquartile range [IQR 70-95%] vs. 65% [IQR 43-77%], p < 0.001) and have good quality of life in three months (71% [IQR 50-90%] vs. 40% [IQR 19-50%], p < 0.001). Surrogates who were most confident in their prognostic abilities were also the most optimistic for good patient outcomes. As such, expectations for patient survival and good quality of life were not associated with level agreement that mechanical ventilation should be continued among confident surrogates, (R2 = 0.03, p = 0.13) and (R2 = 0.01, p = 0.53), respectively. In contrast, among physicians, confidence was not synonymous with optimism. Instead, the significant associations between expectations for patient survival and good quality of life with the agreement that mechanical ventilation should be continued were strengthened when physicians were confident, (R2 = 0.34, p < 0.01) and (R2 = 0.47, p < 0.001), respectively. Conclusion: Surrogates and physicians have different approaches to incorporating their expectations for patient prognosis and their confidence in these expectations when they are making decisions for incapacitated critically ill patients.
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Affiliation(s)
- Kevin Keuper
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Ashley Eaton England
- Department of Psychology, Central Michigan University, Mount Pleasant, Michigan, USA
| | - Raj C Shah
- Department of Family Medicine and the Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Thomas V Quinn
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - James Gerhart
- Department of Psychology, Central Michigan University, Mount Pleasant, Michigan, USA.,Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Jared A Greenberg
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, Illinois, USA
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22
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Neo SHS, Zhou JX, Wong GC, Mok NK, Yee AC, Phua GL. Teaching Communication Micro-Skills to Cardiologists Managing Seriously Ill Patients in Asia: Challenges Encountered Amidst the COVID-19 Pandemic and Future Perspectives. Cureus 2021; 13:e19957. [PMID: 34976539 PMCID: PMC8713428 DOI: 10.7759/cureus.19957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2021] [Indexed: 11/18/2022] Open
Abstract
Background Patients with advanced cardiac conditions value effective symptom control and empathic communication with their doctors. However, studies have shown that empathic communication with seriously ill patients does not occur adequately in cardiology. Therefore, we piloted a program for teaching communication skills in a bite-sized manner. The primary aim of the research was to understand the feasibility and acceptability of the training program and to perform a preliminary evaluation of its efficacy. Methodology Clinicians were recruited from the cardiology unit of a tertiary hospital in Singapore. Patients were also recruited for the audio recording of clinic consults. Recruited patients had to have a chronic cardiac condition and be deemed at risk of dying within one year. We utilized a pre-post intervention design. Prior to the educational intervention, clinicians were asked to audio record a single clinic consult at baseline. They were then asked to participate in a training program that consisted of video-annotated presentations and role-play scenarios. Subsequently, the audio recordings of their clinic consults with seriously ill patients were recorded. The audio recordings were evaluated by trainers and used for feedback with clinicians. Data on the completion rate of the training program were collected. In addition, changes in the clinicians’ self-rated communication skills and views on the acceptability and relevance of the training program were collected. Results Overall, five of the six clinicians (83.3%) completed all sessions in the program. One clinician only completed four out of the five sessions in the program. Clinicians deemed the program acceptable and relevant and found audio recordings to be useful for reflective learning. There was an improvement in the clinicians’ self-assessed competency. However, the planned number of audio recordings could not be completed due to the coronavirus disease 2019 pandemic. Conclusions The pilot training program was acceptable and relevant for the participants. However, it will require adaptation to allow it to be transferrable and scalable to all settings, especially in situations that limit prolonged face-to-face contact.
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Fried TR, Paiva AL, Redding CA, Iannone L, O'Leary JR, Zenoni M, Risi MM, Mejnartowicz S, Rossi JS. Effect of the STAMP (Sharing and Talking About My Preferences) Intervention on Completing Multiple Advance Care Planning Activities in Ambulatory Care : A Cluster Randomized Controlled Trial. Ann Intern Med 2021; 174:1519-1527. [PMID: 34461035 PMCID: PMC8711627 DOI: 10.7326/m21-1007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Interventions with the potential for broad reach in ambulatory settings are necessary to achieve a life course approach to advance care planning. OBJECTIVE To examine the effect of a computer-tailored, behavioral health model-based intervention on the engagement of adults in advance care planning recruited from ambulatory care settings. DESIGN Cluster randomized controlled trial with participant-level analysis. (ClinicalTrials.gov: NCT03137459). SETTING 10 pairs of primary and selected specialty care practices matched on patient sociodemographic information. PARTICIPANTS English-speaking adults aged 55 years or older; 454 adults at practices randomly assigned to usual care and 455 at practices randomly assigned to intervention. INTERVENTION Brief telephone or web-based assessment generating a mailed, individually tailored feedback report with a stage-matched brochure at baseline, 2 months, and 4 months. MEASUREMENTS The primary outcome was completion of the following 4 advance care planning activities at 6 months: identifying and communicating with a trusted person about views on quality versus quantity of life, assignment of a health care agent, completion of a living will, and ensuring that the documents are in the medical record-assessed by a blinded interviewer. Secondary outcomes were completion of individual advance care planning activities. RESULTS Participants were 64% women and 76% White. The mean age was 68.3 years (SD, 8.3). The predicted probability of completing all advance care planning activities in usual care sites was 8.2% (95% CI, 4.9% to 11.4%) versus 14.1% (CI, 11.0% to 17.2%) in intervention sites (adjusted risk difference, 5.2 percentage points [CI, 1.6 to 8.8 percentage points]). Prespecified subgroup analysis found no statistically significant interactions between the intervention and age, education, or race. LIMITATIONS The study was done in a single region and excluded non-English speaking participants. No information was collected about nonparticipants. CONCLUSION A brief, easily delivered, tailored print intervention increased participation in advance care planning in ambulatory care settings. PRIMARY FUNDING SOURCE National Institute of Nursing Research and National Institute of Aging.
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Affiliation(s)
- Terri R Fried
- Yale School of Medicine, New Haven, and Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut (T.R.F.)
| | - Andrea L Paiva
- Cancer Prevention Research Center, College of Health Sciences, University of Rhode Island, Kingston, Rhode Island (A.L.P., C.A.R., J.S.R.)
| | - Colleen A Redding
- Cancer Prevention Research Center, College of Health Sciences, University of Rhode Island, Kingston, Rhode Island (A.L.P., C.A.R., J.S.R.)
| | - Lynne Iannone
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, and Yale School of Medicine, New Haven, Connecticut (L.I., J.O., M.Z.)
| | - John R O'Leary
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, and Yale School of Medicine, New Haven, Connecticut (L.I., J.O., M.Z.)
| | - Maria Zenoni
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, and Yale School of Medicine, New Haven, Connecticut (L.I., J.O., M.Z.)
| | - Megan M Risi
- College of Health Sciences, University of Rhode Island, Kingston, Rhode Island (M.M.R.)
| | | | - Joseph S Rossi
- Cancer Prevention Research Center, College of Health Sciences, University of Rhode Island, Kingston, Rhode Island (A.L.P., C.A.R., J.S.R.)
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Janett-Pellegri C, Eychmüller AS. 'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication? PRAXIS 2021; 110:914-924. [PMID: 34814721 DOI: 10.1024/1661-8157/a003785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
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.'
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Affiliation(s)
- Camilla Janett-Pellegri
- Service de Médicine Interne, Hôpital Cantonal Fribourg, Fribourg
- Universitäres Zentrum für Palliative Care, Inselspital, Universitätsspital Bern, Bern
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The experiences of health professionals, patients, and families with truth disclosure when breaking bad news in palliative care: A qualitative meta-synthesis. Palliat Support Care 2021; 20:433-444. [DOI: 10.1017/s1478951521001243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Objective
Disclosing the truth when breaking bad news continues to be difficult for health professionals, yet it is essential for patients when making informed decisions about their treatment and end-of-life care. This literature review aimed to explore and examine how health professionals, patients, and families experience truth disclosure during the delivery of bad news in the inpatient/outpatient palliative care setting.
Methods
A systemized search for peer-reviewed, published papers between 2013 and 2020 was undertaken in September 2020 using the CINAHL, Medline, and PsycInfo databases. The keywords and MeSH terms (“truth disclosure”) AND (“palliative care or end-of-life care or terminal care or dying”) were used. The search was repeated using (“bad news”) AND (“palliative care or end-of-life care or terminal care or dying”) terms. A meta-synthesis was undertaken to synthesize the findings from the eight papers.
Results
Eight papers were included in the meta-synthesis and were represented by five Western countries. Following the synthesis process, two concepts were identified: “Enablers in breaking bad news” and “Truth avoidance/disclosure.” Several elements formed the concept of Enablers for breaking bad news, such as the therapeutic relationship, reading cues, acknowledgment, language/delivery, time/place, and qualities. A conceptual model was developed to illustrate the findings of the synthesis.
Significance of results
The conceptual model demonstrates a unique way to look at communication dynamics around truth disclosure and avoidance when breaking bad news. Informed decision-making requires an understanding of the whole truth, and therefore truth disclosure is an essential part of breaking bad news.
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Carlini J, Bahudin D, Michaleff ZA, Plunkett E, Shé ÉN, Clark J, Cardona M. Discordance and concordance on perception of quality care at end of life between older patients, caregivers and clinicians: a scoping review. Eur Geriatr Med 2021; 13:87-99. [PMID: 34386928 PMCID: PMC8359918 DOI: 10.1007/s41999-021-00549-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/26/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND This scoping review aimed to investigate the presence of discordance or concordance in the perceptions of end-of-life (EOL) care quality between consumers (i.e. patients aged over 60 in their last years of life and/or their informal caregivers) and clinicians, to inform further improvements in end-of-life care service delivery. METHODS A scoping review of qualitative and quantitative studies was systematically undertaken by searching for English language publications in MEDLINE database and manual reference search of eligible articles. Thematic analysis was employed to identify and extract common concordance and discordance themes leading to the development of analytical constructs. Articles were eligible for inclusion if they reported on consumers' (i.e. older patients aged 60 + years in their final years of life and/or their informal caregivers) and clinicians' (doctors, nurses, social workers, etc.) perspectives on quality of medical, surgical or palliative/supportive care administered to older adults in the last year of life across all healthcare settings. RESULTS Of the 2736 articles screened, 21 articles were included. Four themes identified concordance between consumers' and clinicians' perceptions of care quality: holistic patient care; coordinated care that facilitated EOL; the role of family at EOL; and impact of prognostic uncertainty on care planning. Three themes emerged for discordance of perceptions: understanding the patient needs at EOL; capacity of healthcare system/providers to accommodate family needs; and knowledge and communication of active or palliative care at EOL. CONCLUSIONS While progress has been made on promoting patient autonomy and respecting the family role in representing patient's best interest, gaps remain in terms of care coordination, communication of prognosis, public understanding of the meaning of goals of care including de-escalation of management and enactment of advance care directives by clinicians for people with diminished decision capacity. Public understanding of the meaning of "comfort" care and the need to prevent over-treatment are essential for their satisfaction with care and their ability to embrace the concept of a good death.
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Affiliation(s)
- Joan Carlini
- School of Business, Griffith University, Southport, QLD Australia
- Gold Coast University Hospital Consumer Advisory Group, Southport, QLD Australia
| | - Danial Bahudin
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD Australia
| | - Zoe A. Michaleff
- Institute for Evidence Based Healthcare, Bond University, Robina, QLD Australia
| | - Emily Plunkett
- Palliative Care Service, Robina Hospital, Robina, QLD Australia
| | - Éidín Ní Shé
- School of Population Health, University of New South Wales, Kensington, NSW Australia
| | - Justin Clark
- Institute for Evidence Based Healthcare, Bond University, Robina, QLD Australia
| | - Magnolia Cardona
- Institute for Evidence Based Healthcare, Bond University, Robina, QLD Australia
- Evidence Based Practice Professorial Unit, Gold Coast University Hospital, Level 2, PED building, 1 Hospital Boulevard, Southport, QLD 4215 Australia
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Chuzi S, Ogunseitan A, Cameron KA, Grady K, Schulze L, Wilcox JE. Perceptions of Bereaved Caregivers and Clinicians About End-of-Life Care for Patients With Destination Therapy Left Ventricular Assist Devices. J Am Heart Assoc 2021; 10:e020949. [PMID: 34308687 PMCID: PMC8475670 DOI: 10.1161/jaha.121.020949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/09/2021] [Indexed: 11/26/2022]
Abstract
Background Patients with left ventricular assist devices (LVADs) implanted as destination therapy may receive suboptimal preparation for and care at the end of life, but there is limited understanding of the reasons for these shortcomings. Exploring perceptions of individuals (caregivers and clinicians) who are closely involved in the end-of-life experience with patients with destination therapy LVADs can help identify key opportunities for improving care. Methods and Results We conducted semistructured qualitative interviews with 7 bereaved caregivers of patients with destination therapy LVADs and 10 interdisciplinary LVAD clinicians. Interviews explored perceptions of preparing for end of life, communicating about end of life, and providing and receiving end-of-life care, and were analyzed using a 2-step team-based inductive approach to coding and analysis. Six themes pertaining to end-of-life experiences were derived: (1) timing end-of-life discussions in the setting of unpredictable illness trajectories, (2) prioritizing end-of-life preparation and decision-making, (3) communicating uncertainty while providing support and hope, (4) lack of consensus on responsibility for end-of-life discussions, (5) perception of the LVAD team as invincible, and (6) divergent perceptions of LVAD withdrawal. Conclusions This study revealed 6 unique aspects of end-of-life care for patients with destination therapy LVADs as reported by clinicians and caregivers. Themes coalesced around communication, team-based care, and challenges unique to patients with LVADs at end of life. Programmatic changes may address some aspects, including training clinicians in LVAD-specific communication skills. Other aspects, such as standardizing the role of the palliative care team and developing practical interventions that enable timely advance care planning during LVAD care, will require multifaceted interventions.
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Affiliation(s)
- Sarah Chuzi
- Division of CardiologyDepartment of MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIL
| | - Adeboye Ogunseitan
- Division of Hospital Medicine (Palliative Care)Department of MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIL
| | - Kenzie A. Cameron
- Division of General Internal Medicine and GeriatricsDepartment of MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIL
| | - Kathleen Grady
- Division of CardiologyDepartment of MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIL
- Division of Cardiac SurgeryDepartment of SurgeryFeinberg School of MedicineNorthwestern UniversityChicagoIL
| | - Lauren Schulze
- Division of Cardiac SurgeryDepartment of SurgeryFeinberg School of MedicineNorthwestern UniversityChicagoIL
| | - Jane E. Wilcox
- Division of CardiologyDepartment of MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIL
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Lee C, Forner D, Noel CW, Taylor V, MacKay C, Rigby MH, Corsten M, Trites JR, Taylor SM. Functional and Oncologic Outcomes of Octogenarians Undergoing Transoral Laser Microsurgery for Laryngeal Cancer. OTO Open 2021; 5:2473974X211046957. [PMID: 34604690 PMCID: PMC8485289 DOI: 10.1177/2473974x211046957] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/31/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the oncologic and functional outcomes of transoral laser microsurgery (TLM) for glottic cancers in patients ≥80 years. STUDY DESIGN Prospectively collected case series. SETTING QEII Health Sciences Centre, Halifax, Canada. METHODS This case series used a prospectively collected glottic cancer database to examine consecutive elderly patients (≥80 years old) undergoing TLM. Kaplan-Meier analysis was used to evaluate rates of disease-free, disease-specific, and overall survival as the primary end points of oncologic control. Secondary functional outcomes included voice function, length of hospital stay, and time to readmission. RESULTS From 2005 to 2017, 17 octogenarian patients underwent TLM for glottic cancer. Median follow-up was 4.19 years (interquartile range, 0.71-6.95). Kaplan-Meier estimates of 5-year survival were 78.4% (disease free), 92.9% (disease specific), and 81.9% (overall). The median length of hospital stay was 1 day (range, 0-8). There was only 1 readmission within 30 days of surgery. No patients in this study developed significant surgical or postoperative complications requiring unplanned readmissions. Patient-perceived voice function improved to normal after treatment in 62.5% of patients. CONCLUSION The results of this study suggest that TLM is a safe and effective treatment modality for glottic cancer in patients aged ≥80 years, providing good oncologic control and satisfactory functional outcomes.
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Affiliation(s)
- Changseok Lee
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - David Forner
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - Christopher W. Noel
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Canada
| | - Victoria Taylor
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - Colin MacKay
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - Matthew H. Rigby
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - Martin Corsten
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - Jonathan R. Trites
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - S. Mark Taylor
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
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Lewis ET, Hammill KA, Ticehurst M, Turner RM, Greenaway S, Hillman K, Carlini J, Cardona M. How Do Patients with Life-Limiting Illness and Caregivers Want End-Of-Life Prognostic Information Delivered? A Pilot Study. Healthcare (Basel) 2021; 9:healthcare9070784. [PMID: 34206435 PMCID: PMC8303293 DOI: 10.3390/healthcare9070784] [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] [Received: 05/21/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 11/16/2022] Open
Abstract
We aimed to identify the level of prognostic disclosure, type of prognostic information and delivery format of prognostic communication that older adults diagnosed with a life-limiting illness or caregivers prefer to receive. We developed and pilot tested an open-ended survey to 15 older patients and caregivers who had experience in health services for life-limiting illness either for a relative, friend or themselves. Five hypothetical clinical scenarios of prognostic options were presented to ascertain preferences. The preferred format to receive prognostic information was verbal delivery by the clinician with a written summary. Photos and videos were less favoured, and a table with numbers/percentages was least preferred. Distress levels to the prognostic scenarios were low, with the exception of a photo. We conclude that older patients/caregivers want end-of-life prognostic information delivered the traditional way, verbally by clinicians. Options to deliver prognostic information may vary across patient groups but empower clinicians in introducing end-of-life discussions with patients/caregivers. Our study illustrates the feasibility of involving terminal patients and caregivers in research that contributes to eliciting prognostic preferences. Further research is needed to understand whether the prognostic preferences of hospitalized patients with life-limiting illness differ.
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Affiliation(s)
- Ebony T. Lewis
- School of Population Health, The University of New South Wales, Sydney 2052, Australia
- School of Psychology, The University of New South Wales, Sydney 2052, Australia
- Correspondence:
| | - Kathrine A. Hammill
- School of Science and Health, Western Sydney University, Campbelltown 2560, Australia;
| | - Maree Ticehurst
- South Western Sydney Clinical School, University of New South Wales, Liverpool 2170, Australia; (M.T.); (K.H.)
| | - Robin M. Turner
- Biostatistics Unit, Otago Medical School, University of Otago, Dunedin 9054, New Zealand;
| | - Sally Greenaway
- Supportive and Palliative Medicine, Westmead Hospital, Westmead 2145, Australia;
| | - Ken Hillman
- South Western Sydney Clinical School, University of New South Wales, Liverpool 2170, Australia; (M.T.); (K.H.)
- Intensive Care Unit, Liverpool Hospital, Liverpool 2170, Australia
| | - Joan Carlini
- Department of Marketing, Griffith University, Southport 4222, Australia;
| | - Magnolia Cardona
- Institute for Evidence Based Healthcare, Bond University, Robina 4226, Australia;
- EBP Professorial Unit, Gold Coast University Hospital, Southport 4215, Australia
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Facilitating communication for critically ill patients and their family members: Study protocol for two randomized trials implemented in the U.S. and France. Contemp Clin Trials 2021; 107:106465. [PMID: 34091062 DOI: 10.1016/j.cct.2021.106465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/14/2021] [Accepted: 05/31/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Critically-ill patients and their families suffer a high burden of psychological symptoms due, in part, to many transitions among clinicians and settings during and after critical illness, resulting in fragmented care. Communication facilitators may help. DESIGN AND INTERVENTION We are conducting two cluster-randomized trials, one in the U.S. and one in France, with the goal of evaluating a nurse facilitator trained to support, model, and teach communication strategies enabling patients and families to secure care consistent with patients' goals, beginning in ICU and continuing for 3 months. PARTICIPANTS We will randomize 376 critically-ill patients in the US and 400 in France to intervention or usual care. Eligible patients have a risk of hospital mortality of greater than15% or a chronic illness with a median survival of approximately 2 years or less. OUTCOMES We assess effectiveness with patient- and family-centered outcomes, including symptoms of depression, anxiety, and post-traumatic stress, as well as assessments of goal-concordant care, at 1-, 3-, and 6-months post-randomization. The primary outcome is family symptoms of depression over 6 months. We also evaluate whether the intervention improves value by reducing utilization while improving outcomes. Finally, we use mixed methods to explore implementation factors associated with implementation outcomes (acceptability, fidelity, acceptability, penetration) to inform dissemination. Conducting the trial in U.S. and France will provide insights into differences and similarities between countries. CONCLUSIONS We describe the design of two randomized trials of a communication facilitator for improving outcomes for critically ill patients and their families in two countries.
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Gelfman LP, Mather H, McKendrick K, Wong AY, Hutchinson MD, Lampert RJ, Lipman HI, Matlock DD, Swetz KM, Pinney SP, Morrison RS, Goldstein NE. Non-Concordance between Patient and Clinician Estimates of Prognosis in Advanced Heart Failure. J Card Fail 2021; 27:700-705. [PMID: 34088381 PMCID: PMC8186811 DOI: 10.1016/j.cardfail.2021.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Despite efforts to enhance serious illness communication, patients with advanced heart failure (HF) lack prognostic understanding. OBJECTIVES To determine rate of concordance between HF patients' estimation of their prognosis and their physician's estimate of the patient's prognosis, and to compare patient characteristics associated with concordance. DESIGN Cross-sectional analysis of a cluster randomized controlled trial with 24-month follow-up and analysis completed on 09/01/2020. Patients were enrolled in inpatient and outpatient settings between September 2011 to February 2016 and data collection continued until the last quarter of 2017. SETTING Six teaching hospitals in the U.S. PARTICIPANTS Patients with advanced HF and implantable cardioverter defibrillators (ICDs) at high risk of death. Of 537 patients in the parent study, 407 had complete data for this analysis. INTERVENTION A multi-component communication intervention on conversations between HF clinicians and their patients regarding ICD deactivation and advance care planning. MAIN OUTCOME(S) AND MEASURE(S) Patient self-report of prognosis and physician response to the "surprise question" of 12-month prognosis. Patient-physician prognostic concordance (PPPC) measured in percentage agreement and kappa. Bivariate analyses of characteristics of patients with and without PPPC. RESULTS Among 407 patients (mean age 62.1 years, 29.5% female, 42.4% non-white), 300 (73.7%) dyads had non-PPPC; of which 252 (84.0%) reported a prognosis >1 year when their physician estimated <1 year. Only 107 (26.3%) had PPPC with prognosis of ≤ 1 year (n=20 patients) or > 1 year (n=87 patients); (Κ = -0.20, p = 1.0). Of those with physician estimated prognosis of < 1 year, non-PPPC was more likely among patients with lower symptom burden- number and severity (both p ≤.001), without completed advance directive (p=.001). Among those with physician prognosis estimate > 1 year, no patient characteristic was associated with PPPC or non-PPPC. CONCLUSIONS AND RELEVANCE Non-PPPC between HF patients and their physicians is high. HF patients are more optimistic than clinicians in estimating life expectancy. These data demonstrate there are opportunities to improve the quality of prognosis disclosure between patients with advanced HF and their physicians. Interventions to improve PPPC might include serious illness communication training.
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Affiliation(s)
- Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY.
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Mathew D Hutchinson
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine Tucson, Tucson, AZ
| | - Rachel J Lampert
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine
| | - Hannah I Lipman
- Hackensack Meridian Health, Hackensack, NJ; Hackensack Meridian School of Medicine
| | - Daniel D Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado
| | - Keith M Swetz
- Birmingham Veterans Affairs Medical Center; Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama Birmingham, Birmingham, AL
| | - Sean P Pinney
- Division of Cardiology, UChicago Medicine, Chicago, IL
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY
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Hajizadeh N, Zhang M, Akerman M, Kohn N, Mathew A, Hadjiliadis D, Wang J, Lesser ML. Survival models to support shared decision-making about advance care planning for people with advanced stage cystic fibrosis. BMJ Open Respir Res 2021; 8:8/1/e000794. [PMID: 34031106 PMCID: PMC8149438 DOI: 10.1136/bmjresp-2020-000794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 03/18/2021] [Accepted: 05/02/2021] [Indexed: 11/21/2022] Open
Abstract
Background For people with advanced stage cystic fibrosis (CF), tailored survival estimates could facilitate preparation for decision-making in the event of acutely deteriorating respiratory function. Methods We used the US CF Foundation national database (2008–2013) to identify adult people with incident advanced stage CF (forced expiratory volume in 1 s (FEV1) ≤45% predicted). Using the lasso method for variable selection, we divided the dataset into training and validation samples (2:1), and developed two multivariable Cox proportional hazards models to calculate probabilities of survival from baseline (T0 model), and from 1 year after (T12 model). We also performed Kaplan-Meier survival analyses. Results 4752 people were included. For the T0 model, FEV1; insurance; non-invasive ventilation; supplemental oxygen; Burkholderia colonisation; cirrhosis; depression; dialysis; current smoking; unclassifiable mutation class and cumulative CF exacerbations predicted increased mortality. Baseline transplant evaluation status of ‘accepted, on waiting list’ predicted decreased mortality. For the T12 model, interim decrease in FEV1 >10%, and pulmonary exacerbations additionally increased predicted mortality. Lung transplantation was associated with lower mortality. Of the 4752, 93.5%, 86.4%, 79.7% and 73.9% survived to 1, 2, 3 and 4 years, respectively, without considering any confounding variables. The models had moderate predictive ability indicated by the area under the time-dependent receiver operating characteristic curve (0.787, 95% CI 0.769 to 0.794 for T0 model; and 0.779, 95% CI 0.767 to 0.797 for T12 model). Conclusion We have developed models predicting survival in people with incident advanced stage CF, which can be reapplied over time to support shared decision-making about end-of-life treatment choices and lung transplantation. These estimates must be updated as data become available regarding long-term outcomes for people treated with CF transmembrane conductance regulator modulators.
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Affiliation(s)
- Negin Hajizadeh
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Northwell Health, Manhasset, New York, USA .,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA.,Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Meng Zhang
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.,Biostatistics, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Meredith Akerman
- Biostatistics, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Nina Kohn
- Biostatistics, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Anna Mathew
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Denis Hadjiliadis
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
| | - Janice Wang
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Northwell Health, Manhasset, New York, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Martin L Lesser
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.,Biostatistics, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
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Cardiovascular disease risk prediction in older people: a qualitative study. Br J Gen Pract 2021; 71:e772-e779. [PMID: 34019484 PMCID: PMC8436778 DOI: 10.3399/bjgp.2020.1038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 05/12/2021] [Indexed: 12/25/2022] Open
Abstract
Background Despite cardiovascular disease (CVD) risk prediction equations becoming more widely available for people aged ≥75 years, views of older people on CVD risk assessment are unknown. Aim To explore older people’s views on CVD risk prediction and its assessment. Design and setting Qualitative study of community-dwelling older people in New Zealand. Method A diverse group of older people was purposively recruited. Semi-structured interviews and focus groups were conducted, transcribed verbatim, and thematically analysed. Results Thirty-nine participants (mean age 74 years) of Māori, Pacific, South Asian, and European ethnicities participated in one of 26 interviews or one of three focus groups. Three key themes emerged: poor knowledge and understanding of CVD and its risk assessment; acceptability and perceived benefit of knowing and receiving advice on managing personal CVD risk; and distinguishing between CVD outcomes — stroke and heart attack are not the same. Most participants did not understand CVD terms, but were familiar with the terms ‘heart attack’ and ‘stroke’, and understood lifestyle risk factors for these events. Participants valued CVD outcomes differently, fearing stroke and disability — which might adversely affect independence and quality of life — but were less concerned about a heart attack, which was perceived as causing less disability or swifter death. These findings and preferences were similar across ethnic groups. All but two participants wanted to know their CVD risk, how to manage it, and distinguish between CVD outcomes. Those who did not wish to know perceived this as something only their God could decide. Conclusion To inform clinical decision making for older people, consideration of an individual’s wish to know their risk is important, and risk prediction tools should provide separate event types rather than just composite outcomes.
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Beckwith HKS, Adwaney A, Appelbe M, Gaffney HT, Hill P, Moabi D, Prout VL, Salisbury E, Webster P, Tomlinson JAP, Brown EA. Perceptions of Illness Severity, Treatment Goals, and Life Expectancy: The ePISTLE Study. Kidney Int Rep 2021; 6:1558-1566. [PMID: 34169196 PMCID: PMC8207314 DOI: 10.1016/j.ekir.2021.02.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/08/2021] [Accepted: 02/15/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction A better understanding of factors influencing perceived life expectancy (PLE), interactions between patient prognostic beliefs, experiences of illness, and treatment behavior is urgently needed. Methods Case-notes at 3 hemodialysis units were screened: patients with ≥20% 1-year mortality risk were included. Patients and their health care professionals (HCPs) were invited to complete a structured interview or mixed-methods questionnaire. Four hundred eleven patient notes were screened. Seventy-seven eligible patients were approached and 51 were included. Results Patients predicted significantly higher life expectancies than HCPs (P < 0.0001). Documented cognitive impairment, gender, or increasing age did not affect 1- or 5-year PLE. PLE influenced priorities of care: one-fifth of patients who estimated themselves to have >95% 1-year survival preferred “care focusing on relieving pain and discomfort,” compared with nearly three-quarters of those reporting a ≤50% chance of 1-year survival. Twenty of 51 (39%) patients believed transplantation was an option for them, despite only 4 being waitlisted at the time of the interview. Patients who thought they were transplant candidates were significantly more confident they would be alive at 1 and 5 years and to want resuscitation attempted. Cognitive impairment had no effect on perceived transplant candidacy. A high symptom burden was present and underrecognized by HCPs. High symptom burden was associated with significantly lower PLE at both 1 and 5 years, increased anxiety/depression scores, and treatment choices more likely to prioritize relief of suffering. Conclusion There is a disparity between patient PLE and those of their HCPs. Severity of symptom burden and beliefs regarding PLE or transplant candidacy affect patient treatment preferences.
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Affiliation(s)
- Hannah K S Beckwith
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom.,Department of Renal Medicine, Imperial College London, London, United Kingdom
| | - Anamika Adwaney
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Maura Appelbe
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Helen T Gaffney
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Peter Hill
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Dihlabelo Moabi
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Virginia L Prout
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Emma Salisbury
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Phil Webster
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - James A P Tomlinson
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Edwina A Brown
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom.,Department of Renal Medicine, Imperial College London, London, United Kingdom
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Siouta N, Heylen A, Aertgeerts B, Clement P, Janssens W, Van Cleemput J, Menten J. Quality of Life and Quality of Care in patients with advanced Chronic Heart Failure (CHF) and advanced Chronic Obstructive Pulmonary Disease (COPD): Implication for Palliative Care from a prospective observational study. PROGRESS IN PALLIATIVE CARE 2021. [DOI: 10.1080/09699260.2020.1831248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- N. Siouta
- Palliative care, KU Leuven, Leuven, Belgium
| | - A. Heylen
- Clinical psychologist in the Palliative Support team of the University Hospital Leuven, Leuven, Belgium
| | - B. Aertgeerts
- Center for General Practice, KU Leuven, Leuven, Belgium
| | - P. Clement
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - W. Janssens
- Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - J. Van Cleemput
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - J. Menten
- Laboratory of Experimental Radiotherapy, KU Leuven, Belgium
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36
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van den Broek-Altenburg E, Gramling R, Gothard K, Kroesen M, Chorus C. Using natural language processing to explore heterogeneity in moral terminology in palliative care consultations. BMC Palliat Care 2021; 20:23. [PMID: 33494745 PMCID: PMC7836473 DOI: 10.1186/s12904-021-00716-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/15/2021] [Indexed: 11/22/2022] Open
Abstract
Background High quality serious illness communication requires good understanding of patients’ values and beliefs for their treatment at end of life. Natural Language Processing (NLP) offers a reliable and scalable method for measuring and analyzing value- and belief-related features of conversations in the natural clinical setting. We use a validated NLP corpus and a series of statistical analyses to capture and explain conversation features that characterize the complex domain of moral values and beliefs. The objective of this study was to examine the frequency, distribution and clustering of morality lexicon expressed by patients during palliative care consultation using the Moral Foundations NLP Dictionary. Methods We used text data from 231 audio-recorded and transcribed inpatient PC consultations and data from baseline and follow-up patient questionnaires at two large academic medical centers in the United States. With these data, we identified different moral expressions in patients using text mining techniques. We used latent class analysis to explore if there were qualitatively different underlying patterns in the PC patient population. We used Poisson regressions to analyze if individual patient characteristics, EOL preferences, religion and spiritual beliefs were associated with use of moral terminology. Results We found two latent classes: a class in which patients did not use many expressions of morality in their PC consultations and one in which patients did. Age, race (white), education, spiritual needs, and whether a patient was affiliated with Christianity or another religion were all associated with membership of the first class. Gender, financial security and preference for longevity-focused over comfort focused treatment near EOL did not affect class membership. Conclusions This study is among the first to use text data from a real-world situation to extract information regarding individual foundations of morality. It is the first to test empirically if individual moral expressions are associated with individual characteristics, attitudes and emotions.
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Affiliation(s)
| | - Robert Gramling
- University of Vermont, Robert Larner, M.D. College of Medicine, 89 Beaumont Avenue, Burlington, VT, 05405, USA
| | - Kelly Gothard
- University of Vermont, Robert Larner, M.D. College of Medicine, 89 Beaumont Avenue, Burlington, VT, 05405, USA
| | - Maarten Kroesen
- Delft University of Technology, Stevinweg 1, Delft, CB, 2628, The Netherlands
| | - Caspar Chorus
- Delft University of Technology, Stevinweg 1, Delft, CB, 2628, The Netherlands
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How much time do we have? Longitudinal perception of prognosis in newly-diagnosed high grade glioma patients and caregivers compared to clinicians. J Neurooncol 2021; 152:313-323. [PMID: 33486637 DOI: 10.1007/s11060-021-03700-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Discordant prognostic awareness (PA) can cause distress, impact goals of care and future planning, especially in patients with high grade glioma (pwHGG) who have limited survival. We aimed to evaluate the feasibility of assessing PA of pwHGG, caregivers and clinicians using a single question and to evaluate these responses for discord, alignment and fluctuation over time. METHODS This is a sub-study of an IRB-approved pilot study evaluating early palliative care and longitudinal symptom monitoring via a smart-device tool in 16 pwHGG and their caregivers receiving treatment at the Mayo Clinic Arizona (United States). Eligible patients were ≥ 18 years, English-speaking, newly-diagnosed, and had a willing caregiver. Participants answered a multiple-choice question asking for an estimate of their own or their loved one's survival on a monthly basis. RESULTS All except one patient/caregiver dyad answered the question each time it was asked. The question did not appear to cause discomfort or increase conversations with clinicians around prognosis. PA of patients and caregivers fluctuated monthly, ranging from dismal to overtly optimistic, with a discordance frequency of 68%. Patients tended to be more optimistic than caregivers, and a higher QOL correlated to a more optimistic response. Clinicians' were more hopeful; their prediction tended to fluctuate less than those of patients and caregivers. CONCLUSIONS PA may be assessed in pwHGG and caregivers with a single, frank question. There is clear discordance between PA of patients, their caregivers and clinicians. Understanding fluctuates longitudinally through disease and treatment course. Additional studies on timing and ways of discussing prognosis in this population are needed. CLINICAL TRIAL REGISTRATION NCT04630379.
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38
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Cavanagh CE, Rosman L, Spatz ES, Fried T, Gandhi PU, Soucier RJ, Burg MM. Dying to know: prognosis communication in heart failure. ESC Heart Fail 2020; 7:3452-3463. [PMID: 32969195 PMCID: PMC7754721 DOI: 10.1002/ehf2.12941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/06/2020] [Accepted: 07/19/2020] [Indexed: 12/31/2022] Open
Abstract
Prognosis communication in heart failure is often narrowly defined as a discussion of life expectancy, but as clinical guidelines and research suggest, these discussions should provide a broader understanding of the disease, including information about disease trajectory, the experiences of living with heart failure, potential burden on patients and families, and mortality. Furthermore, despite clinical guidelines recommending early discussions, evidence suggests that these discussions occur infrequently or late in the disease trajectory. We review the literature concerning patient, caregiver, and clinician perspectives on discussions of this type, including the frequency, timing, desire for, effects of, and barriers to their occurrence. We propose an alternate view of prognosis communication, in which the patient and family/caregiver are educated about the nature of the disease at the time of diagnosis, and a process of engagement is undertaken so that the patient's full participation in their care is marshalled, and the care team engages the patient in the informed decision making that will guide care throughout the disease trajectory. We also identify and discuss evidence gaps concerning (i) patient preferences and readiness for prognosis information along the trajectory; (ii) best practices for communicating prognosis information; and (iii) effects of prognosis communication on patient's quality of life, mental health, engagement in critical self-care, and clinical outcomes. Research is needed to determine best practices for engaging patients in prognosis communication and for evaluating the effects of this communication on patient engagement and clinical outcomes.
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Affiliation(s)
- Casey E. Cavanagh
- Department of Psychiatry and Neurobehavioral SciencesUniversity of Virginia School of MedicineCharlottesvilleVAUSA
| | - Lindsey Rosman
- Department of Medicine—CardiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Erica S. Spatz
- Section of Cardiovascular Medicine, Department of Internal MedicineYale School of MedicineNew HavenCTUSA
- Center for Outcomes Research and EvaluationYale School of MedicineNew HavenCTUSA
| | - Terri Fried
- VA Connecticut Healthcare SystemWest HavenCTUSA
- Section of Geriatrics, Department of Internal MedicineYale School of MedicineNew HavenCTUSA
| | - Parul U. Gandhi
- Section of Cardiovascular Medicine, Department of Internal MedicineYale School of MedicineNew HavenCTUSA
- VA Connecticut Healthcare SystemWest HavenCTUSA
| | - Richard J. Soucier
- Section of Cardiovascular Medicine, Department of Internal MedicineYale School of MedicineNew HavenCTUSA
| | - Matthew M. Burg
- Section of Cardiovascular Medicine, Department of Internal MedicineYale School of MedicineNew HavenCTUSA
- VA Connecticut Healthcare SystemWest HavenCTUSA
- Department of AnesthesiologyYale School of MedicineNew HavenCTUSA
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Cardoso F, Paluch-Shimon S, Senkus E, Curigliano G, Aapro MS, André F, Barrios CH, Bergh J, Bhattacharyya GS, Biganzoli L, Boyle F, Cardoso MJ, Carey LA, Cortés J, El Saghir NS, Elzayat M, Eniu A, Fallowfield L, Francis PA, Gelmon K, Gligorov J, Haidinger R, Harbeck N, Hu X, Kaufman B, Kaur R, Kiely BE, Kim SB, Lin NU, Mertz SA, Neciosup S, Offersen BV, Ohno S, Pagani O, Prat A, Penault-Llorca F, Rugo HS, Sledge GW, Thomssen C, Vorobiof DA, Wiseman T, Xu B, Norton L, Costa A, Winer EP. 5th ESO-ESMO international consensus guidelines for advanced breast cancer (ABC 5). Ann Oncol 2020; 31:1623-1649. [PMID: 32979513 PMCID: PMC7510449 DOI: 10.1016/j.annonc.2020.09.010] [Citation(s) in RCA: 742] [Impact Index Per Article: 185.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 01/09/2023] Open
Affiliation(s)
- F Cardoso
- Breast Unit, Champalimaud Clinical Centre/Champalimaud Foundation, Lisbon, Portugal.
| | - S Paluch-Shimon
- Sharett Division of Oncology, Hadassah University Hospital, Jerusalem, Israel
| | - E Senkus
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland
| | - G Curigliano
- Department of Oncology and Hemato-Oncology, European Institute of Oncology, IRCCS, Division of Early Drug Development, University of Milan, Milan, Italy
| | - M S Aapro
- Breast Center, Clinique de Genolier, Genolier, Switzerland
| | - F André
- Department of Medical Oncology, Institut Gustave Roussy, Villejuif, France
| | - C H Barrios
- Latin American Cooperative Oncology Group (LACOG), Grupo Oncoclínicas, Porto Alegre, Brazil
| | - J Bergh
- Department of Oncology-Pathology, Karolinska Institute & University Hospital, Stockholm, Sweden
| | - G S Bhattacharyya
- Department of Medical Oncology, Salt Lake City Medical Centre, Kolkata, India
| | - L Biganzoli
- Department of Medical Oncology, Nuovo Ospedale di Prato - Istituto Toscano Tumori, Prato, Italy
| | - F Boyle
- The Pam McLean Centre, Royal North Shore Hospital, St Leonards, Australia
| | - M-J Cardoso
- Breast Unit, Champalimaud Clinical Centre/Champalimaud Foundation, Lisbon, Portugal; Nova Medical School, Lisbon, Portugal
| | - L A Carey
- Department of Hematology and Oncology, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, USA
| | - J Cortés
- IOB Institute of Oncology, Quiron Group, Madrid & Barcelona, Spain; Department of Oncology, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - N S El Saghir
- Division of Hematology Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Elzayat
- Europa Donna, The European Breast Cancer Coalition, Milan, Italy
| | - A Eniu
- Interdisciplinary Oncology Service (SIC), Riviera-Chablais Hospital, Rennaz, Switzerland
| | - L Fallowfield
- SHORE-C, Brighton & Sussex Medical School, University of Sussex, Brighton, UK
| | - P A Francis
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - K Gelmon
- Medical Oncology Department, BC Cancer Agency, Vancouver, Canada
| | - J Gligorov
- Breast Cancer Expert Center, University Cancer Institute APHP, Sorbonne University, Paris, France
| | - R Haidinger
- Brustkrebs Deutschland e.V., Munich, Germany
| | - N Harbeck
- Breast Centre, Department of Obstetrics and Gynaecology, University of Munich (LMU), Munich, Germany
| | - X Hu
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - B Kaufman
- Department of Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - R Kaur
- Breast Cancer Welfare Association Malaysia, Petaling Jaya, Malaysia
| | - B E Kiely
- NHMRC Clinical Trials Centre, Sydney Medical School, Sydney, Australia
| | - S-B Kim
- Department of Oncology, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
| | - N U Lin
- Susan Smith Center for Women's Cancers - Breast Oncology Center, Dana-Farber Cancer Institute, Boston, USA
| | - S A Mertz
- Metastatic Breast Cancer Network, Inverness, USA
| | - S Neciosup
- Department of Medical Oncology, National Institute of Neoplastic Diseases, Lima, Peru
| | - B V Offersen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - S Ohno
- Breast Oncology Centre, Cancer Institute Hospital, Tokyo, Japan
| | - O Pagani
- Medical School, Geneva University Hospital, Geneva, Switzerland
| | - A Prat
- Department of Medical Oncology, Hospital Clinic of Barcelona, Barcelona, Spain; Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, Barcelona; Department of Medicine, University of Barcelona, Barcelona
| | - F Penault-Llorca
- Department of Biopathology, Centre Jean Perrin, Clermont-Ferrand, France; University Clermont Auvergne/INSERM U1240, Clermont-Ferrand, France
| | - H S Rugo
- Breast Oncology Clinical Trials Education, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, USA
| | - G W Sledge
- Division of Oncology, Stanford School of Medicine, Stanford, USA
| | - C Thomssen
- Department of Gynaecology, Martin Luther University Halle-Wittenburg, Halle, Germany
| | - D A Vorobiof
- Oncology Research Unit, Belong.Life, Tel Aviv, Israel
| | - T Wiseman
- Department of Applied Health Research in Cancer Care, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - B Xu
- Department of Medical Oncology, Cancer Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - L Norton
- Breast Cancer Medicine Service, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - A Costa
- European School of Oncology, Milan, Italy; European School of Oncology, Bellinzona, Switzerland
| | - E P Winer
- Susan Smith Center for Women's Cancers - Breast Oncology Center, Dana-Farber Cancer Institute, Boston, USA
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Hoesseini A, Offerman MPJ, van de Wall-Neecke BJ, Sewnaik A, Wieringa MH, Baatenburg de Jong RJ. Physicians' clinical prediction of survival in head and neck cancer patients in the palliative phase. BMC Palliat Care 2020; 19:176. [PMID: 33234115 PMCID: PMC7687732 DOI: 10.1186/s12904-020-00682-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/09/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The prognosis of patients with incurable head and neck cancer (HNC) is a relevant topic. The mean survival of these patients is 5 months but may vary from weeks to more than 3 years. Discussing the prognosis early in the disease trajectory enables patients to make well-considered end-of-life choices, and contributes to a better quality of life and death. However, physicians often are reluctant to discuss prognosis, partly because of the concern to be inaccurate. This study investigated the accuracy of physicians' clinical prediction of survival of palliative HNC patients. METHODS This study was part of a prospective cohort study in a tertiary cancer center. Patients with incurable HNC diagnosed between 2008 and 2011 (n = 191), and their treating physician were included. Analyses were conducted between July 2018 and February 2019. Patients' survival was clinically predicted by their physician ≤3 weeks after disclosure of the palliative diagnosis. The clinical prediction of survival in weeks (CPS) was based on physicians' clinical assessment of the patient during the outpatient visits. More than 25% difference between the actual survival (AS) and the CPS was regarded as a prediction error. In addition, when the difference between the AS and CPS was 2 weeks or less, this was always considered as correct. RESULTS In 59% (n = 112) of cases survival was overestimated. These patients lived shorter than predicted by their physician (median AS 6 weeks, median CPS 20 weeks). In 18% (n = 35) of the cases survival was correctly predicted. The remaining 23% was underestimated (median AS 35 weeks, median CPS 20 weeks). Besides the differences in AS and CPS, no other significant differences were found between the three groups. There was worse accuracy when predicting survival closer to death: out of the 66 patients who survived 6 weeks or shorter, survival was correctly predicted in only eight (12%). CONCLUSION Physicians tend to overestimate the survival of palliative HNC patients. This optimism can result in suboptimal use of palliative and end-of-life care. The future development of a prognostic model that provides more accurate estimates, could help physicians with personalized prognostic counseling.
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Affiliation(s)
- Arta Hoesseini
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Marinella P J Offerman
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Bojou J van de Wall-Neecke
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Marjan H Wieringa
- Department of Education and Research, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - Robert J Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
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Chesney TR, Haas B, Coburn NG, Mahar AL, Zuk V, Zhao H, Wright FC, Hsu AT, Hallet J. Patient-Centered Time-at-Home Outcomes in Older Adults After Surgical Cancer Treatment. JAMA Surg 2020; 155:e203754. [PMID: 33026417 DOI: 10.1001/jamasurg.2020.3754] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Functional outcomes are central to cancer care decision-making by older adults. Objective To assess the long-term functional outcomes of older adults after a resection for cancer using time at home as the measure. Design, Setting, and Participants This population-based cohort study was conducted in Ontario, Canada, using the administrative databases stored at ICES (formerly the Institute for Clinical Evaluative Sciences). The analysis included adults 70 years or older with a new diagnosis of cancer between January 1, 2007, and December 31, 2017, who underwent a resection 90 days to 180 days after the diagnosis. Patients were followed up until and censored at the date of death, date of last contact, or December 31, 2018. Main Outcomes and Measures The main outcome was time at home, dichotomized as high time at home (defined as ≤14 institution days annually) and low time at home (defined as >14 institution days) during the 5 years after surgical cancer treatment. Time-to-event analyses with Kaplan-Meier methods and multivariable Cox proportional hazards regression models were used. Results A total of 82 037 patients were included, with a median (interquartile range) follow-up of 46 (23-80) months. Of these patients, 52 119 were women (63.5%) and the mean (SD) age was 77.5 (5.7) years. The median (interquartile range) number of days at home per days alive per patient was high, at 0.98 (0.94-0.99) in postoperative year 1, 0.99 (0.97-1.00) in year 2, 0.99 (0.96-1.00) in year 3, 0.99 (0.96-1.00) in year 4, and 0.99 (0.96-1.00) in year 5. The probability of high time at home was 70.3% (95% CI, 70.0%-70.6%) at postoperative year 1 and 53.2% (95% CI, 52.8%-53.5%) at postoperative year 5. Advancing age (≥85 years: hazard ratio [HR], 2.11; 95% CI, 2.04-2.18); preoperative frailty (HR, 1.74; 95% CI, 1.68-1.80); high material deprivation (5th quintile: HR, 1.25; 95% CI, 1.20-1.29); rural residency (HR, 1.14; 95% CI, 1.10-1.18); high-intensity surgical procedure (HR, 2.04; 95% CI, 1.84-2.25); and gastrointestinal (HR, 1.23; 95% CI, 1.18-1.27), gynecologic (HR, 1.31; 95% CI, 1.18-1.45), and oropharyngeal (HR, 1.05; 95% CI, 0.95-1.16) cancers were associated with low time at home. Inpatient acute care was responsible for 76.0% and long-term care was responsible for 2.0% of institution days in postoperative year 1. Inpatient days decreased to 31.0% by year 3, but days in long-term care increased over time. Conclusions and Relevance This study found that older adults predominantly experienced high time at home after resection for cancer, reflecting the overall favorable functional outcomes in this population. The oldest adults and those with preoperative frailty and material deprivation appeared to be the most vulnerable to low time at home, and efforts to optimize and manage expectations about surgical outcomes can be targeted for this population; this information is important for patient counseling regarding surgical cancer treatment and for preparation for postoperative recovery.
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Affiliation(s)
- Tyler R Chesney
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Natalie G Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Victoria Zuk
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Frances C Wright
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
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42
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Gray TF, Forst D, Nipp RD, Greer JA, Temel JS, El-Jawahri A. Prognostic Awareness in Caregivers of Patients with Incurable Cancer. J Palliat Med 2020; 24:561-569. [PMID: 32996821 DOI: 10.1089/jpm.2020.0236] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Little is known about how patients with incurable cancer and caregivers differ in their prognostic awareness, and the relationship between caregiver prognostic awareness and their psychological distress. Objective: To investigate prognostic awareness in caregivers of patients with incurable cancer and prognostic discordance in patient-caregiver dyads and its association with psychological distress. Design: This is a cross-sectional study. Setting/Subjects: In total, subjects were 390 caregivers of adults with incurable lung, gastrointestinal, and brain cancers at a cancer center in the northeastern United States. Measurements: The Prognosis and Treatment Perceptions Questionnaire was used to assess prognostic awareness and Hospital Anxiety and Depression Scale to assess psychological distress. Results: In total, 39.7% (n = 147/370) and 17.3% (n = 64/370) caregivers reported clinically significant anxiety and depression symptoms. And 53.7% of caregivers reported the patients' cancer as "curable" and 44.1% reported the cancer was "not terminal." Caregivers' report of curability was not associated with their anxiety (odds ratio [OR] = 0.99, p = 0.93) or depression (OR = 1.05, p = 0.32) symptoms. Among 42.5% (124/292) and 26.0% (76/292) of dyads (n = 292), both patients and their caregivers agreed in their perception of the cancer as curable and incurable, respectively. In 19.9% of dyads (n = 58), patients reported their cancer as curable, while their caregivers reported it as incurable. In 11.6% of dyads (n = 34), patients reported the cancer as incurable while caregivers reported it as curable. Conclusions: More than half of caregivers have misperceptions about the patients' likelihood of cure, and one-third of patient-caregiver dyads have discordant perceptions. Supportive care interventions may facilitate conversations and enhance prognostic understanding in patients with incurable cancer and their caregivers.
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Affiliation(s)
- Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah Forst
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Ryan D Nipp
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Joseph A Greer
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
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43
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Gelfman LP, Sudore RL, Mather H, McKendrick K, Hutchinson MD, Lampert RJ, Lipman HI, Matlock DD, Swetz KM, Pinney SP, Morrison RS, Goldstein NE. Prognostic Awareness and Goals of Care Discussions Among Patients With Advanced Heart Failure. CIRCULATION. HEART FAILURE 2020; 13:e006502. [PMID: 32873058 DOI: 10.1161/circheartfailure.119.006502] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Prognostic awareness (PA)-the understanding of limited life expectancy-is critical for effective goals of care discussions (GOCD) in which patients discuss their goals and values in the context of their illness. Yet little is known about PA and GOCD in patients with advanced heart failure (HF). This study aims to determine the prevalence of PA among patients with advanced HF and patient characteristics associated with PA and GOCD. METHODS We assessed the prevalence of self-reported PA and GOCD using data from a multisite communication intervention trial among patients with advanced HF with an implantable cardiac defibrillator at high risk of death. RESULTS Of 377 patients (mean age 62 years, 30% female, 42% nonwhite), 78% had PA. Increasing age was a negative predictor of PA (odds ratio, 0.95 [95% CI, 0.92-0.97]; P<0.01). No other patient characteristics were associated with PA. Of those with PA, 26% had a GOCD. Higher comorbidities and prior advance directives were associated with GOCD but were of only borderline statistical significance in a fully adjusted model. Symptom severity (odds ratio, 1.77 [95% CI, 1.19-2.64]; P=0.005) remained a robust and statistically significant positive predictor of having a GOCD in the fully adjusted model. CONCLUSIONS In a sample of patients with advanced HF, the frequency of PA was high, but fewer patients with PA discussed their end-of-life care preferences with their physician. Improved efforts are needed to ensure all patients with advanced HF have an opportunity to have GOCD with their doctors. Clinicians may need to target older patients with HF and continue to focus on those with signs of worsening illness (higher symptoms). Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01459744.
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Affiliation(s)
- Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (L.P.G., R.S.M., N.E.G.)
| | - Rebecca L Sudore
- Division of Geriatrics (R.L.S.), Department of Medicine, University of California San Francisco.,Innovation and Implementation Center for Aging and Palliative Care (I-CAP), Division of Geriatrics (R.L.S.), Department of Medicine, University of California San Francisco.,San Francisco Veterans Affairs Health Care System, CA (R.L.S.)
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mathew D Hutchinson
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ (M.D.H.)
| | - Rachel J Lampert
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT (R.J.L.)
| | - Hannah I Lipman
- Hackensack University Medical Center, Hackensack, NJ (H.I.L.).,Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (H.I.L.)
| | - Daniel D Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (D.D.M.).,VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO (D.D.M.)
| | - Keith M Swetz
- Birmingham Veterans Affairs Medical Center, Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama, Birmingham, AL (K.M.S.)
| | - Sean P Pinney
- Division of Cardiology, Samuel Bronfman Department of Medicine (S.P.P.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (L.P.G., R.S.M., N.E.G.)
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (L.P.G., R.S.M., N.E.G.)
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Gabbard J, Johnson D, Russell G, Spencer S, Williamson JD, McLouth LE, Ferris KG, Sink K, Brenes G, Yang M. Prognostic Awareness, Disease and Palliative Understanding Among Caregivers of Patients With Dementia. Am J Hosp Palliat Care 2020; 37:683-691. [PMID: 31854201 PMCID: PMC10581031 DOI: 10.1177/1049909119895497] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Persons with dementia (PwD) often have significant cognitive deficits and functional limitations, requiring substantial caregiver assistance. Given the high symptom burden and terminal nature of dementia, good prognostic awareness and integration of palliative care (PC) is needed. OBJECTIVE To evaluate prognostic awareness, disease, and PC understanding among caregivers of PwD and to assess for improvements in routine care. DESIGN A cross-sectional study of 2 cohorts at a single-academic medical center. Surveys were mailed to 200 caregivers of PwD in 2012 (cohort 1). Surveys were sent to new subset of caregivers of PwD (n = 80) in 2018 (cohort 2) to assess trends over time. RESULTS A total of 154 of caregivers completed the survey (response rate 55%). Compared to 2012, a higher proportion of caregivers in 2018 reported having conversations about prognosis with PwD's physicians (25% in 2012 vs 45% in 2018; P = .027). However, a large percentage (43% in 2012 and 40% in 2018) of caregivers reported no understanding of the PwD's prognosis. Despite most stating dementia was not curable, only 39% in 2012 and 52% in 2018 (P = .015) understood that dementia was a terminal disease. In addition, only 32% in 2012 and 40% in 2018 (P = .39) felt that they were knowledgeable about PC. CONCLUSIONS Prognostic discussions between caregivers of PwD and the PwD's physicians may be occurring more often; however, a high percentage of caregivers report a poor understanding about the terminal nature of dementia and the role of PC.
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Affiliation(s)
- Jennifer Gabbard
- Section on Gerontology & Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Devin Johnson
- Section on Gerontology & Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Greg Russell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Shenita Spencer
- Center for Supportive Care and Survivorship, Atrium Health, Charlotte, NC, USA
| | - Jeff D. Williamson
- Section on Gerontology & Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Laurie E. McLouth
- Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Keren G. Ferris
- Section on Gerontology & Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kaycee Sink
- Product Development—Neuroscience, Genentech Inc, South San Francisco, CA, USA
| | - Gretchen Brenes
- Section on Gerontology & Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mia Yang
- Section on Gerontology & Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, NC, USA
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45
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Impact of hearing loss on clinical interactions between older adults and health professionals: a systematic review. Eur Geriatr Med 2020; 11:919-928. [DOI: 10.1007/s41999-020-00358-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/08/2020] [Indexed: 10/23/2022]
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Schonberg MA, Karamourtopoulos M, Jacobson AR, Aliberti GM, Pinheiro A, Smith AK, Davis RB, Schuttner LC, Hamel MB. A Strategy to Prepare Primary Care Clinicians for Discussing Stopping Cancer Screening With Adults Older Than 75 Years. Innov Aging 2020; 4:igaa027. [PMID: 32793815 PMCID: PMC7413618 DOI: 10.1093/geroni/igaa027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Indexed: 01/08/2023] Open
Abstract
Background and Objectives Adults older than 75 years are overscreened for cancer, especially those with less than 10-year life expectancy. This study aimed to learn the effects of providing primary care providers (PCPs) with scripts for discussing stopping mammography and colorectal cancer (CRC) screening and with information on patient’s 10-year life expectancy on their patients’ intentions to be screened for these cancers. Research Design and Methods Patient participants, identified via PCP appointment logs, completed a questionnaire pre- and postvisit. Primary care providers were given scripts for discussing stopping screening and information on patient’s 10-year life expectancy before these visits. Primary care providers completed a questionnaire at the end of the study. Patients and PCPs were asked about discussing stopping cancer screening and patient life expectancy. Patient screening intentions (1–15 Likert scale; lower scores suggest lower intentions) were compared pre- and postvisit using the Wilcoxon signed-rank test. Results Ninety patients older than 75 years (47% of eligible patients reached by phone) from 45 PCPs participated. Patient mean age was 80.0 years (SD = 2.9), 43 (48%) were female, and mean life expectancy was 9.7 years (SD = 2.4). Thirty-seven PCPs (12 community-based) completed a questionnaire. Primary care providers found the scripts helpful (32 [89%]) and thought they would use them frequently (29 [81%]). Primary care providers also found patient life expectancy information helpful (35 [97%]). However, only 8 PCPs (22%) reported feeling comfortable discussing patient life expectancy. Patients’ intentions to undergo CRC screening (9.0 [SD = 5.3] to 6.5 [SD = 6.0], p < .0001) and mammography screening (12.9 [SD = 3.0] to 11.7 [SD = 4.9], p = .08) decreased from pre- to postvisit (significantly for CRC). Sixty-three percent of patients (54/86) were interested in discussing life expectancy with their PCP previsit and 56% (47/84) postvisit. Discussion and Implications PCPs found scripts for discussing stopping cancer screening and information on patient life expectancy helpful. Possibly, as a result, their patients older than 75 years had lower intentions of being screened for CRC. Clinical Trials Registration Number NCT03480282
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Affiliation(s)
- Mara A Schonberg
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Alicia R Jacobson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Gianna M Aliberti
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adlin Pinheiro
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California San Francisco
| | - Roger B Davis
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Linnaea C Schuttner
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Washington.,Department of Medicine, University of Washington, Seattle
| | - Mary Beth Hamel
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Ghoshal A, Salins N, Damani A, Chowdhury J, Chitre A, Muckaden MA, Deodhar J, Badwe R. To Tell or Not to Tell: Exploring the Preferences and Attitudes of Patients and Family Caregivers on Disclosure of a Cancer-Related Diagnosis and Prognosis. J Glob Oncol 2020; 5:1-12. [PMID: 31770048 PMCID: PMC6882506 DOI: 10.1200/jgo.19.00132] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To understand the preferences and attitudes of patients and family caregivers on disclosure of cancer diagnosis and prognosis in an Indian setting. METHODS Overall, 250 adult patients with cancer and 250 family caregivers attending the outpatients of a tertiary cancer hospital for the first time were recruited purposively. The mean ages of patients and caregivers were 49.9 years (range, 23-80 years) and 37.9 years (range, 19-67 years), respectively. Separately, they completed prevalidated, close-ended preference questions and were interviewed for open-ended attitude questions. RESULTS A total of 250 adult patients (response rate, 47.17% overall, 73.2% in men, and 26.8% in women) and 250 family caregivers (response rate, 40.65% overall, 84.0% in men, and 16.0% in women) participated. Significant differences were observed in the preference to full disclosure of the name of illness between patients (81.2%) and caregivers (34.0%) and with the expected length of survival between patients (72.8%) and caregivers (8.8%; P < .001). The patients felt that knowing a diagnosis and prognosis may help them be prepared, plan additional treatment, anticipate complications, and plan for future and family. The caregivers felt that patients knowing a diagnosis and prognosis may negatively affect the future course of illness and cause patients to experience stress, depression, loss of hope, and confidence. CONCLUSION Patients with cancer preferred full disclosure of their diagnoses and prognoses, whereas the family caregivers preferred nondisclosure of the same to their patients. This novel information obtained through a large study with varied participants from different parts of the country will help formulate communication strategies for cancer care.
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Affiliation(s)
| | | | | | | | - Arundhati Chitre
- Ramniranjan Jhunjhunwala College of Arts, Science, and Commerce, Mumbai, India
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Hoesseini A, Dronkers EAC, Sewnaik A, Hardillo JAU, Baatenburg de Jong RJ, Offerman MPJ. Head and neck cancer patients' preferences for individualized prognostic information: a focus group study. BMC Cancer 2020; 20:399. [PMID: 32380962 PMCID: PMC7203788 DOI: 10.1186/s12885-020-6554-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 01/17/2020] [Indexed: 12/20/2022] Open
Abstract
Background Head and Neck cancer (HNC) is characterized by significant mortality and morbidity. Treatment is often invasive and interferes with vital functions, resulting in a delicate balance between survival benefit and deterioration in quality of life (QoL). Therefore, including prognostic information during patient counseling can be of great importance. The first aim of this study was to explore HNC patients’ preferences for receiving prognostic information: both qualitative (general terms like “curable cancer”), and quantitative information (numbers, percentages). The second aim of this study was to explore patients’ views on “OncologIQ”, a prognostic model developed to estimate overall survival in newly diagnosed HNC patients. Methods We conducted a single center qualitative study by organizing five focus groups with HNC patients (n = 21) and their caregivers (n = 19), categorized in: 1) small laryngeal carcinomas treated with radiotherapy or laser, 2) extensive oral cavity procedures, 3) total laryngectomy, 4) chemoradiation, 5) other treatments. The patients’ perspective was the main focus. The interview guide consisted of two main topics: life-expectancy and the prognostic model OncologIQ. All focus groups were recorded, transcribed and coded. Themes were derived using content analysis. Results While all patients considered it somewhat to very important to receive information about their life-expectancy, only some of them wanted to receive quantitative information. Disclosing qualitative prognostic information like “the cancer is curable” would give enough reassurance for most patients. Overall, patients thought life-expectancy should not be discussed shortly after cancer diagnosis disclosure, as a certain time is needed to process the first shock. They had a stronger preference for receiving prognostic information in case of a poor prognosis. Prognostic information should also include information on the expected QoL. The pie chart was the most preferred chart for discussing survival rates. Conclusions The participants found it important to receive information on their life-expectancy. While most patients were enough reassured by qualitative prognostic information, some wanted to receive quantitative information like OncologIQs’ estimates. A tailor-made approach is necessary to provide customized prognostic information. A clinical practice guideline was developed to support professionals in sharing prognostic information, aiming to improve shared decision making and patient-centered care.
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Affiliation(s)
- Arta Hoesseini
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands.
| | - Emilie A C Dronkers
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Jose A U Hardillo
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Robert J Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Marinella P J Offerman
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
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Abstract
Prognostication is a vital aspect of decision making because it provides patients and families with information to establish realistic and achievable goals of care, is used in determining eligibility for certain benefits, and helps in targeting interventions to those likely to benefit. Prognostication consists of 3 components: clinicians use their clinical judgment or other tools to estimate the probability of an individual developing a particular outcome over a specific period of time; this prognostic estimate is communicated in accordance with the patient's information preferences; the prognostic estimate is interpreted by the patient or surrogate and used in clinical decision making.
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Affiliation(s)
- Emily J Martin
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles, 757 Westwood Plaza Suite 7501, Los Angeles, CA 90095, USA.
| | - Eric Widera
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, 4150 Clement Street, Box 181G, San Francisco, CA 94121, USA. https://twitter.com/EWidera
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50
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Oppenheim IM, Lee EM, Vasher ST, Zaeh SE, Hart JL, Turnbull AE. Effect of Intensivist Communication in a Simulated Setting on Interpretation of Prognosis Among Family Members of Patients at High Risk of Intensive Care Unit Admission: A Randomized Trial. JAMA Netw Open 2020; 3:e201945. [PMID: 32236533 PMCID: PMC7113731 DOI: 10.1001/jamanetworkopen.2020.1945] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Importance Discordance about prognosis between a patient's health care decision-making surrogate and the treating intensivist is common in the intensive care unit (ICU). Empowering families, friends, and caregivers of patients who are critically ill to make informed decisions about care is important, but it is unclear how best to communicate prognostic information to surrogates when a patient is expected to die. Objective To determine whether family members, who are often health care decision-making surrogates, interpret intensivists as being more optimistic when questions about prognosis in the ICU are answered indirectly. Design, Setting, and Participants This web-based randomized trial was conducted between September 27, 2019, and October 17, 2019, among a national sample of adult children, spouses, partners, or siblings of people with chronic obstructive pulmonary disease who were receiving long-term oxygen therapy. Participants were shown video vignettes depicting an intensivist answering a standardized question about the prognosis of a patient at high risk of death on day 3 of ICU admission. Participants were excluded if they had worked as a physician, nurse, or advanced health care practitioner. Data were analyzed from October 18, 2019, to November 12, 2019. Interventions Participants were randomized to view 1 of 4 intensivist communication styles in response to the question "What do you think is most likely to happen?": (1) a direct response (control), (2) an indirect response comparing the patient's condition with that of other patients, (3) an indirect response describing the patient's deteriorating physiological condition, or (4) redirection to a discussion of the patient's values and goals. Main Outcomes and Measures Participant responses to 2 questions: (1) "If you had to guess, what do you think the doctor thinks is the chance that your loved one will survive this hospitalization?" and (2) "What do you think are the chances that your loved one will survive this hospitalization?" answered using a 0% to 100% probability scale. Results Among 302 participants (median [interquartile range] age, 49 [38-59] years; 204 [68%] women) included in the trial, 165 (55%) were adult children of the individual with chronic obstructive pulmonary disease; 77 participants were randomized to view a direct response, 77 participants were randomized to view an indirect response referencing other patients, 68 participants were randomized to view an indirect response referencing physiological condition, and 80 participants were randomized to view a redirection response. Compared with participants who viewed a direct response, participants who viewed an indirect response referencing other patients (β = 10 [95% CI, 1-19]; P = .03), physiological condition (β = 10 [95% CI, 0-19]; P = .04), or redirection to a discussion of the patient's values and goals (β = 19 [95% CI, 10-28]; P < .001) perceived the intensivist to have a significantly more optimistic prognostic estimate. Conclusions and Relevance These findings suggest that family members interpret indirect or redirection responses to questions about prognosis in the ICU setting as more optimistic than direct responses. Trial Registration ClinicalTrials.gov Identifier: NCT04239209.
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Affiliation(s)
- Ian M Oppenheim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emma M Lee
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Scott T Vasher
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sandra E Zaeh
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joanna L Hart
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University School of Medicine, Baltimore, Maryland
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