Communication in end-stage cancer: review of the literature and future research

Patient values in patient-provider communication about participation in early phase clinical cancer trials: a qualitative analysis before and after implementation of an online value clarification tool intervention

BACKGROUND

Patients with advanced cancer who no longer have standard treatment options available may decide to participate in early phase clinical trials (i.e. experimental treatments with uncertain outcomes). Shared decision-making (SDM) models help to understand considerations that influence patients' decision. Discussion of patient values is essential to SDM, but such communication is often limited in this context and may require new interventions. The OnVaCT intervention, consisting of a preparatory online value clarification tool (OnVaCT) for patients and communication training for oncologists, was previously developed to support SDM. This study aimed to qualitatively explore associations between patient values that are discussed between patients and oncologists during consultations about potential participation in early phase clinical trials before and after implementation of the OnVaCT intervention.

METHODS

This study is part of a prospective multicentre nonrandomized controlled clinical trial and had a between-subjects design: pre-intervention patients received usual care, while post-intervention patients additionally received the OnVaCT. Oncologists participated in the communication training between study phases. Patients' initial consultation on potential early phase clinical trial participation was recorded and transcribed verbatim. Applying a directed approach, two independent coders analysed the transcripts using an initial codebook based on previous studies. Steps of continuous evaluation and revision were repeated until data saturation was reached.

RESULTS

Data saturation was reached after 32 patient-oncologist consultations (i.e. 17 pre-intervention and 15 post-intervention). The analysis revealed the values: hope, perseverance, quality or quantity of life, risk tolerance, trust in the healthcare system/professionals, autonomy, social adherence, altruism, corporeality, acceptance of one's fate, and humanity. Patients in the pre-intervention phase tended to express values briefly and spontaneously. Oncologists acknowledged the importance of patients' values, but generally only gave 'contrasting' examples of why some accept and others refuse to participate in trials. In the post-intervention phase, many oncologists referred to the OnVaCT and/or asked follow-up questions, while patients used longer phrases that combined multiple values, sometimes clearly indicating their weighing.

CONCLUSIONS

While all values were recognized in both study phases, our results have highlighted the different communication patterns around patient values in SDM for potential early phase clinical trial participation before and after implementation of the OnVaCT intervention. This study therefore provides a first (qualitative) indication that the OnVaCT intervention may support patients and oncologists in discussing their values.

TRIAL REGISTRATION

Netherlands Trial Registry: NL7335, registered on July 17, 2018.

A communication intervention to improve prognostic understanding and engagement in advance care planning among diverse advanced cancer patient-caregiver dyads: A pilot study

OBJECTIVES

Accurate prognostic understanding among patients with advanced cancer and their caregivers is associated with greater engagement in advance care planning (ACP) and receipt of goal-concordant care. Poor prognostic understanding is more prevalent among racial and ethnic minority patients. The purpose of this study was to examine the feasibility, acceptability, and impact of a patient-caregiver communication-based intervention to improve prognostic understanding, engagement in ACP, and completion of advance directives among a racially and ethnically diverse, urban sample of patients and their caregivers.

METHODS

Patients with advanced cancer and their caregivers (n = 22 dyads) completed assessments of prognostic understanding, engagement in ACP, and completion of advance directives at baseline and post-intervention, Talking About Cancer (TAC). TAC is a 7-session intervention delivered remotely by licensed social workers that includes distress management and communication skills, review of prognosis, and information on ACP.

RESULTS

TAC met a priori benchmarks for feasibility, acceptability, and fidelity. Prognostic understanding and engagement in ACP did not change over time. However, patients showed increases in completion of advance directives.

SIGNIFICANCE OF RESULTS

TAC was feasible, acceptable, and delivered with high fidelity. Involvement of caregivers in TAC may provide added layers of support to patients facing advanced cancer diagnoses, especially among racial and ethnic minorities. Trends indicated greater completion of advance directives but not in prognostic understanding or engagement in ACP. Future research is needed to optimize the intervention to improve acceptability, tailor to diverse patient populations, and examine the efficacy of TAC in a randomized controlled trial.

Accentuating patient values in shared decision-making: A mixed methods development of an online value clarification tool and communication training in the context of early phase clinical cancer trials

OBJECTIVE

In the shared decision-making (SDM) process for potential early phase clinical cancer trial participation, value clarification is highly recommended. However, exploration and discussion of patient values between patients and oncologists remains limited. This study aims to develop an SDM-supportive intervention, consisting of a preparatory online value clarification tool (OnVaCT) and a communication training.

METHODS

The OnVaCT intervention was developed and pilot-tested by combining theoretical notions on value clarification, with interview studies with patients and oncologists, focus groups with patient representatives and oncologists, and think aloud sessions with patients, following the Medical Research Council (MRC) framework for complex interventions. These human-centered methodologies enabled a user-centered approach at every step of the development process of the intervention.

RESULTS

This study shows relevant patient values and oncologists' perspectives on value exploration and discussion in daily practice. This has been combined with theoretical considerations into the creation of characters based on real-life experiences of patients in the OnVaCT, and how the tool is combined with a communication training for oncologists to improve SDM.

Trust as a Central Factor in Hospice Enrollment Disparities Among Ethnic and Racial Minority Patients: A Qualitative Study of Interrelated and Compounding Factors Impacting Trust

Background: Disparities in end-of-life (EOL) care remain among ethnic/racial minority populations. Choosing hospice care in the United States depends on goals-of-care discussions founded on trust. While studies examine hospice enrollment disparities and others explore trust in hospice settings in general, very few explicitly examine the role of trust in hospice enrollment disparities. Objectives: To explore factors impacting trust and how these might contribute to disparities in hospice enrollment. Design: A qualitative, individual interview study, based on grounded theory. Setting/Subjects: Setting: Rhode Island, USA. Participants: Multiple stakeholders in EOL care, with diverse professional and personal backgrounds. Measurements: In-depth semistructured individual interviews were audio-recorded and transcribed as part of a broader study of hospice enrollment barriers in diverse patients. Analysis: Five researchers did a secondary data analysis, focusing on trust as the central phenomenon of interest. Researchers independently analyzed transcripts, then held iterative group analysis meetings until they reached consensus regarding themes, subthemes, and relationships. Results: Twenty-two participants included five physicians, five nurses, three social workers, two chaplains, one nursing assistant, three administrators, and three patient caregivers/family. Interviews reveal that trust is multidimensional, involving personal- and systems-level trust, and both locus and degree of trust. Factors impacting trust include: fear; communication/relationships; knowledge of hospice; religious/spiritual beliefs; language; and cultural beliefs/experiences. While some are common across groups, several are more prevalent in minority populations. These factors appear to interact in complex ways, unique to individual patients/families, compounding their impact on trust. Conclusions: While gaining patient/family trust regarding EOL decision making is challenging across all groups, minority patients often experience additional compounding factors impacting trust building. More research is needed to mitigate the negative ways these interacting factors impact trust.

Predicting five-year mortality in soft-tissue sarcoma patients

Aims

The aim of this study was to identify factors associated with five-year cancer-related mortality in patients with limb and trunk soft-tissue sarcoma (STS) and develop and validate machine learning algorithms in order to predict five-year cancer-related mortality in these patients.

Methods

Demographic, clinicopathological, and treatment variables of limb and trunk STS patients in the Surveillance, Epidemiology, and End Results Program (SEER) database from 2004 to 2017 were analyzed. Multivariable logistic regression was used to determine factors significantly associated with five-year cancer-related mortality. Various machine learning models were developed and compared using area under the curve (AUC), calibration, and decision curve analysis. The model that performed best on the SEER testing data was further assessed to determine the variables most important in its predictive capacity. This model was externally validated using our institutional dataset.

Results

A total of 13,646 patients with STS from the SEER database were included, of whom 35.9% experienced five-year cancer-related mortality. The random forest model performed the best overall and identified tumour size as the most important variable when predicting mortality in patients with STS, followed by M stage, histological subtype, age, and surgical excision. Each variable was significant in logistic regression. External validation yielded an AUC of 0.752.

Conclusion

This study identified clinically important variables associated with five-year cancer-related mortality in patients with limb and trunk STS, and developed a predictive model that demonstrated good accuracy and predictability. Orthopaedic oncologists may use these findings to further risk-stratify their patients and recommend an optimal course of treatment.

Guidelines for goals of care discussions in patients with gynecologic cancer

This article represents a distillation of literature to provide guidance for goals of care discussions with patients who have gynecologic malignancies. As clinicians who provide surgical care, chemotherapy, and targeted therapeutics, gynecologic oncology clinicians are uniquely positioned to form longitudinal relationships with patients that can enable patient-centered decision making. In this review, we describe optimal timing, components, and best practices for goals of care discussions in gynecologic oncology.

Communication about early palliative care: A qualitative study of oncology providers' perspectives of navigating the artful introduction to the palliative care team

Background

Despite robust evidence for the integration of early palliative care for patients with advanced cancer, many patients still access this approach to care late. Communication about the introduction of Early Palliative Care is an important skill of healthcare providers working in this setting. In the context of limited community understanding about palliative care, patients and their families may express fear or negative reactions to its early introduction. Health professionals may lack the confidence or skill to describe the role and benefits of early palliative care.

Aim

This study sought to explore clinicians' perspectives on communication about referral to early palliative care, specifically identifying facilitators in undertaking this communication task.

Methods

An exploratory qualitative study set within a tertiary oncology service in Victoria, Australia. Semi-structured interviews were conducted with purposively sampled oncology clinicians exploring their perspectives on communication about referral to early palliative care. A reflexive thematic analysis was undertaken by two researchers, including both latent and semantic coding relevant to the research question. Reporting of the research was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

Results

Twelve oncology clinicians (58% female, with 67% > 15 years clinical experience) from medical oncology, surgical oncology, and haematology participated. The artful navigation of communication about early palliative care was characterised by the need for a 'spiel' involving the adoption of a series of strategies or 'tactics' when introducing this service. These themes included: 1) Using carefully selected and rehearsed language; 2) Framing in terms of symptom control; 3) Framing as additive to patient care; 4) Selling the service benefits of early palliative care; 5) Framing acceptance of referral as an altruistic act; and 6) Adopting a phased approach to delivering information about palliative care.

Implications

This study highlights the wide ranging and innovative communication strategies and skills required by health professionals to facilitate referral to early palliative care for cancer patients and their families. Future focus on upskilling clinicians around communication of this topic will be important to ensure successful implementation of models of early palliative care in routine cancer care.

Ethical issues in oncology practice: a qualitative study of stakeholders' experiences and expectations

Background

Clinical Ethics Support Services (CESS) have been established to support healthcare professionals in addressing ethically sensitive issues in clinical practice and, in many countries, they are under development. In the context of growing CESS, exploring how healthcare professionals experience and address clinical ethics issues in their daily practice represents a fundamental step to understand their potential needs. This is even more relevant in the context of extremely sensitive diseases, such as cancer. On this basis, we carried out a qualitative study conducting in-depth semi-structured interviews with stakeholders of a major comprehensive cancer centre in Italy, with the twofold aim of investigating what ethical issues arise in the context of clinical oncology and how they are addressed, as well as stakeholders’ expectations about a potential CESS to be implemented within the Institution.

Methods

The study was conducted within the theoretical framework of Grounded Theory. Participants were healthcare professionals and other key stakeholders working within the cancer centre. The semi-structured interview aimed at exploring common ethical aspects of oncology, investigating stakeholders’ professional experience in dealing with clinical ethics issues, their expectations and requests regarding ethics support services. Transcripts of the interviews were coded and analysed according to the principles of Grounded Theory.

Results

Twenty-one stakeholders were interviewed. Our analysis showed a wide consensus on the identification of ethically relevant issues, above all those concerning communication, end-of-life, and resource allocation. The absence of institutional tools or strategies to address and manage ethical issues at the patient bedside emerged, and this is reflected in the widespread request for their development in the future. The ideal support service should be fast and flexible in order to adapt to different needs and clinical cases.

Conclusions

The interviewees showed a limited degree of ‘ethical awareness’: despite having reported many issues in clinical practice, they could hardly identify and describe the ethical aspects, while  complaining about a lack of ethical resources in their management. To build a truly effective support service, it therefore seems appropriate to take such context into consideration and address the emerged needs. Ethical sensitivity seems to be key and it becomes even more relevant in critical clinical areas, such as the therapeutic pathways of terminally ill patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00803-x.

Decisional Conflict after Deciding on Potential Participation in Early Phase Clinical Cancer Trials: Dependent on Global Health Status, Satisfaction with Communication, and Timing

When standard treatment options are not available anymore, patients with advanced cancer may participate in early phase clinical trials. Improving this complex decision-making process may improve their quality of life. Therefore, this prospective multicenter study with questionnaires untangles several contributing factors to decisional conflict (which reflects the quality of decision-making) in patients with advanced cancer who recently decided upon early phase clinical trial participation (phase I or I/II). We hypothesized that health-related quality of life, health literacy, sense of hope, satisfaction with the consultation, timing of the decision, and the decision explain decisional conflict. Mean decisional conflict in 116 patients was 30.0 (SD = 16.9). Multivariate regression analysis showed that less decisional conflict was reported by patients with better global health status (β = −0.185, p = 0.018), higher satisfaction (β = −0.246, p = 0.002), and who made the decision before (β = −0.543, p < 0.001) or within a week after the consultation (β = −0.427, p < 0.001). These variables explained 37% of the variance in decisional conflict. Healthcare professionals should realize that patients with lower global health status and who need more time to decide may require additional support. Although altering such patient intrinsic characteristics is difficult, oncologists can impact the satisfaction with the consultation. Future research should verify whether effective patient-centered communication could prevent decisional conflict.

Honoring Black Hopes: How to respond when the family is hoping for a miracle

Background: Racial and ethnic disparities in end-of-life healthcare can be reduced by showing physicians how to best respond to a documented underlying cause: African American families’ hopes for a miracle via divine intervention influence their end-of-life medical decisions, like, for example, making them not want to withdraw ventilatory support in cases of poor neurologic prognosis because they are still hoping for God to intervene. 

Methods: Autoethnographic research probing the author’s Spiritual Care experience in this context yields a nuanced, 90-second point-of-care spiritual intervention physicians can use to address the religious aspect of African American families who base end-of-life medical decisions on their hopes for a miracle via divine intervention. Autoethnographic analysis is framed by physician-author, Dr. Jessica Zitter’s documented journey of grappling with this context. The evolution of Dr. Zitter’s responses to miracle-hoping African American families provides a framework for applying autoethnographic analysis to a critical appropriation of the Johns Hopkins “AMEN” communication protocol for families hoping for a miracle. 

Results: The common instinct of white physicians to remain neutral, holding miracle-hoping African American families at arm’s length, rather than supportively engaging their hopes, is shown to be an intellectual ruse for emotional avoidance. A novel, counterintuitive spiritual intervention for the religious aspect of miracle-hoping African American families is integrated into an existing physician communication protocol for responding to families hoping for a miracle with recommendations for utilization of existing communication technology when necessary. 

Conclusion: Properly addressing the religious dimension of African American families hoping for a miracle may help physicians to increase their therapeutic connection with families, decrease their own stress/burnout levels, and eliminate racial and ethnic disparities in end-of-life healthcare. 

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Communication research at the National Cancer Institute, 2013-2019: a grant portfolio analysis

PURPOSE

To analyze communication-focused grants funded by the National Cancer Institute (NCI) between fiscal years 2013 and 2019 to provide insight into the characteristics of funded projects and identify promising areas for future research.

METHODS

iSearch, a portfolio analysis tool, was queried to identify communication-related grants funded by NCI. Abstracts and specific aims were coded for key study characteristics. 344 unique competing grants with a substantial communication component were included in the final analysis. SAS version 9.4 was used to calculate code frequencies.

RESULTS

Most communication grants focused on cancer prevention (n = 197), with fewer targeting diagnosis, treatment, survivorship, or end-of-life. Tobacco product use was the most frequently addressed topic (n = 128). Most grants targeted or measured outcomes at the individual (n = 332) or interpersonal level (n = 127). Cancer patients/survivors (n = 101) and healthcare providers (n = 63) were often the population of focus, while caregivers or those at increased risk for cancer received less attention. Studies were often based in healthcare settings (n = 125); few studies were based in schools or worksites. Many grants employed randomized controlled trials (n = 168), but more novel methods, like optimization trials, were uncommon.

CONCLUSION

NCI's support of health communication research covers a diverse array of topics, populations, and methods. However, the current analysis also points to several promising opportunities for future research, including efforts focused on communication at later stages of the cancer control continuum and at multiple levels of influence, as well as studies that take advantage of a greater diversity of settings and leverage novel methodological approaches.

Narrative Medicine for Healthcare Providers: Improving Practices of Advance Care Planning

Advance care planning (ACP) conversations about treatment preferences and end-of-life goals relate to positive outcomes for patients and families, though ongoing barriers exist. Additionally, providers personal discomfort and personal experiences may influence how they engage (or avoid) ACP conversations. Narrative medicine (NM) offers one approach to help practitioners develop ability to hear and understand the story of others in ways that may overcome barriers to quality conversations. This study investigated the effectiveness of a 3-hour NM workshop to develop communication skills around ACP and facilitate reflection on the relationship between personal experiences and professional practices in ACP and end-of-life care. Twenty-five participants completed post-assessments of the workshop. Key themes included increased awareness, improved skills for active listening and eliciting stories, and improved understanding of how personal experiences shape professional practice. Results indicate practitioners value the NM approach to ACP suggesting this approach may provide impactful change in practice.

Identifying patient values impacting the decision whether to participate in early phase clinical cancer trials: A systematic review

BACKGROUND

For many patients with advanced cancer, the decision whether to participate in early phase clinical trials or not is complex. The decision-making process requires an in-depth discussion of patient values. We therefore aimed to synthesize and describe patient values that may affect early phase clinical trial participation.

METHODS

We conducted a systematic search in seven electronic databases on patient values in relation to patients' decisions to participate in early phase clinical cancer trials.

RESULTS

From 3072 retrieved articles, eleven quantitative and five qualitative studies fulfilled our inclusion criteria. We extracted ten patient values that can contribute to patients' decisions. Overall, patients who seek trial participation usually report hope, trust, quantity of life, altruism, perseverance, faith and/or risk tolerance as important values. Quality of life and humanity are main values of patients who refuse trial participation. Autonomy and social adherence can be reported by both trial seekers or refusers, dependent upon how they are manifested in a patient.

CONCLUSIONS

We identified patient values that frequently play a role in the decision-making process. In the setting of discussing early phase clinical trial participation with patients, healthcare professionals need to be aware of these values. This analysis supports the importance of individual exploration of values. Patients that become aware of their values, e.g. by means of interventions focused on clarifying their values, could feel more empowered to choose. Subsequently, healthcare professionals could improve their support in a patients' decision-making process and reduce the chance of decisional conflict.

Stronger therapeutic alliance is associated with better quality of life among patients with advanced cancer

OBJECTIVE

Patient-oncologist therapeutic alliance is a foundation of quality cancer care, although there is limited research demonstrating its relationship with patient outcomes. We investigated the relationship between therapeutic alliance and patient quality of life with a secondary goal of determining whether the association varied by patients' baseline level of psychological distress.

METHODS

Cross-sectional analysis of baseline data from a randomized clinical trial of 672 patients with advanced cancer participating in a primary palliative care intervention trial. Patients completed baseline self-reported measures of therapeutic alliance (The Human Connection Scale, range: 16-64), overall quality of life (Functional Assessment of Cancer Therapy-Palliative Care, range: 0-184), and psychological distress (Hospital Anxiety and Depression Scale, range: 0-42). First, we determined the relationship between therapeutic alliance and quality of life using multivariable regression adjusting for confounders. We then examined if psychological distress was an effect modifier in this relationship by adding interaction effects of depression and anxiety symptoms on therapeutic alliance into the regression model.

RESULTS

Patients reported high levels of therapeutic alliance (56.4 ± 7.4) and moderate quality of life (130.3 ± 25.5). Stronger therapeutic alliance was associated with better quality of life after adjusting for other confounding factors (β = 3.7, 95% confidence interval = 2.1, 5.3, p < 0.01). The relationship between therapeutic alliance and quality of life was generally consistent regardless of psychological distress.

CONCLUSIONS

Collaborative, trusting relationships between patients with advanced cancer and their oncologists are associated with better patient quality of life. Future research should investigate the causal, longitudinal nature of these relationships.

Hospice Use Among Patients With Cancer: Trends, Barriers, and Future Directions

Patients with advanced cancer and their families frequently encounter clinical and logistical challenges related to end-of-life care. Hospice provides interdisciplinary and holistic care to meet patients' biomedical, psychosocial, and spiritual needs in the last phases of life. Despite increasing general acceptance and use among patients with cancer, hospice remains underused. Underuse stems from ongoing misconceptions regarding hospice and its purpose, coupled with the rapid development of novel anticancer treatments, such as immunotherapies and targeted therapies, that have changed the landscape of possibilities. Furthermore, rapid evolutions in how end-of-life care is structured and reimbursed for will affect how oncology patients will intersect with hospice care. In this review, we explore the current and future challenges to greater integration of hospice care in the care of patients with advanced cancer and propose five recommendations as part of the path forward.

Randomized trial of a hospice video educational tool for patients with advanced cancer and their caregivers

BACKGROUND

Patients with advanced cancer and their caregivers have substantial misperceptions regarding hospice, which contributes to its underuse.

METHODS

The authors conducted a single-site randomized trial of a video educational tool versus a verbal description of hospice in 150 hospitalized patients with advanced cancer and their caregivers. Patients without a caregiver were eligible. Intervention participants (75 patients and 18 caregivers) viewed a 6-minute video depicting hospice. Control participants (75 patients and 26 caregivers) received a verbal description identical to the video narrative. The primary outcome was patient preference for hospice. Secondary outcomes included patient and/or caregiver knowledge and perceptions of hospice, and hospice use.

RESULTS

Between February 2017 and January 2019, approximately 55.7% of eligible patients (150 of 269 eligible patients) and 44 caregivers were enrolled. After the intervention, there was no difference noted with regard to patients' preferences for hospice (86.7% vs 82.7%; P = .651). Patients in the video group reported greater knowledge regarding hospice (9.0 vs 8.4; P = .049) and were less likely to endorse that hospice is only about death (6.7% vs 21.6%; P = .010). Among deceased patients, those assigned to the intervention were more likely to have used hospice (85.2% vs 63.6%; P = .01) and to have had a longer hospice length of stay (median, 12 days vs 3 days; P < .001). After the intervention, caregivers assigned to view the video were more likely to prefer hospice for their loved ones (94.4% vs 65.4%; P = .031), reported greater knowledge concerning hospice (9.7% vs 8.0%; P = .001), and were less likely to endorse that hospice is only about death (0.0% vs 23.1%; P = .066).

CONCLUSIONS

A hospice video did not significantly impact patients' preferences for hospice care. Patients with advanced cancer and their caregivers who were assigned to view the video were more informed regarding hospice and reported more favorable perceptions of hospice. Patients were more likely to use hospice and to have a longer hospice length of stay.

Let us talk about death: gender effects in cancer patients' preferences for end-of-life discussions

Purpose

Patients with advanced cancer often receive suboptimal end-of-life (EOL) care. Particularly males with advanced cancer are more likely to receive EOL care that is more aggressive, even if death is imminent. Critical factors determining EOL care are EOL conversations or advance care planning. However, information about gender-related factors influencing EOL conversations is lacking. Therefore, the current study investigates gender differences concerning the content, the desired time point, and the mode of initiation of EOL conversations in cancer patients.

Methods

In a cross-sectional study, 186 female and male cancer patients were asked about their preferences for EOL discussions using a semi-structured interview, focusing on (a) the importance of six different topics (medical and nursing care, organizational, emotional, social, and spiritual/religious aspects), (b) the desired time point, and (c) the mode of discussion initiation.

Results

The importance of EOL topics differs significantly regarding issue (p = 0.002, η² = 0.02) and gender (p < 0.001, η² = 0.11). Males wish to avoid the engagement in discussions about death and dying particularly if they are anxious about their end-of-life period. They wish to be addressed regarding the “hard facts” nursing and medical care only. In contrast, females prefer to speak more about “soft facts” and to be addressed about each EOL topic. Independent of gender, the majority of patients prefer to talk rather late: when the disease is getting worse (58%), at the end of their therapy, or when loosing self-sufficiency (27.5%).

Conclusion

The tendency of patients to talk late about EOL issues increases the risk of delayed or missed EOL conversations, which may be due to a knowledge gap regarding the possibility of disease-associated incapability. Furthermore, there are significant gender differences influencing the access to EOL conversations. Therefore, for daily clinical routine, we suggest an early two-step, gender-sensitive approach to end-of-life conversations.

Variation in the implementation of PaTz: a method to improve palliative care in general practice - a prospective observational study

Background

PaTz (palliative care at home) is a method to improve palliative care in the primary care setting in the Netherlands. PaTz has three basic principles: (1) local GPs and DNs meet at least six times per year to identify and discuss their patients with a life-threatening illness; (2) these meetings are supervised by a specialist palliative care professional; (3) groups use a palliative care register on which all identified patients are listed. Since the start in 2010, the number of PaTz-groups in the Netherlands has been growing consistently. Although the theory of all PaTz-groups is the same, the practical functioning of PaTz-groups may vary substantially, which may complicate further implementation of PaTz as well as interpretation of effect studies. This study aims to describe the variation in practice of PaTz-groups in the Netherlands.

Method

In this prospective observational study, ten PaTz-groups logged and described the activities in their meetings as well as the registered and discussed patients and topics of discussions in registration forms for a 1 year follow-up period. In addition, non-participatory observations were performed in all participating groups. Meeting and patient characteristics were analysed using descriptive statistics. Conventional content analysis was performed in the analysis of topic discussions.

Results

While the basic principles of PaTz are found in almost every PaTz-group, there is considerable variation in the practice and content of the meetings of different PaTz-groups. Most groups spend little time on other topics than their patients, although the number of patients discussed in a single meeting varies considerably, as well as the time spent on an individual patient. Most registered patients were diagnosed with cancer and patient discussions mainly concerned current affairs and rarely concerned future issues.

Conclusion

The basic principles are the cornerstone of any PaTz-group. At the same time, the observed variation between PaTz-groups indicates that tailoring a PaTz-group to the needs of its participants is important and may enhance its sustainability. The flexibility of PaTz-groups may also provide opportunity to modify the content and tools used, and improve identification of palliative patients and advance care planning.

Realizing better doctor-patient dialogue about choices in palliative care and early phase clinical trial participation: towards an online value clarification tool (OnVaCT)

BACKGROUND

Patients with advanced cancer for whom standard systemic treatment is no longer available may be offered participation in early phase clinical trials. In the decision making process, both medical-technical information and patient values and preferences are important. Since patients report decisional conflict after deciding on participation in these trials, improving the decision making process is essential. We aim to develop and evaluate an Online Value Clarification Tool (OnVaCT) to assist patients in clarifying their values around this end-of-life decision. This improved sharing of values is hypothesized to support medical oncologists in tailoring their information to individual patients' needs and, consequently, to support patients in taking decisions in line with their values and reduce decisional conflict.

METHODS

In the first part, patients' values and preferences and medical oncologists' views hereupon will be explored in interviews and focus groups to build a first prototype OnVaCT using digital communication (serious gaming). Next, we will test feasibility during think aloud sessions, to deliver a ready-to-implement OnVaCT. In the second part, the OnVaCT, with accompanied training module, will be evaluated in a pre-test (12-18 months before implementation) post-test (12-18 months after implementation) study in three major Dutch cancer centres. We will include 276 patients (> 18 years) with advanced cancer for whom standard systemic therapy is no longer available, and who are referred for participation in early phase clinical trials. The first consultation will be recorded to analyse patient-physician communication regarding the discussion of patients' values and the decision making process. Three weeks afterwards, decisional conflict will be measured.

DISCUSSION

This project aims to support the discussion of patient values when considering participation in early phase clinical trials. By including patients before their first appointment with the medical oncologist and recording that consultation, we are able to link decisional conflict to the decision making process, e.g. the communication during consultation. The study faces challenges such as timely including patients within the short period between referral and first consultation. Furthermore, with new treatments being developed rapidly, molecular stratification may affect the patient populations included in the pre-test and post-test periods.

TRIAL REGISTRATION

Netherlands Trial Registry number: NTR7551 (prospective; July 17, 2018).

Illness Understanding and Advance Care Planning in Patients with Advanced Lymphoma

Background: The prognosis of an aggressive lymphoma can change dramatically following failure of first-line treatment. This sudden shift is challenging for the promotion of illness understanding and advance care planning (ACP). Yet, little is known about illness understanding and ACP in patients with aggressive lymphomas. Objective: To examine illness understanding, rates of engagement in ACP, and reasons for lack of ACP engagement in patients with advanced B cell lymphomas. Design: Cross-sectional observational study. Setting/Subjects: Patients (n = 27) with aggressive B cell lymphomas that relapsed after first- or second-line treatment treated at a single urban academic medical center. Measurements: Participants were administered structured surveys by trained staff to obtain self-report measures of illness understanding (i.e., aggressiveness, terminality, curability) and ACP (i.e., discussions of care preferences, completion of advance directives). Results: The majority of patients reported discussing curability (92.6%), prognosis (77.8%), and treatment goals (88.9%) with their medical team. Yet, less than one-third of patients reported being terminally ill (29.6%) and having incurable disease (22.2%). Most patients had a health care proxy (81.5%) and had decided about do-not-resuscitate status (63%), but the majority had not completed a living will (65.4%) or discussed their care preferences with others (55.6%). Conclusions: The accuracy of lymphoma patients' illness understanding following first-line treatment is difficult to determine due to the potential for cure following transplant. However, this study suggests that a large proportion of patients with advanced B cell lymphomas may underestimate the severity of their illness, despite discussing illness severity with their medical team. Providing patients with information on prognosis, and the ACP process may increase engagement in ACP.

The association between PaTz and improved palliative care in the primary care setting: a cross-sectional survey

Background

The PaTz-method (acronym for Palliatieve Thuiszorg, palliative care at home) is perceived to improve coordination, continuity and communication in palliative care in the Netherlands. Although important for further implementation, research showing a clear effect of PaTz on patient-related outcomes is scarce. This study aimed to examine perceived barriers and added value of PaTz and its association with improved care outcomes.

Methods

Ninety-eight Dutch general practitioners and 229 Dutch district nurses filled out an online questionnaire with structured questions on added value and barrier perception of PaTz-participation, and palliative care provided to their most recently deceased patient, distributed online by Dutch medical and nurses’ associations. Data from PaTz-participants and non-participants was compared using Chi-square tests, independent t-tests and logistic regression analyses.

Results

While both PaTz-participants and non-participants perceived PaTz to be beneficial for knowledge collaboration, coordination and continuity of care, time (or lack thereof) is considered the most important barrier for participation. PaTz-participation is associated with discussing five or more end-of-life topics with patients (OR = 3.16) and with another healthcare provider (OR = 2.55). PaTz-participation is also associated with discussing palliative sedation (OR = 3.85) and euthanasia (OR = 2.97) with another healthcare provider. Significant associations with other care outcomes were not found.

Conclusions

General practitioners and district nurses feel that participating in a PaTz-group has benefits, but perceive various barriers for participation. While participating in a PaTz-group is associated with improved communication between healthcare providers and with patients, the effect on patient outcomes remains unclear. To stimulate further implementation, future research should focus on the effect of PaTz on tangible care characteristics and how to facilitate participation and remove barriers.

Racial/ethnic differences in prognosis communication during initial inpatient palliative care consultations among people with advanced cancer

OBJECTIVE

We examined whether conversations involving Black or Latino patients with advanced cancer differ in the presence or characteristics of prognosis communication.

METHODS

We audio-recorded initial consultations between 54 palliative care clinicians and 231 hospitalized people with advanced cancer. We coded for the presence and characteristics of prognosis communication. We examined whether the presence or characteristics of prognosis communication differed by patients' self-reported race/ethnicity.

RESULTS

In 231 consultations, 75.7% contained prognosis communication. Prognosis communication was less than half as likely to occur during conversations with Black or Latino patients (N = 48) compared to others. Among consultations in which prognosis was addressed, those involving Black or Latino patients were more than 8 times less likely to contain optimistically cued prognoses compared to others.

CONCLUSION

Prognosis communication occurred less frequently for Black and Latino patients and included fewer optimistic cues than conversations with other patients. More work is needed to better understand these observed patterns of prognosis communication that vary by race and ethnicity.

PRACTICE IMPLICATIONS

Growing evidence supports prognosis communication being important for end-of-life decision-making and disproportionately rare among non-White populations. Therefore, our findings identify a potentially salient target for clinical interventions that are focused on ameliorating disparities in end-of-life care.

Symptom Assessment and Early Access to Supportive and Palliative Care for Patients With Advanced Solid Tumors in Mexico

BACKGROUND

Early specialized palliative care improves quality of life of patients with advanced cancer, and guidelines encourage its integration into standard oncology care. However, many patients fail to obtain timely palliative/supportive care evaluations, particularly in limited-resource settings. We aimed to determine the proportion of patients with advanced cancer who received an assessment of symptoms and were referred to supportive and palliative care services during the first year after diagnosis in a Mexican hospital.

METHODS

Individuals with newly diagnosed advanced solid tumors and 1 year of follow-up at the oncology clinics in the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran in Mexico City from October 2015 to April 2016 were included in this retrospective study.

RESULTS

Seventy-seven patients were included. Forty-two (54.5%) were referred to the various supportive care services during the first year after diagnosis, and 23 (29.8%) were referred to the palliative care clinic. The most commonly assessed symptoms by oncologists were pain (77.9%), anorexia (74.0%), fatigue (68.8%), and nausea (55.8%), while depression/anxiety were evaluated in 10 (12.9%) patients. The oncologist offered to clarify treatment goals in 39 (50.6%) cases and evaluated the understanding of diagnosis/illness and prognosis in 22 (28.5%).

CONCLUSION

Palliative and supportive care services were widely underutilized, which may be related to a lack of standardized symptom assessments and poor end-of-life communication. Novel strategies are needed to improve the implementation of tools for systematic symptom assessment and to optimize the integration of supportive care interventions into oncology care in developing countries.

Breaking silence: a survey of barriers to goals of care discussions from the perspective of oncology practitioners

Background

Cancer is the leading cause of death in the developed world, and yet healthcare practitioners infrequently discuss goals of care (GoC) with hospitalized cancer patients. We sought to identify barriers to GoC discussions from the perspectives of staff oncologists, oncology residents, and oncology nurses.

Methods

This was a single center survey of staff oncologists, oncology residents, and inpatient oncology nurses. Barriers to GoC discussions were assessed on a 7-point Likert scale (1 = extremely unimportant; 7 = extremely important).

Results

Between July 2013 and May 2014, of 185 eligible oncology clinicians, 30 staff oncologists, 10 oncology residents, and 28 oncology nurses returned surveys (response rate of 37%). The most important barriers to GoC discussions were patient and family factors. They included family members’ difficulty accepting poor prognoses (mean score 5.9, 95% CI [5.7, 6.2]), lack of family agreement in the goals of care (mean score 5.8, 95% CI [5.5, 6.1]), difficulty understanding the limitations of life-sustaining treatments (mean score 5.8, 95% CI [5.6, 6.1]), lack of patients’ capacity to make goals of care decisions (mean score 5.7, 95% CI [5.5, 6.0]), and language barriers (mean score 5.7, 95% CI [5.4, 5.9]). Participants viewed system factors and healthcare provider factors as less important barriers.

Conclusions

Oncology practitioners perceive patient and family factors as the most limiting barriers to GoC discussions. Our findings underscore the need for oncology clinicians to be equipped with strong communication skills to help patients and families navigate GoC discussions.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5333-x) contains supplementary material, which is available to authorized users.

Situating requests for medical aid in dying within the broader context of end-of-life care: ethical considerations

BACKGROUND

Medical aid in dying (MAiD) was introduced in Quebec in 2015. Quebec clinical guidelines recommend that MAiD be approached as a last resort when other care options are insufficient; however, the law sets no such requirement. To date, little is known about when and how requests for MAiD are situated in the broader context of decision-making in end-of-life care; the timing of MAiD raises potential ethical issues.

METHODS

A retrospective chart review of all MAiD requests between December 2015 and June 2017 at two Quebec hospitals and one long-term care centre was conducted to explore the relationship between routine end-of-life care practices and the timing of MAiD requests.

RESULTS

Of 80 patients requesting MAiD, 54% (43) received the intervention. The median number of days between the request for MAiD and the patient's death was 6 days. The majority of palliative care consults (32%) came less than 7 days prior to the MAiD request and in another 25% of cases occurred the day of or after MAiD was requested. 35% of patients had no level of intervention form, or it was documented as 1 or 2 (prolongation of life remains a priority) at the time of the MAiD request and 19% were receiving life-prolonging interventions.

INTERPRETATION

We highlight ethical considerations relating to the timing of MAiD requests within the broader context of end-of-life care. Whether or not MAiD is conceptualised as morally distinct from other end-of-life options is likely to influence clinicians' approach to requests for MAiD as well as the ethical importance of our findings. We suggest that in the wake of the 2015 legislation, requests for MAiD have not always appeared to come after an exploration of other options as professional practice guidelines recommend.

Discrepancy between treatment goals documentation by oncologists and their understanding among cancer patients under active treatment with chemotherapy

OBJECTIVE/BACKGROUND

Discussion of treatment goals between oncologists and patients is challenging. Patients frequently misunderstand goals of therapy. There are several methods to document goals of chemotherapy, however, and are frequently not incorporated into patient charts.

METHODS/DESIGN

Cancer patients receiving their first cycle of chemotherapy were interviewed. Patients' recall of discussions with their oncologist regarding therapy intent was assessed and compared to documentation. An adjusted McNemar's test was utilised. A one-sample proportion test was used to evaluate whether the overall observed rate of discordance was significantly different from the proposed 33% rate; a rate posited as a threshold too high in the clinical sense.

RESULTS

Two hundred and seven eligible patients were interviewed. Oncologist identified treatment goals were not documented in 24.6% of cases and had to be excluded. There was not a significant difference in the directionality of discordance present. Inter-rater agreement between patient and oncologist was found to be adequate (κ = 0.64). The overall rate of discordance (17.29%) was found to be significantly less than the proposed acceptable level of 33% (p < 0.01). Upon univariable analysis, age, gender, marital and employment status were not found to be associated with discordance.

CONCLUSIONS

Discordance between treatment goals documentation and their understanding exists, indicating continued miscommunication between the patient and oncologist.

A Patient-Reported Outcome Instrument to Assess Symptom Burden and Predict Survival in Patients with Advanced Cancer: Flipping the Paradigm to Improve Timing of Palliative and End-of-Life Discussions and Reduce Unwanted Health Care Costs

BACKGROUND

Discussions regarding palliative care and end-of-life care issues are frequently delayed past the time of usefulness, resulting in unwanted medical care. We sought to develop a patient-reported outcome (PRO) instrument that allows patients to voice their symptom burdens and facilitate timing of discussions.

SUBJECTS, MATERIALS, AND METHODS

A seven-item PRO instrument (Cota Patient Assessed Symptom Score-7 item [CPASS-7]) covering physical performance status, pain, burden, and depression was administered (September 2015 through October 2016) with correlation to overall survival, correcting for time to complete survey since diagnosis.

RESULTS

A total of 1,191 patients completed CPASS-7 at a median of 560 days following the diagnosis of advanced cancer. Of these patients, 49% were concerned that they could not do the things they wanted; 35% reported decreased performance status. Financial toxicity was reported by 39% of patients, with family burdens noted in 25%. Although depression was reported by 15%, 43% reported lack of pleasure. Pain was reported by 33%. The median CPASS-7 total symptom burden score was 16 (possible 0-112). With a median follow-up of 15 months from initial survey, 46% had died. Patients with symptom burden scores <29 and ≥29 had a 6-month overall survival rate of 87% and 67%, respectively, and 12-month survival rates of 72% and 50%. A one-point score increase resulted in a 1.8% increase in expected hazard.

CONCLUSION

Patients with advanced cancer with higher levels of symptom burden, as self-reported on the CPASS-7, had inferior survival. The PRO facilitates identification of patients appropriate for reassessment of treatment goals and potentially palliative and end-of-life care in response to symptom burden concerns.

IMPLICATIONS FOR PRACTICE

A seven-item patient-reported outcome (PRO) instrument was administered to 1,191 patients with advanced cancers. Patients self-reporting higher levels of physical and psychological symptom burden had inferior overall survival rates. High individual item symptom PRO responses should serve as a useful trigger to initiate supportive interventions, but when scores indicate global problems, discussions regarding end-of-life care might be appropriate.

Connecting Personal Experiences of Loss and Professional Practices in Advance Care Planning and End-of-Life Care: A Survey of Providers

BACKGROUND

Although practitioners overwhelmingly agree on the importance of advance care planning (ACP) and preparing for the end of life (EOL), the process is fraught with barriers.

OBJECTIVE

The goal of this research was to explore potential connections between providers' own personal experiences and current professional practices in ACP and EOL care.

DESIGN

A cross-sectional survey design, gathering voluntary, anonymous responses from participants between August and December 2016. The survey sought information from providers in 3 distinct areas: (1) personal experiences of loss, (2) personal ACP, and (3) professional practices related to ACP and EOL care.

SETTING/PARTICIPANTS

One hundred and ninety health-care professionals (primarily physicians, nurses, and social workers) participated in the survey across a greater, Metropolitan area in the Midwest.

MEASUREMENTS

Questions for professional practices were subscales from the End-of-Life Professional Caregiver Survey: Patient- and Family-Centered Communication (PFCC) and Effective Care Delivery (ECD). Questions developed by the research team were evaluated by judges chosen for clinical and/or research expertise.

RESULTS

Numerous connections were found between professionals' histories of loss, personal ACP, and professional practices. For example, both clinicians with personal experience caring for someone who is dying and clinicians who had completed their own ACP scored higher in both PFCC and ECD and were more likely to refer patients to hospice and palliative care.

CONCLUSIONS

Results support educational interventions involving opportunities for reflection and completion and communication about ACP. Additionally, educational opportunities for students in health care should focus on incorporating both ACP and greater exposure to hospice and palliative care.

Information Framing Reduces Initial Negative Attitudes in Cancer Patients' Decisions About Hospice Care

BACKGROUND

Negative attitudes toward hospice care might prevent patients with cancer from discussing and choosing hospice as they approach end of life. When making a decision, people often naturally focus on either expected benefits or the avoidance of harm. Behavioral research has demonstrated that framing information in an incongruent manner with patients' underlying motivational focus reduces their negative attitudes toward a disliked option.

OBJECTIVE

Our study tests this communication technique with cancer patients, aiming to reduce negative attitudes toward a potentially beneficial but often-disliked option, that is, hospice care.

METHODS

Patients (n = 42) with active cancer of different types and/or stages completed a paper survey. Participants read a vignette about a patient with advanced cancer and a limited prognosis. In the vignette, the physician's advice to enroll in a hospice program was randomized, creating a congruent message or an incongruent message with patients' underlying motivational focus (e.g., a congruent message for someone most interested in benefits focuses on the benefits of hospice, whereas an incongruent message for this patient focuses on avoiding harm). Patients' attitudes toward hospice were measured before and after receiving the physician's advice.

RESULTS

Regression analyses indicated that information framing significantly influenced patients with strong initial negative attitudes. Patients were more likely to reduce intensity of their initial negative attitude about hospice when receiving an incongruent message (b = -0.23; P < 0.01) than a congruent one (b = -0.13; P = 0.08).

CONCLUSION

This finding suggests a new theory-driven approach to conversations with cancer patients who may harbor negative reactions toward hospice care.

The interactive effect of advanced cancer patient and caregiver prognostic understanding on patients' completion of Do Not Resuscitate orders

OBJECTIVE

Advanced cancer patients' prognostic understanding is associated with completion of Do Not Resuscitate (DNR) orders, which often represent engagement in advance care planning (ACP). Given caregivers' critical roles in patient decision-making about ACP and end-of-life care, caregivers' prognostic understanding may have a large additive effect. The present study examined the association between the main and interactive effects of advanced cancer patient and caregiver prognostic understanding on DNR order completion.

METHODS

Data were analyzed from a combined dataset of 2 sequential multi-institutional, longitudinal cohort studies of patients with advanced cancer and their informal caregivers (n = 279 dyads) from 2002 to 2008 (Coping with Cancer 1) and 2010 to 2015 (Coping with Cancer 2). Patients' and caregivers' prognostic understanding regarding life-expectancy (≤ 12 months [prognostic understanding], >12 months [lack of prognostic understanding]) was assessed. DNR order completion was assessed through self-report and confirmed through cross-checking with medical records.

RESULTS

Multivariable modeling of the main and interactive effects revealed the interactive effect, but not the individual effects, of patients' and caregivers' prognostic understanding was significantly associated with higher odds of patients' DNR order completion, adjusting for potential confounds (AOR = 5.89, P = 0.04). For dyads in which both the patient and caregiver had prognostic understanding regarding life expectancy of ≤12 months, 70.7% of patients had completed DNR orders compared with 31.6% to 38.9% in which 1 or both lacked prognostic understanding.

CONCLUSIONS

Findings highlight the need for ensuring accurate patient and caregiver prognostic understanding in increasing DNR order completion, which may provide a framework for improving engagement in ACP more broadly.

Using motivational interviewing to facilitate death talk in end-of-life care: an ethical analysis

BACKGROUND

Morbidity arising from unprepared bereavement is a problem that affects close personal relations of individuals at the end-of-life. The bereavement studies literature demonstrates that a lack of preparedness for a loved one's death is a risk factor for secondary psychological morbidity among survivors. Short awareness time of death negatively correlates to preparedness for bereavement. The absence of disclosure of end-of-life diagnosis and prognosis to close personal relations ('death talk') between patients and loved ones, or health professionals and loved ones, may contribute to short awareness time of death. To increase awareness time of death, we might attempt to increase patient first-personal disclosure of end-of-life diagnosis and prognosis to loved-ones, and/or patient consent to health professional disclosure of the same.

MAIN TEXT

Interventions based on motivational interviewing in end-of-life care whose aim is to facilitate death talk, either by the patient directly, or by a health professional with the patient's consent, may offer a part solution to the problem of unprepared bereavement. This paper evaluates the ethical permissibility of such interventions. We consider two ethical objections to using motivational interviewing in this way: first, that it is inappropriate for practitioners to seek disclosure as an outcome in this setting; second, that aiming at disclosure risks manipulating individuals into death talk. While it need not be impermissible to direct individuals toward disclosure of end-of-life diagnosis/prognosis, the objection from manipulation implies that it is pro tanto ethically preferable to use motivational interviewing in a non-directive mode in death talk conversations. However, insofar as non-directive motivational interviewing requires more advanced skills, and thus may be more difficult to learn and to practise, we advance that it may be ethically permissible, all things considered, to employ directional, or specific outcome-oriented, motivational interviewing.

CONCLUSION

Motivational interviewing interventions in end-of-life care whose aim is to facilitate death talk, either by the patient directly, or by a health professional with the patient's consent may be ethically permissible, all things considered.

Using a Non-Fit Message Helps to De-Intensify Negative Reactions to Tough Advice

Sometimes physicians need to provide patients with potentially upsetting advice. For example, physicians may recommend hospice for a terminally ill patient because it best meets their needs, but the patient and their family dislike this advised option. We explore whether regulatory non-fit could be used to improve these types of situations. Across five studies in which participants imagined receiving upsetting advice from a physician, we demonstrate that regulatory non-fit between the form of the physician's advice (emphasizing gains vs. avoiding losses) and the participants' motivational orientation (promotion vs. prevention) improves participants' evaluation of an initially disliked option. Regulatory non-fit de-intensifies participants' initial attitudes by making them less confident in their initial judgments and motivating them to think more thoroughly about the arguments presented. Furthermore, consistent with previous research on regulatory fit, we showed that the mechanism of regulatory non-fit differs as a function of participants' cognitive involvement in the evaluation of the option.

Current status of accurate prognostic awareness in advanced/terminally ill cancer patients: Systematic review and meta-regression analysis

BACKGROUND

No systematic meta-analysis is available on the prevalence of cancer patients' accurate prognostic awareness and differences in accurate prognostic awareness by publication year, region, assessment method, and service received.

AIM

To examine the prevalence of advanced/terminal cancer patients' accurate prognostic awareness and differences in accurate prognostic awareness by publication year, region, assessment method, and service received.

DESIGN

Systematic review and meta-analysis.

METHODS

MEDLINE, Embase, The Cochrane Library, CINAHL, and PsycINFO were systematically searched on accurate prognostic awareness in adult patients with advanced/terminal cancer (1990-2014). Pooled prevalences were calculated for accurate prognostic awareness by a random-effects model. Differences in weighted estimates of accurate prognostic awareness were compared by meta-regression.

RESULTS

In total, 34 articles were retrieved for systematic review and meta-analysis. At best, only about half of advanced/terminal cancer patients accurately understood their prognosis (49.1%; 95% confidence interval: 42.7%-55.5%; range: 5.4%-85.7%). Accurate prognostic awareness was independent of service received and publication year, but highest in Australia, followed by East Asia, North America, and southern Europe and the United Kingdom (67.7%, 60.7%, 52.8%, and 36.0%, respectively; p = 0.019). Accurate prognostic awareness was higher by clinician assessment than by patient report (63.2% vs 44.5%, p < 0.001).

CONCLUSION

Less than half of advanced/terminal cancer patients accurately understood their prognosis, with significant variations by region and assessment method. Healthcare professionals should thoroughly assess advanced/terminal cancer patients' preferences for prognostic information and engage them in prognostic discussion early in the cancer trajectory, thus facilitating their accurate prognostic awareness and the quality of end-of-life care decision-making.

Reversing Racial Inequities at the End of Life: A Call for Health Systems to Create Culturally Competent Advance Care Planning Programs Within African American Communities

Racial and cultural barriers inherent in health systems have made the delivery of culturally relevant end of life care that aligns with patient preferences a particular challenge across African American patient populations. The end of life experience has been cited as a public health crisis by the Institute of Medicine (IOM), and this crisis is one felt even more acutely by patients of this minority race. Structural racism has limited access to the planning mechanisms proven to result in quality end of life care; thus, health systems must initiate remedies in the face of dire need, as African Americans face a disproportionate burden of morbidity and mortality from many serious illnesses. Recognizing that education is essential to overcoming barriers to quality care access, the development of new and culturally appropriate models of community engagement surrounding advance care planning is needed to serve and empower African American patients.

Determinants of Patient-Oncologist Prognostic Discordance in Advanced Cancer

Importance

Patients with advanced cancer often report expectations for survival that differ from their oncologists' expectations. Whether patients know that their survival expectations differ from those of their oncologists remains unknown. This distinction is important because knowingly expressing differences of opinion is important for shared decision making, whereas patients not knowing that their understanding differs from that of their treating physician is a potential marker of inadequate communication.

Objective

To describe the prevalence, distribution, and proportion of prognostic discordance that is due to patients' knowingly vs unknowingly expressing an opinion that differs from that of their oncologist.

Design, Setting, and Participants

Cross-sectional study conducted at academic and community oncology practices in Rochester, New York, and Sacramento, California. The sample comprises 236 patients with advanced cancer and their 38 oncologists who participated in a randomized trial of an intervention to improve clinical communication. Participants were enrolled from August 2012 to June 2014 and followed up until October 2015.

Main Outcomes and Measures

We ascertained discordance by comparing patient and oncologist ratings of 2-year survival probability. For discordant pairs, we determined whether patients knew that their opinions differed from those of their oncologists by asking the patients to report how they believed their oncologists rated their 2-year survival.

Results

Among the 236 patients (mean [SD] age, 64.5 [11.4] years; 54% female), 161 patient-oncologist survival prognosis ratings (68%; 95% CI, 62%-75%) were discordant. Discordance was substantially more common among nonwhite patients compared with white patients (95% [95% CI, 86%-100%] vs 65% [95% CI, 58%-73%], respectively; P = .03). Among 161 discordant patients, 144 (89%) did not know that their opinions differed from that of their oncologists and nearly all of them (155 of 161 [96%]) were more optimistic than their oncologists.

Conclusions and Relevance

In this study, patient-oncologist discordance about survival prognosis was common and patients rarely knew that their opinions differed from those of their oncologists.

End-of-Life Conversations and Hospice Placement: Association with Less Aggressive Care Desired in the Nursing Home

Education about end-of-life care and treatment options, communication between family and health care providers, and having advance directives and medical orders in place are important for older adults with chronic, progressive decline and end-stage disease who spend their last days in the nursing home. This study used retrospective data (6 months before death) of long-stay nursing home decedents (N = 300) taken from electronic health records to capture the end-of-life experience. Findings showed for almost all decedents, Do Not Resuscitate and Do Not Intubate orders were in place, and just over one-half had Do Not Hospitalize and No Artificial Feeding orders in place. A small proportion had No Artificial Hydration or No Antibiotic orders in place. Overall, there was congruence between documented medical orders and treatment received. Findings showed that use of hospice and discussions about particular life-sustaining treatments each had significant associations with having less aggressive medical orders in place. These results can inform best practice development to promote high quality, person-directed, end-of-life care for nursing home residents.

Development and psychometric evaluation of the Decisional Engagement Scale (DES-10): A patient-reported psychosocial survey for quality cancer care

In light of recent health care reforms, we have provided an illustrative example of new opportunities available for psychologists to develop patient-reported measures related to health care quality. Patient engagement in health care decision making has been increasingly acknowledged as a vital component of quality cancer care. We developed the 10-item Decisional Engagement Scale (DES-10), a patient-reported measure of engagement in decision making in cancer care that assesses patients' awareness of their diagnosis, sense of empowerment and involvement, and level of information seeking and planning. The National Institutes of Health's ResearchMatch recruitment tool was used to facilitate Internet-mediated data collection from 376 patients with cancer. DES-10 scores demonstrated good internal consistency reliability (α = .80), and the hypothesized unidimensional factor structure fit the data well. The reliability and factor structure were supported across subgroups based on demographic, socioeconomic, and health characteristics. Higher DES-10 scores were associated with better health-related quality of life (r = .31). In concurrent validity analyses controlling for age, socioeconomic status, and health-related quality of life, higher DES-10 scores were associated with higher scores on quality-of-care indices, including greater awareness of one's treatments, greater preferences for shared decision making, and clearer preferences about end-of-life care. A mini-measure, the DES-3, also performed well psychometrically. In conclusion, DES-10 and DES-3 scores showed evidence of reliability and validity, and these brief patient-reported measures can be used by researchers, clinicians, nonprofits, hospitals, insurers, and policymakers interested in evaluating and improving the quality of cancer care. (PsycINFO Database Record

A Patient-Reported Outcome Instrument to Facilitate Timing of End-of-Life Discussions among Patients with Advanced Cancers

BACKGROUND

Honoring the wishes of cancer patients is a responsibility of oncologists; however, end-of-life care (EOLC) discussions are frequently delayed past the point of usefulness.

OBJECTIVE

To develop a patient-reported outcome (PRO) screening tool that facilitates timing of EOLC discussions.

DESIGN

A seven-item PRO instrument covering four clinical and personhood domains [performance status, pain, burden (financial and family), and depression] was administered to patients with advanced malignancies undergoing noncurative therapy. The PRO instrument included the patient's assessment of the importance of each domain. Results were correlated with the oncologist's assessment of appropriateness of continuing aggressive therapy.

SETTING/SUBJECTS

Four hundred thirty-three patients fully completed the PRO instrument between February and March 2015 at a single outpatient cancer center.

RESULTS

There was a difference (p < 0.0001) in median scores among cohorts deemed by their oncologists appropriate to continue noncurative treatments versus patients whose physicians were contemplating or actively engaged in EOLC discussions. The scores for the four individual domains also differed among cohorts. An upper threshold score comprising 46% of patients deemed appropriate to curtail treatment (but inclusive of only 26% of patients deemed appropriate to continue) was determined, facilitating identification of patients for EOLC discussions.

CONCLUSIONS

A seven-item patient-centric PRO instrument was able to separate advanced malignancy patients into cohorts who their physicians deemed were at differing stages in their cancer journey with increasing needs for advance care planning. A study to determine if the threshold scores identified in this pilot correlate with palliative/EOL consultation frequency and patient survival is underway.

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

OBJECTIVE

Clinician discomfort with death may affect care of patients but has not been well-studied. This study explores oncology clinicians' attitudes surrounding their own death and how these attitudes both affect and are affected by their care of dying patients and their communication with them.

METHODS

Qualitative interviews with physicians (n=25), nurse practitioners (n=7), and physician assistants (n=1) in medical or hematologic oncology clinical practices about communication styles, care of terminally ill patients, and personal perspectives about mortality.

RESULTS

Clinicians described three communication styles used with patients about death and dying: direct, indirect, or selectively direct. Most reported an acceptance of their mortality that was "conditional," meaning that that they could not fully know how they would respond if actually terminally ill. For many clinicians, caring for dying patients affected their outlook on life and death, and their own perspectives on life and death affected their approach to caring for dying patients.

CONCLUSION

An awareness of personal mortality may help clinicians to discuss death more openly with patients and to provide better care.

PRACTICE IMPLICATIONS

Efforts to promote self-awareness and communication training are key to facilitating clear communication with and compassionate care of terminally ill patients.

Do patients with lung cancer recall physician-initiated discussions about planning for end-of-life care following disclosure of a terminal prognosis?

BACKGROUND

Communicating with patients about their prognosis and goals of care, including offering opportunities to engage in advance care planning (ACP) is widely recognised as best practice. Little is known about terminally ill patients' perceptions of communication and ACP practice following disclosure of their terminal prognosis.

OBJECTIVES

To examine whether terminally ill patients with lung cancer and their relatives recall conversations with disclosing physicians, about their concerns, goals of care or any offers to engage in ACP.

METHODS

Qualitative study using semistructured interviews with patients and their family members. The study setting was a cancer centre and cancer unit in northern England.

RESULTS

25 patients with advanced lung cancer (18 men and 7 women, aged 47-85) and 19 family members, mainly from lower social economic classes, took part in the study. Participants had little or no recall of physicians initiating discussions about their concerns, or goals of care and did not perceive that they had been provided with either information about or opportunities to engage in ACP. Some participants reported a sense of abandonment following the disclosure of a terminal prognosis. This sense was compounded by a range of difficult emotional experiences following the disclosure.

CONCLUSIONS

It may be inappropriate to initiate discussions about end-of-life care planning immediately following the disclosure of a terminal prognosis. To avoid patients feeling abandoned physicians need to consider how they or another appropriate person can provide information and opportunities for terminally ill patients to engage in a process of ACP.

TRIAL REGISTRATION NUMBER

06/Q2307/22.

Perceptions and Preferences of Patients with Terminal Lung Cancer and Family Caregivers about DNR

BACKGROUND

 Patients with terminal lung cancer and their families are challenged and stressed with the end of life discussions. Do Not Resuscitate (DNR) orders are a critical part of such discussions.

OBJECTIVE

 To understand the perceptions and preferences of patients with terminal lung cancer and their family caregivers around DNR discussions. .

METHODS

 Our quantitative component consisted of a pen-and-paper questionnaire that was followed by a 'think aloud' process to capture perceptions of participants in response to questionnaire items. Qualitative methods included content analysis and constant comparison techniques to identify, code, and categorize primary themes arising from 'think aloud' responses.

RESULTS

 In this pilot study, 10 patients with advanced stage lung cancer and nine family caregivers were enrolled from one tertiary cancer care centre. Three major themes and several sub-themes were identified reflecting participants' psychosocial environment, emotional responses to DNR discussions, and suggestions to improve DNR discussions. Most of the time, both patients and caregivers perceived a supportive environment within their family unit. Some patients were uncertain about their disease extent but most had entertained thoughts about prognosis and DNR status prior to having a discussion with their physician. A range of situations stimulated the DNR discussion. Most patients were uncertain about identifying the most appropriate health care provider (HCP) for DNR discussion. While participants found DNR discussions distressing, patients maintained hope in the face of accepting a terminal diagnosis. There were mixed feelings about the reversibility of a DNR decision and concerns about the care of the patients after being stated as DNR. Participants desired their HCP to be emotionally sensitive, knowledgeable, respectful, and straightforward.

CONCLUSIONS

 Most participants were open about their experiences with psychosocial supports and emotional reactions and made suggestions to HCP to improve DNR discussions. Further examination in larger longitudinal studies is required to validate the observations in the current study.

Patient characteristics associated with prognostic awareness: a study of a Canadian palliative care population using the InterRAI palliative care instrument

CONTEXT

Awareness of their medical prognosis enables terminally ill patients to make decisions on treatments and end-of-life care/planning, and to reach acceptance. Yet, many patients receiving palliative care (PC) are unaware of their prognosis, even when death is imminent and has been discussed with health care providers. A better understanding of patient characteristics associated with prognostic awareness (PA) is needed to develop interventions aimed at improving it.

OBJECTIVES

To identify patient characteristics associated with PA in a PC population.

METHODS

The sample comprised 2090 palliative home care patients in Ontario, Canada, assessed using the interRAI Palliative Care Assessment. Independent variables included sociodemographic, cognitive/physical functioning, mood, psychological well-being, and social support. Using cross-sectional data, an adjusted logistic regression model was developed to identify key patient characteristics associated with PA. A multifaceted definition of PA was assumed and represented dichotomously in the model. Multiple imputation was used to address missing data, generating results similar to the complete case analysis.

RESULTS

The PA was higher in patients with: a shorter prognosis (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.93-4.33), increased hours of informal care (OR 1.71, 95% CI 1.15-2.52), less cognitive impairment (OR 1.61, 95% CI 1.14-2.28), and in patients at peace with life (OR 1.79, 95% CI 1.27-2.53). Site differences were observed but do not reflect differences in age, gender, prognosis, or diagnosis.

CONCLUSION

Some patient characteristics are amenable to clinical intervention to raise PA, such as being at peace, cognitive impairment, and depression. Prognostic communications vary in timing and quality and may underlie our site differences, but further research is required to confirm this.

How, When and Where to Discuss Do Not Resuscitate: A Prospective Study to Compare the Perceptions and Preferences of Patients, Caregivers, and Health Care Providers in a Multidisciplinary Lung Cancer Clinic

Background: Do Not Resuscitate (DNR) is a significant but challenging part of end-of-life discussions when dealing with incurable lung cancer patients. We have explored the perceptions and preferences of patients, their caregivers (CGs), and health care providers (HCPs) and the current practice and opinions on DNR discussions in a multidisciplinary lung cancer clinic.

Materials and Methods: This is a prospective descriptive study with a mixed quantitative and qualitative methodology to capture perceptions of the participants. To obtain a rich description of participant responses to questionnaire items, we employed a ‘think aloud’ process that prompted participants to immediately verbalize their thoughts when responding to questionnaire items. We used content analysis and constant comparison techniques to identify, code and categorize primary themes in the captured data.

Results: Ten patients with advanced-stage lung cancer; nine CGs from the lung clinic and ten HCPs from the Thoracic Disease Site Group (DSG) were enrolled in the study. Most patients had only a limited understanding of DNR. Most CGs had a fair to good understanding of DNR. Most HCPs perceived their patients to have understood DNR most of the time. When patients were interviewed, a theme of “anticipated discussion” about DNR was identified. Patients and CGs expressed having faith in the system and responsible physicians as to when to discuss DNR. HCPs embraced a clinician preference-based decision-making approach to engaging in DNR discussions. They desired more resources, more knowledge, more structure and more time to discuss DNR. Most HCPs felt that it would be worth conducting a prospective clinical trial to determine the best time to discuss DNR.

Conclusions: This pilot study provides a unique mixed quantitative and qualitative understanding of the perceptions of patients with lung cancer and their CGs and HCPs regarding DNR discussion. Our findings will help further the development of evidence-based guidelines and a broad prospective study that would have important implications for policies and practices around DNR discussions in order to reduce the emotional pain of dying patients, their CGs and HCPs.

Physician-patient end-of-life care discussions: correlates and associations with end-of-life care preferences of cancer patients-a cross-sectional survey study

BACKGROUND

Honoring patients' treatment preferences is a key component of high-quality end-of-life care. Connecting clinical practices to patients' preferences requires effective communication. However, few cancer patients reported discussing end-of-life-care preferences with their physicians.

AIM

To identify correlates of physician-patient end-of-life-care discussions and to investigate associations of physician-patient end-of-life-care discussions with patient end-of-life-care preferences.

DESIGN

A cross-sectional survey from April 2011 through November 2012.

SETTING/PARTICIPANTS

A convenience sample of 2467 cancer patients (89.3% participation rate) whose disease was diagnosed as terminal and unresponsive to current curative cancer treatment was recruited from 23 teaching hospitals throughout Taiwan.

RESULTS

Only 7.8% of respondents reported discussing end-of-life-care preferences with their physicians. Physicians were more likely to discuss end-of-life-care preferences with cancer patients who accurately understood their prognosis but less likely to do so if patients were married or received care in a hospital with an inpatient hospice unit. Furthermore, physician-patient end-of-life-care discussions were significantly, positively associated with the likelihood of preferring comfort-oriented care and hospice care, but negatively associated with preferences for receiving cardiopulmonary resuscitation when life is in danger and aggressive life-sustaining treatments at end of life, including intensive care unit admission, cardiac massage, intubation, and mechanical ventilation support.

CONCLUSION

Physician-patient end-of-life-care discussions are correlated with accurate prognostic awareness, marital status, and institutional characteristics and negatively associated with terminally ill cancer patients' preferences for aggressive end-of-life care. Interventions should be developed to facilitate timely end-of-life-care discussions between at-risk patients and their physicians, thus honoring patients' end-of-life-care preferences and possibly avoiding futile life-sustaining treatments.

Competing discourses surrounding primary caregivers of hospice patients

This study helps facilitate health care chaplains' awareness of end-of-life communication experienced by primary caregivers. Relational dialectical theory was used to examine the discourse of twenty primary caregivers of hospice patients. The research questions guiding the study were: what competing discourses do primary caregivers experience during end-of-life care, and how do primary caregivers communicatively manage competing end-of-life discourse? In-depth interviews revealed five major competing discourses which were connected physiologically to the patient's dying trajectories: care versus cure; prolong-life versus end-life; open versus hidden; theodicy; and move-on versus don't-move-on discourse. The primary caregivers negotiated these competing discourses through educating the family, by the use of black humor, spiritualizing, ignoring opposing views, and regulating conversations. Theoretical and practical implications for interventions during end-of-life communication are discussed that may help the Chaplain and families of patients negotiate issues such as signing DNRs, impromptu visits to the hospital, and family conflicts about treatments.

Gender differences in the evolution of illness understanding among patients with advanced cancer

BACKGROUND

Patient understanding of advanced metastatic disease is central to decisions about care near death. Prior studies have focused on gender differences in communication style rather than on illness understanding.

OBJECTIVES

: To evaluate gender differences in terminal illness acknowledgement (TIA), understanding that the disease is incurable and the advanced stage of the disease. To evaluate gender differences in patients' reports of discussions of life expectancy with oncology providers and its effect on differences in illness understanding.

METHODS

Coping with Cancer 2 patients (N = 68) were interviewed before and after a visit with their oncology providers to discuss scan results.

RESULTS

At the prescan interview, there were no statistically significant gender differences in patient measures of illness understanding. At the postscan interview, women were more likely than men to recognize that their illness was incurable (Adjusted Odds Ratio, [AOR] = 5.29; P = .038), know that their cancer was at an advanced stage (AOR = 6.38; P = .013), and report having had discussions of life expectancy with their oncologist (AOR = 4.77; P = .021). Controlling discussions of life expectancy, women were more likely than men to report that their cancer was at an advanced stage (AOR = 9.53; P = .050). Controlling for gender, discussions of life expectancy were associated with higher rates of TIA (AOR = 4.65; P = .036) and higher rates of understanding that the cancer was incurable (AOR = 4.09; P = .085).

CONCLUSIONS

Due largely to gender differences in communication, women over time have a better understanding of their illness than men. More frequent discussions of life expectancy should enhance illness understanding and reduce gender differences.

Connecting with patients and instilling realism in an era of emerging communication possibilities: a review on palliative care communication heading to telecare practice

OBJECTIVE

Appropriate palliative care communication is pivotal to optimizing the quality of life in dying patients and their families. This review aims at describing communication patterns in palliative care and discussing potential relations between communication patterns and upcoming telecare in the practice of palliative care.

METHODS

This review builds on a systematic five-step qualitative analysis of the selected articles: 1. Development of a 'descriptive table of studies reviewed' based on the concept of genre, 2. Open coding of table content and first broad clustering of codes, 3. Intracluster categorization of inductive codes into substantive categories, 4. Constant inter- and intracluster comparison results in identification of genres, and 5. Labeling of genres.

RESULTS

This review includes 71 articles. In the analysis, two communication genres in palliative care proved to be dominant: the conversation to connect, about creating and maintaining a professional-patient/family relationship, and the conversation to instill realism, about telling a clinical truth without diminishing hope.

CONCLUSION

The abovementioned two genres clarify a logical intertwinement between communicative purposes, the socio-ethical background underlying palliative care practice and elements of form.

PRACTICE IMPLICATIONS

Our study supports understanding of current communication in palliative care and anticipates future communicative actions in an era of new communication technologies.