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Ojha A, Zhao SJ, Zhang JT, Simo KA, Liu JY. Gap-App: A sex-distinct AI-based predictor for pancreatic ductal adenocarcinoma survival as a web application open to patients and physicians. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.04.597246. [PMID: 38895246 PMCID: PMC11185613 DOI: 10.1101/2024.06.04.597246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
In this study, using RNA-Seq gene expression data and advanced machine learning techniques, we identified distinct gene expression profiles between male and female pancreatic ductal adenocarcinoma (PDAC) patients. Building upon this insight, we developed sex-specific 3-year survival predictive models, which achieved accuracies of 88.47% for males and 88.94% for females, respectively. These models outperformed a single general model despite the smaller sample sizes, highlighting the value of sex-specific analysis. Based on these findings, we created Gap-App, a web application that enables the use of individual gene expression profiles combined with sex information for personalized survival predictions. Gap-App, the first online tool aiming to bridge the gap between complex genomic data and clinical application and facilitating more precise and individualized cancer care, marks a significant advancement in personalized prognosis. The study not only underscores the importance of acknowledging sex differences in personalized prognosis, but also sets the stage for the shift from traditional one-size-fits-all to more personalized and targeted medicine. The GAP-App service is freely available at www.gap-app.org.
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Affiliation(s)
- Anuj Ojha
- Department of Medicine, College of Medicine, University of Toledo, Toledo, OH, USA
- Department of Bioengineering, College of Engineering, University of Toledo, Toledo, OH, USA
| | - Shu-Jun Zhao
- Department of Medicine, College of Medicine, University of Toledo, Toledo, OH, USA
- Department of Bioengineering, College of Engineering, University of Toledo, Toledo, OH, USA
| | - Jian-Ting Zhang
- Department of Cell and Cancer Biology, College of Medicine, University of Toledo, Toledo, OH, USA
| | - Kerri A. Simo
- Department of Surgery, College of Medicine, University of Toledo, Toledo, OH, USA
- ProMedica Health System, ProMedica Cancer Institute, Toledo, OH, USA
| | - Jing-Yuan Liu
- Department of Medicine, College of Medicine, University of Toledo, Toledo, OH, USA
- Department of Cell and Cancer Biology, College of Medicine, University of Toledo, Toledo, OH, USA
- Department of Bioengineering, College of Engineering, University of Toledo, Toledo, OH, USA
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O'Leary C, Cleary S, Linane H, Hamilton B, Jennings M, Lee Y, Lavan N, O'Reilly M, Twomey M. Palliative radiotherapy and the introduction of a Rapid Access Palliative Clinic in a national radiation oncology network. Ir J Med Sci 2024; 193:577-583. [PMID: 37606800 PMCID: PMC10961263 DOI: 10.1007/s11845-023-03494-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/09/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Palliative radiotherapy (PRT) is commonly used to treat symptoms of advanced cancer. PRT has been associated with elevated 30-day mortality (30DM). A Rapid Access Palliative Clinic (RAPC) can streamline the treatment process for patients receiving treatment. AIMS We reviewed the PRT practices in a radiation oncology network in Ireland, and the implementation of a RAPC. Patient outcomes were assessed to inform future treatment decisions. METHODS A retrospective review of all patients who received PRT over 6 months in 2018 in St. Luke's Radiation Oncology Network (SLRON) was undertaken. We assessed 30DM rates, demographics and referral to specialist palliative care (SPC) services. Subsequently, a retrospective analysis was conducted of a RAPC which ran for 6 months from 2019 to 2020. We assessed treatment data and mortality. RESULTS Over 6 months, 645 patients commenced PRT in the SLRON. The 30DM for this cohort was 15.8% (n = 102), with most patients having lung primaries. Of the 30DM cohort, only 55% (n = 56) were referred to SPC services and only 26.4% (n = 27) had performance status recorded. Over 6 months, 40 patients attended 28 RAPCs. Of these, 88% (n = 35) received PRT. Single fraction therapy was utilised in 60% and 48% of patients underwent CT simulation and treatment on the same day. Ultimately, 75% of patients received SPC referral. CONCLUSIONS Referral rates to SPC services and documentation of performance status were low in our 30DM retrospective review cohort. The RAPC facilitated quick treatment turnaround, fewer hospital visits and referral to SPC services.
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Affiliation(s)
- Cian O'Leary
- St. Luke's Hospital Rathgar, Highfield Road, Rathgar, Dublin 6, Ireland.
| | - Sinead Cleary
- St. Luke's Hospital Rathgar, Highfield Road, Rathgar, Dublin 6, Ireland
| | - Hannah Linane
- St. Luke's Hospital Rathgar, Highfield Road, Rathgar, Dublin 6, Ireland
| | - Barbara Hamilton
- St. Luke's Hospital Rathgar, Highfield Road, Rathgar, Dublin 6, Ireland
| | - Michelle Jennings
- St. Luke's Hospital Rathgar, Highfield Road, Rathgar, Dublin 6, Ireland
| | - Yvonne Lee
- St. Luke's Hospital Rathgar, Highfield Road, Rathgar, Dublin 6, Ireland
| | - Naomi Lavan
- St. Luke's Hospital Rathgar, Highfield Road, Rathgar, Dublin 6, Ireland
| | - Maeve O'Reilly
- St. Luke's Hospital Rathgar, Highfield Road, Rathgar, Dublin 6, Ireland
| | - Marie Twomey
- St. Luke's Hospital Rathgar, Highfield Road, Rathgar, Dublin 6, Ireland
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Murray SA, Boyd K, Moine S, Kendall M, Macpherson S, Mitchell G, Amblàs-Novellas J. Using illness trajectories to inform person centred, advance care planning. BMJ 2024; 384:e067896. [PMID: 38428953 DOI: 10.1136/bmj-2021-067896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Affiliation(s)
- Scott A Murray
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
| | - Kirsty Boyd
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
| | - Sebastien Moine
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
- Health Education and Practices Laboratory, University of Paris 13, Bobigny, France
| | - Marilyn Kendall
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
| | - Stella Macpherson
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK
- patient author, UK
| | | | - Jordi Amblàs-Novellas
- Central Catalonia Chronicity Research Group, Faculty of Medicine, University of Vic-Central University of Catalonia, 08500 Vic, Spain
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Mahes A, Macchi ZA, Martin CS, Katz M, Galifianakis NB, Pantilat SZ, Kutner JS, Sillau S, Kluger BM. The "Surprise Question" for Prognostication in People With Parkinson's Disease and Related Disorders. J Pain Symptom Manage 2024; 67:e1-e7. [PMID: 37838080 PMCID: PMC11068019 DOI: 10.1016/j.jpainsymman.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/30/2023] [Accepted: 10/03/2023] [Indexed: 10/16/2023]
Abstract
CONTEXT Parkinson's disease and related disorders (PDRD) are fatal neurodegenerative disorders characterized by a fluctuating course that can complicate prognostication. The "surprise question" (SQ: "Would you be surprised if your patient died in the next year?") has been used to identify patients with limited prognosis but has not been assessed in PDRD. OBJECTIVES To determine the validity of the SQ in predicting 12-month mortality in PDRD. METHODS Data was analyzed from 301 patients and 34 community-based neurologists who were participating in a clinical trial of outpatient palliative care for patients with PDRD. Clinicians answered the SQ for each patient at baseline. Descriptive statistics at baseline, chi-square tests of independence, 2 × 2 and 2 × 3 cross tables were used. Survival analysis compared SQ responses using Kaplan-Meier curves. Risk estimate analyses identified patient characteristics associated with clinicians' responses. RESULTS Mortality was 10.3% (N = 31) at 1 year. The sensitivity and specificity of the SQ was 80.7% and 58.9%, respectively with AUC = 0.70, positive predictive value of 18.4% and negative predictive value of 96.4%. Older age, atypical parkinsonism, and dementia were associated with responding "no" to the SQ. CONCLUSION The SQ is sensitive to 12-month mortality in PDRD, with a high negative predictive value. The SQ may be useful for identifying patients less likely to die within a year and may be useful for identifying patients with palliative care needs outside of end-of-life care. This latter use may assist in mobilizing early and timely referral to specialist palliative care.
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Affiliation(s)
- Ananth Mahes
- Weill Institute for Neurosciences (A.M., N.B.G.), University of California San Francisco, San Francisco, California.
| | - Zachary A Macchi
- Department of Neurology (Z.A.M., C.S.M., S.S.), University of Colorado School of Medicine, Aurora, Colorado
| | - Christine S Martin
- Department of Neurology (Z.A.M., C.S.M., S.S.), University of Colorado School of Medicine, Aurora, Colorado
| | - Maya Katz
- Department of Neurology and Neurological Sciences (M.K.), Stanford University School of Medicine, Palo Alto, California
| | - Nicholas B Galifianakis
- Weill Institute for Neurosciences (A.M., N.B.G.), University of California San Francisco, San Francisco, California
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine (S.Z.P.), University of California, San Francisco, California
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine (J.S.K.), University of Colorado School of Medicine, Aurora, Colorado
| | - Stefan Sillau
- Department of Neurology (Z.A.M., C.S.M., S.S.), University of Colorado School of Medicine, Aurora, Colorado
| | - Benzi M Kluger
- Departments of Neurology and Medicine (B.M.K.), University of Rochester Medical Center, Rochester, New York
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Kelly E, Spina E, Liantonio J. Comparative Analysis of Palliative Care Needs Identified in Inpatient Rehabilitation and Skilled Nursing Facilities by Multidisciplinary Team Members. Arch Phys Med Rehabil 2023; 104:2027-2034. [PMID: 37331422 DOI: 10.1016/j.apmr.2023.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 05/25/2023] [Accepted: 06/07/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVE Assess access to, need for, and beliefs surrounding specialized palliative care (PC). DESIGN Observational, comparative analysis needs assessment survey. SETTING Four inpatient rehabilitation facilities (IRFs) or skilled nursing facilities with long-term care (SNFs/LTC) that provide subacute rehabilitation within 1 tertiary care system. PARTICIPANTS Allied health professionals, physicians, nursing, case managers, social workers, spiritual care (n=198). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Frequency of patient needs, attitudes about current systems, individual beliefs, and barriers to PC. Confidence in management, communicating, and navigating primary PC competencies among clinical pathway employees. RESULTS Of 198 respondents, 37% said PC was available at their facility. Those in IRF reported higher frequencies of grief/unmet spiritual needs of patients compared with SNF/LTC (P≤.001). Conversely, SNF/LTC reported higher frequencies of agitation, poor appetite, and end-of-life care (P≤.003). Respondents in SNF/LTC felt more confident managing end-of-life care, explaining what hospice and PC are and appropriateness for referral to each, discussing advance directives, determining appropriate decision-makers, and navigating ethical decisions than in IRFs (P≤.007). SNF/LTC participants reported higher effectiveness of their current system involving PC and ease of hospice transition compared with IRFs (P≤.008). A majority agreed that PC does not take away patient hope, could prevent recurrent hospitalizations, improve symptom management, communication, and patient and family satisfaction. The most common reported barriers to PC consultation were (1) attitudes and beliefs of staff or patients and families, (2) system issues with access, cost, or prognosis communication, and (3) lack of understanding of PC role. CONCLUSIONS A gap exists in PC access in IRF and SNF/LTC despite patient needs and staff beliefs. Future studies should focus on identifying which patients should be referred to PC in the post-acute setting and what outcomes can be used as a guide to meet the needs of this growing area of practice.
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Affiliation(s)
- Erin Kelly
- Department of Rehabilitation Medicine, Thomas Jefferson University Hospital, Philadelphia, PA.
| | - Elizabeth Spina
- Division of Palliative Care, Rochester Regional Health, Rochester, NY
| | - John Liantonio
- Department of Family Medicine, Division of Palliative Care, Thomas Jefferson University Hospital, Philadelphia, PA
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Spooner C, Vivat B, White N, Bruun A, Rohde G, Kwek PX, Stone P. What outcomes do studies use to measure the impact of prognostication on people with advanced cancer? Findings from a systematic review of quantitative and qualitative studies. Palliat Med 2023; 37:1345-1364. [PMID: 37586031 PMCID: PMC10548779 DOI: 10.1177/02692163231191148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
BACKGROUND Studies evaluating the impact of prognostication in advanced cancer patients vary in the outcomes they measure, and there is a lack of consensus about which outcomes are most important. AIM To identify outcomes previously reported in prognostic research with people with advanced cancer, as a first step towards constructing a core outcome set for prognostic impact studies. DESIGN A systematic review was conducted and analysed in two subsets: one qualitative and one quantitative. (PROSPERO ID: CRD42022320117; 29/03/2022). DATA SOURCES Six databases were searched from inception to September 2022. We extracted data describing (1) outcomes used to measure the impact of prognostication and (2) patients' and informal caregivers' experiences and perceptions of prognostication in advanced cancer. We classified findings using the Core Outcome Measures in Effectiveness Trials (COMET) initiative taxonomy, along with a narrative description. We appraised retrieved studies for quality, but quality was not a basis for exclusion. RESULTS We identified 42 eligible studies: 32 quantitative, 6 qualitative, 4 mixed methods. We extracted 70 outcomes of prognostication in advanced cancer and organised them into 12 domains: (1) survival; (2) psychiatric outcomes; (3) general outcomes; (4) spiritual/religious/existential functioning/wellbeing, (5) emotional functioning/wellbeing; (6) cognitive functioning; (7) social functioning; (8) global quality of life; (9) delivery of care; (10) perceived health status; (11) personal circumstances; and (12) hospital/hospice use. CONCLUSION Outcome reporting and measurement varied markedly across the studies. A standardised approach to outcome reporting in studies of prognosis is necessary to enhance data synthesis, improve clinical practice and better align with stakeholders' priorities.
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Affiliation(s)
- Caitlin Spooner
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Bella Vivat
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Nicola White
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Andrea Bruun
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Gudrun Rohde
- Marie Curie Palliative Care Research Department, University College London, London, UK
- Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
| | - Pei Xing Kwek
- University College Dublin School of Medicine, University College Dublin, Dublin, Ireland
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, University College London, London, UK
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7
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Spooner C, Vivat B, White N, Stone P. Developing a Core Outcome Set for Prognostic Research in Palliative Cancer Care: Protocol for a Mixed Methods Study. JMIR Res Protoc 2023; 12:e49774. [PMID: 37656505 PMCID: PMC10504625 DOI: 10.2196/49774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Studies exploring the impact of receiving end-of-life prognoses in patients with advanced cancer use a variety of different measures to evaluate the outcomes, and thus report often conflicting findings. The standardization of outcomes reported in studies of prognostication in palliative cancer care could enable uniform assessment and reporting, as well as intertrial comparisons. A core outcome set promotes consistency in outcome selection and reporting among studies within a particular population. We aim to develop a set of core outcomes to be used to measure the impact of end-of-life prognostication in palliative cancer care. OBJECTIVE This protocol outlines the proposed methodology to develop a core outcome set for measuring the impact of end-of-life prognostication in palliative cancer care. METHODS We will adopt a mixed methods approach consisting of 3 phases using methodology recommended by the Core Outcome Measure in Effectiveness Trials (COMET) initiative. In phase I, we will conduct a systematic review to identify existing outcomes that prognostic studies have previously used, so as to inform the development of items and domains for the proposed core outcome set. Phase II will consist of semistructured interviews with patients with advanced cancer who are receiving palliative care, informal caregivers, and clinicians, to explore their perceptions and experiences of end-of-life prognostication. Outcomes identified in the interviews will be combined with those found in existing literature and taken forward to phase III, a Delphi survey, in which we will ask patients, informal caregivers, clinicians, and relevant researchers to rate these outcomes until consensus is achieved as to which are considered to be the most important for inclusion in the core outcome set. The resulting, prioritized outcomes will be discussed in a consensus meeting to agree and endorse the final core outcome set. RESULTS Ethical approval was received for this study in September 2022. As of July 2023, we have completed and published the systematic review (phase I) and have started recruitment for phase II. Data analysis for phase II has not yet started. We expect to complete the study by October 2024. CONCLUSIONS This protocol presents the stepwise approach that will be taken to develop a core outcome set for measuring the impact of end-of-life prognostication in palliative cancer care. The final core outcome set has the potential for translation into clinical practice, allowing for consistent evaluation of emerging prognostic algorithms and improving communication of end-of-life prognostication. This study will also potentially facilitate the design of future clinical trials of the impact of end-of-life prognostication in palliative care that are acceptable to key stakeholders. TRIAL REGISTRATION Core Outcome Measures in Effectiveness Trials 2136; https://www.comet-initiative.org/Studies/Details/2136. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/49774.
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Affiliation(s)
- Caitlin Spooner
- Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
| | - Bella Vivat
- Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
| | - Nicola White
- Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
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Matsumura C, Koyama N, Okuno K, Nakamura N, Sako M, Kurosawa H, Nomura T, Eguchi Y, Ohba K, Yano Y. Survival Prediction of Patients Who Were Terminally Ill Using the EORTC QLQ-C15-PAL Scores and Laboratory Test Values. Palliat Med Rep 2023; 4:202-207. [PMID: 37637762 PMCID: PMC10457602 DOI: 10.1089/pmr.2023.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/29/2023] Open
Abstract
Background Prognostics for patients with cancer is especially important for the supportive care of those who are terminally ill. We previously found that symptom scores as patient-reported outcomes (PROs)-such as dyspnea and fatigue scores-some biochemical parameters, the palliative performance scale (PPS) scores, and symptom clusters were useful prognostic factors; however, the predictability of a prognosis based on these factors remains unclear. Objective To identify appropriate three-week survival predictive factor(s), in terms of performance, in patients who were terminally ill. Design We collected symptom scores as PROs using the Japanese version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care (EORTC QLQ-C15-PAL). Setting/Subjects We used data from terminally ill patients with cancer who were hospitalized at the palliative care unit of the Higashisumiyoshi-Morimoto Hospital (Osaka, Japan) from June 2018 to December 2019 (n = 130), as well as additional data obtained from the same clinical study from January to March 2020 (n = 31). Measurements To evaluate predictive performance, indices such as sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated. Results We found that the presence of a symptom cluster showed high sensitivity but low specificity and that a higher PPS value (>30) showed high specificity but low sensitivity, suggesting that these factors could provide relevant information for survival prognosis (less than or equal to three weeks). Conclusion Symptom clusters obtained from patients is important for effective supportive care of those who are terminally ill.
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Affiliation(s)
- Chikako Matsumura
- Education and Research Center for Clinical Pharmacy, Kyoto Pharmaceutical University, Kyoto, Japan
| | - Nanako Koyama
- Education and Research Center for Clinical Pharmacy, Kyoto Pharmaceutical University, Kyoto, Japan
- Department of Pharmacy, Yodogawa Christian Hospital, Osaka, Japan
| | - Kaho Okuno
- Education and Research Center for Clinical Pharmacy, Kyoto Pharmaceutical University, Kyoto, Japan
| | - Nobuhiko Nakamura
- Education and Research Center for Clinical Pharmacy, Kyoto Pharmaceutical University, Kyoto, Japan
| | - Morito Sako
- Department of Pharmacy, Tachibana Medical Corporation Higashisumiyoshi-Morimoto Hospital, Osaka, Japan
| | - Hideo Kurosawa
- Department of Pharmacy, Tachibana Medical Corporation Higashisumiyoshi-Morimoto Hospital, Osaka, Japan
| | - Takehisa Nomura
- Department of Pharmacy, Tachibana Medical Corporation Higashisumiyoshi-Morimoto Hospital, Osaka, Japan
| | - Yuki Eguchi
- Palliative Care Unit, Tachibana Medical Corporation Higashisumiyoshi-Morimoto Hospital, Osaka, Japan
| | - Kazuki Ohba
- Department of Palliative Care, Tachibana Medical Corporation Higashisumiyoshi-Morimoto Hospital, Osaka, Japan
| | - Yoshitaka Yano
- Education and Research Center for Clinical Pharmacy, Kyoto Pharmaceutical University, Kyoto, Japan
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Yoon SJ, Suh SY, Hiratsuka Y, Choi SE, Kim SH, Koh SJ, Park SA, Seo JY, Kwon JH, Park J, Park Y, Hwang SW, Lee ES, Ahn HY, Cheng SY, Chen PJ, Yamaguchi T, Tsuneto S, Mori M, Morita T. Validation of Modified Models of Objective Prognostic Score in Patients With Advanced Cancer. J Palliat Med 2023; 26:1064-1073. [PMID: 37200448 DOI: 10.1089/jpm.2022.0509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
Background: The objective prognostic score (OPS) needs to be modified to reflect practical palliative care circumstances. Objectives: We aimed to validate modified models of OPS with few or no laboratory tests for patients with advanced cancer. Design: An observational study was performed. Setting/Subjects: A secondary analysis of an international, multicenter cohort study of patients in East Asia was performed. The subjects were inpatients with advanced cancer in the palliative care unit. Measurements: We developed two modified OPS (mOPS) models to predict two-week survival: mOPS-A consisted of two symptoms, two objective signs, and three laboratory results, while mOPS-B consisted of three symptoms, two signs, and no laboratory data. We compared the accuracy of the prognostic models using sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Calibration plots for two-week survival and net reclassification indices (NRIs) were compared for the two models. Survival differences between higher and lower score groups of each model were identified by the log-rank test. Results: We included a total of 1796 subjects having median survival of 19.0 days. We found that mOPS-A had higher specificity (0.805-0.836) and higher AUROCs (0.791-0.797). In contrast, mOPS-B showed higher sensitivity (0.721-0.725) and acceptable AUROCs (0.740-0.751) for prediction of two-week survival. Two mOPSs showed good concordance in calibration plots. Considering NRIs, replacing the original OPS with mOPSs improved overall reclassification (absolute NRI: 0.47-4.15%). Higher score groups of mOPS-A and mOPS-B showed poorer survival than those of lower score groups (p < 0.001). Conclusions: mOPSs used reduced laboratory data and had relatively good accuracy for predicting survival in advanced cancer patients receiving palliative care.
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Affiliation(s)
- Seok-Joon Yoon
- Department of Family Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Sang-Yeon Suh
- Department of Family Medicine, Dongguk University Ilsan Hospital, Goyang-si, South Korea
- Department of Medicine, Dongguk University Medical School, Seoul, South Korea
| | - Yusuke Hiratsuka
- Department of Palliative Medicine, Takeda General Hospital, Aizu Wakamatsu, Japan
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Sung-Eun Choi
- Department of Statistics, Dongguk University, Seoul, South Korea
| | - Sun-Hyun Kim
- Department of Family Medicine, School of Medicine, Catholic Kwandong University International St. Mary's Hospital, Incheon, South Korea
| | - Su-Jin Koh
- Department of Hematology and Oncology, Ulsan University Hospital Ulsan University College of Medicine, Ulsan, South Korea
| | - Shin Ae Park
- Hospice and Palliative Care Center, Department of Family Medicine, Seobuk Hospital, Seoul Metropolitan Government, Seoul, South Korea
| | - Ji-Yeon Seo
- Hospice and Palliative Care Center, Department of Family Medicine, Seobuk Hospital, Seoul Metropolitan Government, Seoul, South Korea
| | - Jung Hye Kwon
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, South Korea
| | - Jeanno Park
- Department of Internal Medicine, Bobath Hospital, Seongnam, South Korea
| | - Youngmin Park
- Department of Family Medicine, Hospice and Palliative Care Center, National Health Insurance Service Ilsan Hospital, Goyang-si, South Korea
| | - Sun Wook Hwang
- Department of Family Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Eon Sook Lee
- Department of Family Medicine, Ilsan Paik Hospital, College of Medicine, Inje University, Goyang-si, South Korea
| | - Hong-Yup Ahn
- Department of Statistics, Dongguk University, Seoul, South Korea
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Ping-Jen Chen
- Department of Family Medicine, Kaohsiung Medical University Hospital, and School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | - Satoru Tsuneto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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10
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Peters PN, Havrilesky LJ, Davidson BA. Guidelines for goals of care discussions in patients with gynecologic cancer. Gynecol Oncol 2023; 174:247-252. [PMID: 37243995 DOI: 10.1016/j.ygyno.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/07/2023] [Accepted: 05/15/2023] [Indexed: 05/29/2023]
Abstract
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.
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Affiliation(s)
- Pamela N Peters
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Duke University Health System, Durham, NC 27710, United States of America.
| | - Laura J Havrilesky
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Duke University Health System, Durham, NC 27710, United States of America
| | - Brittany A Davidson
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Duke University Health System, Durham, NC 27710, United States of America
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Charlton CE, Poon MTC, Brennan PM, Fleuriot JD. Development of prediction models for one-year brain tumour survival using machine learning: a comparison of accuracy and interpretability. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 233:107482. [PMID: 36947980 DOI: 10.1016/j.cmpb.2023.107482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 12/15/2022] [Accepted: 03/12/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND AND OBJECTIVE Prediction of survival in patients diagnosed with a brain tumour is challenging because of heterogeneous tumour behaviours and treatment response. Advances in machine learning have led to the development of clinical prognostic models, but due to the lack of model interpretability, integration into clinical practice is almost non-existent. In this retrospective study, we compare five classification models with varying degrees of interpretability for the prediction of brain tumour survival greater than one year following diagnosis. METHODS 1028 patients aged ≥16 years with a brain tumour diagnosis between April 2012 and April 2020 were included in our study. Three intrinsically interpretable 'glass box' classifiers (Bayesian Rule Lists [BRL], Explainable Boosting Machine [EBM], and Logistic Regression [LR]), and two 'black box' classifiers (Random Forest [RF] and Support Vector Machine [SVM]) were trained on electronic patients records for the prediction of one-year survival. All models were evaluated using balanced accuracy (BAC), F1-score, sensitivity, specificity, and receiver operating characteristics. Black box model interpretability and misclassified predictions were quantified using SHapley Additive exPlanations (SHAP) values and model feature importance was evaluated by clinical experts. RESULTS The RF model achieved the highest BAC of 78.9%, closely followed by SVM (77.7%), LR (77.5%) and EBM (77.1%). Across all models, age, diagnosis (tumour type), functional features, and first treatment were top contributors to the prediction of one year survival. We used EBM and SHAP to explain model misclassifications and investigated the role of feature interactions in prognosis. CONCLUSION Interpretable models are a natural choice for the domain of predictive medicine. Intrinsically interpretable models, such as EBMs, may provide an advantage over traditional clinical assessment of brain tumour prognosis by weighting potential risk factors and their interactions that may be unknown to clinicians. An agreement between model predictions and clinical knowledge is essential for establishing trust in the models decision making process, as well as trust that the model will make accurate predictions when applied to new data.
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Affiliation(s)
- Colleen E Charlton
- Artificial Intelligence and its Applications Institute, School of Informatics, University of Edinburgh, 10 Crichton Street, Edinburgh EH8 9AB, UK.
| | - Michael T C Poon
- Cancer Research UK Brain Tumour Centre of Excellence, CRUK Edinburgh Centre, University of Edinburgh, Edinburgh, UK; Department of Clinical Neuroscience, Royal Infirmary of Edinburgh, 51 Little France Crescent EH16 4SA, UK.; Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Paul M Brennan
- Cancer Research UK Brain Tumour Centre of Excellence, CRUK Edinburgh Centre, University of Edinburgh, Edinburgh, UK; Department of Clinical Neuroscience, Royal Infirmary of Edinburgh, 51 Little France Crescent EH16 4SA, UK.; Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jacques D Fleuriot
- Artificial Intelligence and its Applications Institute, School of Informatics, University of Edinburgh, 10 Crichton Street, Edinburgh EH8 9AB, UK
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12
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Orlovic M, Droney J, Vickerstaff V, Rosling J, Bearne A, Powell M, Riley J, McFarlane P, Koffman J, Stone P. Accuracy of clinical predictions of prognosis at the end-of-life: evidence from routinely collected data in urgent care records. BMC Palliat Care 2023; 22:51. [PMID: 37101274 PMCID: PMC10131555 DOI: 10.1186/s12904-023-01155-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/27/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND The accuracy of prognostication has important implications for patients, families, and health services since it may be linked to clinical decision-making, patient experience and outcomes and resource allocation. Study aim is to evaluate the accuracy of temporal predictions of survival in patients with cancer, dementia, heart, or respiratory disease. METHODS Accuracy of clinical prediction was evaluated using retrospective, observational cohort study of 98,187 individuals with a Coordinate My Care record, the Electronic Palliative Care Coordination System serving London, 2010-2020. The survival times of patients were summarised using median and interquartile ranges. Kaplan Meier survival curves were created to describe and compare survival across prognostic categories and disease trajectories. The extent of agreement between estimated and actual prognosis was quantified using linear weighted Kappa statistic. RESULTS Overall, 3% were predicted to live "days"; 13% "weeks"; 28% "months"; and 56% "year/years". The agreement between estimated and actual prognosis using linear weighted Kappa statistic was highest for patients with dementia/frailty (0.75) and cancer (0.73). Clinicians' estimates were able to discriminate (log-rank p < 0.001) between groups of patients with differing survival prospects. Across all disease groups, the accuracy of survival estimates was high for patients who were likely to live for fewer than 14 days (74% accuracy) or for more than one year (83% accuracy), but less accurate at predicting survival of "weeks" or "months" (32% accuracy). CONCLUSION Clinicians are good at identifying individuals who will die imminently and those who will live for much longer. The accuracy of prognostication for these time frames differs across major disease categories, but remains acceptable even in non-cancer patients, including patients with dementia. Advance Care Planning and timely access to palliative care based on individual patient needs may be beneficial for those where there is significant prognostic uncertainty; those who are neither imminently dying nor expected to live for "years".
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Affiliation(s)
- M Orlovic
- Royal Marsden NHS Foundation Trust, London, SW3 6JJ, United Kingdom
- Imperial College London, London, United Kingdom
| | - J Droney
- Royal Marsden NHS Foundation Trust, London, SW3 6JJ, United Kingdom.
- Imperial College London, London, United Kingdom.
| | - V Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, United Kingdom
| | - J Rosling
- Royal Marsden NHS Foundation Trust, London, SW3 6JJ, United Kingdom
| | - A Bearne
- Royal Marsden NHS Foundation Trust, London, SW3 6JJ, United Kingdom
| | - M Powell
- Royal Marsden NHS Foundation Trust, London, SW3 6JJ, United Kingdom
| | - J Riley
- Royal Marsden NHS Foundation Trust, London, SW3 6JJ, United Kingdom
- Imperial College London, London, United Kingdom
| | - P McFarlane
- Royal Marsden NHS Foundation Trust, London, SW3 6JJ, United Kingdom
| | - J Koffman
- Hull York Medical School, Wolfson Palliative Care Research Centre, University of York, York, United Kingdom
| | - P Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, United Kingdom
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13
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Owusuaa C, van der Padt-Pruijsten A, Drooger JC, Heijns JB, Dietvorst AM, Janssens-van Vliet ECJ, Nieboer D, Aerts JGJV, van der Heide A, van der Rijt CCD. Development of a Clinical Prediction Model for 1-Year Mortality in Patients With Advanced Cancer. JAMA Netw Open 2022; 5:e2244350. [PMID: 36449290 PMCID: PMC9713606 DOI: 10.1001/jamanetworkopen.2022.44350] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
IMPORTANCE To optimize palliative care in patients with cancer who are in their last year of life, timely and accurate prognostication is needed. However, available instruments for prognostication, such as the surprise question ("Would I be surprised if this patient died in the next year?") and various prediction models using clinical variables, are not well validated or lack discriminative ability. OBJECTIVE To develop and validate a prediction model to calculate the 1-year risk of death among patients with advanced cancer. DESIGN, SETTING, AND PARTICIPANTS This multicenter prospective prognostic study was performed in the general oncology inpatient and outpatient clinics of 6 hospitals in the Netherlands. A total of 867 patients were enrolled between June 2 and November 22, 2017, and followed up for 1 year. The primary analyses were performed from October 9 to 25, 2019, with the most recent analyses performed from June 19 to 22, 2022. Cox proportional hazards regression analysis was used to develop a prediction model including 3 categories of candidate predictors: clinician responses to the surprise question, patient clinical characteristics, and patient laboratory values. Data on race and ethnicity were not collected because most patients were expected to be of White race and Dutch ethnicity, and race and ethnicity were not considered as prognostic factors. The models' discriminative ability was assessed using internal-external validation by study hospital and measured using the C statistic. Patients 18 years and older with locally advanced or metastatic cancer were eligible. Patients with hematologic cancer were excluded. MAIN OUTCOMES AND MEASURES The risk of death by 1 year. RESULTS Among 867 patients, the median age was 66 years (IQR, 56-72 years), and 411 individuals (47.4%) were male. The 1-year mortality rate was 41.6% (361 patients). Three prediction models with increasing complexity were developed: (1) a simple model including the surprise question, (2) a clinical model including the surprise question and clinical characteristics (age, cancer type prognosis, visceral metastases, brain metastases, Eastern Cooperative Oncology Group performance status, weight loss, pain, and dyspnea), and (3) an extended model including the surprise question, clinical characteristics, and laboratory values (hemoglobin, C-reactive protein, and serum albumin). The pooled C statistic was 0.69 (95% CI, 0.67-0.71) for the simple model, 0.76 (95% CI, 0.73-0.78) for the clinical model, and 0.78 (95% CI, 0.76-0.80) for the extended model. A nomogram and web-based calculator were developed to support clinicians in adequately caring for patients with advanced cancer. CONCLUSIONS AND RELEVANCE In this study, a prediction model including the surprise question, clinical characteristics, and laboratory values had better discriminative ability in predicting death among patients with advanced cancer than models including the surprise question, clinical characteristics, or laboratory values alone. The nomogram and web-based calculator developed for this study can be used by clinicians to identify patients who may benefit from palliative care and advance care planning. Further exploration of the feasibility and external validity of the model is needed.
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Affiliation(s)
- Catherine Owusuaa
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Jan C. Drooger
- Department of Internal Medicine, Ikazia Hospital, Rotterdam, the Netherlands
| | - Joan B. Heijns
- Department of Internal Medicine, Amphia, Breda, the Netherlands
| | - Anne-Marie Dietvorst
- Department of Internal Medicine, Van Weel Bethesda Hospital, Dirksland, the Netherlands
| | | | - Daan Nieboer
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joachim G. J. V. Aerts
- Department of Pulmonary Diseases, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
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14
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Glick N, Vaisman A, Negru L, Segal G, Itelman E. Mortality prediction upon hospital admission - the value of clinical assessment: A retrospective, matched cohort study. Medicine (Baltimore) 2022; 101:e30917. [PMID: 36181100 PMCID: PMC9524893 DOI: 10.1097/md.0000000000030917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Accurate prediction of mortality upon hospital admission is of great value, both for the sake of patients and appropriate resources' allocation. A myriad of assessment tools exists for this purpose. The evidence relating to the comparative value of clinical assessment versus established indexes are scarce. We analyzed the accuracy of a senior physician's clinical assessment in a retrospective cohort of patients in a crude, general patients' population and later on a propensity matched patients' population. In one department of internal medicine in a tertiary hospital, of 9891 admitted patients, 973 (10%) were categorized as prone to death in a 6-months' duration by a senior physician. The risk of death was significantly higher for these patients [73.1% vs 14.1% mortality within 180 days; hazard ratio (HR) = 7.58; confidence intervals (CI) 7.02-8.19, P < .001]. After accounting for multiple, other patients' variables associated with increased risk of mortality, the correlation remained significant (HR = 3.25; CI 2.85-3.71, P < .001). We further performed a propensity matching analysis (a subgroup of 710 patients, subdivided to two groups with 355 patients each): survival rates were as low as 45% for patients categorized as prone to death compared to 78% in patients who weren't categorized as such (P < .001). Reliance on clinical evaluation, done by an experienced senior physician, is an appropriate tool for mortality prediction upon hospital admission, achieving high accuracy rates.
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Affiliation(s)
- Noam Glick
- Internal Medicine “I”, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Adva Vaisman
- Internal Medicine “I”, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Liat Negru
- Internal Medicine “I”, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Gad Segal
- Internal Medicine “I”, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel
- *Correspondence: Internal Medicine “I”, Chaim Sheba Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel (e-mail: )
| | - Eduard Itelman
- Internal Medicine “I”, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel
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15
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Elsayem AF, Warneke CL, Reyes-Gibby CC, Buffardi LJ, Sadaf H, Chaftari PS, Brock PA, Page VD, Viets-Upchurch J, Lipe D, Alagappan K. "Triple Threat" Conditions Predict Mortality Among Patients With Advanced Cancer Who Present to the Emergency Department. J Emerg Med 2022; 63:355-362. [DOI: 10.1016/j.jemermed.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/19/2022] [Accepted: 05/09/2022] [Indexed: 11/12/2022]
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16
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Deenonpoe R, Sa-Ngiamwibool P, Watcharadetwittaya S, Thanee M, Intuyod K, Kongpan T, Padthaisong S, Nutalai R, Chamgramol Y, Pairojkul C. Fluorescence in situ hybridization detection of chromosome 7 and/or 17 polysomy as a prognostic marker for cholangiocarcinoma. Sci Rep 2022; 12:8441. [PMID: 35589822 PMCID: PMC9119972 DOI: 10.1038/s41598-022-11945-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/03/2022] [Indexed: 11/09/2022] Open
Abstract
Cholangiocarcinoma (CCA) is highly endemic in the Northeast Thailand. Recently, chromosome aberrations provided new insights into pathogenesis of CCA. Therefore, chromosome aberration might be used as a prognostic factor and therapeutic planning of this cancer. This aim of this study is to examine the correlation between an increase of chromosome 7 (C7) and/or 17 (C17) copy number variants (CNVs) with clinicopathological data and the overall survival time (OS) of CCA patients using fluorescence in situ hybridization (FISH) assays. C7 and C17 CNVs were examined using FISH form 157 formalin-fixed paraffin-embedded (FFPE) tissues of CCA patients from Khon Kaen, Thailand between 2011 and 2015. OS was visualized using Kaplan-Meier plot. Univariate and multivariate analyses were used to determine the ability of the clinicopathological parameters to predict OS. C17 > trisomy (odd ratio, 6.944, P < 0.001), C7/17 trisomy (odd ratio; 4.488, P = 0.019), and C7/17 > trisomy (odd ratio; 6.723, P < 0.001) were independently predictive factors for lymph node metastasis. Interestingly, an increase of C7, C17, and C7/17 CNVs in both trisomy and > trisomy was independently correlated with short median OS. An increased of C7 and/or 17 have a potential as a poor prognostic marker in CCA patients.
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Affiliation(s)
- Raksawan Deenonpoe
- Department of Pathology, Faculty of Medicine, Khon Kaen University, 123 Mittraparp Road, Muang District, Khon Kaen, 40002, Thailand. .,Cholangiocarcinoma Research Institute (CARI), Khon Kaen University, Khon Kaen, Thailand.
| | - Prakasit Sa-Ngiamwibool
- Department of Pathology, Faculty of Medicine, Khon Kaen University, 123 Mittraparp Road, Muang District, Khon Kaen, 40002, Thailand.,Cholangiocarcinoma Research Institute (CARI), Khon Kaen University, Khon Kaen, Thailand
| | - Sasithorn Watcharadetwittaya
- Department of Pathology, Faculty of Medicine, Khon Kaen University, 123 Mittraparp Road, Muang District, Khon Kaen, 40002, Thailand.,Cholangiocarcinoma Research Institute (CARI), Khon Kaen University, Khon Kaen, Thailand
| | - Malinee Thanee
- Department of Pathology, Faculty of Medicine, Khon Kaen University, 123 Mittraparp Road, Muang District, Khon Kaen, 40002, Thailand.,Cholangiocarcinoma Research Institute (CARI), Khon Kaen University, Khon Kaen, Thailand
| | - Kitti Intuyod
- Department of Pathology, Faculty of Medicine, Khon Kaen University, 123 Mittraparp Road, Muang District, Khon Kaen, 40002, Thailand
| | - Thachanan Kongpan
- Department of Pathology, Faculty of Medicine, Khon Kaen University, 123 Mittraparp Road, Muang District, Khon Kaen, 40002, Thailand
| | - Sureerat Padthaisong
- Faculty of Allied Health Sciences, Burapha University, Chonburi, 20131, Thailand
| | - Rungtiwa Nutalai
- Department of Pathology, Faculty of Medicine, Khon Kaen University, 123 Mittraparp Road, Muang District, Khon Kaen, 40002, Thailand.,Nuffield Department of Medicine, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Yaovalux Chamgramol
- Department of Pathology, Faculty of Medicine, Khon Kaen University, 123 Mittraparp Road, Muang District, Khon Kaen, 40002, Thailand
| | - Chawalit Pairojkul
- Department of Pathology, Faculty of Medicine, Khon Kaen University, 123 Mittraparp Road, Muang District, Khon Kaen, 40002, Thailand
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17
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Owusuaa C, van der Leest C, Helfrich G, Heller-Baan R, van Loenhout CJ, Herbrink JW, Nieboer D, van der Rijt CCD, van der Heide A. The development of the ADO-SQ model to predict 1-year mortality in patients with COPD. Palliat Med 2022; 36:821-829. [PMID: 35331047 PMCID: PMC9087317 DOI: 10.1177/02692163221080662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Goals of end-of-life care must be adapted to the needs of patients with chronic obstructive pulmonary disease (COPD) who are in the last phase of life. However, identification of those patients is limited by moderate performances of existing prognostic models and by limited validation of the often-recommended surprise question. AIM To develop a clinical prediction model to predict 1-year mortality in patients with COPD. DESIGN Prospective study using logistic regression to develop a model in two steps: (1) external validation of the ADO, BODEX, or CODEX models (A = age; B = body mass index; C = comorbidity; D = dyspnea; EX = exacerbations; O = airflow obstruction); (2) updating of best performing model and extending it with the surprise question. Discriminative performance of the new model was assessed using internal-external validation and measured with area under the curve (AUC). A nomogram and web application were developed. SETTINGS/PARTICIPANTS Patients with COPD from five hospitals (September-November 2017). RESULTS Of the 358 included patients (median age 69.5 years, 50% male), 63 (17%) died within a year. The ADO index (AUC 0.73) had the best discriminative ability compared to the BODEX (AUC 0.71) or CODEX (AUC 0.68), and was extended with the surprise question. The resulting ADO-surprise question (SQ) model had an AUC of 0.79. CONCLUSION The ADO-SQ model offers improved discriminative performance for predicting 1-year mortality compared to the surprise question, ADO, BODEX, or CODEX. A user-friendly nomogram and web application (https://dnieboer.shinyapps.io/copd) were developed. Further external validation of the ADO-SQ in patient groups is needed.
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Affiliation(s)
- Catherine Owusuaa
- Department of Medical Oncology, Erasmus
MC Cancer Institute, Rotterdam, The Netherlands
| | - Cor van der Leest
- Department of Pulmonary Diseases,
Amphia Hospital, Breda, The Netherlands
| | - Gea Helfrich
- Department of Pulmonary Diseases,
Maasstad Hospital, Rotterdam, The Netherlands
| | - Roxane Heller-Baan
- Department of Pulmonary Diseases,
Ikazia Hospital, Rotterdam, The Netherlands
| | - CJ van Loenhout
- Department of Pulmonary Diseases,
Admiraal De Ruyter Hospital, Goes, The Netherlands
| | - Jacobine W Herbrink
- Department of Pulmonary Diseases, Van
Weel Bethesda Hospital, Dirksland, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus
MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Carin CD van der Rijt
- Department of Medical Oncology, Erasmus
MC Cancer Institute, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus
MC, Erasmus University Medical Center, Rotterdam, The Netherlands
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18
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Kim YJ, Yoon SJ, Suh SY, Hiratsuka Y, Kang B, Lee SW, Ahn HY, Suh KJ, Kim JW, Kim SH, Kim JW, Lee KW, Kim JH, Lee JS. Performance of clinician prediction of survival in oncology outpatients with advanced cancer. PLoS One 2022; 17:e0267467. [PMID: 35446910 PMCID: PMC9022805 DOI: 10.1371/journal.pone.0267467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 04/08/2022] [Indexed: 11/19/2022] Open
Abstract
Background
We aimed to investigate the performance of clinician prediction of survival (CPS) and the association between CPS and the prognostic confidence of clinicians in ambulatory medical oncology outpatients.
Methods
Eight medical oncologists estimated the expected survival of their patients in a prospective cohort study. They were asked to provide a temporal type of CPS in weeks, together with their level of confidence for each prediction (0–100%). We analyzed the accuracy of CPS, the association between CPS and the prognostic confidence, and the characteristics of patients showing inaccurate CPS.
Results
A total of 200 advanced cancer patients were enrolled and the median overall survival was 7.6 months. CPS was accurate in 67 (33.5%) patients, underestimated in 87 (43.5%), and overestimated in 46 (23.0%). The overall accuracy of CPS for 12-week, 24-week, 36-week, and 48-week survival was 83.0%, 72.0%, 75.5%, and 74.0%, respectively. The specificity was highest for 12-week survival (90.2%) and the sensitivity was highest for 48-week survival (96.1%). The sensitivity of 12-week CPS was 51.4% and the area under the receiver operating characteristic (AUROC) curve was 0.79 (95% confidence interval [CI] 0.71–0.87). The prognostic confidence of clinicians was not significantly associated with the accuracy of prediction (P = 0.359). Patients with overestimated survival had significantly poorer global health status and physical/role/emotional functioning in the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Additionally, they showed significantly higher levels of fatigue, nausea/vomiting, pain, dyspnea, and loss of appetite.
Conclusion
The overall accuracy of CPS in predicting 12-week to 48-week survival was high in medical oncology outpatients. However the sensitivity of 12-week CPS was low and prognostic confidence was not associated with the accuracy of CPS. Patients with overestimated CPS showed poorer quality of life and higher symptom burden.
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Affiliation(s)
- Yu Jung Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Seok Joon Yoon
- Department of Family Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Sang-Yeon Suh
- Department of Family Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
- Department of Medicine, Dongguk University Medical School, Seoul, South Korea
- * E-mail:
| | - Yusuke Hiratsuka
- Department of Palliative Medicine, Takeda General Hospital, Aizu Wakamatsu, Japan
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Beodeul Kang
- Division of Medical Oncology, Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Si Won Lee
- Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Yonsei Cancer Center, Seoul, South Korea
| | - Hong-Yup Ahn
- Department of Statistics, Dongguk University Medical School, Seoul, South Korea
| | - Koung Jin Suh
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ji-Won Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Se Hyun Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin Won Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Keun-Wook Lee
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jee Hyun Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jong Seok Lee
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
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19
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Blum M, Gelfman LP, McKendrick K, Pinney SP, Goldstein NE. Enhancing Palliative Care for Patients With Advanced Heart Failure Through Simple Prognostication Tools: A Comparison of the Surprise Question, the Number of Previous Heart Failure Hospitalizations, and the Seattle Heart Failure Model for Predicting 1-Year Survival. Front Cardiovasc Med 2022; 9:836237. [PMID: 35479267 PMCID: PMC9035562 DOI: 10.3389/fcvm.2022.836237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Score-based survival prediction in patients with advanced heart failure (HF) is complicated. Easy-to-use prognostication tools could inform clinical decision-making and palliative care delivery. Objective To compare the prognostic utility of the Seattle HF model (SHFM), the surprise question (SQ), and the number of HF hospitalizations (NoH) within the last 12 months for predicting 1-year survival in patients with advanced HF. Methods We retrospectively analyzed data from a cluster-randomized controlled trial of advanced HF patients, predominantly with reduced ejection fraction. Primary outcome was the prognostic discrimination of SHFM, SQ (“Would you be surprised if this patient were to die within 1 year?”) answered by HF cardiologists, and NoH, assessed by receiver operating characteristic (ROC) curve analysis. Optimal cut-offs were calculated using Youden’s index (SHFM: <86% predicted 1-year survival; NoH ≥ 2). Results Of 535 subjects, 82 (15.3%) had died after 1-year of follow-up. SHFM, SQ, and NoH yielded a similar area under the ROC curve [SHFM: 0.65 (0.60–0.71 95% CI); SQ: 0.58 (0.54–0.63 95% CI); NoH: 0.56 (0.50–0.62 95% CI)] and similar sensitivity [SHFM: 0.76 (0.65–0.84 95% CI); SQ: 0.84 (0.74–0.91 95% CI); NoH: 0.56 (0.45–0.67 95% CI)]. As compared to SHFM, SQ had lower specificity [SQ: 0.33 (0.28–0.37 95% CI) vs. SHFM: 0.55 (0.50–0.60 95% CI)] while NoH had similar specificity [0.56 (0.51–0.61 95% CI)]. SQ combined with NoH showed significantly higher specificity [0.68 (0.64–0.73 95% CI)]. Conclusion SQ and NoH yielded comparable utility to SHFM for 1-year survival prediction among advanced HF patients, are easy-to-use and could inform bedside decision-making.
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Affiliation(s)
- Moritz Blum
- Department of Internal Medicine and Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- *Correspondence: Moritz Blum,
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- James J. Peters Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center, Bronx, NY, United States
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sean P. Pinney
- Department of Medicine, University of Chicago Medicine, Chicago, IL, United States
| | - Nathan E. Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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20
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Bergsträsser E, Lukose S, Zimmermann K, Oxenius A. Palliative Care in Children With Advanced Heart Disease in a Tertiary Care Environment: A Mini Review. Front Cardiovasc Med 2022; 9:863031. [PMID: 35463792 PMCID: PMC9023876 DOI: 10.3389/fcvm.2022.863031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Palliative care for children continues to evolve. More recently, this has also been true in the field of pediatric cardiology, particularly for children with advanced heart disease. In these children, similarly to children with cancer, treatment successes are offset by the risks of long-term morbidities, including premature death. This mini review aims to provide an overview of current knowledge on children suffering from advanced heart disease, their medical care during various phases of illness (including the palliative and end-of-life phase), symptom burden, experiences of parents, prognostic understanding of parents and physicians, and current status of the involvement of pediatric palliative care. In conclusion, the suffering of these children at the end of their young lives is pronounced and many parents feel prepared neither for medical problems nor for the child’s death. An effective and mutually trusting partnership between pediatric cardiology and pediatric palliative care would appear to be a prerequisite for the timely involvement of palliative care in further supporting these children and their families.
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Affiliation(s)
- Eva Bergsträsser
- Pediatric Palliative Care, Department of Medicine I, University Children’s Hospital Zurich, Zurich, Switzerland
- *Correspondence: Eva Bergsträsser,
| | - Saumya Lukose
- Pediatric Palliative Care, Department of Medicine I, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Karin Zimmermann
- Pediatric Palliative Care, Department of Medicine I, University Children’s Hospital Zurich, Zurich, Switzerland
- Department Public Health, Nursing Science, University of Basel, Basel, Switzerland
| | - Angela Oxenius
- Pediatric Cardiology, Heart Center, University Children’s Hospital Zurich, Zurich, Switzerland
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21
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Sallnow L, Smith R, Ahmedzai SH, Bhadelia A, Chamberlain C, Cong Y, Doble B, Dullie L, Durie R, Finkelstein EA, Guglani S, Hodson M, Husebø BS, Kellehear A, Kitzinger C, Knaul FM, Murray SA, Neuberger J, O'Mahony S, Rajagopal MR, Russell S, Sase E, Sleeman KE, Solomon S, Taylor R, Tutu van Furth M, Wyatt K. Report of the Lancet Commission on the Value of Death: bringing death back into life. Lancet 2022; 399:837-884. [PMID: 35114146 PMCID: PMC8803389 DOI: 10.1016/s0140-6736(21)02314-x] [Citation(s) in RCA: 189] [Impact Index Per Article: 94.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 10/06/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | | | | | - Afsan Bhadelia
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | - Yali Cong
- Peking University Health Science Center, Beijing, China
| | | | | | | | | | | | | | | | | | | | | | | | - Julia Neuberger
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Sarah Russell
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Eriko Sase
- Georgetown University, Washington, DC, USA
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22
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Bloom JR, Marshall DC, Rodriguez-Russo C, Martin E, Jones JA, Dharmarajan KV. Prognostic disclosure in oncology - current communication models: a scoping review. BMJ Support Palliat Care 2022; 12:167-177. [PMID: 35144938 DOI: 10.1136/bmjspcare-2021-003313] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/08/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prognostic disclosure is essential to informed decision making in oncology, yet many oncologists are unsure how to successfully facilitate this discussion. This scoping review determines what prognostic communication models exist, compares and contrasts these models, and explores the supporting evidence. METHOD A protocol was created for this study using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols extension for Scoping Reviews. Comprehensive literature searches of electronic databases MEDLINE, EMBASE, PsycINFO and Cochrane CENTRAL were executed to identify relevant publications between 1971 and 2020. RESULTS In total, 1532 articles were identified, of which 78 met inclusion criteria and contained 5 communication models. Three of these have been validated in randomised controlled trials (the Serious Illness Conversation Guide, the Four Habits Model and the ADAPT acronym) and have demonstrated improved objective communication measures and patient reported outcomes. All three models emphasise the importance of exploring patients' illness understanding and treatment preferences, communicating prognosis and responding to emotion. CONCLUSION Communicating prognostic estimates is a core competency skill in advanced cancer care. This scoping review highlights available communication models and identifies areas in need of further assessment. Such areas include how to maintain learnt communication skills for lifelong practice, how to assess patient and caregiver understanding during and after these conversations, and how to best scale these protocols at the institutional and national levels.
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Affiliation(s)
- Julie Rachel Bloom
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Carlos Rodriguez-Russo
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Martin
- Palliative Care Program, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Joshua Adam Jones
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kavita Vyas Dharmarajan
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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23
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Hoerger M, Gramling R, Epstein R, Fenton JJ, Mohile S, Kravitz R, Mossman B, Prigerson H, Alonzi S, Malhotra K, Duberstein P. Patient, Caregiver, and Oncologist Predictions of Quality of Life in Advanced Cancer: Accuracy and Associations with End-of-Life Care and Caregiver Bereavement. Psychooncology 2022; 31:978-984. [PMID: 35088926 DOI: 10.1002/pon.5887] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/08/2021] [Accepted: 12/15/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Informed treatment decision-making necessitates accurate prognostication,including predictions about quality of life. We examined whether oncologists, patients with advanced cancer, and caregivers accurately predict patients' future quality of life and whether these predictions are prospectively associated with end-of-life care and bereavement. METHODS We secondary analyses of clinical trial data. Patients with advanced cancer (n=156), caregivers (n=156), and oncologists (n=38) predicted patient quality of life 3 months into the future. Patients subsequently rated their quality of life 3 months later. Medical record data documented chemotherapy and emergency department (ED)/inpatient visits in the 30 days before death (n=79 decedents). Caregivers self-reported on depression, anxiety, grief, purpose, 21 and regret 7-months post-mortem. In mixed-effects models, patient, caregiver, and oncologist quality-of-life predictions at study entry were used to predict end-of-life care and caregiver outcomes, controlling for patients' quality of life at 3-month follow-up, demographic and clinical characteristics, and nesting within oncologists. RESULTS Caregivers (P<.0001) and oncologists (P=.001) predicted lower quality of life than what patients actually experienced. Among decedents, 24.0% received chemotherapy and 54.5% had an ED/inpatient visit. When caregivers' predictions were more negative, patients were less likely to receive chemotherapy (P=.028) or have an ED/inpatient visit (P=.033), and caregivers reported worse depression (P=.002), anxiety (P=.019), and grief (P=.028) and less purpose in life (P<.001) 7-months post-mortem. CONCLUSION When caregivers have more negative expectations about patients' quality of life, patients receive less intensive end-of-life care, and caregivers report worse bereavement This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Michael Hoerger
- Tulane Cancer Center, New Orleans, LA.,Tulane University, Department of Psychology, New Orleans, LA
| | - Robert Gramling
- Department of Family Medicine,Burlington, University of Vermont, VT
| | - Ronald Epstein
- Department of Medicine, University of Rochester Medical Center, Rochester, NY.,Wilmot Cancer Institute, Rochester, NY
| | - Joshua J Fenton
- Center forHealthcare Policy and Research, University of California Davis, Sacramento, CA
| | - Supriya Mohile
- Department of Medicine, University of Rochester Medical Center, Rochester, NY.,Wilmot Cancer Institute, Rochester, NY
| | - Richard Kravitz
- Center forHealthcare Policy and Research, University of California Davis, Sacramento, CA.,Departmentof Internal Medicine, University of California Davis, Sacramento, CA
| | - Brenna Mossman
- Tulane University, Department of Psychology, New Orleans, LA
| | - Holly Prigerson
- Weill Cornell Medicine, Department of Medicine, Center for Research on End-of-Life Care, New York, NY
| | - Sarah Alonzi
- Tulane University, Department of Psychology, New Orleans, LA
| | - Kirti Malhotra
- Departmentof Internal Medicine, University of California Davis, Sacramento, CA
| | - Paul Duberstein
- Rutgers School of Public Health,Department of Health Behavior, Society, and Policy, Piscataway, NJ
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24
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Cross SH, Ramkalawan JR, Ring JF, Boucher NA. “That little bit of time”: Transition-to-Hospice Perspectives from Hospice Staff and Bereaved Family. Innov Aging 2022; 6:igab057. [PMID: 35155835 PMCID: PMC8827325 DOI: 10.1093/geroni/igab057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives Many patients lack understanding of hospice services and their preparation for the transition to hospice at home may be insufficient. This study explored how hospice admissions staff and caregivers of hospice patients perceive the hospice admission process and the transition to hospice at home. Research Design and Methods We conducted in-depth, semistructured interviews with 2 subgroups: hospice admissions staff (n = 15) and bereaved caregivers of former hospice patients (n = 20). We performed a 3-coder descriptive content analysis. Results There were 4 overall themes: (a) issues relating to the referring/prehospice provider, (b) issues relating to hospital discharge/care transition home, (c) issues relating to the first touch of hospice, and (d) the impact of coronavirus disease 2019 (COVID-19) on hospice admissions. Patients are often referred to hospice without clear prognostic understanding, at times placing staff in the uncomfortable position of breaking difficult news. Stigma may make patients and families fearful of enrolling in hospice, and misconceptions about hospice are common. Caregivers emphasize the need for increased attention to their emotional needs. Staff revealed the emotional challenges they experience conducting admissions. Both staff and caregivers indicate that the transition to hospice is often emotionally and logistically burdensome, especially when discharging home from the hospital. Both subgroups report insufficient caregiver preparation for taking care of a dying patient at home, particularly regarding medication management. COVID-19 created challenges yet prompted innovative changes to hospice admission processes. Discussion and Implications Findings demonstrate a need to improve the hospice admissions process, better supporting terminally ill patients and their families.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University, Durham, NC, USA
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - Janel R Ramkalawan
- Sanford School of Public Policy, Duke University, Durham, NC, USA
- School of Medicine, Duke University, Durham, NC, USA
| | | | - Nathan A Boucher
- Sanford School of Public Policy, Duke University, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health System HSR&D, Durham, NC, USA
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25
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Bergstraesser E, Thienprayoon R, Brook LA, Fraser LK, Hynson JL, Rosenberg AR, Snaman JM, Weaver MS, Widger K, Zernikow B, Jones CA, Schlögl M. Top Ten Tips Palliative Care Clinicians Should Know About Prognostication in Children. J Palliat Med 2021; 24:1725-1731. [PMID: 34726519 DOI: 10.1089/jpm.2021.0439] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pediatric palliative care (PPC) is different from palliative care (PC) for adults. However, conceptualizing PPC remains cumbersome due to the high heterogeneity of often rare diseases, the high diversity of disease trajectories, and the particular difficulty to predict the future of an individual, severely ill child. This article aims to provide an overview and critical reflection of different aspects of prognostication in children with PC needs. This includes different diseases from neurology to oncology, from the unborn baby to the young adult, new approaches in treatment, advance care planning, and, most important, communication with the affected child as well as parents.
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Affiliation(s)
- Eva Bergstraesser
- Department of Pediatric Palliative Care, University Children's Hospital Zurich, Zurich, Switzerland
| | - Rachel Thienprayoon
- Division of Palliative Care, Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lynda A Brook
- Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Lorna K Fraser
- Martin House Research Centre, University of York, Heslington, United Kingdom
| | - Jenny L Hynson
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Abby R Rosenberg
- Palliative Care and Resilience Lab, Seattle Children's Research Institute, Seattle, Washington, USA.,Department of Pediatrics, Division of Hematology/Oncology, University of Washington School of Medicine, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence at the University of Washington, Seattle, Washington, USA
| | - Jennifer M Snaman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Meaghann S Weaver
- Division of Pediatric Palliative Care, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, Nebraska, USA.,National Center for Ethics in Healthcare, Washington, DC, USA
| | - Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, Univeristy of Toronto, Toronto, Ontario, Canada.,Pediatric Advanced Care Team, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Boris Zernikow
- Pediatric Palliative Care Centre, Children's and Adolescents' Hospital Datteln, Germany.,Department of Children's Pain Therapy and Pediatric Palliative Care, Datteln, Germany.,Faculty of Health-School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,Universtiy Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
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26
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Stone P, White N, Oostendorp LJM, Llewellyn H, Vickerstaff V. Comparing the performance of the palliative prognostic (PaP) score with clinical predictions of survival: A systematic review. Eur J Cancer 2021; 158:27-35. [PMID: 34649086 DOI: 10.1016/j.ejca.2021.08.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/31/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND In patients with advanced cancer, prognosis is usually determined using clinicians' predictions of survival (CPS). The palliative prognostic (PaP) score is a prognostic algorithm that was developed to predict survival in patients with advanced cancer. The score categorises patients into three risk groups in accordance with their probability of surviving for 30 days. The relative accuracy of PaP and CPS is unclear. DESIGN This was a systematic review of MEDLINE, Embase, AMED, CINAHL Plus and the Cochrane Database of Systematic Reviews and Trials from inception up to June 2021. The inclusion criteria were studies in adults with advanced cancer reporting data on performance of both PaP and CPS. Data were extracted on accuracy of prognoses and where available on discrimination (area under the receiver operating characteristic curve or C-index) and/or diagnostic performance (sensitivity, specificity). RESULTS Eleven studies were included. One study reported a direct comparison between PaP risk groups and equivalent risk groups defined by CPS and found that PaP was as accurate as CPS. Five studies reported discrimination of PaP as a continuous total score (rather than using the previously validated risk categories) and reported C-statistics that ranged from 0.64 (95% confidence interval [CI] 0.54, 0.74) up to 0.90 (95% CI 0.87, 0.92). Other studies compared PaP against CPS using non-equivalent metrics (e.g. comparing probability estimates against length of survival estimates). CONCLUSIONS PaP risk categories and CPS are equally able to discriminate between patients with different survival probabilities. Total PaP scores show good discrimination between patients in accordance with their length of survival. The role of PaP in clinical practice still needs to be defined. TRIAL REGISTRATION PROSPERO (CRD42021241074, 5th March 2021).
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Affiliation(s)
- Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK.
| | - Nicola White
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | - Linda J M Oostendorp
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | - Henry Llewellyn
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK; Primary Care and Population Health, Institute of Epidemiology and Health Care, University College London (UCL), London, UK
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27
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Williams S, Layard Horsfall H, Funnell JP, Hanrahan JG, Khan DZ, Muirhead W, Stoyanov D, Marcus HJ. Artificial Intelligence in Brain Tumour Surgery-An Emerging Paradigm. Cancers (Basel) 2021; 13:cancers13195010. [PMID: 34638495 PMCID: PMC8508169 DOI: 10.3390/cancers13195010] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/02/2021] [Accepted: 10/03/2021] [Indexed: 01/01/2023] Open
Abstract
Artificial intelligence (AI) platforms have the potential to cause a paradigm shift in brain tumour surgery. Brain tumour surgery augmented with AI can result in safer and more effective treatment. In this review article, we explore the current and future role of AI in patients undergoing brain tumour surgery, including aiding diagnosis, optimising the surgical plan, providing support during the operation, and better predicting the prognosis. Finally, we discuss barriers to the successful clinical implementation, the ethical concerns, and we provide our perspective on how the field could be advanced.
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Affiliation(s)
- Simon Williams
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
- Correspondence:
| | - Hugo Layard Horsfall
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
| | - Jonathan P. Funnell
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
| | - John G. Hanrahan
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
| | - Danyal Z. Khan
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
| | - William Muirhead
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
| | - Danail Stoyanov
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
| | - Hani J. Marcus
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
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28
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Frydman JL, Hauck K, Lowy J, Gelfman LP. Improving the Care of Patients With Serious Illness: What Are the Palliative Care Education Needs of Internal Medicine Residents? Am J Hosp Palliat Care 2021; 38:1218-1224. [PMID: 33478256 PMCID: PMC9979276 DOI: 10.1177/1049909120987207] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Hospitalized patients with serious illness have significant symptom burden and face complex medical decisions that often require goals of care discussions. Given the shortage of specialty palliative care providers, there is a pressing need to improve the palliative care skills of internal medicine (IM) residents, who have a central role in the care of seriously ill patients hospitalized at academic medical centers. METHODS We conducted an anonymous survey of IM residents at a large, urban, academic medical center to identify which aspects of palliative care trainees find most important and their knowledge gaps in palliative care. The survey measured trainees' self-assessed degree of importance and knowledge of core palliative care skills and evaluated frequency of completing advance care planning documentation. RESULTS Overall, 51 (23%) IM residents completed the survey. The majority of trainees considered multiple palliative care skills to be "very important/important": symptom management, prognostication, introducing the palliative care approach, discussing code status, and breaking serious news. Across these same skills, trainees reported variable levels of knowledge. In our sample, trainees reported completing healthcare proxy forms and Medical Orders for Life-Sustaining Treatment infrequently. CONCLUSIONS IM trainees rated core palliative care skills as important to their practice. Yet, they reported knowledge gaps across multiple core palliative care skills that should be addressed given their role as frontline providers for patients with serious illness.
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Affiliation(s)
- Julia L. Frydman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Kevin Hauck
- Department of Medicine, New York University Grossman School of Medicine
| | - Joseph Lowy
- Department of Medicine, New York University Grossman School of Medicine
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
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29
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Hubbard G, Broadfoot K, Carolan C, van Woerden HC. An Exploratory Qualitative Study of Computer Screening to Support Decision-Making about Use of Palliative Care Registers in Primary Care: GP Think Aloud and Patient and Carer Interviews. J Prim Care Community Health 2021; 12:21501327211024402. [PMID: 34120501 PMCID: PMC8202315 DOI: 10.1177/21501327211024402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objectives: This study aimed to understand factors that influence general practitioner (GP) use of automated computer screening to identify patients for the palliative care register (PCR) and the experiences of palliative care and this emerging technology from patients’ and carers’ perspectives. Methods: A computer screening program electronically searches primary care records in routine clinical practice to identify patients with advanced illness who are not already on a PCR. Five GPs were asked to “think aloud” about adding patients identified by computer screening to the PCR. Key informant interviews with 6 patients on the PCR and 4 carers about their experiences of palliative care while on the PCR and their views of this technology. Data were analyzed thematically. Results and Conclusions: Using computer screening, 29% additional patients were added by GPs to the PCR. GP decision-making for the PCR was informed by clinical factors such as: if being treated with curative intent; having stable or unstable disease; end-stage disease, frailty; the likelihood of dying within the next 12 months; and psychosocial factors such as, age, personality, patient preference and social support. Six (60%) patients/carers did not know that they/their relative was on the PCR. From a patient/carer perspective, having a non-curative illness was not in and of itself sufficient reason for being on the PCR; other factors such as, unstable disease and avoiding pain and suffering were equally if not more, important. Patients and carers considered that computer screening should support but not replace, GP decision-making about the PCR. Computer screening merits ongoing development as a tool to aid clinical decision-making around entry to a PCR, but should not be used as a sole criterion. Care need, irrespective of diagnosis, disease trajectory or prognosis, should determine care.
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Affiliation(s)
- Gill Hubbard
- University of the Highlands and Islands, Inverness, UK
| | | | - Clare Carolan
- University of the Highlands and Islands, Inverness, UK
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30
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Koyama N, Matsumura C, Shitashimizu Y, Sako M, Kurosawa H, Nomura T, Eguchi Y, Ohba K, Yano Y. The role of EORTC QLQ-C15-PAL scores and inflammatory biomarkers in predicting survival in terminally ill patients with cancer. BMC Cancer 2021; 21:304. [PMID: 33757453 PMCID: PMC7988985 DOI: 10.1186/s12885-021-08049-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/16/2021] [Indexed: 01/19/2023] Open
Abstract
Background The clinical use of patient-reported outcomes as compared to inflammatory biomarkers for predicting cancer survival remains a challenge in palliative care settings. We evaluated the role of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative scores (EORTC QLQ-C15-PAL) and the inflammatory biomarkers C-reactive protein (CRP), albumin (Alb), and neutrophil-lymphocyte ratio (NLR) for survival prediction in patients with advanced cancer. Methods This was an observational study in terminally ill patients with cancer hospitalized in a palliative care unit between June 2018 and December 2019. Patients’ data collected at the time of hospitalization were analyzed. Cox regression was performed to examine significant factors influencing survival. A receiver operating characteristic (ROC) analysis was performed to estimate cut-off values for predicting survival within 3 weeks, and a log-rank test was performed to compare survival curves between groups divided by the cut-off values. Results Totally, 130 patients participated in the study. Cox regression suggested that the QLQ-C15-PAL dyspnea and fatigue scores and levels of CRP, Alb, and NLR were significantly associated with survival time, and cut-off values were 66.67, 66.67, 3.0 mg/dL, 2.5 g/dL, and 8.2, respectively. The areas under ROC curves of these variables were 0.6–0.7. There were statistically significant differences in the survival curves between groups categorized using each of these cut-off values (p < .05 for all cases). Conclusion Our findings suggest that the assessment of not only objective indicators for the systemic inflammatory response but also patient-reported outcomes using EORTC QLQ-C15-PAL is beneficial for the prediction of short-term survival in terminally ill patients with cancer. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08049-3.
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Affiliation(s)
- Nanako Koyama
- Education and Research Center for Clinical Pharmacy, Kyoto Pharmaceutical University, 5-Nakauchi-cho, Misasagi, Yamashina-ku, Kyoto, 607-8414, Japan
| | - Chikako Matsumura
- Education and Research Center for Clinical Pharmacy, Kyoto Pharmaceutical University, 5-Nakauchi-cho, Misasagi, Yamashina-ku, Kyoto, 607-8414, Japan
| | - Yoshihiro Shitashimizu
- Education and Research Center for Clinical Pharmacy, Kyoto Pharmaceutical University, 5-Nakauchi-cho, Misasagi, Yamashina-ku, Kyoto, 607-8414, Japan
| | - Morito Sako
- Department of Pharmacy, Tachibana Medical Corporation Higashisumiyoshi-Morimoto Hospital, Osaka, Japan
| | - Hideo Kurosawa
- Department of Pharmacy, Tachibana Medical Corporation Higashisumiyoshi-Morimoto Hospital, Osaka, Japan
| | - Takehisa Nomura
- Department of Pharmacy, Tachibana Medical Corporation Higashisumiyoshi-Morimoto Hospital, Osaka, Japan
| | - Yuki Eguchi
- Palliative Care Unit, Tachibana Medical Corporation Higashisumiyoshi-Morimoto Hospital, Osaka, Japan
| | - Kazuki Ohba
- Department of Palliative Care, Tachibana Medical Corporation Higashisumiyoshi-Morimoto Hospital, Osaka, Japan
| | - Yoshitaka Yano
- Education and Research Center for Clinical Pharmacy, Kyoto Pharmaceutical University, 5-Nakauchi-cho, Misasagi, Yamashina-ku, Kyoto, 607-8414, Japan.
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Yarnell CJ, Jewell LM, Astell A, Pinto R, Devine LA, Detsky ME, Downar J, Ilan R, Rawal S, Wong N, You JJ, Fowler RA. Observational study of agreement between attending and trainee physicians on the surprise question: "Would you be surprised if this patient died in the next 12 months?". PLoS One 2021; 16:e0247571. [PMID: 33630939 PMCID: PMC7906409 DOI: 10.1371/journal.pone.0247571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/10/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Optimal end-of-life care requires identifying patients that are near the end of life. The extent to which attending physicians and trainee physicians agree on the prognoses of their patients is unknown. We investigated agreement between attending and trainee physician on the surprise question: "Would you be surprised if this patient died in the next 12 months?", a question intended to assess mortality risk and unmet palliative care needs. METHODS This was a multicentre prospective cohort study of general internal medicine patients at 7 tertiary academic hospitals in Ontario, Canada. General internal medicine attending and senior trainee physician dyads were asked the surprise question for each of the patients for whom they were responsible. Surprise question response agreement was quantified by Cohen's kappa using Bayesian multilevel modeling to account for clustering by physician dyad. Mortality was recorded at 12 months. RESULTS Surprise question responses encompassed 546 patients from 30 attending-trainee physician dyads on academic general internal medicine teams at 7 tertiary academic hospitals in Ontario, Canada. Patients had median age 75 years (IQR 60-85), 260 (48%) were female, and 138 (25%) were dependent for some or all activities of daily living. Trainee and attending physician responses agreed in 406 (75%) patients with adjusted Cohen's kappa of 0.54 (95% credible interval 0.41 to 0.66). Vital status was confirmed for 417 (76%) patients of whom 160 (38% of 417) had died. Using a response of "No" to predict 12-month mortality had positive likelihood ratios of 1.84 (95% CrI 1.55 to 2.22, trainee physicians) and 1.51 (95% CrI 1.30 to 1.72, attending physicians), and negative likelihood ratios of 0.31 (95% CrI 0.17 to 0.48, trainee physicians) and 0.25 (95% CrI 0.10 to 0.46, attending physicians). CONCLUSION Trainee and attending physician responses to the surprise question agreed in 54% of cases after correcting for chance agreement. Physicians had similar discriminative accuracy; both groups had better accuracy predicting which patients would survive as opposed to which patients would die. Different opinions of a patient's prognosis may contribute to confusion for patients and missed opportunities for engagement with palliative care services.
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Affiliation(s)
- Christopher J. Yarnell
- Institute of Health Management, Policy, and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, Sinai Health System, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Laura M. Jewell
- Memorial University of Newfoundland, Discipline of Family Medicine, Happy Valley-Goose Bay, Canada
| | - Alex Astell
- University of Manitoba Faculty of Medicine, Section of Critical Care Medicine, Manitoba, Canada
| | - Ruxandra Pinto
- Sunnybrook Health Sciences Centre Department of Critical Care, Toronto, Canada
| | - Luke A. Devine
- Department of Medicine, Sinai Health System, Toronto, Canada
- University of Toronto Temerty Faculty of Medicine, Division of General Internal Medicine, Toronto, Canada
| | - Michael E. Detsky
- Department of Medicine, Sinai Health System, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - James Downar
- The Ottawa Hospital, Ottawa, Canada
- University of Ottawa Faculty of Medicine, Division of Palliative Care, Ottawa, Canada
| | - Roy Ilan
- Department of Critical Care Medicine, Rambam Health Care Campus, Technion, Israel Institute of Technology, Haifa, Israel
| | - Shail Rawal
- University of Toronto Temerty Faculty of Medicine, Division of General Internal Medicine, Toronto, Canada
- University Health Network, General Internal Medicine, Toronto, Canada
| | - Natalie Wong
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- University of Toronto Temerty Faculty of Medicine, Division of General Internal Medicine, Toronto, Canada
- Departments of General Internal Medicine and Critical Care Medicine, St Michael’s Hospital, Toronto, Canada
| | - John J. You
- Division of General Internal and Hospitalist Medicine, Department of Medicine, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Rob A. Fowler
- Institute of Health Management, Policy, and Evaluation, University of Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Centre Department of Critical Care, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
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Owusuaa C, van Beelen I, van der Heide A, van der Rijt CCD. Physicians' views on the usefulness and feasibility of identifying and disclosing patients' last phase of life: a focus group study. BMJ Support Palliat Care 2021:bmjspcare-2020-002764. [PMID: 33619221 DOI: 10.1136/bmjspcare-2020-002764] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Accurate assessment that a patient is in the last phase of life is a prerequisite for timely initiation of palliative care in patients with a life-limiting disease, such as advanced cancer or advanced organ failure. Several palliative care quality standards recommend the surprise question (SQ) to identify those patients. Little is known about physicians' views on identifying and disclosing the last phase of life of patients with different illness trajectories. METHODS Data from two focus groups were analysed using thematic analysis with a phenomenological approach. RESULTS Fifteen medical specialists and general practitioners participated. Participants thought prediction of patients' last phase of life, i.e. expected death within 1 year, is important. They seemed to find that prediction is more difficult in patients with advanced organ failure compared with cancer. The SQ was considered a useful prognostic tool; its use is facilitated by its simplicity but hampered by its subjective character. The medical specialist was considered mainly responsible for prognosticating and gradually disclosing the last phase. Participants' reluctance to such disclosure was related to uncertainty around prognostication, concerns about depriving patients of hope, affecting the physician-patient relationship, or a lack of time or availability of palliative care services. CONCLUSIONS Physicians consider the assessment of patients' last phase of life important and support use of the SQ in patients with different illness trajectories. However, barriers in disclosing expected death are prognostic uncertainty, possible deprivation of hope, physician-patient relationship, and lack of time or palliative care services. Future studies should examine patients' preferences for those discussions.
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Affiliation(s)
- Catherine Owusuaa
- Medical Oncology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Irene van Beelen
- Medical Oncology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
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Tarbi EC, Gramling R, Bradway C, Broden EG, Meghani SH. "I Had a Lot More Planned": The Existential Dimensions of Prognosis Communication with Adults with Advanced Cancer. J Palliat Med 2021; 24:1443-1454. [PMID: 33534644 DOI: 10.1089/jpm.2020.0696] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Communication about prognosis is a key ingredient of effective palliative care. When patients with advanced cancer develop increased prognostic understanding, there is potential for existential distress to occur. However, the existential dimensions of prognosis communication are underexplored. Objective: To describe the existential dimensions of prognosis communication in naturally-occurring palliative care conversations. Methods: This study was an explanatory sequential mixed methods design. We analyzed a random subset of patients from the Palliative Care Communication Research Initiative (PCCRI) parent study (n = 34, contributing to 45 palliative care conversations). Data were based on audio-recorded and transcribed inpatient palliative care conversations between adults with advanced cancer, their families, and palliative care clinicians. We stratified the study sample by levels of prognosis communication, and qualitatively examined patterns of existential communication, comparing the intensity, frequency, and content, within and across levels. Results: Existential communication was more common, and of stronger intensity, within conversations with higher levels of prognosis communication. Conversations with more prognosis communication appeared to exhibit a shift toward the existential and away from the more physical nature of the serious illness experience. Conclusion: Existential and prognosis communication are intimately linked within palliative care conversations. Results highlight the multiplicity and mutuality of concerns that arise when contemplating mortality, drawing attention to areas of palliative care communication that warrant future research.
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Affiliation(s)
- Elise C Tarbi
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Robert Gramling
- Department of Family Medicine, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Christine Bradway
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Elizabeth G Broden
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Salimah H Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Kubi B, Johnston FM. A 3-month Journey: The Case of a 29-year Old Woman With Metastatic Renal Cell Carcinoma. Am Surg 2020; 86:1445-1449. [PMID: 33135421 DOI: 10.1177/0003134820965956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Early goal-oriented conversations at the end of life can help alleviate suffering and anxiety for surgical patients with cancer and their loved ones. This is especially important in the young adult population in whom there are limited patient-reported perspectives about their experiences at the end of life. We report the illustrative case of a 29-year-old woman who underwent palliative surgery for widely metastatic renal cell carcinoma. Her postoperative course was complicated by a proximal anastomotic stricture, bilateral pulmonary emboli, and delayed gastric emptying, ultimately leading to a functional decline in health and quality of life. Several wide-ranging palliative care needs arose during our patient's surgery, discharge, and subsequent readmissions. In addition to our patient's case, we discuss 3 fundamental surgical palliative care principles, and broad considerations for end-of-life management of young adults with advanced malignancies.
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Affiliation(s)
- Boateng Kubi
- School of Medicine, 1500Johns Hopkins University, Baltimore, MD, USA
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35
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Ansari AA, Pomerantz DH, Abedini N, Jayes RL, Matti-Orozco B, Havyer RD. Clinical Progress Note: Addressing Prognosis in Advanced Dementia. J Hosp Med 2020; 15:678-680. [PMID: 31634101 DOI: 10.12788/jhm.3316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 08/23/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Aziz A Ansari
- Division of Hospital Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Daniel H Pomerantz
- Division of General Internal Medicine and Department of Family Medicine (Palliative Care), Albert Einstein College of Medicine, Bronx, New York
- Department of Medicine, Montefiore New Rochelle Hospital, New Rochelle, New York
| | - Nauzley Abedini
- Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan
- National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan
| | - Robert L Jayes
- Division of Geriatrics and Palliative Medicine, George Washington University Medical Faculty Associates, Washington, DC
| | - Brenda Matti-Orozco
- Division of General Internal Medicine & Palliative Medicine, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Rachel D Havyer
- Division of Community Internal Medicine and Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota
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Levoy K, Tarbi EC, De Santis JP. End-of-life decision making in the context of chronic life-limiting disease: a concept analysis and conceptual model. Nurs Outlook 2020; 68:784-807. [PMID: 32943221 PMCID: PMC7704858 DOI: 10.1016/j.outlook.2020.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 06/26/2020] [Accepted: 07/10/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Conceptual ambiguities prevent advancements in end-of-life decision making in clinical practice and research. PURPOSE To clarify the components of and stakeholders (patients, caregivers, healthcare providers) involved in end-of-life decision making in the context of chronic life-limiting disease and develop a conceptual model. METHOD Walker and Avant's approach to concept analysis. FINDINGS End-of-life decision making is a process, not a discrete event, that begins with preparation, including decision maker designation and iterative stakeholder communication throughout the chronic illness (antecedents). These processes inform end-of-life decisions during terminal illness, involving: 1) serial choices 2) weighed in terms of potential outcomes 3) through patient and caregiver collaboration (attributes). Components impact patients' death, caregivers' bereavement, and healthcare systems' outcomes (consequences). DISCUSSION Findings provide a foundation for improved inquiry into and measurement of the end-of-life decision making process, accounting for the dose, content, and quality the antecedent and attribute factors that collectively contribute to outcomes.
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Affiliation(s)
- Kristin Levoy
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA.
| | - Elise C Tarbi
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Joseph P De Santis
- University of Miami School of Nursing and Health Studies, Coral Gables, FL
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Zhou J, Xu S, Cao Z, Tang J, Fang X, Qin L, Zhou F, He Y, Zhong X, Hu M, Wang Y, Lu F, Bao Y, Dai X, Wu Q. Validation of the Palliative Prognostic Index, Performance Status-Based Palliative Prognostic Index and Chinese Prognostic Scale in a home palliative care setting for patients with advanced cancer in China. BMC Palliat Care 2020; 19:167. [PMID: 33129305 PMCID: PMC7603699 DOI: 10.1186/s12904-020-00676-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 10/22/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The predictive value of the prognostic tool for patients with advanced cancer is uncertain in mainland China, especially in the home-based palliative care (HPC) setting. This study aimed to compare the accuracy of the Palliative Prognostic Index (PPI), the Performance Status-Based Palliative Prognostic Index (PS-PPI), and the Chinese Prognosis Scale (ChPS) for patients with advanced cancer in the HPC setting in mainland China. METHODS Patients with advanced cancer admitted to the hospice center of Yuebei People's Hospital between January 2014 and December 2018 were retrospectively calculated the scores according to the three prognostic tools. The Kaplan-Meier method was used to compare survival times among different risk groups. Receiver operating characteristic curve analysis was used to assess the predictive value. The accuracy of 21-, 42- and 90-day survival was compared among the three prognostic tools. RESULTS A total of 1863 patients were included. Survival time among the risk groups of all prognostic tools was significantly different from each other except for the PPI. The AUROC of the ChPS was significantly higher than that of the PPI and PS-PPI for 7-, 14, 21-, 42-, 90-, 120-, 150- and 180-day survival (P < 0.05). The AUROC of the PPI and PS-PPI were not significantly different from each other (P > 0.05). CONCLUSIONS The ChPS is more suitable than the PPI and PS-PPI for advanced cancer patients in the HPC setting. More researches are needed to verify the predictive value of the ChPS, PPI, and PS-PPI in the HPC setting in the future.
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Affiliation(s)
- Jun Zhou
- Department of Spine Surgery, Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong China
| | - Sitao Xu
- Department of Spine Surgery, Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong China
| | - Ziye Cao
- Department of Spine Surgery, Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong China
| | - Jing Tang
- Department of Spine Surgery, Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong China
| | - Xiang Fang
- Department of Spine Surgery, Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong China
| | - Ling Qin
- Department of Spine Surgery, Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong China
| | - Fangping Zhou
- Department of Nursing, Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong China
| | - Yuzhen He
- Department of Nursing, Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong China
- Hospice center of Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong China
| | - Xueren Zhong
- Department of Spine Surgery, Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong China
| | - Mingcai Hu
- Hospice center of Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong China
| | - Yan Wang
- Emergency rescue command center of Shaoguan city, Shaoguan, Guangdong China
| | - Fengjuan Lu
- Hospice center of Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi China
| | - Yongzheng Bao
- Department of Spine Surgery, Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong China
| | - Xiangheng Dai
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong China
| | - Qiang Wu
- Department of Spine Surgery, Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong China
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Development of a Patient-Centered Framework for Oncology Clinicians to Address Uncertainty in Cancer Care During the COVID-19 Pandemic. Curr Treat Options Oncol 2020; 21:99. [PMID: 33119833 PMCID: PMC7594962 DOI: 10.1007/s11864-020-00795-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 01/26/2023]
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Hauge AM. One last round of chemo? Insights from conversations between oncologists and lung cancer patients about prognosis and treatment decisions. Soc Sci Med 2020; 266:113413. [PMID: 33096509 DOI: 10.1016/j.socscimed.2020.113413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/18/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Abstract
One more chemo or one too many? The increasing use of expensive cancer treatments close to the patient's death is often explained by oncologists' failure to communicate to patients how close to dying they are, implying that patients are often both ill-prepared and over-treated when they die. This article aims at interrogating the politically charged task of prognosticating. Drawing on an ethnographic study of conversations between oncologists and patients with metastatic lung cancer in a Danish oncology clinic, I show that oncologists utilize, rather than avoid, prognostication in their negotiations with patients about treatment withdrawal. The study informs the emerging sociology of prognosis in three ways: First, prognostication is not only about foreseeing and foretelling, but also about shaping the patient's process of dying. Second, oncologists prognosticate differently depending on the level of certainty about the patient's trajectory. To unfold these differences, the article provides a terminology that distinguishes between four 'modes of prognostication', namely hinting, informing, calibrating and organizing. Third, prognosticating can unfold over time through multiple consultations, emphasizing the relevance of adopting methodologies enabling the study of prognosticating over time.
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Affiliation(s)
- Amalie M Hauge
- VIVE - the Danish Center for Social Science Research, Herluf Trollesgade 11, 1052, København K, Denmark.
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Ho GK(E, Chye R, Jang D, Sutton P, Sullivan S, Seah D. Factors Associated with Re-Enrollment of Patients from a Specialist Community Palliative Care Service. J Palliat Med 2020; 23:1342-1348. [DOI: 10.1089/jpm.2019.0385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ge Kai (Eunice) Ho
- HammondCare Palliative and Supportive Care Services, Greenwich Hospital, Sydney, New South Wales, Australia
- Sacred Heart Supportive and Palliative Care, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Richard Chye
- Sacred Heart Supportive and Palliative Care, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales Medicine, New South Wales, Australia
- School of Medicine, University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Danny Jang
- Sacred Heart Supportive and Palliative Care, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Patricia Sutton
- Sacred Heart Supportive and Palliative Care, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Palliative Care Service, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Sandra Sullivan
- Sacred Heart Supportive and Palliative Care, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Primary and Community Health Service, Bankstown Community Health, South Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Davinia Seah
- Sacred Heart Supportive and Palliative Care, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales Medicine, New South Wales, Australia
- School of Medicine, University of Notre Dame Australia, Sydney, New South Wales, Australia
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Prognostic Tools in Hospice and Palliative Medicine. PHYSICIAN ASSISTANT CLINICS 2020. [DOI: 10.1016/j.cpha.2020.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Prognostication is a vital aspect of decision making because it provides patients and families with information to establish realistic and achievable goals of care, is used in determining eligibility for certain benefits, and helps in targeting interventions to those likely to benefit. Prognostication consists of 3 components: clinicians use their clinical judgment or other tools to estimate the probability of an individual developing a particular outcome over a specific period of time; this prognostic estimate is communicated in accordance with the patient's information preferences; the prognostic estimate is interpreted by the patient or surrogate and used in clinical decision making.
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Affiliation(s)
- Emily J Martin
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles, 757 Westwood Plaza Suite 7501, Los Angeles, CA 90095, USA.
| | - Eric Widera
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, 4150 Clement Street, Box 181G, San Francisco, CA 94121, USA. https://twitter.com/EWidera
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Chu C, Anderson R, White N, Stone P. Prognosticating for Adult Patients With Advanced Incurable Cancer: a Needed Oncologist Skill. Curr Treat Options Oncol 2020; 21:5. [PMID: 31950387 PMCID: PMC6965075 DOI: 10.1007/s11864-019-0698-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patients with advanced cancer and their families commonly seek information about prognosis to aid decision-making in medical (e.g. surrounding treatment), psychological (e.g. saying goodbye), and social (e.g. getting affairs in order) domains. Oncologists therefore have a responsibility to identify and address these requests by formulating and sensitively communicating information about prognosis. Current evidence suggests that clinician predictions are correlated with actual survival but tend to be overestimations. In an attempt to cultivate prognostic skills, it is recommended that clinicians practice formulating and recording subjective estimates of prognosis in advanced cancer patient’s medical notes. When possible, a multi-professional prognostic estimate should be sought as these may be more accurate than individual predictions alone. Clinicians may consider auditing the accuracy of their predictions periodically and using feedback from this process to improve their prognostic skills. Clinicians may also consider using validated prognostic tools to complement their clinical judgements. However, there is currently only limited evidence about the comparative accuracy of different prognostic tools or the extent to which these measures are superior to clinical judgement. Oncologists and palliative care physicians should ensure that they receive adequate training in advanced communication skills, which builds upon their pre-existing skills, to sensitively deliver information on prognosis. In particular, clinicians should acknowledge their own prognostic uncertainty and should emphasise the supportive care that can continue to be provided after stopping cancer-directed therapies.
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Affiliation(s)
- Christina Chu
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Rebecca Anderson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Nicola White
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
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White N, Oostendorp LJM, Tomlinson C, Yardley S, Ricciardi F, Gökalp H, Minton O, Boland JW, Clark B, Harries P, Stone P. Online training improves medical students' ability to recognise when a person is dying: The ORaClES randomised controlled trial. Palliat Med 2020; 34:134-144. [PMID: 31722611 PMCID: PMC6952943 DOI: 10.1177/0269216319880767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recognising dying is a key clinical skill for doctors, yet there is little training. AIM To assess the effectiveness of an online training resource designed to enhance medical students' ability to recognise dying. DESIGN Online multicentre double-blind randomised controlled trial (NCT03360812). The training resource for the intervention group was developed from a group of expert palliative care doctors' weightings of various signs/symptoms to recognise dying. The control group received no training. SETTING/PARTICIPANTS Participants were senior UK medical students. They reviewed 92 patient summaries and provided a probability of death within 72 hours (0% certain survival - 100% certain death) pre, post, and 2 weeks after the training. Primary outcome: (1) Mean Absolute Difference (MAD) score between participants' and the experts' scores, immediately post intervention. Secondary outcomes: (2) weight attributed to each factor, (3) learning effect and (4) level of expertise (Cochran-Weiss-Shanteau (CWS)). RESULTS Out of 168 participants, 135 completed the trial (80%); 66 received the intervention (49%). After using the training resource, the intervention group had better agreement with the experts in their survival estimates (δMAD = -3.43, 95% CI -0.11 to -0.34, p = <0.001) and weighting of clinical factors. There was no learning effect of the MAD scores at the 2-week time point (δMAD = 1.50, 95% CI -0.87 to 3.86, p = 0.21). At the 2-week time point, the intervention group was statistically more expert in their decision-making versus controls (intervention CWS = 146.04 (SD 140.21), control CWS = 110.75 (SD 104.05); p = 0.01). CONCLUSION The online training resource proved effective in altering the decision-making of medical students to agree more with expert decision-making.
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Affiliation(s)
- Nicola White
- Marie Curie Palliative Care Research
Department, Division of Psychiatry, University College London (UCL), London,
UK
| | - Linda JM Oostendorp
- Marie Curie Palliative Care Research
Department, Division of Psychiatry, University College London (UCL), London,
UK
| | | | - Sarah Yardley
- Marie Curie Palliative Care Research
Department, Division of Psychiatry, University College London (UCL), London,
UK
- Central and North West London NHS
Foundation Trust, London, UK
| | - Federico Ricciardi
- Marie Curie Palliative Care Research
Department, Division of Psychiatry, University College London (UCL), London,
UK
- Department of Statistical Science,
University College London (UCL), London, UK
| | - Hülya Gökalp
- Department of Electrical and Electronics
Engineering, Ondokuz Mayis University, Samsun, Turkey
- Department of Clinical Sciences, Brunel
University London, London, UK
| | - Ollie Minton
- Brighton and Sussex University Hospitals
NHS Trust, Brighton, UK
| | | | - Ben Clark
- Imperial College Healthcare NHS Trust,
London, UK
| | - Priscilla Harries
- Department of Clinical Sciences, Brunel
University London, London, UK
- Centre for Applied Health and Social
Care Research, Faculty of Health, Social Care and Education, Kingston University and
St George’s, University of London, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research
Department, Division of Psychiatry, University College London (UCL), London,
UK
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Preto DD, Pantano NDP, Paiva BSR, Zanardo CDO, Paiva CE. Clinical Prediction of Survival in Advanced Cancer Outpatients: Do Experienced Physicians and With Prior Patient Evaluation Make More Accurate Predictions? J Pain Symptom Manage 2020; 59:e7-e10. [PMID: 31585161 DOI: 10.1016/j.jpainsymman.2019.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 11/23/2022]
Affiliation(s)
- Daniel D'Almeida Preto
- Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Department of Clinical Oncology, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.
| | - Naitielle de Paula Pantano
- Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Researcher Support Centre, Learning and Research Institute, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Bianca Sakamoto Ribeiro Paiva
- Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Researcher Support Centre, Learning and Research Institute, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Cleyton de Oliveira Zanardo
- Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Researcher Support Centre, Learning and Research Institute, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Carlos Eduardo Paiva
- Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Department of Clinical Oncology, Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Researcher Support Centre, Learning and Research Institute, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
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Raubenheimer PJ, Day C, Abdullah F, Manning K, Cupido C, Peter J. The utility of a shortened palliative care screening tool to predict death within 12 months - a prospective observational study in two south African hospitals with a high HIV burden. BMC Palliat Care 2019; 18:101. [PMID: 31722691 PMCID: PMC6854790 DOI: 10.1186/s12904-019-0487-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/04/2019] [Indexed: 12/02/2022] Open
Abstract
Background Timely identification of people who are at risk of dying is an important first component of end-of-life care. Clinicians often fail to identify such patients, thus trigger tools have been developed to assist in this process. We aimed to evaluate the performance of a identification tool (based on the Gold Standards Framework Prognostic Indicator Guidance) to predict death at 12 months in a population of hospitalised patients in South Africa. Methods Patients admitted to the acute medical services in two public hospitals in Cape Town, South Africa were enrolled in a prospective observational study. Demographic data were collected from patients and patient notes. Patients were assessed within two days of admission by two trained clinicians who were not the primary care givers, using the identification tool. Outcome mortality data were obtained from patient folders, the hospital electronic patient management system and the Western Cape Provincial death registry which links a unique patient identification number with national death certificate records and system wide electronic records. Results 822 patients (median age of 52 years), admitted with a variety of medical conditions were assessed during their admission. 22% of the cohort were HIV-infected. 218 patients were identified using the screening tool as being in the last year of their lives. Mortality in this group was 56% at 12 months, compared with 7% for those not meeting any criteria. The specific indicator component of the tool performed best in predicting death in both HIV-infected and HIV-uninfected patients, with a sensitivity of 74% (68–81%), specificity of 85% (83–88%), a positive predictive value of 56% (49–63%) and a negative predictive value of 93% (91–95%). The hazard ratio of 12-month mortality for those identified vs not was 11.52 (7.87–16.9, p < 0.001). Conclusions The identification tool is suitable for use in hospitals in low-middle income country setting that have both a high communicable and non-communicable disease burden amongst young patients, the majority under age 60.
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Affiliation(s)
- Peter J Raubenheimer
- Division of General Medicine, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa.
| | - Cascia Day
- Division of General Medicine, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Faried Abdullah
- Division of General Medicine, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Katherine Manning
- Division of General Medicine, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Clint Cupido
- Division of General Medicine, Department of Medicine, Victoria Hospital Wynberg and University of Cape Town, Cape Town, South Africa
| | - Jonny Peter
- Division of General Medicine, and Division of Immunology and Allergology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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Abstract
An accurate prognosis about how long a terminally ill patient has left to live, when disclosed sensitively in open discussions, can facilitate patient-centred care and shared decision making. In addition, several guidelines, policies and funding streams rely, to some extent, on a clinician estimated prognosis. However, clinician predictions alone have been shown to be unreliable and over-optimistic. The factors underlying clinicians' prognostic decisions (particularly at the very end of life) are beginning to be elucidated. As an alternative to clinicians' subjective estimates, a number of prognostic algorithms and scores have been developed and validated, but only a few have consistently shown superiority to clinician predictions. Therefore, an element of uncertainty remains and this needs to be acknowledged when having conversations with patients and their families. Guidelines are available to advise clinicians about how to prepare for, participate in and record prognostic conversations.
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Affiliation(s)
- Christina Chu
- University College London, London, UK and specialty trainee in palliative medicine, Barts Health NHS Trust, London, UK
| | - Nicola White
- Marie Curie Palliative Care Research Department, University College London, London, UK
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O’Connor M, Breen LJ, Watts KJ, James H, Goodridge R. A Tripartite Model of Community Attitudes to Palliative Care. Am J Hosp Palliat Care 2019; 36:877-884. [DOI: 10.1177/1049909119858352] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Despite a growth in palliative care services, access and referral patterns are inconsistent and only a minority of people who would benefit from such care receive it. Use of palliative care is also affected by community attitudes toward palliative care. As such, determining community attitudes toward palliative care is crucial. We also need to determine what predicts attitudes in order to provide appropriate information and education. Objectives: The 2 research questions were: (1) What are community attitudes toward palliative care? and (2) what are the determinants of community attitudes toward palliative care? Design: A tripartite model of attitudes was used, which articulates attitudes as comprising knowledge and experience, emotions, and beliefs. A cross-sectional descriptive survey was used. Participants: A community sample of 180 participants completed the survey. Results: The average attitude and belief responses were very positive, the average emotions responses were somewhat positive. The sample had good knowledge of palliative care. Lowest knowledge scores were reported for the items: “Euthanasia is not part of palliative care,” “Palliative care does not prolong or shorten life,” and “Specialist palliative care is only available in hospitals.” After controlling place of birth and age, it was found that beliefs, emotions, and knowledge each accounted for a significant proportion of unique variance in attitude toward palliative care. Each variable had a positive relationship with attitude. Conclusion: Beliefs, emotions, and knowledge all need to be incorporated into palliative care community education programs.
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Affiliation(s)
- Moira O’Connor
- School of Psychology, Curtin University, Perth, Western Australia
| | - Lauren J. Breen
- School of Psychology, Curtin University, Perth, Western Australia
| | - Kaaren J. Watts
- School of Psychology, Curtin University, Perth, Western Australia
| | - Henry James
- School of Psychology, Curtin University, Perth, Western Australia
| | - Rhys Goodridge
- School of Psychology, Curtin University, Perth, Western Australia
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Ingersoll LT, Alexander SC, Priest J, Ladwig S, Anderson W, Fiscella K, Epstein RM, Norton SA, Gramling R. Racial/ethnic differences in prognosis communication during initial inpatient palliative care consultations among people with advanced cancer. PATIENT EDUCATION AND COUNSELING 2019; 102:1098-1103. [PMID: 30642715 DOI: 10.1016/j.pec.2019.01.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/12/2018] [Accepted: 01/02/2019] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- Luke T Ingersoll
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America.
| | - Stewart C Alexander
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Jeff Priest
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Susan Ladwig
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Wendy Anderson
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Kevin Fiscella
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Ronald M Epstein
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Sally A Norton
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Robert Gramling
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
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Ingersoll LT, Alexander SC, Ladwig S, Anderson W, Norton SA, Gramling R. The contagion of optimism: The relationship between patient optimism and palliative care clinician overestimation of survival among hospitalized patients with advanced cancer. Psychooncology 2019; 28:1286-1292. [PMID: 31020758 DOI: 10.1002/pon.5080] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/28/2019] [Accepted: 04/01/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Clinicians frequently overestimate survival time among seriously ill patients, and this can result in medical treatment at end of life that does not reflect the patient's preferences. Little is known, however, about the sources of clinicians' optimistic bias in survival estimation. Related work in social networks and experimental psychology demonstrates that psychological states-such as optimism-can transfer from one person to another. METHODS We directly observed and audio recorded 189 initial inpatient palliative care consultations among hospitalized patients with advanced cancer. Patients self-reported their level of trait optimism and expectations for survival prognosis prior to the palliative care consultation, and the palliative care clinicians rated their expectations for the patient's survival time following the initial conversation with the patient. We followed patient mortality for 6 months. RESULTS Patient optimism was associated with clinician overestimation of their survival in a dose-response relationship. Clinicians were approximately three times as likely to overestimate the survival of patients endorsing both high trait optimism and optimistic ratings of their survival time compared with neither (OR: 2.95; 95% CI: 1.24-7.02). This association was not attenuated by adjustment for age, gender, race, ethnicity, education, income, cancer type, functional status, quality of life, or white blood cell count (ORadj : 3.45; 95% CI: 1.24-9.66). CONCLUSION Patients' optimism may have some influence over their clinicians' prognostic judgments.
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Affiliation(s)
- Luke T Ingersoll
- Department of Consumer Science, Purdue University, West Lafayette, IN
| | | | - Susan Ladwig
- Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | - Wendy Anderson
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Sally A Norton
- School of Nursing, University of Rochester Medical Center, Rochester, NW
| | - Robert Gramling
- Palliative Medicine Division, University of Vermont Medical Center, Burlington, VT
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