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Cailleteau A, Ferrer L, Geffroy D, Fleury V, Lalire P, Doré M, Rousseau C. Are Dual-Phase 18F-Fluorodeoxyglucose PET-mpMRI Diagnostic Performances to Distinguish Brain Tumour Radionecrosis/Recurrence after Cranial Radiotherapy Usable in Routine? Cancers (Basel) 2024; 16:3216. [PMID: 39335186 PMCID: PMC11429908 DOI: 10.3390/cancers16183216] [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: 08/20/2024] [Revised: 09/11/2024] [Accepted: 09/16/2024] [Indexed: 09/30/2024] Open
Abstract
Brain metastases or primary brain tumours had poor prognosis until the use of high dose radiotherapy. However, radionecrosis is a complex challenge in the post-radiotherapy management of these patients due to the difficulty of distinguishing this complication from local tumour recurrence. MRI alone has a variable specificity and sensibility, as does PET-CT imaging. We aimed to investigate the diagnostic performance of dual-phase 18F-FDG PET-mpMRI to distinguish cerebral radionecrosis from local tumour recurrence after cranial radiotherapy. A retrospective analysis was conducted between May 2021 and September 2022. Inclusion criteria encompassed patients with inconclusive MRI findings post-radiotherapy and history of cerebral radiotherapy for primary or metastatic brain lesions. Lesions are assessed qualitatively and semi-quantitatively. The gold standard to assess radionecrosis was histopathology or a composite criterion at three months. The study evaluated 24 lesions in 23 patients. Qualitative analysis yielded 85.7% sensitivity and 75% specificity. Semi-quantitative analysis, based on contralateral background noise, achieved 100% sensitivity and 50% specificity. Moreover, using contralateral frontal lobe background noise resulted in higher performances with 92% sensitivity and 63% specificity. Stratification by lesion type demonstrated 100% sensitivity and specificity rates for metastatic lesions. The diagnostic performance of dual-phase 18F-FDG PET-mpMRI shows promising results for metastatic lesions.
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Affiliation(s)
- Axel Cailleteau
- Department of Radiotherapy, ICO René Gauducheau, 44800 Saint Herblain, France
| | - Ludovic Ferrer
- Department of Nuclear Medicine, ICO René Gauducheau, 44800 Saint Herblain, France
- Nantes Université, Univ Angers, INSERM, CNRS, CRCI2NA, F-44000 Nantes, France
| | - Delphine Geffroy
- Department of Radiology, ICO René Gauducheau, 44800 Saint Herblain, France
| | - Vincent Fleury
- Department of Nuclear Medicine, ICO René Gauducheau, 44800 Saint Herblain, France
| | - Paul Lalire
- Department of Nuclear Medicine, ICO René Gauducheau, 44800 Saint Herblain, France
| | - Mélanie Doré
- Department of Radiotherapy, ICO René Gauducheau, 44800 Saint Herblain, France
| | - Caroline Rousseau
- Department of Nuclear Medicine, ICO René Gauducheau, 44800 Saint Herblain, France
- Nantes Université, Univ Angers, INSERM, CNRS, CRCI2NA, F-44000 Nantes, France
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Sofronas M, Wright DK, Macdonald ME, Bitzas V, Carnevale FA. "More Areas of Grey": Ambiguities in Neuropalliative Care. J Hosp Palliat Nurs 2024:00129191-990000000-00155. [PMID: 39231616 DOI: 10.1097/njh.0000000000001054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Abstract
Neuropalliative care as a clinical speciality aims to address the unique end-of-life needs and concerns of patients with neurologic disease. Although literature has outlined clinical hurdles, a more nuanced understanding of how neuropalliative care was experienced, conceptualized, and enacted could provide context and depth to better outline practice and research priorities. This article presents findings from an ethnographic study of neuropalliative care conducted in a university-affiliated, tertiary care neurological hospital in Canada with a dedicated neuropalliative consultation service. Specifically, this article examines how clinical hurdles outlined in the neuropalliative literature were experienced and addressed by multiple stakeholders, including patients, families, and clinicians. These clinical hurdles include locating the scope of neuropalliative care, ascertaining the impact of prognostic uncertainty and poor recognition of the dying patient, and navigating the tensions between curative and palliative philosophies. In the discussion, the implications of these clinical hurdles are addressed, concluding with reflections on the role of ethnography, palliative care in the context of functional changes, and broadening approaches to uncertainty.
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Rodenbach RA, Thordardottir T, Brauer M, Hall AC, Ward E, Smith CB, Campbell TC. Balancing risks and rewards: How hematologists discuss uncertainty in allogeneic hematopoietic cell transplantation outcomes. PATIENT EDUCATION AND COUNSELING 2024; 123:108177. [PMID: 38341898 PMCID: PMC10997451 DOI: 10.1016/j.pec.2024.108177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 01/11/2024] [Accepted: 01/26/2024] [Indexed: 02/13/2024]
Abstract
OBJECTIVE Allogeneic hematopoietic cell transplant (alloHCT) offers many patients with blood cancers a chance of cure but carries risks. We characterized how hematologists discuss the high-risk, high-reward concept of alloHCT. METHODS Qualitative analysis of video-recorded virtual encounters of hematologists who routinely perform alloHCT with actors portraying an older man recently diagnosed with high-risk myelodysplastic syndrome. RESULTS Hematologists (n = 37) were a median age of 44 years, 65% male, and 68% white. They frequently used "teeter-totter" language that juxtaposed alloHCT's risks and rewards in a dynamic, quickly alternating fashion and communicated uncertainty in transplant outcomes. This dialogue oscillated between encouragement about alloHCT's potential for cure and caution about its risks and occurred within single speech turns and in exchanges between hematologist and patient. Fewer hematologists outlined their big-picture stance on transplant's risks and benefits early in the conversation. Meanwhile, hematologists varied in how they counseled patients to manage transplant-related uncertainty and consider treatment decision making. CONCLUSION Hematologists use "teeter-totter" language to express hope and concern, confidence and uncertainty, and encouragement and caution about the high-risk, high-reward nature of alloHCT. PRACTICE IMPLICATIONS Teeter-totter language may help frame big-picture content about alloHCT's risks and benefits that is essential for patient education and decision making.
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Affiliation(s)
| | | | - Markus Brauer
- University of Wisconsin Department of Psychology, Madison, WI, USA
| | - Aric C Hall
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | - Earlise Ward
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Family Medicine and Community Health, Madison, WI, USA
| | | | - Toby C Campbell
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA
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Masel EK, Baer J, Wenzel C. Integrating Palliative Care Into the Management of Genitourinary Malignancies. Am Soc Clin Oncol Educ Book 2024; 44:e438644. [PMID: 38662976 DOI: 10.1200/edbk_438644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Palliative care (PC) plays a critical role in managing the difficulties associated with genitourinary malignancies. Its primary aim is to improve the overall health of patients, provide support to both patients and their caregivers, and help individuals to navigate the complex decisions about treatment and end-of-life care. PC takes a holistic approach to patient care, recognizing that genitourinary malignancies affect multiple aspects of a person's life. By addressing physical, emotional, social, and spiritual needs, PC aims to provide comprehensive support that is consistent with the patient's values and preferences. The goal is to optimize comfort, minimize distress, and enhance the patient's quality of life throughout the course of the illness. PC is not a one-off intervention, but an ongoing source of support. This article aims to provide a thorough overview of the critical elements involved in addressing the challenges posed by genitourinary cancers, emphasizing the importance of palliative interventions. We will highlight the multifaceted aspects of care and explore strategies to optimize the overall well-being of patients throughout the course of treatment for genitourinary malignancies.
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Affiliation(s)
- Eva K Masel
- Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Joachim Baer
- Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Claudia Wenzel
- Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Besbris JM, Taylor LP. Palliative Care in Neuro-oncology. Semin Neurol 2024; 44:26-35. [PMID: 38176423 DOI: 10.1055/s-0043-1777703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
Historically, the practice of neurology as an independent subspecialty from internal medicine began in Europe and the United States in the 1930s. The American Academy of Neurology (AAN) was founded 75 years ago in 1948, solidifying its emergence as a stand-alone discipline of medicine. In 1967, St. Christopher's Hospice, the first free standing hospice home, was opened in London by Dame Cicely Saunders. Dame Saunders is considered a pioneer in the development of the hospice movement, and she embodies the importance of the multi-disciplinary team in the care of the patient, as she began her career as a nurse, then became a social worker and, finally, a physician. A decade later, in 1978, Dr. Balfour Mount, a Canadian urologic cancer surgeon, coined the term "palliative care" ("to improve the quality of life") after having spent time with Dr. Saunders at St. Christopher's some years earlier. The field of palliative care continued to develop as a distinct subspecialty focused on improving quality of life for patients at any age and in any stage of serious illness. In a 1996 position statement, the AAN made clear that the practice of primary palliative care is the responsibility of all neurologists to their patients. Finally, coming full circle, the specialty of neuro-palliative care, a subspecialty not just of neurology but of palliative medicine, became established around 2018. Neuro-palliative care can be seen as a specialty focusing on the holistic approach to symptom management in patients suffering from neurologic disease with the aim of improved symptom control and attention to the psychologic and spiritual aspects of illness.
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Eppel-Meichlinger J, Mayer H, Steiner E, Kobleder A. From existential uncertainty to a new mindset promoting recovery: Exploring the development of uncertainty experience in women with vulvar neoplasia - A qualitative longitudinal study. BMC Womens Health 2024; 24:35. [PMID: 38218781 PMCID: PMC10788007 DOI: 10.1186/s12905-024-02889-4] [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: 05/11/2023] [Accepted: 01/06/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Women with vulvar neoplasia continue to experience uncertainty up to six months post-surgery. Uncertainty in illness is considered a significant psychosocial stressor, that negatively influences symptom distress, self-management strategies and quality of life. According to the Reconceptualized Uncertainty in Illness Theory, the appraisal of uncertainty changes positively over time in chronic illness. We aimed at exploring whether and how the experience of uncertainty develops in women with vulvar neoplasia. METHODS We selected a purposive sample of seven women diagnosed with vulvar neoplasia in four Swiss and one Austrian women's clinic. By means of a qualitative longitudinal study, we conducted 30 individual interviews at five points of time during one year after diagnosis. We applied Saldaña's analytical questions for longitudinal qualitative research. RESULTS First, participants experienced uncertainty as an existential threat, then an inherent part of their illness, and finally a certainty. Women initially associated the existential threat with a high risk for suffering from severe health deteriorations. Participants that could reduce their individually assessed risk by adopting health promoting behaviors, accepted the remaining uncertainty. From now on they reframed uncertainty into a certainty. This new mindset was based on a belief of promoting recovery and reducing the risk of recurrence. CONCLUSIONS The long-lasting and oscillating nature of uncertainty should receive attention in supportive oncology care. Uncertainty concerning existential issues is of special importance since it can inhibit a positive development of uncertainty experience.
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Affiliation(s)
- Jasmin Eppel-Meichlinger
- Department of General Health Studies, Division Nursing Science with focus on Person-centred Care Research, Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, Krems, Austria.
- Vienna Doctoral School of Social Sciences, University of Vienna, Vienna, Austria.
| | - Hanna Mayer
- Department of General Health Studies, Division Nursing Science with focus on Person-centred Care Research, Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, Krems, Austria
| | - Enikö Steiner
- Department of Obstetrics and Gynecology, Vienna General University Hospital, Vienna, Austria
| | - Andrea Kobleder
- Institute of Applied Nursing Science, Eastern Switzerland University of Applied Sciences, St.Gallen, Switzerland
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Obispo B, Cruz-Castellanos P, Fernández-Montes A, Coca-Membribes S, Rogado J, Antoñanzas M, Castillo-Trujillo OA, López-Ceballos H, Rodríguez-González A, Jiménez-Fonseca P, Calderon C. Coping strategies as mediators of uncertainty and psychological distress in patients with advanced cancer. Psychooncology 2023; 32:1694-1701. [PMID: 37789602 DOI: 10.1002/pon.6219] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/11/2023] [Accepted: 09/14/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE Uncertainty in the context of advanced cancer diagnosis often incurs significant psychological distress. The aims were to evaluate the incidence of psychological distress upon diagnosis of advanced cancer and to analyze whether the relationship between illness uncertainty and psychological distress can be mediated by coping strategies. METHODS A multicenter, prospective, cross-sectional study was conducted in 15 medical oncology departments across Spain. Individuals with unresectable advanced cancer completed questionnaires on uncertainty (Michel Uncertainty of Illness Scale, coping strategies (Mental Adjustment to Cancer, M-MAC), and psychological distress (Brief Symptom Inventory, BSI-18) after the diagnostic and treatment appointment and before beginning systemic cancer treatment. RESULTS 841 patients eligible for systemic treatment with palliative intent were included between February 2020 and April 2022. A total of 71.7% had clinically significant levels of psychological distress. Univariate analyses identified that the groups with less psychological distress were male (ηp2 = 0.016), married (ηp2 = 0.006), and had a better performance status (ηp2 = 0.007). The most widely used coping strategies were positive attitude and cognitive avoidance. A positive relationship was found between uncertainty, coping strategies, and psychological distress (p < 0.05). Participants who responded with anxious preoccupation suffered more helplessness and psychological distress, while those who responded with cognitive avoidance displayed greater positive attitude and lesser psychological distress. CONCLUSION Patients with newly diagnosed unresectable advanced cancer frequently experience psychological distress in the face of uncertainty, potentially influenced by coping strategies like cognitive avoidance.
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Affiliation(s)
- Berta Obispo
- Department of Medical Oncology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - Ana Fernández-Montes
- Department of Medical Oncology, Complejo Hospitalario Universitario de Ourense - CHUO, Ourense, Spain
| | - Sara Coca-Membribes
- Department of Medical Oncology, Hospital Universitario de Canarias, La Laguna, Spain
| | - Jacobo Rogado
- Department of Medical Oncology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Mónica Antoñanzas
- Department of Medical Oncology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | - Helena López-Ceballos
- Department of Medical Oncology, Hospital San Pedro de Alcántara de Caceres, Cáceres, Spain
| | - Adán Rodríguez-González
- Department of Medical Oncology, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - Paula Jiménez-Fonseca
- Department of Medical Oncology, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - Caterina Calderon
- Department of Clinical Psychology and Psychobiology, University of Barcelona, Barcelona, Spain
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Akkuş Y, Menekli T. Determining the Relationship Between Intolerance of Uncertainty and Attitudes Toward Complementary and Alternative Medicine in Patients With Cancer. Holist Nurs Pract 2023; 37:277-284. [PMID: 37595120 DOI: 10.1097/hnp.0000000000000600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Disease-related uncertainty and the factors associated with uncertainty in patients with cancer have not been adequately investigated. This study aimed to determine the relationship between intolerance of uncertainty and attitudes toward complementary and alternative medicine (CAM) in patients with cancer. This cross-sectional descriptive study included 351 patients treated in the oncology clinic of a university hospital. All participants completed the Holistic Complementary and Alternative Medicine Questionnaire (HCAMQ) and the 12-item Intolerance of Uncertainty Scale (IUS-12). Most patients (84.3%) said that they had information about CAM, 39.7% reported obtaining this information from their social environment, 83.2% said that they believed that CAM methods are effective, and 76.0% reported not telling health care professionals about their CAM use. Mean IUS-12 and HCAMQ total scores were 46.53 ± 2.05 and 32.11 ± 2.32, respectively, and showed a weak negative correlation. The patients in our study showed high intolerance of uncertainty and a moderately positive attitude toward CAM, and most patients did not notify health care professionals of their CAM use. Therefore, we recommend assessing intolerance of uncertainty and CAM use in this patient group. By identifying patients experiencing uncertainty and seeking different treatment, nurses can support patients physiologically, psychologically, and socially, and can explain the effects of CAM use.
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Affiliation(s)
- Yeliz Akkuş
- Department of Nursing, Health Science Faculty, Kafkas University, Kars, Turkey (Dr Akkuş); and Department of Nursing, Health Science Faculty, Turgut Ozal University, Malatya Turkey (Dr Menekli)
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Cattermole TC, Schimmel ML, Carpenter RL, Callas PW, Gramling R, Bertges DJ, Ferranti KM. Integration of palliative care consultation into the management of patients with chronic limb-threatening ischemia. J Vasc Surg 2023; 78:454-463. [PMID: 37088444 DOI: 10.1016/j.jvs.2022.12.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/21/2022] [Accepted: 12/06/2022] [Indexed: 04/25/2023]
Abstract
OBJECTIVE We assessed the feasibility of integrating palliative care consultation into the routine management of patients with chronic limb-threatening ischemia (CLTI). Additionally, we sought to describe patient-reported outcomes from the palliative care and vascular literature in patients with CLTI receiving a palliative care consultation at our institution. METHODS This was a single-institution, prospective, observational study that aimed to assess feasibility of incorporating palliative care consultation into the management of patients admitted to our tertiary academic medical center with CLTI by looking at utilization of palliative care before and after implementation of a protocol-based palliative care referral system. A survey comprised of patient-reported outcomes from the palliative care literature was administered to patients before and after palliative consultation. Length of stay and mortality were compared between our study cohort and a historic cohort of patients admitted with CLTI. RESULTS Over a 14-month enrollment period, 44% of patients (n = 39) with CLTI (rest pain, 36%; tissue loss, 64%) admitted to the vascular service received palliative care consultation, compared with 5% of patients (n = 4) who would have met criteria over the preceding 14 months before our protocol was instituted. The mean age was 69 years, 23% were female, 92% were white, and 49% were able to ambulate independently. Revascularization included bypass (46%), peripheral vascular intervention (23%), and femoral endarterectomy (21%). Additional procedures included minor amputation or wound debridement (26%) and major amputation (15%). No patients received medical management alone. After receiving palliative care consultation, patients reported experiencing less emotional distress than before consultation (P = .03). They also reported being less bothered by uncertainty regarding what to expect from the course of their illness (P = .002). Fewer patients reported being unsure of the purpose of their medical care after palliative care consultation (8%) vs before (18%), although this was not statistically significant (P = .10). Median length of stay was longer in the study group compared with the historic cohort (8 vs 7 days; P = .02). There was no difference in 30-day mortality (3% vs 8%; P = .42) between the study group and the historic cohort (n = 77). CONCLUSIONS Integrating inpatient palliative care consultation into the routine management of patients with CLTI is feasible and may improve emotional domains of health-related quality of life. This study laid the foundation for future studies on longer term outcomes of patients with CLTI undergoing palliative care consultation as well as the benefit of outpatient palliative care consultation in patients with CLTI.
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Affiliation(s)
| | | | | | - Peter W Callas
- University of Vermont College of Medicine, Burlington, VT
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Pitman S, Mason N, Cardona M, Lewis E, O'Shea M, Flood J, Kirk M, Seymour J, Duncan A. Triggering palliative care referrals through the identification of poor prognosis in older patients presented to emergency departments in rural Australia. Int J Palliat Nurs 2023; 29:83-90. [PMID: 36822616 DOI: 10.12968/ijpn.2023.29.2.83] [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: 02/25/2023]
Abstract
Background: Without objective screening for risk of death, the palliative care needs of older patients near the end of life may be unrecognised and unmet. Aim: This study aimed to estimate the usefulness of the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL) tool in determining older patients' risk of death within 3-months after initial hospital admission. Methods: A prospective cohort study of 235 patients aged 70+ years, who presented to two rural emergency departments in two adjacent Australian states, was utilised. The 'risk of death' of each patient was screened with the CriSTAL prognostic tool. Their 3-month follow-up outcomes were assessed through telephone interviews and a clinical record review. Findings: A CriSTAL cut-off score of more than 7 yielded a sensitivity of 80.7% and specificity of 70.81% for a 3-month risk of death. Palliative care services were only used by 31% of the deceased in their last trimester of life. Conclusion: Prognostic tools provide a viable means of identifying individuals with a poor prognosis. Identification can trigger an earlier referral to palliative care, which will benefit the patient's wellbeing and quality of life.
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Affiliation(s)
| | - Naomi Mason
- Social Worker, Wodonga Community Palliative Care; Albury Wodonga Health, Australia
| | | | - Ebony Lewis
- Associate Lecturer, University of New South Wales, Australia
| | - Michael O'Shea
- Clinical Nurse Consultant, Albury Wodonga Health, Australia
| | | | - Mindy Kirk
- Social Worker, Albury Wodonga Health, Australia
| | | | - Anne Duncan
- Nurse Practitioner, Albury Wodonga Health, Australia
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Ozdemir S, Lee JJ, Yang GM, Malhotra C, Teo I, Pham NT, Manalo MF, Hapuarachchi T, Mariam L, Rahman R, Finkelstein E. Awareness and Utilization of Palliative Care Among Advanced Cancer Patients in Asia. J Pain Symptom Manage 2022; 64:e195-e201. [PMID: 35705117 DOI: 10.1016/j.jpainsymman.2022.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 05/09/2022] [Accepted: 06/03/2022] [Indexed: 11/16/2022]
Abstract
CONTEXT To date, little is known about palliative care (PC) awareness and utilization in low- and middle-income countries (LMICs) in Asia. OBJECTIVES This study aimed to investigate PC awareness and its predictors, utilization of PC services, and perceived utilization barriers among advanced cancer patients from select hospitals in Asian LMICs. METHODS This cross-sectional study analyzed data of 759 advanced cancer patients at major hospitals of four LMICs in Asia (i.e., Bangladesh, Philippines, Sri Lanka, and Vietnam). The predictors of PC awareness were investigated using multivariable logistic regression. RESULTS Overall PC awareness was 30.8% (n = 234). Patients with higher education (OR = 1.0; CI = 1.0,1.1), from upper-middle or high-income households (compared to low-income) (OR = 2.0; CI = 1.2,3.3), awareness of disease severity (OR = 1.5; CI = 1.0,2.2), and higher pain severity (OR = 1.1; CI = 1.0,1.2) had higher odds of PC awareness. Compared to patients who perceived themselves as being very informed about disease trajectory, those who were unsure (OR = 0.5; CI = 0.3,0.8) or uninformed (OR = 0.5; CI = 0.3,0.9) had lower odds of PC awareness. The PC utilization rate was 35.0% (n = 82) among those with PC awareness, and 47.8% (n = 66) among patients recommended PC by a healthcare professional (n = 138). The most cited PC utilization barriers were currently receiving anti-cancer treatment (n = 43; 33.9%), and having insufficient information about PC (n = 41; 32.3%). CONCLUSION The low awareness of PC services in these major hospitals in Asian LMICs highlights that more effort may be required to promote the awareness of PC in this region. The efforts should especially focus on those from disadvantaged groups to reduce the gap in PC awareness.
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Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care (S.O., J.J.L., M.Y., C.M., I.T., E.F.), Duke-NUS Medical School, Singapore; Programme in Health Services & Systems Research (S.O., J.J.L., C.M., I.T., E.F.), Duke-NUS Medical School, Singapore.
| | - Jia Jia Lee
- Lien Centre for Palliative Care (S.O., J.J.L., M.Y., C.M., I.T., E.F.), Duke-NUS Medical School, Singapore; Programme in Health Services & Systems Research (S.O., J.J.L., C.M., I.T., E.F.), Duke-NUS Medical School, Singapore
| | - Grace Meijuan Yang
- Lien Centre for Palliative Care (S.O., J.J.L., M.Y., C.M., I.T., E.F.), Duke-NUS Medical School, Singapore; Division of Palliative and Supportive Care (M.Y.), National Cancer Centre Singapore, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care (S.O., J.J.L., M.Y., C.M., I.T., E.F.), Duke-NUS Medical School, Singapore; Programme in Health Services & Systems Research (S.O., J.J.L., C.M., I.T., E.F.), Duke-NUS Medical School, Singapore
| | - Irene Teo
- Lien Centre for Palliative Care (S.O., J.J.L., M.Y., C.M., I.T., E.F.), Duke-NUS Medical School, Singapore; Programme in Health Services & Systems Research (S.O., J.J.L., C.M., I.T., E.F.), Duke-NUS Medical School, Singapore
| | | | | | | | - Lubna Mariam
- Department of Radiation Oncology (L.M.), National Institute of Cancer Research & Hospital, Dhaka, Bangladesh
| | - Rubayat Rahman
- Department of Palliative Medicine (R.R.), Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Eric Finkelstein
- Lien Centre for Palliative Care (S.O., J.J.L., M.Y., C.M., I.T., E.F.), Duke-NUS Medical School, Singapore; Programme in Health Services & Systems Research (S.O., J.J.L., C.M., I.T., E.F.), Duke-NUS Medical School, Singapore
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Gramling CJ, Durieux BN, Clarfeld LA, Javed A, Matt JE, Manukyan V, Braddish T, Wong A, Wills J, Hirsch L, Straton J, Cheney N, Eppstein MJ, Rizzo DM, Gramling R. Epidemiology of Connectional Silence in specialist serious illness conversations. PATIENT EDUCATION AND COUNSELING 2022; 105:2005-2011. [PMID: 34799186 DOI: 10.1016/j.pec.2021.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 06/13/2023]
Abstract
CONTEXT Human connection can reduce suffering and facilitate meaningful decision-making amid the often terrifying experience of hospitalization for advanced cancer. Some conversational pauses indicate human connection, but we know little about their prevalence, distribution or association with outcomes. PURPOSE To describe the epidemiology of Connectional Silence during serious illness conversations in advanced cancer. METHODS We audio-recorded 226 inpatient palliative care consultations at two academic centers. We identified pauses lasting 2+ seconds and distinguished Connectional Silences from other pauses, sub-categorized as either Invitational (ICS) or Emotional (ECS). We identified treatment decisional status pre-consultation from medical records and post-consultation via clinicians. Patients self-reported quality-of-life before and one day after consultation. RESULTS Among all 6769 two-second silences, we observed 328 (4.8%) ECS and 240 (3.5%) ICS. ECS prevalence was associated with decisions favoring fewer disease-focused treatments (ORadj: 2.12; 95% CI: 1.12, 4.06). Earlier conversational ECS was associated with improved quality-of-life (p = 0.01). ICS prevalence was associated with clinicians' prognosis expectations. CONCLUSIONS Connectional Silences during specialist serious illness conversations are associated with decision-making and improved patient quality-of-life. Further work is necessary to evaluate potential causal relationships. PRACTICE IMPLICATIONS Pauses offer important opportunities to advance the science of human connection in serious illness decision-making.
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Affiliation(s)
| | | | | | - Ali Javed
- Department of Computer Science, University of Vermont, Burlington, VT, USA
| | - Jeremy E Matt
- Complex Systems & Data Science, University of Vermont, Burlington, VT, USA
| | | | - Tess Braddish
- Department of Family Medicine, University of Vermont, Burlington, VT, USA
| | - Ann Wong
- University of Vermont, Burlington, VT, USA
| | | | | | | | - Nicholas Cheney
- Department of Computer Science, University of Vermont, Burlington, VT, USA
| | | | - Donna M Rizzo
- Department of Civil Engineering, University of Vermont, Burlington, VT, USA
| | - Robert Gramling
- Department of Family Medicine, University of Vermont, Burlington, VT, USA.
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13
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Edelen MO, Rodriguez A, Huang W, Gramling R, Ahluwalia SC. A novel Scale to Assess Palliative Care Patients' Experience of Feeling Heard and Understood. J Pain Symptom Manage 2022; 63:689-697.e1. [PMID: 35017018 DOI: 10.1016/j.jpainsymman.2022.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 02/06/2023]
Abstract
CONTEXT Patient experience of palliative care serves as an important indicator of quality and patient-centeredness. OBJECTIVES To develop a novel patient-reported scale measuring ambulatory palliative care patients' experience of feeling heard and understood by their providers. METHODS We used self-reported patient experience data collected via mixed-mode survey administration. We conducted an exploratory factor analysis (EFA) and an expert panel ranking exercise to reduce the 10-item set based on underlying dimensionality. We then used item response theory (IRT) to calibrate remaining items based on psychometric properties and test information and precision. We considered item-level fit and examined the standardized local dependence chi-square statistics. We evaluated candidate items for differential item functioning by survey mode. We evaluated the test-retest reliability and validity of the final scale. RESULTS The EFA yielded a single factor (9/10 items had loadings > 0.80 on the single factor). We removed two items with the lowest factor loadings and ranked by the expert panel as being least reflective of the overall construct. IRT calibration of the remaining eight items showed high slopes (range 2.66 - 5.18); location parameters were all negative (range -0.90 - -0.36). We removed two more items based on local dependence indices and item-level fit. Combining psychometric information with the expert ratings we established the final 4-item scale, which was reliable (Cronbach's alpha = 0.84; polychoric correlation coefficient = 0.72) and had good convergent validity. CONCLUSIONS This novel multi-item Feeling Heard and Understood scale can be used to measure and improve ambulatory palliative care patient experience.
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Affiliation(s)
- Maria O Edelen
- Behavioral & Policy Sciences Department, RAND Corporation, Boston, Massachusetts, USA
| | - Anthony Rodriguez
- Behavioral & Policy Sciences Department, RAND Corporation, Boston, Massachusetts, USA
| | - Wenjing Huang
- Behavioral & Policy Sciences Department, RAND Corporation, Boston, Massachusetts, USA
| | - Robert Gramling
- University of Vermont, Department of Family Medicine, Burlington, Vermont
| | - Sangeeta C Ahluwalia
- Behavioral & Policy Sciences Department, RAND Corporation, Santa Monica, California, USA.
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14
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Han PKJ, Scharnetzki E, Anderson E, DiPalazzo J, Strout TD, Gutheil C, Lucas FL, Edelman E, Rueter J. Epistemic Beliefs: Relationship to Future Expectancies and Quality of Life in Cancer Patients. J Pain Symptom Manage 2022; 63:512-521. [PMID: 34952170 PMCID: PMC8930513 DOI: 10.1016/j.jpainsymman.2021.12.017] [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] [Received: 10/14/2021] [Revised: 12/08/2021] [Accepted: 12/11/2021] [Indexed: 11/28/2022]
Abstract
CONTEXT Expectations about the future (future expectancies) are important determinants of psychological well-being among cancer patients, but the strategies patients use to maintain positive and cope with negative expectancies are incompletely understood. OBJECTIVES To obtain preliminary evidence on the potential role of one strategy for managing future expectancies: the adoption of "epistemic beliefs" in fundamental limits to medical knowledge. METHODS A sample of 1307 primarily advanced-stage cancer patients participating in a genomic tumor testing study in community oncology practices completed measures of epistemic beliefs, positive future expectancies, and mental and physical health-related quality of life (HRQOL). Descriptive and linear regression analyses were conducted to assess the relationships between these factors and test two hypotheses: 1) epistemic beliefs affirming fundamental limits to medical knowledge ("fallibilistic epistemic beliefs") are associated with positive future expectancies and mental HRQOL, and 2) positive future expectancies mediate this association. RESULTS Participants reported relatively high beliefs in limits to medical knowledge (M = 2.94, s.d.=.67) and positive future expectancies (M = 3.01, s.d.=.62) (range 0-4), and relatively low mental and physical HRQOL. Consistent with hypotheses, fallibilistic epistemic beliefs were associated with positive future expectancies (b = 0.11, SE=.03, P< 0.001) and greater mental HRQOL (b = 0.99, SE=.34, P = 0.004); positive expectancies also mediated the association between epistemic beliefs and mental HRQOL (Sobel Z=4.27, P<0.001). CONCLUSIONS Epistemic beliefs in limits to medical knowledge are associated with positive future expectancies and greater mental HRQOL; positive expectancies mediate the association between epistemic beliefs and HRQOL. More research is needed to confirm these relationships and elucidate their causal mechanisms.
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Affiliation(s)
- Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine; Tufts University School of Medicine (P.K.J.H., E.A., T.D.S., F.L.L.), Boston, Massachusetts.
| | - Elizabeth Scharnetzki
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine
| | - Eric Anderson
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine; Tufts University School of Medicine (P.K.J.H., E.A., T.D.S., F.L.L.), Boston, Massachusetts
| | - John DiPalazzo
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine
| | - Tania D Strout
- Tufts University School of Medicine (P.K.J.H., E.A., T.D.S., F.L.L.), Boston, Massachusetts; Department of Emergency Medicine, Maine Medical Center (T.D.S.), Portland, Maine
| | - Caitlin Gutheil
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine
| | - F Lee Lucas
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine; Tufts University School of Medicine (P.K.J.H., E.A., T.D.S., F.L.L.), Boston, Massachusetts
| | - Emily Edelman
- The Jackson Laboratory (E.E., J.R.), Bar Harbor, Maine
| | - Jens Rueter
- The Jackson Laboratory (E.E., J.R.), Bar Harbor, Maine
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15
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Temel JS, Petrillo LA, Greer JA. Patient-Centered Palliative Care for Patients With Advanced Lung Cancer. J Clin Oncol 2022; 40:626-634. [PMID: 34985932 DOI: 10.1200/jco.21.01710] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The evidence base demonstrating the benefits of an early focus on palliative care for patients with serious cancers, including advanced lung cancer, is substantial. Early involvement of specialty-trained palliative care clinicians in the care of patients with advanced lung cancer improves patient-reported outcomes, such as quality of life, and health care delivery, including hospice utilization. Since the time that many of these palliative care trials were conducted, the paradigm of cancer care for many cancers, including lung cancer, has changed dramatically. The majority of patients with advanced lung cancer are now treated with immune checkpoint inhibitors or targeted therapies, both of which have had a significant impact on patient's experience and outcomes. With this changing landscape of lung cancer therapeutics, patients are facing new and different challenges, including dealing with novel side effect profiles and coping with greater uncertainty regarding their prognosis. Patients who are living longer with their advanced cancer also struggle with how to address survivorship issues, such as sexual health and exercise, and decision making about end-of-life care. Although palliative care clinicians remain well-suited to address these care needs, they may need to learn new skills to support patients treated with novel therapies. Additionally, as the experience of patients with advanced lung cancer is becoming more varied and individualized, palliative care research interventions and clinical programs should also be delivered in a patient-centered manner to best meet patient's needs and improve their outcomes. Tailored and technology-based palliative care interventions are promising strategies for delivering patient-centered palliative care.
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Affiliation(s)
- Jennifer S Temel
- Harvard Medical School, Boston, MA.,Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Laura A Petrillo
- Harvard Medical School, Boston, MA.,Division of Palliative Care, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Joseph A Greer
- Harvard Medical School, Boston, MA.,Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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16
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Chen AT, Tsui S, Sharma RK. Characterizing uncertainty in goals-of-care discussions among black and white patients: a qualitative study. Palliat Care 2022; 21:24. [PMID: 35177049 PMCID: PMC8851788 DOI: 10.1186/s12904-022-00912-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Uncertainty has been associated with distress and poorer quality of life in patients with advanced cancer. Prior studies have focused on prognostic uncertainty; little is known about other types of uncertainty that patients and family members experience when discussing goals of care. Understanding the types of uncertainty expressed and differences between Black and White patients can inform the development of uncertainty management interventions. METHODS This study sought to characterize the types of uncertainty expressed by Black and White patients and family members within the context of information needs during inpatient goals-of-care discussions. We performed a secondary analysis of transcripts from 62 recorded goals-of-care discussions that occurred between 2012 and 2014 at an urban, academic medical center in the United States. We applied an adapted taxonomy of uncertainty to data coded as describing information needs and used an inductive qualitative analysis method to analyze the discussions. We report the types of uncertainty expressed in these discussions. RESULTS Fifty discussions included patient or family expressions of information needs. Of these, 40 discussions (n=16 Black and n=24 White) included statements of uncertainty. Black and White patients and families most frequently expressed uncertainty related to processes and structures of care (system-centered uncertainty) and to treatment (scientific uncertainty). Statements of prognostic uncertainty focused on quantitative information among Whites and on qualitative information and expectations for the future among Blacks. CONCLUSIONS Black and White patients and families frequently expressed system-centered uncertainty, suggesting this may be an important target for intervention. Addressing other sources of uncertainty, such as prognostic uncertainty, may need more tailored approaches.
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Affiliation(s)
- Annie T Chen
- Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, 850 Republican St, Box 358047, 98109, Seattle, WA, United States.
| | - Shelley Tsui
- University of Washington, WA, Seattle, United States
| | - Rashmi K Sharma
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, United States
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17
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Turner K, Brownstein NC, Thompson Z, Naqa IE, Luo Y, Jim HS, Rollison DE, Howard R, Zeng D, Rosenberg SA, Perez B, Saltos A, Oswald LB, Gonzalez BD, Islam JY, Tabriz AA, Zhang W, Dilling TJ. Longitudinal patient-reported outcomes and survival among early-stage non-small cell lung cancer patients receiving stereotactic body radiotherapy. Radiother Oncol 2022; 167:116-121. [PMID: 34953934 PMCID: PMC8934278 DOI: 10.1016/j.radonc.2021.12.021] [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: 10/13/2021] [Revised: 12/07/2021] [Accepted: 12/15/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE The study objective was to determine whether longitudinal changes in patient-reported outcomes (PROs) were associated with survival among early-stage, non-small cell lung cancer (NSCLC) patients undergoing stereotactic body radiation therapy (SBRT). MATERIALS AND METHODS Data were obtained from January 2015 through March 2020. We ran a joint probability model to assess the relationship between time-to-death, and longitudinal PRO measurements. PROs were measured through the Edmonton Symptom Assessment Scale (ESAS). We controlled for other covariates likely to affect symptom burden and survival including stage, tumor diameter, comorbidities, gender, race/ethnicity, relationship status, age, and smoking status. RESULTS The sample included 510 early-stage NSCLC patients undergoing SBRT. The median age was 73.8 (range: 46.3-94.6). The survival component of the joint model demonstrates that longitudinal changes in ESAS scores are significantly associated with worse survival (HR: 1.04; 95% CI: 1.02-1.05). This finding suggests a one-unit increase in ESAS score increased probability of death by 4%. Other factors significantly associated with worse survival included older age (HR: 1.04; 95% CI: 1.03-1.05), larger tumor diameter (HR: 1.21; 95% CI: 1.01-1.46), male gender (HR: 1.87; 95% CI: 1.36-2.57), and current smoking status (HR: 2.39; 95% CI: 1.25-4.56). CONCLUSION PROs are increasingly being collected as a part of routine care delivery to improve symptom management. Healthcare systems can integrate these data with other real-world data to predict patient outcomes, such as survival. Capturing longitudinal PROs-in addition to PROs at diagnosis-may add prognostic value for estimating survival among early-stage NSCLC patients undergoing SBRT.
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Affiliation(s)
- Kea Turner
- Department of Health Outcomes and Behavior, 12902 USF
Magnolia Drive, Moffitt Cancer Center, US
| | - Naomi C. Brownstein
- Department of Biostatistics and Bioinformatics, 12902 USF
Magnolia Drive, Moffitt Cancer Center, US
| | - Zachary Thompson
- Department of Biostatistics and Bioinformatics, 12902 USF
Magnolia Drive, Moffitt Cancer Center, US
| | - Issam El Naqa
- Department of Machine Learning, 12902 USF Magnolia Drive,
Moffitt Cancer Center, US
| | - Yi Luo
- Department of Machine Learning, 12902 USF Magnolia Drive,
Moffitt Cancer Center, US
| | - Heather S.L. Jim
- Department of Health Outcomes and Behavior, 12902 USF
Magnolia Drive, Moffitt Cancer Center, US
| | - Dana E. Rollison
- Department of Cancer Epidemiology, 12902 USF Magnolia
Drive, Moffitt Cancer Center, US
| | - Rachel Howard
- Department of Health Informatics, 12902 USF Magnolia
Drive, Moffitt Cancer Center, US
| | - Desmond Zeng
- Morsani College of Medicine, 12901 Bruce B. Downs
Boulevard, University of South Florida, US
| | - Stephen A. Rosenberg
- Department of Radiation Oncology, 12902 USF Magnolia
Drive, Moffitt Cancer Center, US,Department of Thoracic Oncology, 12902 USF Magnolia Drive,
Moffitt Cancer Center, US
| | - Bradford Perez
- Department of Radiation Oncology, 12902 USF Magnolia
Drive, Moffitt Cancer Center, US,Department of Thoracic Oncology, 12902 USF Magnolia Drive,
Moffitt Cancer Center, US
| | - Andreas Saltos
- Department of Thoracic Oncology, 12902 USF Magnolia Drive,
Moffitt Cancer Center, US
| | - Laura B. Oswald
- Department of Health Outcomes and Behavior, 12902 USF
Magnolia Drive, Moffitt Cancer Center, US
| | - Brian D. Gonzalez
- Department of Health Outcomes and Behavior, 12902 USF
Magnolia Drive, Moffitt Cancer Center, US
| | - Jessica Y. Islam
- Department of Cancer Epidemiology, 12902 USF Magnolia
Drive, Moffitt Cancer Center, US
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, 12902 USF
Magnolia Drive, Moffitt Cancer Center, US
| | - Wenbin Zhang
- Department of Machine Learning, 500 Forbes Avenue, Gates
Hillman Center, Carnegie Mellon University, US
| | - Thomas J. Dilling
- Department of Radiation Oncology, 12902 USF Magnolia
Drive, Moffitt Cancer Center, US,Department of Thoracic Oncology, 12902 USF Magnolia Drive,
Moffitt Cancer Center, US
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18
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Hauser J. What palliative care physicians wish neurologists knew. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:85-92. [PMID: 36055722 DOI: 10.1016/b978-0-323-85029-2.00013-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This chapter describes several features of palliative care that we believe can assist neurologists in caring for patients with serious illness. These features include the importance of recognizing suffering, the central of total pain (including physical, emotional, spiritual, and existential aspects), structural features of palliative care such as the distinction been palliative care and hospice, and the concept of primary and specialty palliative care. Structural features of palliative care such as interdisciplinary teamwork, approaches to self-care, and a perspective on prognostic uncertainty are also considered. Throughout this chapter, the focus is on ways in which neurologists can integrate these approaches in caring for patients and their families.
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Affiliation(s)
- Joshua Hauser
- Department of Medicine, Northwestern Feinberg School of Medicine, Northwestern University, Chicago, IL, United States; Department of Medicine, Jesse Brown VA Medical Center, Northwestern University, Chicago, IL, United States.
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19
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Gramling R, Javed A, Durieux BN, Clarfeld LA, Matt JE, Rizzo DM, Wong A, Braddish T, Gramling CJ, Wills J, Arnoldy F, Straton J, Cheney N, Eppstein MJ, Gramling D. Conversational stories & self organizing maps: Innovations for the scalable study of uncertainty in healthcare communication. PATIENT EDUCATION AND COUNSELING 2021; 104:2616-2621. [PMID: 34353689 DOI: 10.1016/j.pec.2021.07.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 07/27/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Understanding uncertainty in participatory decision-making requires scientific attention to interaction between what actually happens when patients, families and clinicians engage one another in conversation and the multi-level contexts in which these occur. Achieving this understanding will require conceptually grounded and scalable methods for use in large samples of people representing diversity in cultures, speaking and decision-making norms, and clinical situations. DISCUSSION Here, we focus on serious illness and describe Conversational Stories as a scalable and conceptually grounded framework for characterizing uncertainty expression in these clinical contexts. Using actual conversations from a large direct-observation cohort study, we demonstrate how natural language processing and unsupervised machine learning methods can reveal underlying types of uncertainty stories in serious illness conversations. CONCLUSIONS Conversational Storytelling offers a meaningful analytic framework for scalable computational methods to study uncertainty in healthcare conversations.
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Affiliation(s)
- Robert Gramling
- University of Vermont, Department of Family Medicine, Burlington, VT, USA.
| | - Ali Javed
- University of Vermont, Department of Computer Science, Burlington, VT, USA
| | | | | | - Jeremy E Matt
- University of Vermont, Complex Systems & Data Science, USA
| | - Donna M Rizzo
- University of Vermont, Department of Civil & Environmental Engineering, Burlington, VT, USA
| | - Ann Wong
- University of Vermont, Burlington, VT, USA
| | - Tess Braddish
- University of Vermont, Department of Family Medicine, Burlington, VT, USA
| | | | | | - Francesca Arnoldy
- University of Vermont, Continuing and Distance Education, Burlington, VT, USA
| | | | - Nicholas Cheney
- University of Vermont, Department of Computer Science, Burlington, VT, USA
| | | | - David Gramling
- University of British Columbia, Department of Central, Eastern and Northern European Studies, Vancouver, BC, Canada
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20
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Raghav K, Hwang H, Jácome AA, Bhang E, Willett A, Huey RW, Dhillon NP, Modha J, Smaglo B, Matamoros A, Estrella JS, Jao J, Overman MJ, Wang X, Greco FA, Loree JM, Varadhachary GR. Development and Validation of a Novel Nomogram for Individualized Prediction of Survival in Cancer of Unknown Primary. Clin Cancer Res 2021; 27:3414-3421. [PMID: 33858857 DOI: 10.1158/1078-0432.ccr-20-4117] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/23/2020] [Accepted: 04/09/2021] [Indexed: 01/04/2023]
Abstract
PURPOSE Prognostic uncertainty is a major challenge for cancer of unknown primary (CUP). Current models limit a meaningful patient-provider dialogue. We aimed to establish a nomogram for predicting overall survival (OS) in CUP based on robust clinicopathologic prognostic factors. EXPERIMENTAL DESIGN We evaluated 521 patients with CUP at MD Anderson Cancer Center (MDACC; Houston, TX; 2012-2016). Baseline variables were analyzed using Cox regression and nomogram developed using significant predictors. Predictive accuracy and discriminatory performance were assessed by calibration curves, concordance probability estimate (CPE ± SE), and concordance statistic (C-index). The model was subjected to bootstrapping and multi-institutional external validations using two independent CUP cohorts: V1 [MDACC (2017), N = 103] and V2 (BC Cancer, Vancouver, Canada and Sarah Cannon Cancer Center/Tennessee Oncology, Nashville, TN; N = 302). RESULTS Baseline characteristics of entire cohort (N = 926) included: median age (63 years), women (51%), Eastern Cooperative Oncology Group performance status (ECOG PS) 0-1 (64%), adenocarcinomas (52%), ≥3 sites of metastases (30%), and median follow-up duration and OS of 40.1 and 14.7 months, respectively. Five independent prognostic factors were identified: gender, ECOG PS, histology, number of metastatic sites, and neutrophil-lymphocyte ratio. The resulting model predicted OS with CPE of 0.69 [SE: ± 0.01; C-index: 0.71 (95% confidence interval: 0.68-0.74)] outperforming Culine/Seve prognostic models (CPE: 0.59 ± 0.01). CPE for external validation cohorts V1 and V2 were 0.67 (± 0.02) and 0.70 (± 0.01), respectively. Calibration curves for 1-year OS showed strong agreement between nomogram prediction and actual observations in all cohorts. CONCLUSIONS Our user-friendly CUP nomogram integrating commonly available baseline factors provides robust personalized prognostication which can aid clinical decision making and selection/stratification for clinical trials.
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Affiliation(s)
- Kanwal Raghav
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hyunsoo Hwang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alexandre A Jácome
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eric Bhang
- BC Cancer, Vancouver, British Columbia, Canada
| | - Anneleis Willett
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ryan W Huey
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nishat P Dhillon
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jignesh Modha
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brandon Smaglo
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Aurelio Matamoros
- Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Justin Jao
- BC Cancer, Vancouver, British Columbia, Canada
| | - Michael J Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - F Anthony Greco
- Sarah Cannon Cancer Center/Tennessee Oncology, Nashville, Tennessee
| | | | - Gauri R Varadhachary
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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21
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Abstract
BACKGROUND Psychological distress is a common problem that occurs in advanced cancer patients; however, the concept has not been sufficiently specified or clearly described. OBJECTIVE To develop succinct understanding of psychological distress among advanced cancer patients. METHODS A literature search was conducted using the CINAHL, PubMed, and MEDLINE databases from 1988 to 2018. The analysis used the 8 steps of concept analysis developed by Walker and Avant. The final articles selected focused on definitions, predictors, determinant factors, and measurements of psychological distress in advanced cancer. RESULTS Analysis identified that psychological distress in terms of advanced cancer has 5 defining attributes: (1) anxiety, (2) depression, (3) death anxiety, (4) demoralization, and (5) a perceived inability to cope effectively. The primary antecedent is treatment complexity. The consequences are acceptance and living in the present positively, lower performance status, poor quality of life, suicide, and hastened death. CONCLUSIONS This concept analysis clarifies the meaning of the concept and differentiates the concept of psychological distress from other emotional symptoms that advanced cancer patients commonly experience. It provides clarity in meaning by examining various ways the concept is used in the area of nursing. IMPLICATIONS FOR PRACTICE The identified attributes of psychological distress play vital roles in nursing assessments and should be used as guidance for nurses to provide appropriate nursing care for advanced cancer patients. Interventions should address antecedents and consequences of the concept and consider individuals as persons with unique characteristics.
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22
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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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Gramling R, Straton J, Ingersoll LT, Clarfeld LA, Hirsch L, Gramling CJ, Durieux BN, Rizzo DM, Eppstein MJ, Alexander SC. Epidemiology of Fear, Sadness, and Anger Expression in Palliative Care Conversations. J Pain Symptom Manage 2021; 61:246-253.e1. [PMID: 32822753 DOI: 10.1016/j.jpainsymman.2020.08.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Advancing the science of serious illness communication requires methods for measuring characteristics of conversations in large studies. Understanding which characteristics predict clinically important outcomes can help prioritize attention to scalable measure development. OBJECTIVES To understand whether audibly recognizable expressions of distressing emotion during palliative care serious illness conversations are associated with ratings of patient experience or six-month enrollment in hospice. METHODS We audiorecorded initial palliative care consultations involving 231 hospitalized people with advanced cancer at two large academic medical centers. We coded conversations for expressions of fear, anger, and sadness. We examined the distribution of these expressions and their association with pre/post ratings of feeling heard and understood and six-month hospice enrollment after the consultation. RESULTS Nearly six in 10 conversations included at least one audible expression of distressing emotion (59%; 137 of 231). Among conversations with such an expression, fear was the most prevalent (72%; 98 of 137) followed by sadness (50%; 69 of 137) and anger (45%; 62 of 137). Anger expression was associated with more disease-focused end-of-life treatment preferences, pre/post consultation improvement in feeling heard and understood and lower six-month hospice enrollment. Fear was strongly associated with preconsultation patient ratings of shorter survival expectations. Sadness did not exhibit strong association with patient descriptors or outcomes. CONCLUSION Fear, anger, and sadness are commonly expressed in hospital-based palliative care consultations with people who have advanced cancer. Anger is an epidemiologically useful predictor of important clinical outcomes.
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Affiliation(s)
- Robert Gramling
- Department of Family Medicine, University of Vermont, Burlington, VT, USA.
| | | | - Lukas T Ingersoll
- Department of Public Health, Purdue University, West Lafayette, IN, USA
| | | | | | | | | | - Donna M Rizzo
- Department of Civil & Environmental Engineering, University of Vermont, Burlington, VT, USA
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24
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Verduzco-Aguirre HC, Babu D, Mohile SG, Bautista J, Xu H, Culakova E, Canin B, Zhang Y, Wells M, Epstein RM, Duberstein P, McHugh C, Dale W, Conlin A, Bearden J, Berenberg J, Tejani M, Loh KP. Associations of Uncertainty With Psychological Health and Quality of Life in Older Adults With Advanced Cancer. J Pain Symptom Manage 2021; 61:369-376.e1. [PMID: 32822750 PMCID: PMC7854861 DOI: 10.1016/j.jpainsymman.2020.08.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/06/2020] [Accepted: 08/08/2020] [Indexed: 02/08/2023]
Abstract
CONTEXT Older adults with advanced cancer face uncertainty related to their disease and treatment. OBJECTIVES To evaluate the associations of uncertainty with psychological health and quality of life (QoL) in older adults with advanced cancer. METHODS Secondary cross-sectional analysis of baseline data from a national clustered geriatric assessment trial. Patients 70 years and older with advanced cancer considering a new line of chemotherapy were recruited. We measured uncertainty using the modified nine-item Mishel Uncertainty in Illness Scale. Dependent variables included anxiety (Generalized Anxiety Disorder-7), depression (Generalized Depression Scale-15), distress (distress thermometer), QoL (Functional Assessment of Cancer Therapy-General), and emotional well-being (Functional Assessment of Cancer Therapy-General subscale). We used multivariate linear regression analyses to evaluate the association of uncertainty with each dependent variable. We conducted a partial least squares analysis with a variable importance in projection (VIP) plot to assess the contribution of individual variables to the model. Variables with a VIP <0.8 were considered less influential. RESULTS We included 527 patients (median age 76 years; range 70-96). In multivariate analyses, higher levels of uncertainty were significantly associated with greater anxiety (β = 0.11; SE = 0.04), depression (β = 0.09; SE = 0.02), distress (β = 0.12; SE = 0.02), as well as lower QoL (β = -1.08; SE = 0.11) and emotional well-being (β = -0.29; SE = 0.03); the effect sizes were considered small. Uncertainty items related to disease and treatment were most strongly associated with psychological health and QoL scores (all VIP >0.8). CONCLUSION Uncertainty among older patients with advanced cancer is associated with worse psychological health and QoL. Tailored uncertainty management strategies are warranted.
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Affiliation(s)
- Haydee C Verduzco-Aguirre
- Department of Hemato-Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Dilip Babu
- Kaiser Permanente, Portland, Oregon, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Javier Bautista
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Huiwen Xu
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Eva Culakova
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Beverly Canin
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Yingzi Zhang
- University of Rochester School of Nursing, Rochester, New York, USA
| | - Megan Wells
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Ronald M Epstein
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Paul Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Colin McHugh
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - William Dale
- Department of Supportive Care Medicine, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Alison Conlin
- Pacific Cancer Research Consortium National Cancer Institute Community Oncology Research Program (NCORP), Seattle, Washington, USA
| | - James Bearden
- Southeast Clinical Oncology Research Consortium NCORP, Winston-Salem, North Carolina, USA
| | - Jeffrey Berenberg
- Hawaii Minority Underserved National Cancer Institute Community Oncology Research Program (MU-NCORP), Honolulu, Hawaii, USA
| | | | - Kah Poh Loh
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA.
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25
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van den Broek-Altenburg E, Gramling R, Gothard K, Kroesen M, Chorus C. Using natural language processing to explore heterogeneity in moral terminology in palliative care consultations. BMC Palliat Care 2021; 20:23. [PMID: 33494745 PMCID: PMC7836473 DOI: 10.1186/s12904-021-00716-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/15/2021] [Indexed: 11/22/2022] Open
Abstract
Background High quality serious illness communication requires good understanding of patients’ values and beliefs for their treatment at end of life. Natural Language Processing (NLP) offers a reliable and scalable method for measuring and analyzing value- and belief-related features of conversations in the natural clinical setting. We use a validated NLP corpus and a series of statistical analyses to capture and explain conversation features that characterize the complex domain of moral values and beliefs. The objective of this study was to examine the frequency, distribution and clustering of morality lexicon expressed by patients during palliative care consultation using the Moral Foundations NLP Dictionary. Methods We used text data from 231 audio-recorded and transcribed inpatient PC consultations and data from baseline and follow-up patient questionnaires at two large academic medical centers in the United States. With these data, we identified different moral expressions in patients using text mining techniques. We used latent class analysis to explore if there were qualitatively different underlying patterns in the PC patient population. We used Poisson regressions to analyze if individual patient characteristics, EOL preferences, religion and spiritual beliefs were associated with use of moral terminology. Results We found two latent classes: a class in which patients did not use many expressions of morality in their PC consultations and one in which patients did. Age, race (white), education, spiritual needs, and whether a patient was affiliated with Christianity or another religion were all associated with membership of the first class. Gender, financial security and preference for longevity-focused over comfort focused treatment near EOL did not affect class membership. Conclusions This study is among the first to use text data from a real-world situation to extract information regarding individual foundations of morality. It is the first to test empirically if individual moral expressions are associated with individual characteristics, attitudes and emotions.
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Affiliation(s)
| | - Robert Gramling
- University of Vermont, Robert Larner, M.D. College of Medicine, 89 Beaumont Avenue, Burlington, VT, 05405, USA
| | - Kelly Gothard
- University of Vermont, Robert Larner, M.D. College of Medicine, 89 Beaumont Avenue, Burlington, VT, 05405, USA
| | - Maarten Kroesen
- Delft University of Technology, Stevinweg 1, Delft, CB, 2628, The Netherlands
| | - Caspar Chorus
- Delft University of Technology, Stevinweg 1, Delft, CB, 2628, The Netherlands
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26
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Hui D, Mo L, Paiva CE. The Importance of Prognostication: Impact of Prognostic Predictions, Disclosures, Awareness, and Acceptance on Patient Outcomes. Curr Treat Options Oncol 2021; 22:12. [PMID: 33432524 DOI: 10.1007/s11864-020-00810-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 02/05/2023]
Abstract
OPINION STATEMENT In the advanced cancer setting, patients, families, and clinicians are often confronted with an uncertain future regarding treatment outcomes and survival. Greater certainty on what to expect can enhance decision-making for many personal and healthcare issues. Although 70-90% of patients with advanced cancer desire open and honest prognostic disclosure, a small proportion do not want to know. Approximately half of patients with advanced cancer have an inaccurate understanding of their illness, which could negatively impact their decision-making. In this review, we use a conceptual framework to highlight 5 key steps along the prognostic continuum, including (1) prognostic formulation, (2) prognostic disclosure, (3) prognostic awareness, (4) prognostic acceptance, and (5) prognosis-based decision-making. We shall summarize the impact of prognostic predictions, disclosure, awareness, and acceptance on various patient and caregiver outcomes, such as hope, trust, anxiety, depression, chemotherapy use, and care planning. Based on where the patient is at along the prognostic continuum, we propose 5 different subgroups (avoidance: "I don't want to know"; discordant, "I never wanted to know"; anxious, "I don't know what's happening"; concerned, "I don't like this"; acceptance, "I know how to plan ahead"). Although prognostication is not necessarily a linear process, recognizing where the patient is at cognitively and emotionally along the prognostic continuum may allow clinicians to provide personalized interventions, such as specialist palliative care and psychology referral, towards personalizing prognostic disclosure, enhancing prognostic awareness, increasing prognostic acceptance, and supporting decision-making and, ultimately, improving patient outcomes.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Unit 1414 - 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Li Mo
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Unit 1414 - 1515 Holcombe Blvd, Houston, TX, 77030, USA.,The Center of Gerontology and Geriatrics, National Clinical Research Center of Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Nair D, Bonnet K, Wild MG, Umeukeje EM, Fissell RB, Faulkner ML, Bahri NS, Bruce MA, Schlundt DG, Wallston KA, Cavanaugh KL. Psychological Adaptation to Serious Illness: A Qualitative Study of Culturally Diverse Patients With Advanced Chronic Kidney Disease. J Pain Symptom Manage 2021; 61:32-41.e2. [PMID: 32711122 PMCID: PMC7770006 DOI: 10.1016/j.jpainsymman.2020.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 12/27/2022]
Abstract
CONTEXT Psychological distress is associated with adverse health outcomes in serious illness and magnified among patients of low socioeconomic status. Aspects of one's culture, such as religion and spirituality, can influence these patients' coping response to distress. Advanced chronic kidney disease (CKD) is a serious illness that disproportionately affects patients of low socioeconomic status, but a theory-based understanding of this group's lived experience of CKD is lacking. OBJECTIVES We explored the cognitions, emotions, and coping behaviors of patients with CKD with emphasis on those of low socioeconomic status. We further inquired into any influences of religion or spirituality. METHODS We interviewed 50 English-speaking or Spanish-speaking adults with advanced CKD from three medical centers in Nashville, Tennessee. Analyses occurred with isolation of themes; development of a coding system; and creation of a conceptual framework using an inductive-deductive approach. RESULTS Median age was 65 years; median annual income was $17,500 per year; and 48% of participants had not progressed beyond high school. Key beliefs (awareness of mortality and lack of control) influenced patients' emotions (existential distress in the form of death anxiety, prognostic uncertainty, and hopelessness) and coping behaviors (acceptance, avoidance, emotion regulation via spirituality, and seeking socialsupport via a religious community). CONCLUSION Individuals with advanced CKD and low socioeconomic status lack control over disease progression, experience death anxiety and existential distress, and emphasize spirituality to cope. Our study identifies novel components for a psychotherapeutic intervention for patients with advanced CKD at high risk for adverse health outcomes.
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Affiliation(s)
- Devika Nair
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Vanderbilt O'Brien Center for Kidney Disease, Nashville, Tennessee, USA.
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA
| | - Marcus G Wild
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA
| | - Ebele M Umeukeje
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Vanderbilt O'Brien Center for Kidney Disease, Nashville, Tennessee, USA
| | - Rachel B Fissell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Vanderbilt O'Brien Center for Kidney Disease, Nashville, Tennessee, USA
| | | | - Nader S Bahri
- Division of Nephrology, Meharry Medical College, Nashville, Tennessee, USA
| | - Marino A Bruce
- Program for Research on Faith, Justice, and Health, Department of Population Health, John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, Mississippi, USA; Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David G Schlundt
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA
| | - Kenneth A Wallston
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kerri L Cavanaugh
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Vanderbilt O'Brien Center for Kidney Disease, Nashville, Tennessee, USA; Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Thinking clearly about dignity:
relationships between cognitive processes
underlying perceived dignity as determinants
of psychological adjustment. HEALTH PSYCHOLOGY REPORT 2021. [DOI: 10.5114/hpr.2021.111398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Dealing with prognostic uncertainty: the role of prognostic models and websites for patients with advanced cancer. Curr Opin Support Palliat Care 2020; 13:360-368. [PMID: 31689273 DOI: 10.1097/spc.0000000000000459] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To provide an updated overview of prognostic models in advanced cancer and highlight the role of prognostic calculators. RECENT FINDINGS In the advanced cancer setting, many important healthcare decisions are driven by a patient's prognosis. However, there is much uncertainty in formulating prognosis, particularly in the era of novel cancer therapeutics. Multiple prognostic models have been validated for patients seen by palliative care and have a life expectancy of a few months or less, such as the Palliative Performance Scale, Palliative Prognostic Score, Palliative Prognostic Index, Objective Prognostic Score, and Prognosis in Palliative Care Study Predictor. However, these models are seldom used in clinical practice because of challenges related to limited accuracy when applied individually and difficulties with model selection, computation, and interpretation. Online prognostic calculators emerge as tools to facilitate knowledge translation by overcoming the above challenges. For example, www.predictsurvival.com provides the output for seven prognostic indexes simultaneously based on 11 variables. SUMMARY Prognostic models and prognostic websites are currently available to augment prognostication in the advanced cancer setting. Further studies are needed to examine their impact on prognostic accuracy, confidence, and clinical outcomes.
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Evaluation of an End-of-Life Essentials Online Education Module on Chronic Complex Illness End-of-Life Care. Healthcare (Basel) 2020; 8:healthcare8030297. [PMID: 32854394 PMCID: PMC7551176 DOI: 10.3390/healthcare8030297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/13/2020] [Accepted: 08/19/2020] [Indexed: 11/16/2022] Open
Abstract
Chronic complex illness/multimorbidity is a leading cause of death worldwide. Many people with chronic complex illnesses die in hospital, with the overall quality of end-of-life care requiring substantial improvement, necessitating an increase in the knowledge of the health professionals caring for them. End-of-Life-Essentials (EOLE) offers online education modules for health professionals working in acute hospitals, including one on chronic complex illness. A quantitative pre-post-evaluation analysis was undertaken on data from learners (n = 1489), who completed a questionnaire related to knowledge gained from module completion between December 2018 and November 2019. A qualitative post-evaluation analysis was also conducted using data on learner responses to a question posed between May and November 2019. Results showed a significant positive impact on learners' knowledge, skill, attitude, and confidence in providing end-of-life care to patients living with chronic complex illness. The majority (82.9%, n = 900) intended to change their practice after module completion. A total of n = 559 qualitative comments were analysed thematically, with three major themes emerging: Patient centred care and care planning, Discussion of prognosis, and Valued communication skills. This evaluation has demonstrated that healthcare professionals could benefit from this education to improve quality of care of the dying.
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Sedhom R, Gupta A, Smith TJ. Short Hospice Length of Service in a Comprehensive Cancer Center. J Palliat Med 2020; 24:257-260. [PMID: 32302497 DOI: 10.1089/jpm.2019.0634] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The benefits of hospice for patients with advanced cancer are well established. Short hospice length of service (LOS) is a marker of poor quality care and patient and family dissatisfaction. Interventions based on behavioral science might reduce suboptimal hospice use. Objective: To assess effects of peer comparisons on rates of short hospice LOS for cancer patients at a tertiary comprehensive cancer center. Design: Pre-post design utilizing a peer-comparison feedback intervention comparing individual oncologist hospice data. Setting: Urban, academic, comprehensive cancer center in Maryland. Measurements: Hospice enrollment rate. Median hospice LOS and percentage short hospice LOS (defined as ≤7 days). Results: Sixty oncologists received the intervention. Before the intervention, 394 patients enrolled in hospice for a period of 21 months (18.76 enrollments per month). Median hospice LOS was 14.5 days. After the intervention, 418 patients enrolled in hospice for 14 months (29.85 enrollments per month). Median hospice LOS was nine days. The percentage of patients experiencing a short hospice LOS increased from 33.3% to 43.5%. Conclusions: The methods are not sufficient to conclude that the intervention does not improve hospice use. A substantial number of patients with cancer who used hospice had LOS ≤7 days, a marker of poor quality. Using peer comparison in combination with additional behavioral interventions should be considered to improve end-of-life care.
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Affiliation(s)
- Ramy Sedhom
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
| | - Arjun Gupta
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
| | - Thomas J Smith
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
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Moving closer to death: understanding psychosocial distress among older veterans with advanced cancers. Support Care Cancer 2020; 28:5919-5931. [PMID: 32281033 DOI: 10.1007/s00520-020-05452-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 04/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Early identification of psychosocial distress is important to address the needs of vulnerable populations and influence symptom management. Older veterans diagnosed with life-limiting cancers are particularly vulnerable because they often have unmet needs, experiencing psychological or emotional problems and gaps in healthcare communication, which extends suffering. Lack of emotional support, ongoing physical pain, and unresolved symptom control can further increase distress among older veterans, contributing to complexity of decision-making for end of life (EOL) care. OBJECTIVE We explored older veterans' experiences and identification of psychosocial distress in cancer care to better understand how they describe distress while facing the end of life. METHODS Guiding this study is a conceptual framework from psychosocial oncology with the multifactorial experience of distress indicated by NCCN guidelines for distress screening. We use a phenomenological approach to explore the experience of psychosocial distress among older veterans diagnosed with advanced cancers at risk for dying within a year. INCLUSION CRITERIA Provider response of "no" to, "Would you be surprised if your patient died within a year?" and "yes", to the question, "Have you talked with your patient about the severity of their illness as being life-limiting, terminal?" RESULTS Five themes emerged: (1) the meaning of distress: "It's hard to explain"; (2) severity of advanced cancer: "There's no stage five"; (3) distressing thoughts about the possibility of dying: "Either way, it's life limiting"; (4) coping: "Deal with it and hope for a better day"; and (5) personal factors: "I don't want to be anything but a man who can handle adversity." Findings suggest older veterans may have unique cancer experiences different from other populations. CONCLUSION Older veterans in this study exhibited distressing symptoms which demonstrate they are at risk for declining health and in need of support for their distress. Healthcare providers are urged to understand the complexity of distress to provide the best possible treatment for older veterans.
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Dauphin S, Van Wolputte S, Jansen L, De Burghgraeve T, Buntinx F, van den Akker M. Using Liminality and Subjunctivity to Better Understand How Patients With Cancer Experience Uncertainty Throughout Their Illness Trajectory. QUALITATIVE HEALTH RESEARCH 2020; 30:356-365. [PMID: 31617448 DOI: 10.1177/1049732319880542] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Uncertainty is a central theme in the illness experiences of older cancer patients throughout their illness trajectory. Mishel's popular theory on uncertainty during illness approaches uncertainty as an outcome and is characterized by the patient's inability to find meaning in illness events. This study used the concepts of liminality and subjunctivity to explore uncertainty throughout the illness trajectory of cancer patients. We interviewed 18 older (age range = 57-92 years) patients with breast cancer or gastro-intestinal cancer 3 to 4 years post diagnosis. Our analysis is based on the QUAGOL guide that draws on elements of grounded theory such as constant comparison. We found that liminality and subjunctivity provide a useful frame for understanding uncertainty with a specific focus on its productive potential and meaning making. Health care professionals should be open to acquiring a complete picture of patients' diverse and dynamic experiences of uncertainty in the different stages of their illness trajectory.
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Affiliation(s)
| | | | | | | | - Frank Buntinx
- KU Leuven, Leuven, Belgium
- Maastricht University, Maastricht, The Netherlands
| | - Marjan van den Akker
- KU Leuven, Leuven, Belgium
- Maastricht University, Maastricht, The Netherlands
- Johann Wolfgang Goethe University, Frankfurt am Main, Germany
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Gilmour F, Riccobono R, Haraldsdottir E. The value of poetry therapy for people in palliative and end of life care. PROGRESS IN PALLIATIVE CARE 2019. [DOI: 10.1080/09699260.2019.1684866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Fiona Gilmour
- University of St. Andrews, St Andrews, Scotland
- Queen Margaret University, Musselburgh, Scotland
| | - Rossella Riccobono
- School of Modern LanguagesUniversity of St. Andrews, St Andrews, Scotland
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Derry HM, Epstein AS, Lichtenthal WG, Prigerson HG. Emotions in the room: common emotional reactions to discussions of poor prognosis and tools to address them. Expert Rev Anticancer Ther 2019; 19:689-696. [PMID: 31382794 PMCID: PMC6709526 DOI: 10.1080/14737140.2019.1651648] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/30/2019] [Indexed: 12/15/2022]
Abstract
Introduction: Advanced cancer patients often want prognostic information, and discussions of prognosis have been shown to enhance patient understanding of their illness. Such discussions can lead to high-quality, value-consistent care at the end of life, yet they are also often emotionally challenging. Despite how common and normal it is for patients to experience transient emotional distress when receiving 'bad news' about prognosis, emotional responses have been under-addressed in existing literature on prognostic discussions. Areas covered: Drawing upon psychology research, principles of skilled clinical communication, and published approaches to discussions of serious illness, we summarize patients' common emotional reactions and coping strategies. We then provide suggestions for how to respond to them in clinic. Expert opinion: Ultimately, effective management of emotional reactions to bad news may lead to earlier, more frequent, and more transparent discussions of prognosis, thus promoting cancer patients' understanding of, and adjustment to, their illness and improving the quality of their end-of-life care.
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Derry HM, Reid MC, Prigerson HG. Advanced cancer patients' understanding of prognostic information: Applying insights from psychological research. Cancer Med 2019; 8:4081-4088. [PMID: 31199597 PMCID: PMC6675734 DOI: 10.1002/cam4.2331] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/06/2019] [Accepted: 05/22/2019] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Informed medical decision-making at the end of life often requires engaging in highly emotional, potentially upsetting discussions about prognosis, while ensuring that patients grasp its personal meaning. Behavioral science offers insights into ways to promote prognostic understanding among patients with advanced cancer. SUMMARY In this literature review, we synthesize complementary findings from basic behavioral science and applied clinical research, which suggest that psychological factors can significantly influence both patients' clinical interactions and their prognostic understanding. For example, stress and emotion can affect cognition, which may shape how patients process complex medical information. Additionally, clinicians may be less likely to share prognostic information with distressed patients who, in turn, may be hesitant to ask about their prognosis for fear of the answer. Although traditional approaches for increasing advanced cancer patients' understanding focus on improving information delivery, these efforts may not be sufficient without corresponding interventions that assist patients in managing distress. CONCLUSIONS Psychological barriers may limit opportunities for patients to fully understand their prognosis and to receive high quality of end-of-life care that is linked with an accurate understanding of their disease and treatment options. Failure to attend to patients' emotional distress may undermine efforts to improve medical communication. This underscores the importance of increased attention to the psychological factors that impede patients' comprehension of material shared in cancer clinic visits, in order to inform interventions that address patient distress both before and after receiving "bad news." Integrating findings from psychological research into prognostic discussions may not only improve advanced cancer patients' mental health, but may also promote their ability to make informed, value-consistent medical decisions.
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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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Metin S, Demirci H, Metin AT. Effect of health literacy of caregivers on survival rates of patients under palliative care. Scand J Caring Sci 2019; 33:669-676. [PMID: 30735265 DOI: 10.1111/scs.12662] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/07/2019] [Indexed: 01/03/2023]
Abstract
AIM In this study, we aimed to investigate the effect of health literacy of the patient caregiver on the care results of palliative care patients. METHODS Two hundred and forty-two patients who were hospitalised in palliative care units of seven hospitals in the city in January 2018 were involved in the study. Mortality of the patients was checked 3 months later. A survey interrogating the sociodemographic characteristics of the patients and Turkish translation of Health Literacy Survey - European Union to measure the health literacy level of the caregivers were used. RESULTS About 19.50% of the patient caregivers are in adequate (sufficient/perfect) HL group in term of general HL. Caregivers had difficulty to access information/knowledge of what to do in case of emergency. Prevalence of bedsore occurrence in patients whose caregiver has 'inadequate' HL is higher than patients whose caregiver has 'adequate' HL. Rate of 'inadequate HL' of the caregiver is higher in dead group. As the length of hospitalisation variable value increases 1 unit, risk of mortality decreases 2%. CONCLUSIONS Health literacy levels of the individuals dealing with the care of palliative unit patients hospitalised in our region are low. Amelioration of health literacy of the caregivers will have a direct effect on patient health and prevention of complications. Improving health literacy must be a priority target for a more quality patient care and less complication. The issues that caregivers felt themselves insufficient should be addressed and necessary actions should be taken in the identified issues.
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Affiliation(s)
- Salih Metin
- Department of Family Medicine, University of Health Sciences Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Hakan Demirci
- Department of Family Medicine, University of Health Sciences Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
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Gramling R, Gajary-Coots E, Cimino J, Fiscella K, Epstein R, Ladwig S, Anderson W, Alexander SC, Han PK, Gramling D, Norton SA. Palliative Care Clinician Overestimation of Survival in Advanced Cancer: Disparities and Association With End-of-Life Care. J Pain Symptom Manage 2019; 57:233-240. [PMID: 30391655 DOI: 10.1016/j.jpainsymman.2018.10.510] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/24/2018] [Accepted: 10/25/2018] [Indexed: 10/27/2022]
Abstract
CONTEXT Clinicians frequently overestimate survival time in serious illness. OBJECTIVE The objective of this study was to understand the frequency of overestimation in palliative care (PC) and the relation with end-of-life (EOL) treatment. METHODS This is a multisite cohort study of 230 hospitalized patients with advanced cancer who consulted with PC between 2013 and 2016. We asked the consulting PC clinician to make their "best guess" about the patients' "most likely survival time, assuming that their illnesses are allowed to take their natural course" (<24 hours; 24 hours to less than two weeks; two weeks to less than three months; three months to less than six months; six months or longer). We followed patients for up to six month for mortality and EOL treatment utilization. Patients completed a brief interviewer-facilitated questionnaire at study enrollment. RESULTS Median survival was 37 days (interquartile range: 12 days, 97 days) and 186/230 (81%) died during the follow-up period. Forty-one percent of clinicians' predictions were accurate. Among inaccurate prognoses, 85% were overestimates. Among those who died, overestimates were substantially associated with less hospice use (ORadj: 0.40; 95% CI: 0.16-0.99) and later hospice enrollment (within 72 hours of death ORadj: 0.33; 95% CI: 0.15-0.74). PC clinicians were substantially more likely to overestimate survival for patients who identified as Black or Latino compared to others (ORadj: 3.89; 95% CI: 1.64-9.22). EOL treatment preferences did not explain either of these findings. CONCLUSION Overestimation is common in PC, associated with lower hospice use and a potentially mutable source of racial/ethnic disparity in EOL care.
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Smith AB, Daneshmand S, Patel S, Pohar K, Trabulsi E, Woods M, Downs T, Huang W, Taylor J, Jones J, O'Donnell M, Bivalacqua T, DeCastro J, Steinberg G, Kamat A, Resnick M, Konety B, Schoenberg M, Jones JS, Lotan Y. Patient-reported outcomes of blue-light flexible cystoscopy with hexaminolevulinate in the surveillance of bladder cancer: results from a prospective multicentre study. BJU Int 2019; 123:35-41. [PMID: 29979488 DOI: 10.1111/bju.14481] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate blue-light flexible cystoscopy (BLFC) with hexaminolevulinate in the office surveillance of patients with non-muscle-invasive bladder cancer with a high risk of recurrence by assessing its impact on pain, anxiety, subjective value of the test and patient willingness to pay. MATERIALS AND METHODS A prospective, multicentre, phase III study was conducted during which the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety, Pain and 'Was It Worth It' questionnaires were administered at baseline, after surveillance with BLFC and after resection for those referred to the operating room. Comparisons of scores were performed between groups. RESULTS A total of 304 patients were enrolled, of whom 103 were referred for surgical examination. Of these, 63 were found to have histologically confirmed malignancy. Pain levels were low throughout the study. Anxiety levels decreased after BLFC (∆ = -2.6), with a greater decrease among those with negative pathology results (P = 0.051). No differences in anxiety were noted based on gender, BLFC results, or test performance (true-positive/false-positive). Most patients found BLFC 'worthwhile' (94%), would 'do it again' (94%) and 'would recommend it to others' (91%), with no differences based on BLFC results or test performance. Most patients undergoing BLFC (76%) were willing to pay out of pocket. CONCLUSIONS Anxiety decreased after BLFC in patients with negative pathology, including patients with false-positive results. Most of the patients undergoing BLFC were willing to pay out of pocket, found the procedure worthwhile and would recommend it to others, irrespective of whether they had a positive BLFC result or whether this was false-positive after surgery.
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Affiliation(s)
| | | | | | | | - Edouard Trabulsi
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - William Huang
- New York University School of Medicine, New York, NY, USA
| | | | | | | | | | - Joel DeCastro
- Columbia University Medical Center, New York, NY, USA
| | | | - Ashish Kamat
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | | | | | - Mark Schoenberg
- Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Yair Lotan
- UT Southwestern Medical Center, Dallas, TX, USA
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Gramling R, Ingersoll LT, Anderson W, Priest J, Berns S, Cheung K, Norton SA, Alexander SC. End-of-Life Preferences, Length-of-Life Conversations, and Hospice Enrollment in Palliative Care: A Direct Observation Cohort Study among People with Advanced Cancer. J Palliat Med 2018; 22:152-156. [PMID: 30526222 DOI: 10.1089/jpm.2018.0476] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
CONTEXT Prognosis communication is one hypothesized mechanism by which effective palliative care (PC) promotes preference-concordant treatment near end of life (EOL), but little is known about this relationship. METHODS This is a multisite cohort study of 231 hospitalized patients with advanced cancer who consulted with PC. We audio-recorded the initial consultation with the PC team and coded conversations for all statements regarding expectations for how long the patient will live. We refer to these statements as length-of-life talk. We followed patients for up to six months to determine EOL treatment utilization, including hospice enrollment. Patients completed a brief interviewer-facilitated questionnaire at study enrollment. RESULTS Forty-four percent (101/231) of observed conversations contained at least one statement about expectations for length of life, and 60% of patients (139/231) enrolled in hospice during the six months following these conversations. The association between length-of-life talk and hospice enrollment was strong among those (155/231) who endorsed treatment preferences favoring comfort over longevity in the last weeks to months of life (odds ratio [OR]adj = 2.98; 95% confidence interval [CI] = 1.34-6.65) and weak/absent among others (69/231; ORadj = 0.70; 95% CI = 0.16-3.04). CONCLUSIONS Talking about expectations for remaining length of life during PC consultations is associated with six-month hospice enrollment among people with advanced cancer who endorse preferences for EOL treatment that favor comfort over longevity.
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Affiliation(s)
- Robert Gramling
- 1 Department of Family Medicine, Division of Palliative Medicine, University of Vermont Medical Center, Burlington, Vermont
| | - Luke T Ingersoll
- 2 Department of Consumer Science, Purdue University, West Lafayette, Indiana
| | - Wendy Anderson
- 3 Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Jeff Priest
- 4 Medical Biostatistics Unit, University of Vermont, Burlington, Vermont
| | - Stephen Berns
- 5 Department of Family Medicine, University of Vermont, Burlington, Vermont
| | - Katharine Cheung
- 6 Department of Medicine, University of Vermont, Burlington, Vermont
| | - Sally A Norton
- 7 School of Nursing, University of Rochester, Rochester, New York
| | - Stewart C Alexander
- 2 Department of Consumer Science, Purdue University, West Lafayette, Indiana
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