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García-Navarro EB, Araujo-Hernández M, Rigabert A, Rojas-Ocaña MJ. Attitudes of nursing degree students towards end of life processes. A cultural approach (Spain-Senegal). PLoS One 2021; 16:e0254870. [PMID: 34415902 PMCID: PMC8378746 DOI: 10.1371/journal.pone.0254870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/05/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction The concept of death is abstract, complex and has a number of meanings. Thus, its understanding and the approach taken to it depend, to a large extent, on aspects such as age, culture, training and religion. Nursing students have regular contact with the process of death and so it is of great interest to understand the attitudes they have towards it. As we live in a plural society it is even more interesting to not only understand the attitudes of Spanish students but, also, those of students coming from other countries. In the present article, we seek to identify and compare the attitudes held by nursing degree students at Hekima-Santé University (Senegal) and the University of Huelva (Spain) about end of life processes. The study identifies elements that condition attitudes and coping with death, whilst considering curricular differences with regards to specific end of life training. Method A descriptive, cross-sectional and multi-center study was conducted. The overall sample (N = 142) was divided into groups: Hekima-Santé University (Dakar, Senegal) and the University of Huelva (Huelva, Spain). The measurement instruments used were an ad-hoc questionnaire and Bugen´s Coping with Death Scale. Results Statistically significant differences (p = 0.005, 95%CI) were found in relation to overall Bugen Scale scores. We can confirm that specialized end of life training (University of Huelva, Spain) did not lead to better coping when compared with a population whose academic curriculum did not provide specific training and who engaged in more religious practices (Hekima-Santé University, Senegal). Conclusions In cultures where religion not only influences the spiritual dimension of the individual, but acts in the ethical and moral system and consequently in the economic, educational and family sphere, the accompaniment at the end of life transcends the formative plane. Considering the plural society in which we live, the training that integrates the Degree in Nursing with regard to the care of the final process, must be multidimensional in which spirituality and faith are integrated, working emotional and attentional skills, as well as cultural competence strategies in this process.
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Affiliation(s)
- E. Begoña García-Navarro
- Department of Nursing and Health Sciences, University of Huelva, Huelva, Spain
- Research Group ESEIS, Social Studies and Social Intervention, Center for Research in Contemporary Thought and Innovation for Development (COIDESO), University of Huelva, Huelva, Spain
| | | | - Alina Rigabert
- Methodology and Data Analysis Department, Andalusia Beturia Foundation for Health Research (FABIS), Huelva, Spain
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2
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Kistler CE, Van Dongen MJ, Ernecoff NC, Daaleman TP, Hanson LC. Evaluating the care provision of a community-based serious-illness care program via chart measures. BMC Geriatr 2020; 20:351. [PMID: 32933473 PMCID: PMC7493350 DOI: 10.1186/s12877-020-01736-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 08/25/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Although quality-of-care domains for home-based primary and palliative programs have been proposed, they have had limited testing in practice. Our aim was to evaluate the care provision in a community-based serious-illness care program, a combined home-based primary and palliative care model. METHODS Retrospective chart review of patients in an academic community-based serious-illness care program in central North Carolina from August 2014 to March 2016 (n = 159). Chart review included demographics, health status, and operationalized measures of seven quality-of-care domains: medical assessment, care coordination, safety, quality of life, provider competency, goal attainment, and access. RESULTS Patients were mostly women (56%) with an average age of 70 years. Patients were multi-morbid (53% ≥3 comorbidities), functionally impaired (45% had impairment in ≥2 activities of daily living) and 32% had dementia. During the study period, 31% of patients died. Chart review found high rates assessment of functional status (97%), falls (98%), and medication safety (96%). Rates of pain assessment (70%), advance directive discussions (65%), influenza vaccination (59%), and depression assessment (54% of those with a diagnosis of depression) were lower. Cognitive barriers, spiritual needs, and behavioral issues were assessed infrequently (35, 22, 21%, respectively). CONCLUSION This study is one of the first to operationalize and examine quality-of-care measures for a community-based serious-illness care program, an emerging model for vulnerable adults. Our operationalization should not constitute validation of these measures and revealed areas for improvement; however, the community-based serious-illness care program performed well in several key quality-of-care domains. Future work is needed to validate these measures.
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Affiliation(s)
- Christine E. Kistler
- grid.410711.20000 0001 1034 1720Department of Family Medicine, University of North Carolina, 590 Manning Drive, CB #7595, Chapel Hill, NC 27599 USA ,grid.410711.20000 0001 1034 1720Department of Internal Medicine, University of North Carolina, Chapel Hill, NC USA ,grid.410711.20000 0001 1034 1720Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC USA
| | - Matthew J. Van Dongen
- grid.410711.20000 0001 1034 1720Department of Internal Medicine, University of North Carolina, Chapel Hill, NC USA
| | - Natalie C. Ernecoff
- grid.21925.3d0000 0004 1936 9000Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Timothy P. Daaleman
- grid.410711.20000 0001 1034 1720Department of Family Medicine, University of North Carolina, 590 Manning Drive, CB #7595, Chapel Hill, NC 27599 USA
| | - Laura C. Hanson
- grid.410711.20000 0001 1034 1720Department of Internal Medicine, University of North Carolina, Chapel Hill, NC USA ,grid.410711.20000 0001 1034 1720Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC USA
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3
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Paladino J, Brannen E, Benotti E, Henrich N, Ritchie C, Sanders J, Lakin JR. Implementing Serious Illness Communication Processes in Primary Care: A Qualitative Study. Am J Hosp Palliat Care 2020; 38:459-466. [PMID: 32794412 DOI: 10.1177/1049909120951095] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Primary care clinicians face barriers to engaging patients in conversations about prognosis, values, and goals ("serious illness conversations"). We introduced a structured, multi-component intervention, the Serious Illness Care Program (SICP), to facilitate conversations in the primary care setting. We present findings of a qualitative study to explore practical aspects of program implementation. METHODS We conducted semi-structured interviews of participating primary care physicians, nurse care coordinators, and social workers and coded transcripts to assess the activities used to integrate SICP into the workflow. RESULTS We conducted interviews with 14 of 46 clinicians from 6 primary care clinics, stopping with thematic saturation. Qualitative analysis revealed major themes around activities in the timing of the conversation (before, during, and after) and overarching insights about the program. Clinicians used a variety of strategies to adapt program components while preserving key program goals, including processes to generate accountability to ensure that conversations happen in busy clinical workflows. The interviews revealed changes to clinicians' mindset and norms, such as the recognition of the need to start conversations earlier in the illness course and the use of more expansive models of prognostic communication that address function and quality of life. Data also revealed indicators of sustainable behavior change and the spread of communication practices to patients outside the intended program scope. CONCLUSION SICP served as a framework for primary care clinicians to integrate serious illness communication into routine care. The shifts in processes employed by inter-professional clinicians revealed comprehensive models for prognostic communication and creative workflows to ensure that patients with complex illnesses had proactive, longitudinal, and patient-centered serious illness conversations and care planning.
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Affiliation(s)
- Joanna Paladino
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Elise Brannen
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily Benotti
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA
| | - Natalie Henrich
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA
| | - Christine Ritchie
- Harvard Medical School, Boston, MA, USA.,Division of Palliative Medicine, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Justin Sanders
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Psychosocial Oncology and Palliative Care, 1855Dana-Farber Cancer Institute, Boston, MA, USA
| | - Joshua R Lakin
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Psychosocial Oncology and Palliative Care, 1855Dana-Farber Cancer Institute, Boston, MA, USA
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4
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Myers JD. The Role of the Physician Assistant in Hospice and Palliative Medicine. PHYSICIAN ASSISTANT CLINICS 2020. [DOI: 10.1016/j.cpha.2020.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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5
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Paladino J, Koritsanszky L, Neal BJ, Lakin JR, Kavanagh J, Lipsitz S, Fromme EK, Sanders J, Benjamin E, Block S, Bernacki R. Effect of the Serious Illness Care Program on Health Care Utilization at the End of Life for Patients with Cancer. J Palliat Med 2020; 23:1365-1369. [PMID: 31904304 DOI: 10.1089/jpm.2019.0437] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Objectives: To determine the effect of the Serious Illness Care Program on health care utilization at the end of life in oncology. Design: Analysis of the secondary outcome of health care utilization as part of a cluster-randomized clinical trial that ran from 2012 to 2016. Clinicians in the intervention group received training, coaching, and system supports to have discussions with patients using a Serious Illness Conversation Guide (SICG); clinicians in the control arm followed usual care. Setting/Subject: Patients with advanced cancer who died within two years of enrollment at the Dana-Farber Cancer Institute. Measurement: Health care utilization was abstracted from the electronic medical record using the National Quality Forum (NQF)-endorsed indicators of aggressive cancer care at the end of life and scored from 0 to 6 (one point for each aggressive indicator); t tests and chi-square tests were used to determine differences between intervention and control patients. Results: The charts of 159 patients who died were reviewed. Neither the main outcome of mean number of aggressive indicators (0.9 vs. 0.9, p = 0.84) nor the proportion of patients with any aggressive care (49% intervention [95% CI: 40-57] vs. 54% control [95% CI: 42-67]) differed between patients in the intervention and control groups. Conclusion: In this analysis of a secondary outcome from a randomized clinical trial of the Serious Illness Care Program, intervention and control patients had similar end-of-life health care utilization as measured by the mean number of NQF-endorsed indicators. Future research efforts should focus on studying the strategies by which communication about patients' prognosis, values, and goals leads to personalized care plans.
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Affiliation(s)
- Joanna Paladino
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Luca Koritsanszky
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Brandon J Neal
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Joshua R Lakin
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jane Kavanagh
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Stu Lipsitz
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Erik K Fromme
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Justin Sanders
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Evan Benjamin
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Susan Block
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rachelle Bernacki
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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6
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Sanders JJ, Paladino J, Reaves E, Luetke-Stahlman H, Anhang Price R, Lorenz K, Hanson LC, Curtis JR, Meier DE, Fromme EK, Block SD. Quality Measurement of Serious Illness Communication: Recommendations for Health Systems Based on Findings from a Symposium of National Experts. J Palliat Med 2019; 23:13-21. [PMID: 31721629 DOI: 10.1089/jpm.2019.0335] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Communication between clinicians and patients fundamentally shapes the experience of serious illness. There is increasing recognition that health systems should routinely implement structures and processes to assure high-quality serious illness communication (SIC) and measure the effectiveness of their efforts on key outcomes. The absence, underdevelopment, or limited applicability of quality measures related specifically to SIC, and their limited application only to those seen by specialist palliative and hospice care teams, hinder efforts to improve care planning, service delivery, and health outcomes for all seriously ill patients. Objective: We convened an expert stakeholder symposium and subsequently surveyed participants to consider challenges, opportunities, priorities, and strategies to improve quality measurement specific to SIC. Results: We identified several barriers and opportunities to improving quality measurement of SIC. These include issues related to the definition of SIC, methodological challenges related to measuring SIC and related outcomes, underutilization of technologies that can facilitate measurement, and measurement development, and dissemination. Conclusions: Patients, clinicians, and health systems increasingly align around the importance of high-quality communication in serious illness. We offer recommendations for various stakeholder groups to advance SIC quality measurement. Enthusiasm and a sense of urgency among health systems to drive and measure communication improvements inform our proposal for a set of example measures for implementation now.
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Affiliation(s)
- Justin J Sanders
- Harvard Medical School, Boston, Massachusetts
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joanna Paladino
- Harvard Medical School, Boston, Massachusetts
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Erica Reaves
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | - Karl Lorenz
- Division of Palliative Care, Palo Alto VA Health Care System, Stanford University School of Medicine, Palo Alto, California
| | - Laura C Hanson
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
- Division of Geriatric Medicine and Palliative Care Program, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
| | - Diane E Meier
- Center to Advance Palliative Care, New York, New York
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erik K Fromme
- Harvard Medical School, Boston, Massachusetts
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Susan D Block
- Harvard Medical School, Boston, Massachusetts
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
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7
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Ernecoff NC, Hanson LC, Fox AL, Daaleman TP, Kistler CE. Palliative Care in a Community-Based Serious-Illness Care Program. J Palliat Med 2019; 23:692-697. [PMID: 31644370 DOI: 10.1089/jpm.2019.0174] [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] [Indexed: 12/15/2022] Open
Abstract
Background: Although community-based serious-illness care (CBSC) is an innovative care model, it is unclear to what extent CBSC addresses palliative care needs, particularly for those patients near death. Objectives: To evaluate palliative care services of a CBSC program. Design: Retrospective chart reviews. Setting/Subjects: Patients enrolled in a CBSC program in central North Carolina. Measurement: Descriptive statistics of palliative care needs and services, such as symptom management, psychosocial support, and advance care planning (ACP), for survivors and decedents. Results: Patients were seen in an 18-month time frame (n = 159). Mean enrollment in the program was 261.1 days (standard deviation 180.6). Patients' average age was 70 years, 56% were female, and 33% were black. Patients' most frequent comorbidities were dementia (32%), heart failure (32%), and diabetes (28%). Fifty patients (31%) died during the study period. Clinicians most frequently screened for pain (70%), constipation (57%), and dyspnea (57%). Of those screened positive, clinicians most frequently treated pain (92%), anxiety (84%), and constipation (83%). Among the 54% who screened positive for psychosocial distress, 82% received support. Clinicians screened 22% for spiritual needs; 4% received spiritual care. Among decedents, 66% were enrolled in hospice; 14% died in in-hospital. Decedents were more likely than survivors to have ACP (34% vs. 18%, p = 0.03) and a primary goal of comfort (40% vs. 12%, p < 0.01). Conclusions: A CBSC program provided palliative care services comparable with other home-based palliative care programs. Although the CBSC program does not address all domains of palliative care, it provided most with symptom management, psychosocial support, and ACP.
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Affiliation(s)
- Natalie C Ernecoff
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Laura C Hanson
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA.,Division of Geriatrics and Palliative Care Program, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Alexandra L Fox
- Department of Clinical Social Work, Central Regional Hospital, Butner, North Carolina, USA
| | - Timothy P Daaleman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Family Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Christine E Kistler
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Family Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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8
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Bernacki R, Paladino J, Neville BA, Hutchings M, Kavanagh J, Geerse OP, Lakin J, Sanders JJ, Miller K, Lipsitz S, Gawande AA, Block SD. Effect of the Serious Illness Care Program in Outpatient Oncology: A Cluster Randomized Clinical Trial. JAMA Intern Med 2019; 179:751-759. [PMID: 30870563 PMCID: PMC6547155 DOI: 10.1001/jamainternmed.2019.0077] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE High-quality conversations between clinicians and seriously ill patients about values and goals are associated with improved outcomes but occur infrequently. OBJECTIVE To examine feasibility, acceptability, and effect of a communication quality-improvement intervention (Serious Illness Care Program) on patient outcomes. DESIGN, SETTING, AND PARTICIPANTS A cluster randomized clinical trial of the Serious Illness Care Program in an outpatient oncology setting was conducted. Patients with advanced cancer (n = 278) and oncology clinicians (n = 91) participated between September 1, 2012, and June 30, 2016. Data analysis was performed from September 1, 2016, to December 27, 2018. All analyses were conducted based on intention to treat. INTERVENTIONS Tools, training, and system changes. MAIN OUTCOMES AND MEASURES The coprimary outcomes included goal-concordant care (Life Priorities) and peacefulness (Peace, Equanimity, and Acceptance in the Cancer Experience questionnaire) at the end of life. Secondary outcomes included therapeutic alliance (Human Connection Scale), anxiety (Generalized Anxiety Disorder 7 scale), depression (Patient Health Questionnaire 9), and survival. Uptake and effectiveness of clinician training, clinician use of the conversation tool, and conversation duration were evaluated. RESULTS Data from 91 clinicians in 41 clusters (72.9% participation; intervention, n = 48; control, n = 43; 52 [57.1%] women) and 278 patients (45.8% participation; intervention, n = 134; control, n = 144; 148 [53.2%] women) were analyzed. Forty-seven clinicians (97.9%) rated the training as effective (mean [SD] score, 4.3 [0.7] of 5.0 possible); of 39 who received a reminder, 34 (87.2%) completed at least 1 conversation (median duration, 19 minutes; range, 5-70). Peacefulness, therapeutic alliance, anxiety, and depression did not differ at baseline. The coprimary outcomes were evaluated in 64 patients; no significant differences were found between the intervention and control groups. However, the trial demonstrated significant reductions in the proportion of patients with moderate to severe anxiety (10.2% vs 5.0%; P = .05) and depression symptoms (20.8% vs 10.6%; P = .04) in the intervention group at 14 weeks after baseline. Anxiety reduction was sustained at 24 weeks (10.4% vs 4.2%; P = .02), but depression reduction was not sustained (17.8% vs 12.5%; P = .31). Survival and therapeutic alliance did not differ between groups. CONCLUSIONS AND RELEVANCE The results of this cluster randomized clinical trial were null with respect to the coprimary outcomes of goal-concordant care and peacefulness at the end of life. Methodologic challenges for the primary outcomes, including measure selection and sample size, limit the conclusions that can be drawn from the study. However, the significant reductions in anxiety and depression in the intervention group are clinically meaningful and require further study. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01786811.
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Affiliation(s)
- Rachelle Bernacki
- Harvard Medical School, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Ariadne Labs, Brigham and Women's Hospital, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joanna Paladino
- Harvard Medical School, Boston, Massachusetts.,Ariadne Labs, Brigham and Women's Hospital, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Bridget A Neville
- Ariadne Labs, Brigham and Women's Hospital, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Mathilde Hutchings
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Ariadne Labs, Brigham and Women's Hospital, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jane Kavanagh
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Ariadne Labs, Brigham and Women's Hospital, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Olaf P Geerse
- Ariadne Labs, Brigham and Women's Hospital, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Department of Pulmonary Diseases, University Medical Center Groningen, Groningen, the Netherlands
| | - Joshua Lakin
- Harvard Medical School, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin J Sanders
- Harvard Medical School, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Ariadne Labs, Brigham and Women's Hospital, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kate Miller
- Ariadne Labs, Brigham and Women's Hospital, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Stuart Lipsitz
- Ariadne Labs, Brigham and Women's Hospital, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Atul A Gawande
- Harvard Medical School, Boston, Massachusetts.,Ariadne Labs, Brigham and Women's Hospital, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Susan D Block
- Harvard Medical School, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Ariadne Labs, Brigham and Women's Hospital, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
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9
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Anne Calton B, Ritchie C. “Yes! We Have a Home-Based Palliative Care Program!”. J Am Geriatr Soc 2019; 67:1113-1114. [DOI: 10.1111/jgs.15843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 01/31/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Brook Anne Calton
- Division of Palliative Medicine; University of California, San Francisco; San Francisco California
| | - Christine Ritchie
- Division of Geriatrics, Department of Medicine; University of California, San Francisco; San Francisco California
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10
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Ornstein KA, Wolff JL, Bollens-Lund E, Rahman OK, Kelley AS. Spousal Caregivers Are Caregiving Alone In The Last Years Of Life. Health Aff (Millwood) 2019; 38:964-972. [PMID: 31158025 PMCID: PMC6760240 DOI: 10.1377/hlthaff.2019.00087] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Caregiving in the last years of life is associated with increased depression and negative health outcomes for surviving spouses, many of whom are themselves in poor health. Yet it is unclear how often spouses are caregiving alone, how they differ from supported spouses, and whether lack of support affects postbereavement outcomes. We hypothesized that spouses who were solo caregivers-that is, the only caregivers (paid or unpaid) who provided assistance with a spouse's self-care or household activities-would experience more depression after bereavement than supported spouses would. Using information from the Health and Retirement Study, we found that 55 percent of the spouses of community-dwelling married people with disability were solo caregivers. Solo caregiving was even common among people who cared for spouses with dementia and those with adult children living close by. Bereavement outcomes did not differ between solo and supported caregiving spouses. Caregiving spouses are often isolated and may benefit from greater support, particularly during the final years before bereavement. While some state and federal policy proposals aim to systematically recognize and assess caregivers, further innovations in care delivery and reimbursement are needed to adequately support seriously ill older adults and their caregivers. Ultimately, the focus of serious illness care must be expanded from the patient to the family unit.
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Affiliation(s)
- Katherine A Ornstein
- Katherine A. Ornstein ( ) is an assistant professor in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, in New York City
| | - Jennifer L Wolff
- Jennifer L. Wolff is a professor of public health at Johns Hopkins University, in Baltimore, Maryland
| | - Evan Bollens-Lund
- Evan Bollens-Lund is an analyst in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Omari-Khalid Rahman
- Omari-Khalid Rahman is an analyst in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Amy S Kelley
- Amy S. Kelley is an associate professor in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
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