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Shimer S, Allen OS, Yang C, Canavan M, Westvold S, Kim N, Morillo J, Parker T, Wallace N, Smith CB, Adelson KB. Prognostic Understanding, Goals of Care, and Quality of Life in Hospitalized Patients with Leukemia or Multiple Myeloma. J Palliat Med 2024; 27:879-887. [PMID: 38990245 DOI: 10.1089/jpm.2023.0530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024] Open
Abstract
Background: Prior studies reveal a lack of illness understanding and prognostic awareness among patients with hematological malignancies. We evaluated prognostic awareness and illness understanding among patients with acute leukemia and multiple myeloma (MM) and measured patient-hematologist discordance. Methods: We prospectively enrolled patients with acute leukemia and MM at Mount Sinai Hospital or Yale New Haven Hospital between August 2015 and February 2020. Patients were administered a survey assessing prognostic awareness, goals of care (GOC), and quality of life. Hematologists completed a similar survey for each patient. We assessed discordance across the cohort of patients and hematologists using the likelihood-ratio chi-square test and within patient-hematologist pairs using the kappa (κ) statistic. Results: We enrolled 185 patients (137 with leukemia and 48 with MM) and 29 hematologists. Among patients, 137 (74%) self-identified as White, 27 (15%) as Black, and 21 (11%) as Hispanic. Across the entire cohort, patients were significantly more optimistic about treatment goals compared with hematologists (p = 0.027). Within patient-hematologist pairs, hematologists were significantly more optimistic than patients with respect to line of treatment (κ = 0.03). For both leukemia and MM cohorts, patients were significantly more likely to respond "don't know" or deferring to a faith-based response with 88 (64%) and 34 (71%), respectively, compared with only 28 (20%) and 11 (23%) of hematologists, respectively. Conclusions: We observed significant discordance regarding prognosis and GOC among patients with hematological malignancies and their hematologists. These data support future interventions to improve prognostic understanding among this patient population to facilitate informed treatment choices.
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Affiliation(s)
- Sophia Shimer
- Yale School of Medicine, New Haven, Connecticut, USA
- Beth Israel Deaconess Medical Center, New Haven, Connecticut, USA
| | - Olivia S Allen
- Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, New York, USA
| | - Chen Yang
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Nina Kim
- Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, New York, USA
| | - Jose Morillo
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Terri Parker
- Beth Israel Deaconess Medical Center, New Haven, Connecticut, USA
| | | | - Cardinale B Smith
- Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, New York, USA
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kerin B Adelson
- Yale School of Medicine, New Haven, Connecticut, USA
- MD Anderson Cancer Center, Houston, Texas, USA
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Gebel C, Kruschel I, Bodinger S, Simon ST, Eichenauer DA, Pralong A, Wedding U. Palliative care for patients with hematologic malignancies in Germany: a nationwide survey on everyday practice and influencing factors from the perspective of treating physicians. Ann Hematol 2024; 103:1753-1763. [PMID: 38538976 PMCID: PMC11009764 DOI: 10.1007/s00277-024-05726-8] [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: 02/01/2024] [Accepted: 03/22/2024] [Indexed: 04/13/2024]
Abstract
Integrating palliative care into the treatment of patients with advanced hematological malignancies (HM) remains challenging. To explore treating physicians' perspectives on current palliative care practice and to evaluate factors influencing integration, we conducted a nationwide online survey. Based on literature and expert review, the survey addressed the importance of palliative care, communication about life-threatening conditions, challenges in establishing goals of care, and factors influencing the integration of palliative care. 207 physicians treating patients with HM in Germany participated. We used standard descriptive statistics to analyze quantitative data and a content structuring approach. Most physicians considered palliative care in HM to be very important (60.6%) and discussed life-threatening conditions with more than half of their patients (52%), especially when goals of care were changed (87.0%) or when patients raised the topic (84.0%). Disease-related factors, different professional perspectives on prognosis, and patient hopes were the main barriers to changing goals of care, but collaboration with colleagues and multidisciplinary teams provided important support. Time constraints were identified as the main barrier to integrating palliative care. The majority worked well with palliative care teams. Referral processes and conditions were perceived as minor barriers. The study highlights the need to address barriers to integrating palliative care into the management of patients with advanced HM. Future research should aim at optimizing palliative care for patients with HM.
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Affiliation(s)
- Cordula Gebel
- Department of Palliative Care, University Hospital Jena, Friedrich-Schiller University, Jena, Germany.
- Comprehensive Cancer Center Central Germany (CCCG), Cologne, Germany.
| | - Isabel Kruschel
- Department of Palliative Care, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG), Cologne, Germany
| | - Steffi Bodinger
- Department of Palliative Care, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG), Cologne, Germany
| | - Steffen T Simon
- Department of Palliative Medicine, Faculty of Medicine and Cologne University Hospital, Center for Integrated Oncology Aachen Bonn Dusseldorf Cologne, Cologne, Germany
| | - Dennis A Eichenauer
- First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Dusseldorf Cologne, University of Cologne, Cologne, Germany
| | - Anne Pralong
- Department of Palliative Medicine, Faculty of Medicine and Cologne University Hospital, Center for Integrated Oncology Aachen Bonn Dusseldorf Cologne, Cologne, Germany
| | - Ulrich Wedding
- Department of Palliative Care, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG), Cologne, Germany
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Rao V, Linsky S, Knobf MT. Perspectives of Patients With Relapsed and Refractory Acute Myeloid Leukemia and High-Risk Myelodysplastic Syndrome on Patient-Clinician Communication About Prognosis and the Future. Palliat Med Rep 2024; 5:53-62. [PMID: 38249836 PMCID: PMC10797310 DOI: 10.1089/pmr.2023.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 01/23/2024] Open
Abstract
Background Patients with acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS) experience unpredictable disease trajectories and high prognostic uncertainty, which serve as barriers to patient-clinician communication about prognosis and their values and preferences for the future in the event of worsening health. Little is known about patients' day-to-day lived experiences and how this shapes their willingness to engage in such conversations. Objectives To explore participant perspectives on living with their illness and patient-clinician communication about prognosis and the future. Design This is a qualitative study using semi-structured interviews. Setting/Subjects Patients with relapsed and refractory (R/R) AML and high-risk MDS from a northeastern U.S. cancer center. Data Collection Interviews were transcribed verbatim and thematic analysis was used to generate findings. Results Of the 14 participants, the mean age was 66 years, 79% were men, 93% were White, married, and had AML. The overarching theme that describes the experience was "Taking One Day at a Time" in a Fog of Uncertainty. Uncertainty was a universal perception related to the challenges for clinicians to predict prognosis. To cope with uncertainty, most participants tried to focus on the present and maintain normality in everyday life. Participants valued encouragement and positivity in patient-clinician communication, however, the majority were not ready to discuss prognosis and the future in the event of worsening health. Of note, 7 of 14 participants died within three months after the interview. Conclusions These data describe a unique perspective of patients with R/R AML and high-risk MDS that clinicians could use to enhance communication strategies.
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Affiliation(s)
- Vinay Rao
- Division of Palliative Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sarah Linsky
- School of Nursing, Yale University, Orange, Connecticut, USA
| | - M. Tish Knobf
- School of Nursing, Yale University, Orange, Connecticut, USA
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Maas DS, Hughes S, Macmillan PJ, Rodriguez Carranza LP, Nguyen M. Physician Perceptions and Beliefs Regarding End-of-Life Care in a Central California Health System. Am J Hosp Palliat Care 2023; 40:1079-1086. [PMID: 36426418 DOI: 10.1177/10499091221141624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Objective: We sought to describe the preparedness, beliefs, and experience regarding end-of-life (EOL) care for in-training and attending physicians. We hoped to clarify how medical training impacts views about EOL, and topics where physicians desire more EOL training. Methods: An online anonymous survey was sent to 766 physicians who worked at Community Medical Centers in Fresno, California from October to December 2016. Descriptive statistics of the population were compiled. Chi-squared and Mann-Whitney U tests comparing differences in personal experience, and preparedness and confidence with palliative care topics by training level were performed. Results: 195 physicians responded to the survey (25%). Respondents were 42% in-training, 55% male, 57% Caucasian, and 38% Christian. Compared to attendings those in-training were younger, more often female, and more likely to have a DO degree. The 2 groups did not differ in ethnicity, specialty, or religion. Attendings were more likely than those in-training (46% vs 14%, P < .001) to have an advance directive, reported a higher level of formal training in discussing prognosis (P = .037), and had higher confidence with palliative care topics like delivering bad news (P = .002), discussing resuscitation status (P = .015), and discussing the new California EOL Option Act (P < .001). Thirty-two percent of respondents believed patients often starve at EOL. Otherwise, knowledge was 90% correct. Conclusions: Physicians in-training are less prepared to discuss EOL topics. Physicians in-training and attendings desire more education in pain management at EOL.
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Affiliation(s)
- David S Maas
- Hospice and Palliative Medicine Fellowship, University of California San Francisco Fresno Family and Community Medicine, Fresno, CA, USA
| | - Susan Hughes
- University of California San Francisco Fresno Family and Community Medicine, Fresno, CA, USA
| | - Patrick J Macmillan
- University of California San Francisco Fresno Internal Medicine, Fresno, CA, USA
| | | | - Madeline Nguyen
- Family and Community Medicine, Peach Tree Health, Sacramento, CA, USA
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Iizuka-Honma H, Mitsumori T, Yoshikawa S, Takizawa H, Noguchi M. Factors Associated With Survival in Patients With End-of-Life Hematological Malignancies Who Received Chemotherapy: A Retrospective Single-Institution Study. Am J Hosp Palliat Care 2023; 40:812-819. [PMID: 36413462 DOI: 10.1177/10499091221142502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Clinicians can appropriately terminate treatment or reduce treatment intensity by determining prognostic factors of end-of-life chemotherapy. In particular, it provides important information for patients with hematological malignancies who receive chemotherapy until near-the-end of life compared with patients with solid tumors. This study aimed to clarify whether existing prognostic tools are associated with the survival in patients with end-of-life hematological malignancies who received chemotherapy. METHODS We retrospectively reviewed the records of 247 patients diagnosed with hematological malignancies and died at our university hospital hematology ward between May 2015 and May 2021. We performed multivariate analysis in 82 (33.2%) patients who received end-of-life chemotherapy using the Palliative Prognostic Index (PPI) and inflammation-based prognostic models, such as the Glasgow Prognostic Score (GPS), Prognostic Nutritional Index (PNI), and Controlling Nutrition Status (CONUT). RESULTS On comparing 82 patients who received end-of-life chemotherapy with 165 patients who did not, the proportion of patients with PPI group A, GPS score = 0, and CONUT normal/mild was significantly higher among patients who received chemotherapy. In multivariate analysis, we identified PPI groups B (2.0 < PPI ≤ 4.0) and C (PPI > 4.0) [hazard ratio (HR) 2.1290, 95% CI 1.1830-3.828, P = .01166, respectively] and age ≥ 65 years (HR 2.0170, 95% CI 1.1280-3.607, P = .01805) were associated with overall survival. CONCLUSION PPI use and age were independent associating factors for patients with hematological malignancies receiving end-of-life chemotherapy. PPI, a popular prognostic tool may be helpful for patients and hematologists to make decisions about end-of-life care.
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Affiliation(s)
- Hiroko Iizuka-Honma
- Department of Hematology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Toru Mitsumori
- Department of Hematology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Seiichiro Yoshikawa
- Cancer Therapeutic Center, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Haruko Takizawa
- Department of Hematology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Masaaki Noguchi
- Department of Hematology, Juntendo University Urayasu Hospital, Chiba, Japan
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Graham LJ, Hite A, Harris J, Belcher G. Silent Conversations: Goals of Care and End-of-Life Quality in Relapsed High-Risk Leukemia. J Adv Pract Oncol 2023; 14:380-387. [PMID: 37576364 PMCID: PMC10414529 DOI: 10.6004/jadpro.2023.14.5.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023] Open
Abstract
Background Advanced practice providers (APPs) affect high-quality health care through leadership, evidence-based practice implementation, and quality improvement projects. When planning solutions to clinical problems, leadership must solicit APP input to promote success. Hematology patients are more likely to receive poor-quality end-of-life (EOL) care than those with solid tumors. Regardless of disease, aggressive EOL care is increasing despite evidence that it is often inconsistent with patients' goals of care (GOC). Data regarding this phenomenon in hematology specifically is lacking. The distorted association of "end of life" with "goals of care" has "silenced" crucial goals discussions in patients with relapsed or refractory high-risk leukemia, which raises concerns for the provision of care that is inconsistent with patients' values and preferences. Hematologists may possess certain traits and distinct barriers leading to what one might call an aversion to GOC discussions in the inpatient setting. Aims (1) Quantify hematologists' rate of participation in a GOC pathway initiative during two separate months. (2) Explore the hematologists' definition of and barriers to having GOC discussions. Design This is a mixed-methods, explanatory sequential design (follow-up explanations variant). Sample Quantitative: Hematology inpatient admissions during two nonconsecutive months in 2021. Qualitative: Eighteen leukemia hematologists from one dedicated cancer center. Results During the 2 months, an average of 36% of admissions met the criteria for GOC pathway initiation, 19% of those had an appropriate initiation order, and < 1% had a properly documented and billed GOC discussion. Nine hematologists responded to a SurveyMonkey poll with two questions. All nine included clinical situation and communication in their definition of GOC discussions. Time limitations and prognostic uncertainty were the two most reported barriers. Discussion The findings demonstrate that the apprehension of hematologists to have GOC conversations is similarly seen in the APPs' reluctance to initiate a pathway intended to lead to GOC conversations. The percentage of eligible inpatient admissions meeting the specified criteria was similar between the 2 months; however, the number of appropriate referrals and documented or billed GOC discussions was higher in the earlier month, demonstrating temporal decline. Further research inquiry is needed to explore causation of this phenomenon.
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Affiliation(s)
| | - Amy Hite
- From Pittsburg State University, Pittsburg, Kansas
| | | | - Greg Belcher
- From Pittsburg State University, Pittsburg, Kansas
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7
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Differential Impact of a Multicomponent Goals-of-Care Program in Patients with Hematologic and Solid Malignancies. Cancers (Basel) 2023; 15:cancers15051507. [PMID: 36900298 PMCID: PMC10001115 DOI: 10.3390/cancers15051507] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/24/2023] [Accepted: 02/25/2023] [Indexed: 03/08/2023] Open
Abstract
We recently reported that an interdisciplinary multicomponent goals-of-care (myGOC) program was associated with an improvement in goals-of-care (GOC) documentation and hospital outcomes; however, it is unclear if the benefit was uniform between patients with hematologic malignancies and solid tumors. In this retrospective cohort study, we compared the change in hospital outcomes and GOC documentation before and after myGOC program implementation between patients with hematologic malignancies and solid tumors. We examined the change in outcomes in consecutive medical inpatients before (May 2019-December 2019) and after (May 2020-December 2020) implementation of the myGOC program. The primary outcome was intensive care unit (ICU) mortality. Secondary outcomes included GOC documentation. In total, 5036 (43.4%) patients with hematologic malignancies and 6563 (56.6%) with solid tumors were included. Patients with hematologic malignancies had no significant change in ICU mortality between 2019 and 2020 (26.4% vs. 28.3%), while patients with solid tumors had a significant reduction (32.6% vs. 18.8%) with a significant between-group difference (OR 2.29, 95% CI 1.35, 3.88; p = 0.004). GOC documentation improved significantly in both groups, with greater changes observed in the hematologic group. Despite greater GOC documentation in the hematologic group, ICU mortality only improved in patients with solid tumors.
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Sjöberg E, Axelsson B. Prognostic information and care plans for patients dying of cancer. Acta Oncol 2023; 62:210-213. [PMID: 36772807 DOI: 10.1080/0284186x.2023.2175622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Affiliation(s)
- E Sjöberg
- Medical Programme, Umeå University, and FoU Östersund City, Sweden
| | - B Axelsson
- Department of Radiation Sciences, Umeå University, and FoU Östersund, Umeå, Sweden
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Patient-physician conversations about life-sustaining treatment: Treatment preferences and participant assessments. Palliat Support Care 2023; 21:20-26. [PMID: 36814149 DOI: 10.1017/s1478951521001875] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE In 2019, the Danish parliament issued legislation requiring Danish physicians to clarify and honor seriously ill patients' treatment preferences. The American POLST (Physician Orders for Life-Sustaining Treatment) document could be a valuable model for this process. The aim of the study was to examine patients' preferences for life-sustaining treatment and participant assessment of a Danish POLST form. METHODS The study is a prospective intervention based on a pilot-tested Danish POLST form. Participant assessments were examined using questionnaire surveys. Patients with serious illness and/or frailty from seven hospital wards, two general practitioners, and four nursing homes were included. The patients and their physicians completed the POLST form based on a process of shared decision-making. RESULTS A total of 95 patients (aged 41-95) participated. Hereof, 88% declined cardiopulmonary resuscitation, 83% preferred limited medical interventions or comfort care, and 74% did not require artificial nutrition. The preferences were similar within age groups, genders, and locations, but with a tendency toward younger patients being more in favor of full treatment and nursing home residents being more in favor of cardiopulmonary resuscitation. Questionnaire response rates were 69% (66/95) for patients, 79% (22/28) for physicians, and 31% (9/29) for nurses. Hereof, the majority of patients, physicians, and nurses found that the POLST form was usable for conversations and decision-making about life-sustaining treatment to either a high or very high degree. SIGNIFICANCE OF RESULTS The majority of seriously ill patients did not want a resuscitation attempt and opted for selected treatments. The majority of participants found that the Danish POLST was usable for conversations and decisions about life-sustaining treatment to either a high or a very high degree, and that the POLST form facilitated an opportunity to openly discuss life-sustaining treatment.
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Dark-Freudeman A, Bensadon BA. Advance care planning: End-of-life hopes and fears among community dwelling adults. J Health Psychol 2022; 27:3177-3189. [PMID: 35445612 DOI: 10.1177/13591053221089726] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
End-of-life (EOL) medical care in the United States often does not align with patients' goals and preferences. This study explored EOL hopes and fears among 86 community-dwelling adults and examined medical and psychological predictors of death anxiety. Common EOL hopes included absence of suffering, closure, and personal fulfillment. Common EOL fears included suffering, lack of competence, and specific types of death. Fear of the dying process was greater than fear of death itself. Health predicted death anxiety; age alone, did not. Advance care planning and clinical decision making should include these psychological insights and explicitly address EOL hopes and fears.
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Withdrawal: "Assessment of prognostic understanding, perceived goals of care, and quality of life in hospitalized patients with leukemia or multiple myeloma" Olivia S. Allen, Nina Kim, Jose Morillo, Cardinale B. Smith. Cancer 2021; 127:4316. [PMID: 33891716 DOI: 10.1002/cncr.33599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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12
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Wedding U. Palliative care of patients with haematological malignancies: strategies to overcome difficulties via integrated care. THE LANCET HEALTHY LONGEVITY 2021; 2:e746-e753. [DOI: 10.1016/s2666-7568(21)00213-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 12/01/2022]
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Janett-Pellegri C, Eychmüller AS. 'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication? PRAXIS 2021; 110:914-924. [PMID: 34814721 DOI: 10.1024/1661-8157/a003785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Uncertainty, fear to harm the patient, discomfort handling the discussion and lack of time are the most cited barriers to prognostic disclosure. Physicians can be reassured that patients desire the truth about prognosis and can manage the discussion without harm, including the uncertainty of the information, if approached in a sensitive manner. Conversational guides could provide support in preparing such difficult conversations. Communicating 'with realism and hope' is possible, and anxiety is normal for both patients and clinicians during prognostic disclosure. As a clinician pointed out: 'I had asked a mentor once if it ever got easier. - No. But you get better at it.'
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Affiliation(s)
- Camilla Janett-Pellegri
- Service de Médicine Interne, Hôpital Cantonal Fribourg, Fribourg
- Universitäres Zentrum für Palliative Care, Inselspital, Universitätsspital Bern, Bern
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Laryionava K, Schildmann J, Wensing M, Wedding U, Surmann B, Woydack L, Krug K, Winkler E. Development and Evaluation of a Decision Aid to Support Patients' Participatory Decision-Making for Tumor-Specific and Palliative Therapy for Advanced Cancer: Protocol for a Pre-Post Study. JMIR Res Protoc 2021; 10:e24954. [PMID: 34533464 PMCID: PMC8486990 DOI: 10.2196/24954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 11/21/2022] Open
Abstract
Background To support advanced cancer patients and their oncologists in therapeutic decisions, we aim to develop a decision aid (DA) in a multiphased, bicentric study. The DA aims to help patients to better understand risks and benefits of the available treatment options including the options of standard palliative care or cancer-specific treatment (ie, off-label drug use within an individual treatment plan). Objective This study protocol outlines the development and testing of the DA in a pre-post study targeting a heterogeneous population of advanced cancer patients. Methods In the first step, we will assess patients’ information and decisional needs as well as the views of the health care providers regarding the content and implementation of the DA. Through a scoping review, we aim to analyze specific characteristics of the decision-making process and to specify the treatment options, outcomes, and probabilities. An interdisciplinary research group of experts will develop and review the DA. In the second step, testing of the DA (design and field testing) with patients and oncologists will be conducted. As a last step, we will run a pre-post design study with 70 doctor-patient encounters to assess improvements on the primary study outcome: patients’ level of decisional conflict. In addition, the user acceptance of all involved parties will be tested. Results Interviews with cancer patients, oncologists, and health care providers (ie, nurses, nutritionists) as well as a literature review from phase I have been completed. The field testing is scheduled for April 2021 to August 2021, with the final revision scheduled for September 2021. The pre-post study of the DA and acceptance testing are scheduled to start in October 2021 and shall be finished in September 2022. Conclusions A unique feature of this study is the development of a DA for patients with different types of advanced cancer, which covers a wide range of topics relevant for patients near the end of life such as forgoing cancer-specific therapy and switching to best supportive care. Trial Registration ClinicalTrials.gov NCT04606238; https://clinicaltrials.gov/ct2/show/NCT04606238. International Registered Report Identifier (IRRID) DERR1-10.2196/24954
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Affiliation(s)
- Katsiaryna Laryionava
- Institute for History and Ethics of Medicine, Centre for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Centre for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Michael Wensing
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Ullrich Wedding
- Palliative Care, Department of Internal Medicine II, University of Jena, Jena, Germany
| | - Bastian Surmann
- Health Economics and Health Care Management, Bielefeld University, Bielefeld, Germany
| | - Lena Woydack
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Katja Krug
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Eva Winkler
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
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15
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Iizuka-Honma H, Mitsumori T, Yoshikawa S, Takizawa H, Noguchi M. Prognostic Value of Palliative Prognostic Index for Hospitalized Patients With End-of-Life Hematologic Malignancies in a Japanese University Hospital. JCO Oncol Pract 2021; 18:e108-e116. [PMID: 34357786 DOI: 10.1200/op.21.00243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Uncertainty of prognosis is one reason patients with hematologic malignancies receive aggressive therapy near end of life more often than those with advanced solid tumors. It is unknown whether end-of-life prognosis prediction models are useful for patients with hematologic malignancies, especially hospitalized patients receiving chemotherapy, because most prognostic models were developed for patients with solid tumors. The purpose of this study was to evaluate the prognostic accuracy of the Palliative Prognostic Index (PPI) for end-of-life patients with advanced hematologic malignancies. METHODS We retrospectively reviewed the records of 143 patients who became resistant to standard chemotherapy and died of disease progression in our university hospital hematology ward between May 2015 and November 2019. Patients were classified according to PPI scores (groups: A, PPI ≤ 2.0; B, 2.0 < PPI ≤ 4.0; and C, PPI > 4.0) based on their clinical charts at admission. The median overall survival for each patient (95% confidence interval) was calculated using the Kaplan-Meier method. Log-rank tests were used to determine significant differences between survival curves. RESULTS Median patient age was 76 years (range: 39-92 years), and 59% were men. Median overall survival times in the PPI groups A, B, and C were 58 days, 36 days, and 10 days, respectively. Statistically significant differences in survival time were observed between the groups (P < .01); prediction accuracy was similar to that for patients with different diagnoses. CONCLUSION The usefulness of PPI was validated for near-end-of-life hospitalized patients with hematologic malignancies.
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Affiliation(s)
- Hiroko Iizuka-Honma
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Toru Mitsumori
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Seiichiro Yoshikawa
- Cancer Therapeutic Center, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Haruko Takizawa
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Masaaki Noguchi
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu, Japan
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16
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Habib AR, Chen R, Magnavita ES, Jaung T, Awad MM, Odejide O, Abel GA. Prevalence and Tolerance of Prognostic Uncertainty Among Thoracic Oncologists. Oncologist 2021; 26:e1480-e1482. [PMID: 33844365 DOI: 10.1002/onco.13788] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 04/02/2021] [Indexed: 11/06/2022] Open
Abstract
We undertook a cross-sectional survey of a random sample of thoracic oncologists from the American Society of Clinical Oncology clinical directory to characterize whether prognostic uncertainty has increased and if tolerance of uncertainty is associated with prognostic discussion practices. We also assessed the Physicians' Reactions to Uncertainty Scale and presented a vignette about an incurable patient with uncertain life expectancy. One hundred and ninety-two of 438 surveys (43.8%) were received. Of the respondents, 52.1% agreed "there is more prognostic uncertainty in the management of lung cancer now than 10 years ago," and 37.4% noted difficulty "staying up-to-date." In multivariable analyses, physician-reported anxiety about uncertainty (p = .05) and reluctance to disclose uncertainty (p = .04) were inversely associated with reporting having prognostic discussions with most patients. For the vignette, 92.1% reported they would discuss incurability, but only 76.3% said they would discuss the patient's life expectancy. Our data suggest prognostic uncertainty has increased in thoracic oncology and oncologists' tolerance of uncertainty may affect discussion practices.
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Affiliation(s)
- Anand R Habib
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Richard Chen
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Emily S Magnavita
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Tim Jaung
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Mark M Awad
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Oreofe Odejide
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Gregory A Abel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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17
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Abstract
PURPOSE OF REVIEW Our goal was to provide healthcare professionals (HCPs) with evidence-based data about what can be done to handle prognostic discussions with empathy. RECENT FINDINGS First, disclosing prognosis involves a good reason to do so and making sure that the patient will be able to process the discussion. Second, communication tips are given for the three dimensions of empathy: "establishing rapport with the patient," which should not be overlooked; the emotional dimension, which involves an accurate understanding of the patient and communication skills; and the "active/positive" dimension which is about giving hope, explaining things clearly and helping patients take control with shared decision-making and a planned future. Although communication tips are helpful, empathy training should be based more on the development of HCPs' emotional skills, in order to help them regulate their emotions and thus be more comfortable with those of patients and families. Furthermore, research into empathy toward minorities and relatives is needed.
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Affiliation(s)
- Sophie Lelorain
- Univ. Lille, CNRS, UMR 9193 - SCALab - Sciences Cognitives et Sciences Affectives, F-59000, Lille, France.
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18
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Gray TF, Temel JS, El-Jawahri A. Illness and prognostic understanding in patients with hematologic malignancies. Blood Rev 2020; 45:100692. [PMID: 32284227 DOI: 10.1016/j.blre.2020.100692] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/04/2020] [Accepted: 04/02/2020] [Indexed: 12/25/2022]
Abstract
It is critical for patients with hematologic malignancies to have an accurate understanding of their illness and prognosis to make informed treatment decisions. Illness and prognostic understanding have primarily been studied in patients with solid tumors, however, data in patients with hematologic malignancies are rapidly growing. Patients with hematologic malignancies often face a unique and unpredictable illness trajectory with the possibility of cure persisting even in relapsed and refractory settings. These patients often require intensive therapies such as high-dose chemotherapy, hematopoietic stem cell transplantation (HCT), or CAR T-cell therapy, which carry with them significant risk of morbidity, mortality, and prognostic uncertainty. In this review article, we first described the current literature on illness and prognostic understanding in patients with hematologic malignancies including 1) patients' varying desire for prognostic information; (2) patients' prognostic misperceptions, (3) the association between patients' prognostic understanding and their psychological outcomes; and (4) barriers to prognostic understanding. Next, we examined insights gained from the literature about illness and prognostic understanding in patients with solid tumors to guide our understanding of the research gaps in hematologic malignancies. Future studies are needed to better delineate the longitudinal relationship between prognostic understanding, psychological distress, and coping in patients with hematologic malignancies. Strategies such as communicating effectively about prognosis, cultivating adaptive coping in the face of a terminal prognosis, and integrating specialty palliative care for patients with hematologic malignancies have the potential to improve patients' prognostic understanding and their quality of life and care.
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Affiliation(s)
- Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jennifer S Temel
- Massachusetts General Hospital Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Areej El-Jawahri
- Massachusetts General Hospital Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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19
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Specific challenges in end-of-life care for patients with hematological malignancies. Curr Opin Support Palliat Care 2019; 13:369-379. [DOI: 10.1097/spc.0000000000000470] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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20
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Kaye EC, Gattas M, Bluebond-Langner M, Baker JN. Longitudinal investigation of prognostic communication: Feasibility and acceptability of studying serial disease reevaluation conversations in children with high-risk cancer. Cancer 2019; 126:131-139. [PMID: 31532566 PMCID: PMC6916406 DOI: 10.1002/cncr.32499] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/18/2019] [Accepted: 07/30/2019] [Indexed: 12/16/2022]
Abstract
Background Prospective investigation of medical dialogue is considered the gold standard in prognostic communication research. To the authors' knowledge, the achievability of collecting mixed methods data across an evolving illness trajectory for children with cancer is unknown. Methods The objective of the current study was to investigate the feasibility and acceptability of recording sequential medical discussions at disease reevaluation time points for children with high‐risk cancer. Mixed methods data (ie, surveys, interviews, checklists, and chart reviews) corresponding to each disease reevaluation conversation also were captured in real‐time for 34 patients across 24 months at an academic pediatric cancer center. Results All eligible oncology clinicians (65 of 65 clinicians; 100%) and the majority of eligible patient/parent dyads (34 of 41 dyads; 82.9%) enrolled on the study; of 200 disease reevaluation discussions, 185 discussions (92.5%) were recorded, totaling >3300 minutes of recorded medical dialogue. Longitudinal data were captured for 31 of 34 patient/parent dyads (91.2%). The vast majority of study materials were completed, including 138 of 139 nonverbal communication checklists (99.3%), all 49 oncologist surveys (100%), 40 of 49 parent surveys (81.6%), all 34 oncologist interviews (100%), and 24 of 34 parent interviews (70.6%). Only 1 parent reported participation to be a “very” distressing experience, no parents believed that their level of distress warranted speaking with a psychosocial provider, and the majority of parents (18 of 29 parents; 62.1%) described study participation as “somewhat” or “very” useful to them. Conclusions The prospective, longitudinal investigation of prognostic communication using a mixed methods approach appears to be feasible and acceptable to clinicians, patients, and families. The study of sensitive content can be accomplished without causing undue participant burden or harm, thereby enabling further advancement of communication research. The prospective, longitudinal investigation of prognostic communication at stressful disease reevaluation time points is feasible and acceptable to clinicians, children with high‐risk cancer, and families. A mixed methods approach enables the study of highly sensitive and stressful content without causing undue participant burden or harm, thereby allowing the further advancement of communication research within the field.
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Affiliation(s)
- Erica C Kaye
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Melanie Gattas
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Myra Bluebond-Langner
- Louis Dundas Centre for Children's Palliative Care, University College London Great Ormond Street Institute of Child Health, London, United Kingdom.,Department of Sociology, Anthropology, and Criminal Justice, Rutgers University, Camden, New Jersey
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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