Prognostic Awareness in Caregivers of Patients with Incurable Cancer

Prognostic understanding among advanced heart failure patients and their caregivers: A longitudinal dyadic study

OBJECTIVES

To examine heart failure patients' and caregivers' prognostic understanding (PU) over time, and patient and caregiver factors associated with their own and each other's PU.

METHODS

We used longitudinal dyadic data from Singapore, involving surveys with 95 heart failure patient-caregiver dyads every 4 months for up to 4 years. We assessed the association of PU with patient health status, caregiver psychological distress and caregiving hours using random effects multinomial logistic models, controlling for patient and caregiver characteristics.

RESULTS

At baseline, half of patients and caregivers reported correct PU. Patient and caregiver variables were associated with their own and each other's PU. Patients with poorer functional well-being were less likely to report correct PU [Average Marginal Effects (95 % CI) 0.008 (0.002, 0.015)] versus incorrect PU. Greater caregiver psychological distress was associated with a lower likelihood of caregivers reporting a correct PU [- 0.008 (-0.014, -0.002)]. Higher caregiving hours reduced the likelihood of patients reporting correct [- 0.002 (-0.003, -0.001)] and increased the likelihood of patients reporting uncertain [0.001 (0, 0.002)] PU.

CONCLUSIONS

We found PU among patients and caregivers was influenced by their own and each other's experience. Our findings highlight the importance of ongoing communication to enhance PU of patients and caregivers.

The experience of living with malignant meningioma

OBJECTIVES

Meningiomas are the most common, primary intracranial tumor and most are benign. Little is known of the rare patient group living with a malignant meningioma, comprising 1-3% of all meningiomas. Our aim was to explore how patients perceived quality of daily life after a malignant meningioma diagnosis.

METHODS

This qualitative explorative study was composed of individual semi-structured interviews. Eligible patients (n = 12) were selected based on ability to participate in an interview, from a background population of 23 patients diagnosed with malignant meningioma at Rigshospitalet from 2000 to 2021. We performed an inductive thematic analysis following Braun and Clarke's guidelines.

RESULTS

Eight patients were interviewed. The analysis revealed 4 overarching themes: (1) perceived illness and cause of symptoms, (2) identity, roles, and interaction, (3) threat and uncertainty of the future, and (4) belief in authority. The perceived quality of daily life is negatively impacted by the disease. Patients experience a shift in self-concept and close interactions, and some struggle with accepting a new everyday life. Patients have a high risk of discordant prognostic awareness in relation to health-care professionals.

SIGNIFICANCE OF RESULTS

We provide a much-needed patient-centered perspective of living with malignant meningioma: quality of life was affected by perception of threat and an uncertainty of the future. Perception of illness and the interpretation of the cause of symptoms varied between subjects, but a common trait was that patients' identity, roles, and interactions were affected. Shared decision-making and a strengthened continuity during follow-up could aid this rare patient group.

Caregiver Engagement in Serious Illness Communication in a Long-Term Acute Care Hospital Setting

CONTEXT

Prolonged management of critical illnesses in long-term acute care hospitals (LTACH) makes serious illness communication (SIC), a clinical imperative. SIC in LTACH is challenging as clinicians often lack training and patients are typically unable to participate-making caregivers central.

OBJECTIVES

This qualitative descriptive study characterized caregiver engagement in SIC encounters, while considering influencing factors, following the implementation of Ariadne Labs' SIC training at a LTACH in the Northeastern United States.

METHODS

Clinicians' documented SIC notes (2019-2020) were analyzed using directed content analysis. Codes were grouped into four categories generated from two factors that influence SIC-evidence of prognostic understanding (yes/no) and documented preferences (yes/no)-and caregiver engagement themes identified within each category.

RESULTS

Across 125 patient cases, 251 SIC notes were analyzed. In the presence of prognostic understanding and documented preferences, caregivers acted as upholders of patients' wishes (29%). With prognostic understanding but undocumented preferences, caregivers were postponers of healthcare decision-making (34%). When lacking prognostic understanding but having documented preferences, caregivers tended to be searchers, intent on identifying continued treatment options (13%). With poor prognostic understanding and undocumented preferences, caregivers were strugglers, having difficulty with the clinicians or family unit over healthcare decision-making (21%).

CONCLUSION

The findings suggest that two factors-prognostic understanding and documented preferences-are critical factors clinicians can leverage in tailoring SIC to meet caregivers' SIC needs in the LTACH setting. Such strategies shift attention away from SIC content alone toward factors that influence caregivers' ability to meaningfully engage in SIC to advance healthcare decision-making.

Instability in Caregivers' Perception of Dementia as a Terminal Disease

OBJECTIVES

Family caregivers' perception that dementia is a terminal disease influence end-of-life (EoL) care of persons with severe dementia (PwSDs). Yet, this perception and the extent to which it changes over time is underexplored. We assessed PwSD caregivers' perception of dementia as a terminal disease and changes in this perception over time.

DESIGN

Prospective cohort.

SETTING AND PARTICIPANTS

Two hundred fifteen primary informal caregivers of community-dwelling PWSDs in Singapore were surveyed every 4 months over a period of 16 months.

METHODS

We assessed the proportion of caregivers who perceived that dementia is a terminal disease and the extent to which it changed between the previous time points. Using mixed effects multinomial regression models, we assessed factors associated with caregivers' perception and changes in perception between consecutive time points.

RESULTS

At baseline, only 26% of the caregivers reported correctly that dementia is a terminal disease. This changed over time, not necessarily toward a correct perception. Caregivers of PwSDs with an acute medical condition in the last 4 months (risk ratio [RR] 2.19, 95% CI 1.21, 3.97) and those with higher functional dependence (RR 1.11, 95% CI 1.01,1.22) were more likely and those of older PwSDs were less likely (RR 0.87, 95% CI 0.81, 0.93) to perceive dementia as a terminal disease. Caregivers of PwSDs who had experienced an acute medical problem in the last 4 months (RR 1.58, 95% CI 1.00, 2.49) were also more likely to shift their perception toward being correct. Caregivers of PwSDs who had more agitation behaviors were more likely to shift their perception toward being incorrect (RR 1.04, 95% CI 1.00,1.07) CONCLUSIONS AND IMPLICATIONS: Few caregivers perceived dementia as terminal, and this perception changed over time and differed according to age and the health status of PwSD. Results have implications regarding the frequency of prognostic discussions.

Perceptions of prognosis and end-of-life care outcomes in patients with advanced lung and gastrointestinal cancer

BACKGROUND

Many patients with advanced cancer have misperceptions of their prognosis, which may impact end-of-life decision-making. Data regarding associations between prognostic perceptions over time and end-of-life care outcomes are lacking.

AIM

To describe patients' perceptions of their prognosis with advanced cancer and examine associations between these perceptions and end-of-life care outcomes.

DESIGN

Secondary analysis of longitudinal data from a randomized controlled trial of a palliative care intervention for patients with newly diagnosed incurable cancer.

SETTING/PARTICIPANTS

Conducted at an outpatient cancer center in the northeastern United States and patients were within 8 weeks of a diagnosis with incurable lung or non-colorectal gastrointestinal cancer.

RESULTS

We enrolled 350 patients in the parent trial, of which 80.5% (281/350) died during the study period. Overall, 59.4% (164/276) of patients reported they were terminally ill, and 66.1% (154/233) reported that their cancer was likely curable at the assessment closest to death. Patient acknowledgment of terminal illness was only associated with lower risk of hospitalizations in the last 30 days of life (OR = 0.52, p = 0.025). Patients who reported their cancer as likely curable were less likely to utilize hospice (OR = 0.25, p = 0.002) or die at home (OR = 0.56, p = 0.043), and they were more likely to be hospitalized in the last 30 days of life (OR = 2.28, p = 0.011).

CONCLUSIONS

Patients' perceptions of their prognosis are associated with important end-of-life care outcomes. Interventions are needed to enhance patients' perceptions of their prognosis and optimize their end-of-life care.

Patient-Caregiver Dyads' Prognostic Information Preferences and Perceptions in Advanced Cancer

CONTEXT

Prognostic information is considered important for advanced cancer patients and primary informal caregivers to prepare for the end of life. Little is known about discordance in patients' and caregivers' prognostic information preferences and prognostic perceptions, while such discordance complicates adaptive dyadic coping, clinical interactions and care plans.

OBJECTIVES

To investigate the extent of patient-caregiver discordance in prognostic information preferences and perceptions, and the factors associated with discordant prognostic perceptions.

METHODS

We conducted secondary analyses of a cross-sectional study (PROSPECT, 2019-2021). Advanced cancer patients (median overall survival ≤12 months) from seven Dutch hospitals and caregivers completed structured surveys (n = 412 dyads).

RESULTS

Seven percent of patient-caregiver dyads had discordant information preferences regarding the likelihood of cure; 24%-25% had discordant information preferences regarding mortality risk (5/2/1 year). Seventeen percent of dyads had discordant perceptions of the likelihood of cure; 12%-25% had discordant perceptions of mortality risk (5/2/1 year). Dyads with discordant prognostic information preferences (P < 0.05) and dyads in which patients reported better physical functioning (P < 0.01) were significantly more likely to perceive the one-year mortality risk discordantly.

CONCLUSION

Physicians should be sensitive to discordant prognostic information preferences and prognostic perceptions among patient-caregiver dyads in advanced cancer care.

Prognostic Awareness in Terminally Ill Cancer Patients: A Narrative Literature Review of the Processes Involved

High prognostic awareness (PA) is seen by many as a threat to terminal patients' psychological well-being. Whether this concern is supported by evidence or not is still a matter of discussion, given the heterogeneity of existing findings. This ambiguity points to the importance of considering contextual processes involved in the relationship between high PA and psychological outcomes, as a possible mediator and moderator mechanism. Aiming to capture a holistic image of the relationship between PA and the psychological experiences of patients, we adapted a narrative method to synthesize and discusses patient-related (physical symptoms, coping strategy, spirituality) and external (family support, received medical care) processes as potential explaining mechanisms.

Quality of life, psychological distress, and prognostic perceptions in caregivers of patients with multiple myeloma

Although caregivers of patients with multiple myeloma (MM) play a critical role in supporting their loved ones throughout the illness course, studies examining caregiver quality of life (QOL), psychological distress, and prognostic awareness are lacking. We conducted a cross-sectional, multisite study of patients undergoing treatment with MM and their caregivers. Eligible caregivers were enrolled to 1 of 3 cohorts based on lines of therapy. Caregivers completed validated questionnaires to assess their QOL, psychological distress, and perceptions of prognosis. We enrolled 127 caregivers of patients with MM (newly diagnosed [n = 43], 2-3 lines of therapy [n = 40], and ≥4 lines of therapy [n = 44]). Caregiver QOL and psychological distress did not differ by line of therapy. The rate of clinically significant anxiety, depression, and posttraumatic stress disorder symptoms were 44.1% (56/127), 15.8% (20/127), and 24.4% (31/127), respectively. When examined in dyads, caregivers reported higher rates of clinically significant anxiety (44.4% [55/124] vs 22.5% [28/124]) compared with patients with MM. Most caregivers (84.2%, 101/120) reported that the oncologist had informed them that the patient's cancer was incurable; however, only 50.9% (58/114) and 53.6% (59/110) of caregivers acknowledged the patient's cancer was terminal and incurable, respectively. Caregivers of patients undergoing treatment for MM experience substantial psychological distress across the disease continuum, particularly anxiety. The majority of caregivers of patients with MM report that knowing the patient's prognosis is extremely important and report that the oncologist told them that the patient was incurable. Nevertheless, a significant portion of caregivers believe that the patient's MM is curable.

Patient-caregiver communication concordance in cancer-refinement of the Cancer Communication Assessment Tool in an Australian sample

PURPOSE

The objective of this study was to expand the international psychometric validation of the Cancer Communication Assessment Tool for Patients and Families (CCAT-PF) within a sample of Australian cancer patients.

METHODS

Survey data from 181 cancer patient-caregiver dyads ≥ 18 years of age with solid or haematological cancers were analysed (85.4% response rate). Spearman's rho was used to examine the correlation between CCAT-P and CCAT-F scores and weighted kappa the agreement between them. Exploratory factor analysis using scree plot and Kaiser-Guttman criteria was conducted to evaluate the scale structure. Cronbach's α and Pearson correlation coefficients were used to measure internal consistency and concurrent validity respectively.

RESULTS

Mean scores were the following: CCAT-P 46.2 (9.8), CCAT-F 45.7 (9.4), and CCAT-PF 24.1 (8.0). We confirmed the poor concordance between patient and caregiver reporting of items in the CCAT-PF, with all but two items having weighted kappa values < 0.20 and Spearman's rho < 0.19. We derived a three-factor solution, disclosure, limitation of treatment, and treatment decision making, with reliability ranging from Cronbach's α = 0.43-0.53. The CCAT-P and CCAT-F showed strong correlations with preparation for decision-making (CCAT-P: r = 0.0.92; CCATF: r = 0.0.93) but were weakly associated with patient/caregiver distress related with having difficult conversations on future care planning.

CONCLUSION

Preliminary validation of the CCAT-PF in the Australian setting has shown some similar psychometric properties to previously published studies, further supporting its potential utility as a tool to assess patient-caregiver dyadic communication.

TRIAL REGISTRATION

ACTRN12620001035910 12/10/2020 retrospectively registered.

Association Between Caregiver-Oncologist Discordance in Patient's Life Expectancy Estimates and Caregiver Perceived Autonomy Support by the Oncologist

BACKGROUND

Caregiver perceived autonomy support by the oncologist is important for caregiver well-being and may be affected by the patient's survival. We determined the association of caregiver-oncologist discordance in patient's life expectancy estimates with perceived autonomy support over time and whether the association differed by patient survival status.

MATERIALS AND METHODS

We used data from a geriatric assessment cluster-randomized trial (URCC 13070) that recruited patients aged at least 70 years with incurable cancer considering or receiving treatment, their caregivers, and their oncologists. At baseline, caregivers and oncologists were asked to estimate patient's life expectancy (0-6 months, 7-12 months, 1-2 years, 2-5 years, and >5 years; any difference in response was considered discordant). At 4-6 weeks, 3 months, and 6 months, caregivers completed the Health Care Climate Questionnaire (HCCQ), which measured perceived autonomy support by the oncologist. Generalized estimating equation modeling was conducted to assess the association of baseline caregiver-oncologist discordance with longitudinal HCCQ scores, stratified by patient 6-month survival status.

RESULTS

Discordant life expectancy estimates were present in 72.0% of dyads. In multivariate analyses, caregiver-oncologist discordance in patient's life expectancy estimates was associated with higher caregiver HCCQ scores. In stratified analysis, caregiver-oncologist discordance was associated with lower caregiver HCCQ scores (β = -3.46; 95% CI, -4.64 to -2.29) among patients who died within 6 months but with higher caregiver HCCQ scores (β = 1.33; 95% CI, 0.63-2.04) among patients who survived beyond 6 months.

CONCLUSION

Interventions aimed at mitigating discordance need to consider its association with caregiver perceived autonomy support and patient's survival in order to better inform caregiver expectations.

IMPLICATIONS FOR PRACTICE

Among patients who died within the first 6 months, caregivers who estimated a different length of life for the patient compared with oncologists were more likely to report lower support from the oncologist, whereas the opposite relationship was seen within patients who survived beyond the first 6 months. When designing interventions to improve caregiver understanding of the patient's prognosis, its relationship with caregiver-perceived support and patient's survival needs to be considered.

Prognostic awareness in advanced cancer patients and their caregivers: A longitudinal cohort study

OBJECTIVE

The aim of this study was to analyse longitudinal development of prognostic awareness in advanced cancer patients and their families.

METHODS

This was a longitudinal cohort study, involving 134 adult cancer patients, 91 primary family caregivers and 21 treating oncologists. Key eligibility criterion for patients was life expectancy less than 1 year (estimated by their oncologists using the 12-month surprised question). Structured interviews, including tools to measure prognostic awareness, health information needs, and demographics were conducted face to face or via phone three times over 9 months. Forty-four patients completed all three phases of data collection.

RESULTS

Only 16% of patients reported accurate prognostic awareness, 58% being partially aware. Prognostic awareness of both patients and family caregivers remained stable over the course of the study, with only small non-significant changes. Gender, education, type of cancer, spirituality or health information needs were not associated with the level of prognostic awareness. Family caregivers reported more accurate prognostic awareness, which was not associated with patients' own prognostic awareness (agreement rate 59%, weighted kappa 0.348, CI = 0.185-0.510).

CONCLUSIONS

Prognostic awareness appears to be a stable concept over the course of the illness. Clinicians must focus on the initial patients' understanding of the disease and be able to communicate the prognostic information effectively from the early stages of patients' trajectory.