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Glover AC, Jia Z, Waybill K, Vesel T. Life-Sustaining Treatment and Advance Care Documentation among Chinese American ICU Decedents. J Pain Symptom Manage 2024; 68:53-60. [PMID: 38574875 DOI: 10.1016/j.jpainsymman.2024.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/22/2024] [Accepted: 03/27/2024] [Indexed: 04/06/2024]
Abstract
CONTEXT Despite being one of the fastest growing ethnic groups in the U.S., there exists a gap in how treatment preferences among Chinese Americans are expressed and enacted upon in inpatient settings. OBJECTIVES To compare the rates of advance care documentation and life-sustaining treatment between Chinese American and White American ICU decedents. METHODS In this matched retrospective decedent cohort study, we included four ICUs within a tertiary medical center located in a Chinatown neighborhood. The Chinese American cohort included adult patients during the terminal admission in the ICU with primary language identified as Chinese (Mandarin, Cantonese, Taishanese). The White American cohort was matched according to age, sex, year of death, and admitting diagnosis. RESULTS We identified 154 decedents in each cohort. Despite similar odds on admission, Chinese American decedents had higher odds of DNR completion (OR 1.82; 95%CI 0.99-3.40) and DNI completion (OR 1.81; 95%CI, 1.07-1.57) during the terminal ICU admission. Although Chinese American decedents had similar odds of intubation (aOR 0.90; 95%CI, 0.55-1.48), a higher proportion signed a DNI after intubation (41% vs 25%). Chinese American decedents also had higher odds of CPR (aOR 2.03; 95%CI, 1.03-41.6) with three Chinese American decedents receiving CPR despite a signed DNR order (12% vs 0%). CONCLUSIONS During terminal ICU admissions, Chinese American decedents were more likely to complete advance care documentation and to receive CPR than White American decedents. Changes in code status were more common for Chinese Americans after intubation. Further research is needed to understand these differences and identify opportunities for goal-concordant care.
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Affiliation(s)
- Avery Caz Glover
- Tufts University School of Medicine (A.C.G.), Boston, MA; Brandeis University (A.C.G.), Heller School for Social Policy and Management, Waltham, MA
| | - Zhimeng Jia
- Temmy Latner Centre for Palliative Care (Z.J.), Toronto, Ontario, Canada; Department of Family and Community Medicine (Z.J.), University of Toronto, Ontario, Canada; Program in Global Palliative Care (Z.J.), Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
| | - Kathleen Waybill
- Tufts Medical Center (K.W.), Division of Pulmonary and Critical Care, Boston, MA
| | - Tamara Vesel
- Chief, Division of Palliative Care (T.V.), Tufts Medical Center, Associate Professor, Medicine and Pediatrics, Tufts University School of Medicine, Boston, MA.
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Suen MHP, Chow AYM, Woo RKW, Yuen SK. What makes advance care planning discussion so difficult? A systematic review of the factors of advance care planning in healthcare settings. Palliat Support Care 2024:1-14. [PMID: 38766704 DOI: 10.1017/s1478951524000464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
OBJECTIVES Existing systematic reviews related to advance care planning (ACP) largely focus on specific groups and intervention efficacy or are limited to contextual factors. This research aims to identify the modifiable factors perceived by different users of ACP in healthcare settings and inform healthcare professionals about the factors affecting ACP practice. METHODS Five English-language databases (ProQuest, PubMed, CINAHL Plus, Scopus, and Medline) and two Chinese-language databases (CNKI and NCL) were searched up to November 2022. Empirical research identifying factors related to ACP in healthcare settings was included. ACP is defined as a discussion process on future end-of-life care. Thematic synthesis was performed on all included studies. RESULTS A total of 1871 unique articles were screened; the full texts of 193 were assessed by 4 reviewers, and 45 articles were included for analysis. Twenty-two (54%) studies were qualitative, 15 (33%) were quantitative, and 6 (13%) used mixed methods. Foci varied from 28 (62%) studies on a single subject group (either patient, family, or physician), 11 (25%) on 2 subject groups (either patient and family or patient and healthcare professional), and 6 (13%) covered 3 subject groups (patient, family, and healthcare professional). Among the 17 studies involving more than 1 subject group, only 2 adopted a dyadic lens in analysis. Complex interwoven factors were categorized into (1) intrapersonal factors, (2) interpersonal factors, and (3) socio-environmental factors, with a total of 11 themes: personal belief, emotions, the burden on others, timing, responsiveness, relationship, family dynamics, experience, person taking the lead, culture, and support. SIGNIFICANCE OF RESULTS Patients, families, and healthcare professionals are the essential stakeholders of ACP in healthcare settings. Factors are interweaved among the intrapersonal, interpersonal, and socio-environmental dimensions. Research is warranted to examine the dynamic interactions of the 3 essential stakeholders from a multidimensional perspective, and the mechanism of the interweaving of factors.
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Affiliation(s)
- Margaret Hay Ping Suen
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong
| | - Amy Yin Man Chow
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong
- Jockey Club End-of-Life Community Care Project, The University of Hong Kong, Hong Kong
| | | | - Sze Kit Yuen
- Caritas Medical Centre, Hospital Authority, Hong Kong
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Lochmann M, Girodet M, Despax J, Baudry V, Duranti J, Mastroianni B, Vanacker H, Vinceneux A, Brahmi M, Renard O, Verlingue L, Amini-Adle M, Swalduz A, Gautier J, Ducimetière F, Anota A, Cassier PA, Chvetzoff G, Christophe V. Qualitative evaluation of motives for acceptance or refusal of early palliative care in patients included in early-phase clinical trials in a French comprehensive cancer center: the PALPHA study. Support Care Cancer 2024; 32:353. [PMID: 38748187 DOI: 10.1007/s00520-024-08535-x] [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: 12/14/2023] [Accepted: 04/29/2024] [Indexed: 06/18/2024]
Abstract
PURPOSE The integration of palliative care (PC) into oncological management is recommended well before the end of life. It improves quality of life and symptom control and reduces the aggressiveness of end-of-life care. However, its appropriate timing is still debated. Entry into an early-phase clinical trial (ECT) represents hopes for the patient when standard treatments have failed. It is an opportune moment to integrate PC to preserve the patient's general health status. The objective of this study was to evaluate the motives for acceptance or refusal of early PC management in patients included in an ECT. METHODS Patients eligible to enter an ECT were identified and concomitant PC was proposed. All patients received exploratory interviews conducted by a researcher. Their contents were analyzed in a double-blind thematic analysis with a self-determination model. RESULTS Motives for acceptance (PC acceptors: n = 27) were both intrinsic (e.g., pain relief, psychological support, anticipation of the future) and extrinsic (e.g., trust in the medical profession, for a relative, to support the advance of research). Motives for refusal (PC refusers: n = 3) were solely intrinsic (e.g., PC associated with death, negative representation of psychological support, no need for additional care, claim of independence). CONCLUSIONS The motives of acceptors and refusers are not internalized in the same way and call for different autonomy needs. Acceptors and refusers are influenced by opposite representations of PC and a different perception of mixed management.
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Affiliation(s)
- Mathilde Lochmann
- Département des Sciences Humaines et Sociales (SHS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France.
| | - Magali Girodet
- Département des Sciences Humaines et Sociales (SHS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
- Evaluation Médicale et Sarcomes (EMS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Johanna Despax
- Département des Sciences Humaines et Sociales (SHS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Valentine Baudry
- Département des Sciences Humaines et Sociales (SHS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Julie Duranti
- Département Interdisciplinaire des Soins de Support en Oncologie, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex 08, France
| | - Bénédicte Mastroianni
- Département Interdisciplinaire des Soins de Support en Oncologie, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex 08, France
| | - Hélène Vanacker
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Armelle Vinceneux
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Mehdi Brahmi
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Olivier Renard
- Département Interdisciplinaire des Soins de Support en Oncologie, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex 08, France
| | - Loïc Verlingue
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Mona Amini-Adle
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Aurélie Swalduz
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Julien Gautier
- Direction de la Recherche Clinique et de l'Innovation (DRCI), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Françoise Ducimetière
- Evaluation Médicale et Sarcomes (EMS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Amélie Anota
- Département des Sciences Humaines et Sociales (SHS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
- Direction de la Recherche Clinique et de l'Innovation (DRCI), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Philippe A Cassier
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Gisèle Chvetzoff
- Département Interdisciplinaire des Soins de Support en Oncologie, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex 08, France
| | - Véronique Christophe
- Département des Sciences Humaines et Sociales (SHS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
- Centre de Recherche sur le Cancer de Lyon (CRCL), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
- Université Claude Bernard Lyon 1 (UCBL), 43 Bd du 11 Novembre 1918, 69100, Villeurbanne, France
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Sy M, Ritchie CS, Vranceanu AM, Bakhshaie J. Palliative Care Clinical Trials in Underrepresented Ethnic and Racial Minorities: A Narrative Review. J Palliat Med 2024; 27:688-698. [PMID: 38064535 DOI: 10.1089/jpm.2023.0124] [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] [Indexed: 02/12/2024] Open
Abstract
Introduction: A growing number of patients with serious illness who would benefit from palliative care are part of ethnoracial minority groups. Nevertheless, large disparities in provision of palliative services exist for minoritized populations. Furthermore, there is a relative dearth of palliative care research focused on minority groups and how best to provide high-quality, culturally tailored palliative care. The aim of this narrative review is to summarize the existing literature regarding palliative care clinical trials in underrepresented minority populations, describe methodological approaches, and provide guidance on future palliative care-focused clinical trials. Methods: We used the Scale for the Assessment of Narrative Review Articles (SANRA) and Cochrane's guidelines on conducting reviews. We used PubMed and Clinicaltrials.gov to review published, full-text articles or protocols (1950-2022), and limited to palliative care interventions focused on ethnoracial minority populations. We included randomized clinical trials (RCTs), including pilot and feasibility trials, protocols of RCTs, and studies that report RCT methodology. Two reviewers independently assessed eligibility. Results: Our search yielded 585 publications; of these, 30 met the full-text review criteria and 16 studies met our criteria for inclusion. We deemed nine articles as having low risk of bias and four as having high risk of bias. Discussion: Commonly used methodologic approaches for clinical trials in underrepresented minority populations included the following: the use of written and visual materials that were no higher than a sixth-grade reading level, the use of patient and lay health navigators, bilingual and multicultural study staff and study materials, race-concordant staff, the option of in-person and virtual visits that accommodated the patient and family's schedule, recruitment from faith communities, and the use of community-engaged research principles. Future palliative care clinical trials should expand on the strategies described in this article, adopt effective strategies currently used in nonpalliative care interventions, and innovate around the principles of community-engaged research.
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Affiliation(s)
- Maimouna Sy
- Center for Aging and Serious Illness, Department of Palliative Care and Geriatric Medicine, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christine Seel Ritchie
- Center for Aging and Serious Illness, Department of Palliative Care and Geriatric Medicine, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ana-Maria Vranceanu
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jafar Bakhshaie
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
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Izumi S(S, Garcia E, Kualaau A, Sloan DE, DeSanto-Madeya S, Candrian C, Anderson E, Sanders J. Advance care planning as perceived by marginalized populations: Willing to engage and facing obstacles. PLoS One 2024; 19:e0301426. [PMID: 38557983 PMCID: PMC10984538 DOI: 10.1371/journal.pone.0301426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 03/17/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Health disparities exist in end-of-life (EOL) care. Individuals and communities that are marginalized due to their race, ethnicity, income, geographic location, language, or cultural background experience systemic barriers to access and receive lower quality EOL care. Advance care planning (ACP) prepares patients and their caregivers for EOL decision-making for the purpose of promoting high-quality EOL care. Low engagement in ACP among marginalized populations is thought to have contributed to disparity in EOL care. To advance health equity and deliver care that aligns with the goals and values of each individual, there is a need to improve ACP for marginalized populations. AIM To describe how patients from marginalized populations experience and perceive ACP. METHODS We used an interpretive phenomenological approach with semi-structured qualitative interviews. Participants were recruited from four primary care clinics and one nursing home in a US Pacific Northwest city. Thirty patients from marginalized populations with serious illness participated in individual interviews between January and December 2021. Participants were asked to describe their experiences and perceptions about ACP during the interviews. RESULTS The mean age of 30 participants was 69.5; 19 (63%) were women; 12 (40%) identified as Asian/Pacific Islanders, 10 (33%) as Black; and 9 (30%) were non-native English speakers. Our three key findings were: 1) patients from marginalized populations are willing to engage in ACP; 2) there were multiple obstacles to engaging in ACP; and 3) meaningful ACP conversations could happen when clinicians listen. Although participants from marginalized populations were willing to engage in ACP, a fragmented and restrictive healthcare system and clinicians' biased behaviors or lack of interest in knowing their patients were obstacles. Participants who felt their clinicians took time and listened were encouraged to engage in ACP. CONCLUSION Patients from marginalized populations are willing to engage in ACP conversations despite a common belief otherwise. However, obstacles to meaningful ACP conversations with healthcare providers exist. Clinicians need to be aware of these obstacles and listen to build trust and engage marginalized patients in mutually meaningful ACP conversations.
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Affiliation(s)
- Shigeko (Seiko) Izumi
- School of Nursing, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Ellen Garcia
- School of Nursing, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Andrew Kualaau
- School of Nursing, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Danetta E. Sloan
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Susan DeSanto-Madeya
- College of Nursing, University of Rhode Island, Providence, Rhode Island, United States of America
| | - Carey Candrian
- School of Medicine, University of Colorado, Aurora, Colorado, United States of America
| | - Elizabeth Anderson
- Pacific Institute for Research and Evaluation, Louisville, Kentucky, United States of America
| | - Justin Sanders
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
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Parajuli J, Larson KL. Changing Life Plans: When to Engage Caregivers of Older Adults With Cancer in Advance Care Planning. J Hosp Palliat Nurs 2024; 26:29-35. [PMID: 37697472 DOI: 10.1097/njh.0000000000000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
Advance care planning (ACP) is a continuous process where individuals discuss and document their end-of-life preferences with trusted caregivers and health care providers. Caregivers are pivotal to include in ACP discussions because they assist loved ones to navigate serious medical illness. The purpose of this study was to examine caregivers' engagement in ACP decision making with their loved ones with cancer. A qualitative descriptive design was used, informed by Engel's biopsychosocial model, with a convenience sample of 14 caregivers in North Carolina. Virtual interviews were conducted using a semistructured interview guide. Using prevalence logic, the overarching theme of "Changing Life Plans" was explained by two subthemes, "Learning the Diagnosis" and "Keeping Them on Track." The timing and location of ACP conversations were important considerations. Over half of the participants (64%) had no knowledge or had misconceptions about ACP, and 5 had accurate knowledge. Nurses could develop partnerships with community leaders trained in palliative care principles to begin conversations early with community members. Advocacy groups might hold events, such as the Hello Game, in community settings to facilitate early ACP conversations.
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Zhou Y, Bai Z, Cheng L, Zheng Q, Li L. Reliability and Validity of the Chinese Version of Advance Care Planning Self-efficacy Scale for Physicians. J Palliat Care 2024; 39:36-46. [PMID: 37415494 DOI: 10.1177/08258597231185679] [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: 07/08/2023]
Abstract
Background: Chinese patients prefer physicians to initiate advance care planning (ACP) conversations, but there is no appropriate tool to evaluate physicians' ACP self-efficacy level in mainland China. This study aimed to translate the ACP self-efficacy scale into Chinese (ACP-SEc) and measure its psychometric properties among clinical physicians. Method: The original scale was translated by literal translation, synthesis, and reverse translation, according to Brislin's translation model. Seven experts were invited to further revise the scale and evaluate the content validity. 348 physicians were conveniently sampled to evaluate the reliability and validity of the scale from May to June 2021 in 7 tertiary hospitals. Results: The ACP-SEc contained 17 items, 1 dimension, with a total score of 17 to 85 points. In this study, the critical ratios of the items ranged from 12.533 to 23.306, the item-total correlation coefficients ranged from 0.619 to 0.839. The item-content validity index ranged from 0.86 to 1.00, and the average scale-level content validity index was 0.98. In total, 75.507% of the total variance was explained by 1 common factor. The results of confirmatory factor analysis showed that the fitting indices of the modified model were desirable. The ACP-SEc was moderately correlated with General Self-Efficacy Scale (r = 0.675, P < .001), and it differentiated between physician groups based on the knowledge level of ACP, palliative care or ACP-related training experience, attitude toward ACP, willingness to initiate ACP discussions with patients, and experience of discussing ACP with family and friends, willingness to initiate ACP discussions with family and friends (P <.05). The total Cronbach's α and test-retest reliability of the scale were .960 and .976, respectively. Conclusion: The ACP-SEc shows good reliability and validity, and it can be used to assess the ACP self-efficacy level of physicians.
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Affiliation(s)
- Yanan Zhou
- Department of Nursing, The Third Affiliated Hospital of the Naval Military Medical University, Shanghai, China
| | - Zhiling Bai
- Department of Pharmacy, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Lin Cheng
- Military patient management section, The 926th Hospital of the joint logistics support force of the Chinese people's Liberation Army, Kaiyuan, China
| | - Qin Zheng
- Department of Nursing, The Third Affiliated Hospital of the Naval Military Medical University, Shanghai, China
| | - Li Li
- Department of Nursing, The Third Affiliated Hospital of the Naval Military Medical University, Shanghai, China
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Nouri S, Li L, Huang C, Chung A, Stokes SC, Pan S, Wong EC, Newman J, Woo JW, Cheng J, Tan CH, Wertz M, Wood-Hughes E, Quinn M, Pantilat SZ, Lyles CR, Ritchie CS, Sudore RL. "At the End I Have a Say": Engaging the Chinese Community in Advance Care Planning. J Pain Symptom Manage 2023; 66:551-560.e1. [PMID: 37536524 PMCID: PMC10593504 DOI: 10.1016/j.jpainsymman.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/22/2023] [Accepted: 07/24/2023] [Indexed: 08/05/2023]
Abstract
CONTEXT Despite the association of advance care planning (ACP) with improved patient and caregiver outcomes, Chinese American elders have low rates of ACP. OBJECTIVES Assess ACP facilitators/barriers in the San Francisco (SF) Chinese community and codesign, implement, and test community-based ACP-promoting pilot events. METHODS A Chinese Community Committee (N = 19 community-based organization leaders, health system representatives, community members) conducted focus groups in Cantonese and English with Chinese older adults (age ≥55), caregivers, and community leaders. The Committee designed and implemented pilot events in-person and online. We analyzed focus group data using thematic analysis; assessed pre-to-post-event readiness to engage in ACP (validated survey; 14 scale, 4 = most ready); and assessed event acceptability. RESULTS A total of 34 people participated in six focus groups. Themes described Chinese community-specific importance of ACP (e.g., reduces family burden), barriers (e.g., younger generations lack tools to discuss ACP with elders and vice versa), and facilitators (e.g., intergenerational events, culturally/linguistically appropriate materials). Based on focus groups findings, the Committee developed a novel ACP tool and designed intergenerational events. A total of 195 participants attended 10 events; 95% were Chinese, 90% spoke Chinese languages, 80% were women. ACP readiness increased significantly (1.66 [SD 0.84] vs. 2.03 [SD 0.85]; P < 0.001); 94% of participants were comfortable attending and 96% would recommend events. CONCLUSION Community-developed intergenerational events that highlight the value of ACP and address barriers are acceptable and increase ACP engagement in the Chinese community.
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Affiliation(s)
- Sarah Nouri
- Division of Palliative Medicine, Department of Medicine (S.N., M.Q., S.Z.P.), University of California San Francisco, San Francisco, California, USA.
| | - Lingsheng Li
- Division of Geriatrics, Department of Medicine (L.L.), University of California San Francisco, San Francisco, California, USA
| | - Carrie Huang
- Thriving in Place (C.H.), San Francisco, California, USA
| | - Anni Chung
- Self-Help for the Elderly (A.C.), San Francisco, California, USA
| | - Sandy Chen Stokes
- Chinese American Coalition for Compassionate Care (S.C.S., S.P.), Cupertino, California, USA
| | - Shirley Pan
- Chinese American Coalition for Compassionate Care (S.C.S., S.P.), Cupertino, California, USA
| | - Elizabeth C Wong
- Independent community advocate (E.C.W.), San Francisco, California, USA
| | - Jeffrey Newman
- Institute for Health & Aging, University of California San Francisco (J.N.), San Francisco, California, USA
| | - Joseph W Woo
- Chinese Community Healthcare Association (J.W.W.), San Francisco, California, USA
| | - Joyce Cheng
- Chinese Community Health Resource Center (J.C.), San Francisco, California, USA
| | - Charissa H Tan
- John A. Burns School of Medicine, University of Hawai'i at Mānoa (C.H.T.), Honolulu, Hawaii, USA
| | - Molly Wertz
- Molly Wertz Consulting (M.W.), San Francisco, California, USA
| | - Elyse Wood-Hughes
- Richmond Senior Center, Golden Gate Senior Services (E.W.H.), San Francisco, California, USA
| | - Mara Quinn
- Division of Palliative Medicine, Department of Medicine (S.N., M.Q., S.Z.P.), University of California San Francisco, San Francisco, California, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine (S.N., M.Q., S.Z.P.), University of California San Francisco, San Francisco, California, USA
| | - Courtney R Lyles
- Division of General Internal Medicine, Department of Medicine (C.R.L.), Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Christine S Ritchie
- Division of Palliative Care and Geriatric Medicine, Department of Medicine (C.S.R.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine (R.L.S.), University of California San Francisco, San Francisco, California, USA
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Lin CP, Chiang CH, Sheu SJ. Using the Kipling method to explore the contextual factors of decision-making during advance care planning for older cancer patients, their family, and health-care professionals: A qualitative secondary analysis. Palliat Support Care 2023:1-7. [PMID: 37859416 DOI: 10.1017/s1478951523001256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
OBJECTIVES Advance care planning (ACP) interventions are supposed to affect patients' autonomy and family health-care outcomes positively. However, the clinical benefits of ACP actualization and associated contextual factors merit questioning. Therefore, this study explores the critical contextual and procedural factors related to ACP decision-making based on the actual situation of older patients with cancer encountering end-of-life care in Taiwan. METHODS This retrospective qualitative secondary analysis used the Kipling method (5W1H) to explore further the critical contextual and procedural factors related to ACP decision-making processes. We applied thematic analysis and dual coding for 35 narratives, including 10 patients with cancer, 10 family caregivers, and 15 health-care staff, derived from a preliminary qualitative study regarding palliative care decision-making among patients with advanced cancer, their families, and health-care staff. RESULTS We identified 6 domains detailing the contextual factors for ACP decision-making: (1) WHO (decision makers); (2) WHAT (discussion content); (3) WHEN (care plan for which disease stage); (4) WHERE (patient's situational location); (5) WHY (reasons underpinning the decisions); and (6) HOW (the way to form the decisions). SIGNIFICANCE OF RESULTS Using the Kipling method to elaborate the contextual factors for ACP decision-making among older patients with cancer strengthens the understanding of complicated end-of-life care decision-making procedure. This study also demonstrates the dynamic and cultural complexity and the various factors considered during end-of-life care and future ACP discussion.
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Affiliation(s)
- Cheng-Pei Lin
- Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, King's College London, London, UK
| | - Chia-Hsuan Chiang
- Department of Nursing, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shuh-Jen Sheu
- Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
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10
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Zhang P, Sun F, Hirsch J. Perceived Barriers and Social Cultural Factors Associated With Advance Care Planning Conversations Among Chinese American Older Adults. J Appl Gerontol 2023; 42:2110-2118. [PMID: 37204849 DOI: 10.1177/07334648231176142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
Despite the well-documented benefits of advance care planning (ACP), persistent racial and ethnic disparities continue to exist in ACP engagement. Guided by a social ecological model, this study examined perceived barriers and sociocultural factors associated with informal ACP conversations among Chinese American older adults. A purposive sample of 281 community-dwelling older Chinese Americans aged 55 years or older in Arizona and Maryland completed a survey in 2018. Hierarchical logistic regression models were conducted. There were 26.5% of participants who engaged in advance care planning. Lower perceived barriers and sociocultural factors (i.e., length of stay in the U.S. and English language proficiency) were positively associated with ACP conversations. Social support had a significant moderation effect. Findings highlighted the importance of language services and social support in facilitating ACP discussions among older Chinese immigrants. Effective strategies are needed to reduce the barriers to ACP at various levels for older Chinese American populations.
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Affiliation(s)
- Peiyuan Zhang
- School of Social Work, University of Maryland, Baltimore, MD, USA
| | - Fei Sun
- School of Social Work, Michigan State University, East Lansing, MI, USA
| | - Jen Hirsch
- School of Social Work, Michigan State University, East Lansing, MI, USA
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Libert Y, Choucroun L, Razavi D, Merckaert I. Advance care planning in oncology: a scoping review and some recommendations. Curr Opin Oncol 2023; 35:261-275. [PMID: 37222205 DOI: 10.1097/cco.0000000000000951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
PURPOSE OF REVIEW Cancer patients' communication with their relatives and healthcare professionals (HCPs) is essential for advance care planning (ACP). The purpose of this scoping review was to synthesize recent research findings about factors enabling cancer patients', their relatives', and physicians' communication about ACP, and to propose recommendations for future ACP implementation in cancer care. RECENT FINDINGS This review confirmed the importance of aspects of the cancer care context (i.e., culture) as ACP uptake-predisposing and -enabling factors. It highlighted the difficulty of determining who should initiate ACP discussion, with which patients and at what time-points. It also highlighted a lack of consideration for socioemotional processes in the study of ACP uptake despite evidence that cancer patients', relatives' and physicians' discomforts that arise from communication about end-of-life and the wish to safeguard each other are main obstacles to ACP implementation. SUMMARY Based on these recent findings, we propose an ACP communication model, developed with the consideration of factors reported to influence ACP uptake and communication in healthcare, and integrating socioemotional processes. The testing of the model may yield suggestions for innovative interventions that can support communication about ACP and promote a better uptake in clinical practice.
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Affiliation(s)
- Yves Libert
- Université libre de Bruxelles (ULB), Faculté des Sciences Psychologiques et de l'Éducation
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (H.U.B), Institut Jules Bordet, Service de Psychologie (Secteur Psycho-Oncologie)
| | - Lisa Choucroun
- Université libre de Bruxelles (ULB), Faculté des Sciences Psychologiques et de l'Éducation
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (H.U.B), Institut Jules Bordet, Service de Psychologie (Secteur Psycho-Oncologie)
| | - Darius Razavi
- Université libre de Bruxelles (ULB), Faculté des Sciences Psychologiques et de l'Éducation
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (H.U.B), Institut Jules Bordet, Service de Psychologie (Secteur Psycho-Oncologie)
- Centre de Psycho-Oncologie, Brussels, Belgium
| | - Isabelle Merckaert
- Université libre de Bruxelles (ULB), Faculté des Sciences Psychologiques et de l'Éducation
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (H.U.B), Institut Jules Bordet, Service de Psychologie (Secteur Psycho-Oncologie)
- Centre de Psycho-Oncologie, Brussels, Belgium
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Obama K, Fujimori M, Okamura M, Kadowaki M, Ueno T, Boku N, Mori M, Akechi T, Yamaguchi T, Oyamada S, Okizaki A, Miyaji T, Sakurai N, Uchitomi Y. Effectiveness of a facilitation programme using a mobile application for initiating advance care planning discussions between patients with advanced cancer and healthcare providers: protocol for a randomised controlled trial (J-SUPPORT 2104). BMJ Open 2023; 13:e069557. [PMID: 36977536 PMCID: PMC10069562 DOI: 10.1136/bmjopen-2022-069557] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
INTRODUCTION Timely implementation of the discussion process of advance care planning (ACP) is recommended. The communication attitude of healthcare providers is critical in ACP facilitation; thus, improving their communication attitudes may reduce patient distress and unnecessary aggressive treatment while enhancing care satisfaction. Digital mobile devices are being developed for behavioural interventions owing to their low space and time restrictions and ease of information sharing. This study aims to evaluate the effectiveness of an intervention programme using an application intended to facilitate patient questioning behaviour on improving communication related to ACP between patients with advanced cancer and healthcare providers. METHODS AND ANALYSIS This study uses a parallel-group, evaluator-blind, randomised controlled trial design. We plan to recruit 264 adult patients with incurable advanced cancer at the National Cancer Centre in Tokyo, Japan. Intervention group participants use a mobile application ACP programme and undergo a 30 min interview with a trained intervention provider for discussions with the oncologist at the next patient visit, while control group participants continue their usual treatment. The primary outcome is the oncologist's communication behaviour score assessed using audiorecordings of the consultation. Secondary outcomes include communication between patients and oncologists and the patients' distress, quality of life, care goals and preferences, and medical care utilisation. We will use a full analysis set including the registered participant population who receive at least a part of the intervention. ETHICS AND DISSEMINATION The study protocol was reviewed and approved by the Scientific Advisory Board of the Japan Supportive, Palliative and Psychosocial Oncology Group (Registration No. 2104) and the Institutional Review Board of the National Cancer Centre Hospital (registration No. 2020-500). Written informed consent is obtained from the patients. The results of the trial will be published in peer-reviewed scientific journals and presented at scientific meetings. TRIAL REGISTRATION NUMBERS UMIN000045305, NCT05045040.
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Affiliation(s)
- Kyoko Obama
- Institute for Cancer Control, National Cancer Center Japan, Tokyo, Japan
| | - Maiko Fujimori
- Institute for Cancer Control, National Cancer Center Japan, Tokyo, Japan
| | - Masako Okamura
- Institute for Cancer Control, National Cancer Center Japan, Tokyo, Japan
| | - Midori Kadowaki
- Institute for Cancer Control, National Cancer Center Japan, Tokyo, Japan
| | | | - Narikazu Boku
- Department of Oncology and General Medicine, IMSUT Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara Hospital, Hamamatsu, Japan
| | - Tatsuo Akechi
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Ayumi Okizaki
- Institute for Cancer Control, National Cancer Center Japan, Tokyo, Japan
| | - Tempei Miyaji
- Institute for Cancer Control, National Cancer Center Japan, Tokyo, Japan
| | - Naomi Sakurai
- Cancer Survivors Recruiting Project, General Incorporated Association, Tokyo, Japan
| | - Yosuke Uchitomi
- Institute for Cancer Control, National Cancer Center Japan, Tokyo, Japan
- Innovation Center for Supportive, Palliative and Psychosocial Care, National Cancer Center Hospital, Chuo-ku, Japan
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Pan CX, Luo EJ, Wang E, Szeto DA, Lum H, Ma J, Chen Stokes S, Chan S, Wong C, Guo J, Wang L, Chang V, Crupi RS. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Chinese American Patients. J Palliat Med 2023; 26:423-430. [PMID: 36260416 DOI: 10.1089/jpm.2022.0470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The Chinese American population is one of the fastest-growing communities in the United States, composed of ∼5.4 million people, and represents ∼5.5% of overseas Chinese populations. With an expected exponential population rise, Chinese American patients who experience serious illness or approach end-of-life (EOL) may find their cultural values influencing the medical care they receive. Palliative care clinicians must recognize diverse cultural beliefs and preferences of Chinese American patients and their families. In this study, we provide 10 cultural pearls to guide the provision of palliative and EOL care for Chinese American patients, including discussions of Chinese traditions, communication strategies for Chinese patients and families, advance care planning, and EOL care beliefs.
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Affiliation(s)
- Cynthia X Pan
- Division of Geriatrics and Palliative Care Medicine, Department of Medicine, NewYork-Presbyterian Queens, Weill Cornell Medicine, Flushing, New York, USA
| | - Esther J Luo
- Outpatient Palliative Care, Supportive Care Services, Kaiser Permanente, Santa Clara, California, USA
| | - Eric Wang
- Division of Geriatrics and Palliative Care Medicine, Department of Medicine, NewYork-Presbyterian Queens, Flushing, New York, USA
| | - Deborah A Szeto
- Inpatient Palliative Care, Supportive Care Services, Kaiser Permanente, Santa Clara, California, USA
| | - Hillary Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jessica Ma
- Geriatric Research, Education, and Clinical Center, Durham VA Health System, Durham, North Carolina, USA.,Division of Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sandy Chen Stokes
- Chinese American Coalition for Compassionate Care (CACCC), Shingle Springs, California, USA
| | - Sandy Chan
- Department of Palliative Medicine and Geriatrics, Stanford Health Care. Palo Alto, California, USA
| | - Christian Wong
- Department of Medicine, Albany Medical Center, Albany, New York, USA
| | - Jing Guo
- Division of Hospital Medicine, Department of Medicine, NewYork-Presbyterian Queens, Weill Cornell Medicine, Flushing, New York, USA
| | - Lifeng Wang
- Department of Pastoral Care and Education, NewYork-Presbyterian Queens, Flushing, New York, USA
| | - Victor Chang
- Section Hematology/Oncology, Medical Service, VA New Jersey Health Care System, East Orange, New Jersey, USA.,Division of Hematology Oncology, Department of Medicine, Rutgers New Jersey Medical School, Newark New Jersey, USA
| | - Robert S Crupi
- Division of Geriatrics and Palliative Care Medicine, Department of Medicine, NewYork-Presbyterian Queens, Weill Cornell Medicine, Flushing, New York, USA
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Li Z, Beck ER, McIlfatrick S, Hasson F. Chinese Diaspora Communities' Knowledge of and Engagement with Advance Care Planning: A Systematic Integrative Review. J Palliat Care 2023:8258597231158321. [PMID: 36843565 DOI: 10.1177/08258597231158321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
OBJECTIVES To synthesize evidence regarding Chinese diasporas' understanding, experience, and factors influencing engagement with advance care planning. Methods: A systematic integrative review using content analysis. Seven electronic databases (Embase, CINAHL, SCOPUS, Web of Science, Medline (OVID), PsycINFo, and The Cochrane Library) and gray resources were searched for studies from January 1990 to March 2022. Study quality appraisal was undertaken. Results: 27 articles were identified and rated as moderate to good. Two overarching and interrelated themes were identified, "Awareness and knowledge" and "Engagement with advance care planning." There are low levels of awareness, knowledge and engagement with advance care planning for Chinese diaspora. Findings highlight that this is influenced by two key factors. First, the geographic context and legal, cultural, and social systems within which the Chinese diasporas are living act as a potential catalyst to enhance awareness and engagement with advance care planning. Second, aspects of Chinese diasporas' original culture, such as filial piety and a taboo surrounding death, were reported to negatively affect the promotion and engagement of advance care planning. Significance of Results: Chinese diasporas are intermediaries between two divergent cultures that intertwine to strongly influence engagement with advance care planning. Hence, a bespoke culturally tailored approach should be accommodated in future research and practice for Chinese communities in multicultural countries to further advance palliative and end-of-life care awareness among this group.
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Affiliation(s)
- Zhuangshuang Li
- 547713 Institute of Nursing and Health Research, School of Nursing, Ulster University, Belfast, Northern Ireland
| | - Esther Ruth Beck
- 547713 Institute of Nursing and Health Research, School of Nursing, Ulster University, Belfast, Northern Ireland
| | - Sonja McIlfatrick
- 547713 Institute of Nursing and Health Research, School of Nursing, Ulster University, Belfast, Northern Ireland
| | - Felicity Hasson
- 547713 Institute of Nursing and Health Research, School of Nursing, Ulster University, Belfast, Northern Ireland
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Robbel C, Vesel L, Ernst E, He Y, Vesel T. Community Member and Health Care Provider Perspectives on Communication With Chinese American Patients With Cancer: A Qualitative Study. JCO Oncol Pract 2022; 18:e1927-e1934. [PMID: 36265104 PMCID: PMC9750549 DOI: 10.1200/op.22.00047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 07/23/2022] [Accepted: 08/15/2022] [Indexed: 11/05/2022] Open
Abstract
PURPOSE Effective health care provider-patient discussions of cancer diagnoses and prognoses are essential to enhance health outcomes in oncology. Chinese Americans have been designated an underserved population in oncology by the National Institutes of Health. We explored the perspectives of Boston Chinese American community members and health care providers regarding communication preferences and decision making in oncology care. METHODS In this inductive, qualitative study, we conducted virtual, semi-structured interviews with 21 health care providers with experience in caring for Chinese American patients with cancer and 25 older Boston Chinatown community members who self-identify as Chinese or Chinese American. Thematic analysis was performed. RESULTS Two major themes were identified. First, provider communication should incorporate a gentle but truthful approach, careful word choice, authority-led style, and professionalism. Second, the family plays a large role in medical and nonmedical settings, and a family-centered approach to communication should be used. CONCLUSION Our study builds on and challenges current knowledge regarding oncologic communication with Chinese American patients. A focus on the improvement of provider-patient cancer communication for Chinese Americans will improve care quality and satisfaction among patients and clinicians alike and serve to decrease disparities in care.
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Affiliation(s)
- Courtney Robbel
- Division of Hematology Oncology, Tufts Medical Center, Boston, MA 02111
- Department of Hematology Oncology, Atrius Health, Boston, MA 02215
| | - Linda Vesel
- Ariadne Labs at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, MA
| | - Emma Ernst
- Tufts University School of Medicine, Boston, MA
| | - Yang He
- Greater Boston Chinese Golden Age Center, Boston, MA
| | - Tamara Vesel
- Tufts University School of Medicine, Boston, MA
- Division of Palliative Care, Tufts Medical Center, Boston, MA
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Trevizan FB, Paiva CE, Julião M, de Oliveira Valentino TC, Miwa MU, Mingardi M, D'Almeida Preto D, Ciorlia JB, de Angelis Nascimento MS, Kovács MJ, Dadalto L, de Oliveira LC, da Costa Rosa KS, Ribeiro Paiva BS. Comprehension and Decision-Making Capacity Questionnaire About Palliative Care and Advance Care Planning: A Delphi Study. J Palliat Care 2022; 38:41-51. [PMID: 36168276 DOI: 10.1177/08258597221128676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE(S) To develop a questionnaire that assesses the level of comprehension and decision-making capacity of patients with breast cancer about palliative care and advance care planning. Methods: Questionnaire items were based on the scientific literature. Delphi Consensus, a three-round survey with experts (n = 14), evaluated the relevance, clarity, and redundancies of the items. A pretest with breast cancer patients (n = 15) evaluated whether they comprehended each item and identified doubts or discomforts. Results: The initial questionnaire was composed of 38 items. After the Delphi, 18 items were restructured, six were added, and 16 were removed. In the pretest phase, all items with the survey header, guidelines, and Likert model were evaluated. All items accomplished ≥80% cut-off score and were kept as in the original version. The final version of the questionnaire have 28 itens and five domains: determination, responsibility, independence, self-knowledge, and knowledge of reality. Conclusions: This study represents the first step in the development of a questionnaire that may be used in oncology clinical practice. The main findings revealed that Delphi and pretesting increased the quality of the questionnaire, making it compelling to assess breast cancer patients' comprehension and decision-making capacity about PC and ACP.
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Affiliation(s)
- Fulvio Bergamo Trevizan
- GPQual - Research Group on Palliative Care and Quality of Life - 67766Barretos Cancer Hospital, Brazil
| | - Carlos Eduardo Paiva
- GPQual - Research Group on Palliative Care and Quality of Life - 67766Barretos Cancer Hospital, Brazil
| | - Miguel Julião
- Community Support Team in Palliative Care - Sintra, Portugal
| | | | - Michelle Uchida Miwa
- GPQual - Research Group on Palliative Care and Quality of Life - 67766Barretos Cancer Hospital, Brazil
| | - Mirella Mingardi
- GPQual - Research Group on Palliative Care and Quality of Life - 67766Barretos Cancer Hospital, Brazil
| | - Daniel D'Almeida Preto
- GPQual - Research Group on Palliative Care and Quality of Life - 67766Barretos Cancer Hospital, Brazil
| | - Juliana Beraldo Ciorlia
- GPQual - Research Group on Palliative Care and Quality of Life - 67766Barretos Cancer Hospital, Brazil
| | | | - Maria Júlia Kovács
- Department of Psychology of Learning, Development and Personality Psychology in 28133University of São Paulo (USP) - São Paulo, Brazil
| | - Luciana Dadalto
- 241167Newton Paiva University Center - Belo Horizonte, Brazil
| | - Livia Costa de Oliveira
- National Cancer Institute José Alencar Gomes da Silva (INCA) - Palliative Care Unit. Rio de Janeiro, Brazil
| | - Karla Santos da Costa Rosa
- National Cancer Institute José Alencar Gomes da Silva (INCA) - Palliative Care Unit. Rio de Janeiro, Brazil
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