Barriers to end-of-life discussion with advanced cancer patient as perceived by oncologists, certified/specialized nurses in cancer nursing and medical social workers

End-of-life conversations for the older person: A concept analysis

AIM

The aim of this concept analysis is to seek clarity as to what end-of-life conversations involve by developing a clear working definition and using model cases to conceptualise the defining attributes of an end-of-life conversations with the older person.

DESIGN

Walker and Avant's eight step approach to Concept Analysis.

DATA SOURCES

Four databases were searched, including PubMed, CINAHL, PsycINFO, and Scopus. A total of 339 publications were identified with 30 papers meeting the inclusion criteria and put forward for the final conceptual analysis.

RESULTS

The defining attributes associated with end-of life conversations included (1) an ongoing process of older person empowerment, (2) discussion's concerning values and preferences concerning end-of-life issues, and (3) maintaining an open dialogue between all concerned individuals. Antecedents were associated with the older person is their readiness to talk openly about death and dying. Consequences were identified as having a better understanding of what death and dying may mean to the older person in a more specific manner.

CONCLUSIONS

End-of-life conversations are vital in understanding an individual's values and preferences at the end of life, and yet, the concept of the end-of-life conversation has not been well defined in the literature. End-of-life conversations with the older person encompass ongoing discussions and maintaining open dialogue around end-of-life care while developing strategies to promote individual empowerment in making informed choices. Using a conceptual model, aides in addressing aspects of end-of-life conversations and an acknowledgment of the dynamic process of end-of-life conversations.

Systemic anticancer therapy near the end of life: an analysis of factors influencing treatment in advanced tumor disease

BACKGROUND

Systemic anticancer treatment (SACT) for advanced cancer patients with limited prognosis before death is associated with high toxicity and reduced quality of life. Guidelines discourage this approach as low-value care. However, a significant number of patients continue to receive SACT in the last 30 days of life.

MATERIALS AND METHODS

A retrospective study was carried out at the University Hospital Krems, encompassing the analysis of patients who were diagnosed with a solid tumor and died between 2017 and 2021, with a particular focus on the use of end-of-life (EOL) SACT.

RESULTS

A total of 685 patients were included in the study. SACT was applied in 342 (49.9%) patients, of whom 143 (41.8%, total population: 20.9%) patients received SACT within the last 30 days of life. Median time from last SACT to death was 44.5 days. The analysis of potential factors impacting the administration of EOL SACT revealed the following significant findings: type of SACT [P < 0.001, targeted therapy odds ratio (OR) 5.09, 95% confidence interval (CI) 2.26-11.48; chemotherapy/targeted therapy OR 3.60, 95% CI 1.47-8.82; immune checkpoint inhibitor OR 2.32, 95% CI 1.37-3.92], no referral to palliative care (PC) (P = 0.009, OR 1.86, 95% CI 1.16-2.96), no admission to PC ward (P < 0.001, OR 2.70, 95% CI 1.67-4.35), and poor Eastern Cooperative Oncology Group (ECOG) performance status (≥2, P < 0.001, OR 3.35, 95% CI 1.93-5.83).

CONCLUSION

The timing of SACT near the EOL is significantly influenced by several factors, including the type of SACT, referral to PC services, admission to PC unit, and ECOG performance status. These findings underscore the complexity of treatment decisions in advanced cancer care and highlight the need for personalized, patient-centered approaches that consider both clinical and patient-related factors to optimize care at the EOL.

The quality of dying and death of patients with cancer from Shanghai in China from the perspective of healthcare providers: A cross-sectional study

Objective

To evaluate the quality of dying and death among deceased patients with cancer in Shanghai from the perspective of healthcare providers.

Methods

This cross-sectional study was conducted in Shanghai from April to July 2023. A convenience sample of 261 healthcare providers working at eight healthcare institutions participated. Each participant was asked to evaluate the quality of dying and death of one deceased patient who had been cared for recently using the Good Death Scale for patients in China (GDS-PCN). The scale included family companionship (eight items), dying with peace (six items), professional care (six items), preparation & no regrets (five items), maintaining dignity (four items), keeping autonomy (four items), and physical wellbeing (three items) seven dimensions, 36 items.

Results

The total GDS-PCN score was 144.11 ± 17.86. The professional care dimension scored the highest (4.21 ± 0.58), whereas the preparation and no regret dimension scored the lowest (3.75 ± 0.70). Significant differences in the GDS-PCN scores were based on the healthcare institution grade, ward type, hospitalization duration, communication about the condition, treatment, and death-related topics with the healthcare provider, and decision-making style (P < 0.05). The quality of dying and death of the deceased patients was higher among those who received care in community health service centers and hospice wards, those who had been hospitalized for more than 15 days, those who had discussed their personal conditions, treatment, and death-related topics with healthcare providers to a greater extent; and those who were involved in decision-making (P < 0.05).

Conclusion

The overall quality of dying and death among cancer patients in Shanghai is moderate to high, but the quality of dying and death in the preparation and no regret dimension and the keeping autonomy dimension still have room for improvement. Increased utilization of hospice care and better communication between patients and healthcare providers may enhance decedents' quality of dying and death. Future research on this topic is required from different perspectives and on a broader scale in the mainland of China.

Question prompt list intervention for patients with advanced cancer: a systematic review and meta-analysis

BACKGROUND

Enhanced communication in end-of-life care (EOL) improves preparation and treatment decisions for patients with advanced cancer, affecting their quality of life at the end of life. Question prompt list (QPL) has been shown to enhance physician-patient communication in patients with cancer, but there is a lack of systematic review and meta-analysis for those with advanced cancer. Enhanced communication in end-of-life care improves preparation and treatment decisions for patients with advanced cancer, affecting their quality of life at the end of life.

OBJECTIVE

To review the effectiveness of QPL intervention on physician-patient communication and health outcomes during consultation in patients with advanced cancer.

METHODS

CINAHL, Embase, Scopus, and PsycINFO databases were undertaken using inclusion criteria for relevant articles up to August 2021. Pooled standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated using random-effects models. We used the Cochrane risk-of-bias assessment tool and modified Jadad scale to assess the quality of the studies.

RESULTS

Seven RCTs with 1059 participants were included, of which six studies were eligible for the meta-analysis. The pooled meta-analysis results indicated that QPL in patients with advanced cancer had a significant positive effect on the total number of questions asked (SMD, 0.73; 95% CI, 0.28 to 1.18; I2 = 83%) and on the patients' expectations for the future (SMD, 0.67; 95% CI, 0.08 to 1.25; I2 = 88%). There were no significant improvements in health-related outcomes such as end of life, anxiety, and quality of life.

CONCLUSIONS

Using QPL in advanced cancer consultations boosts patient questions which helps communication but not health-related indicators. Optimal results depend on full reading, but timing varies. Future research should examine the relationship between communication and health outcomes, including patient/physician behavior and social context.

Patients', families' and healthcare providers' perspectives on end-of-life communication in Chinese hospital settings: A qualitative study protocol

BACKGROUND

Perspectives of key stakeholders should be fully considered to enhance culturally appropriate strategies in end-of-life communication and strengthen healthcare service delivery. So far, little research evidence is available on Chinese patients', families', and healthcare professionals' experiences with and perspectives of end-of-life communication in hospital settings.

AIM

The current study aims to explore experiences, perceptions and suggestions of end-of-life communication among Chinese terminally ill patients, their families and healthcare providers.

METHODS

The phenomenology qualitative approach will be adopted. Semi-structured in-depth interviews and focus group discussions will be used to collect relevant data. Eligible terminally ill patients, family caregivers and healthcare providers will be recruited in two hospitals in Mainland China via purposive sampling. Thematic analysis will be performed to analyse data. The Standards for Reporting Qualitative Research (SRQR) checklist will be followed for reporting. This study has been registered at ClinicalTrials.gov (NCT05734781).

DISCUSSION

This qualitative study is, as far as we are aware, the first to specifically address patient/family-provider end-of-life communication in the Chinese social-cultural context. The results hold the potential to enrich current knowledge of end-of-life communication, navigate culturally appropriate communication strategies, and inform the development of related training programs for healthcare providers in hospital settings.

Barriers and facilitators that hospital clinicians perceive to discuss the personal values, wishes, and needs of patients in palliative care: a mixed-methods systematic review

Background

The exploration and monitoring of the personal values, wishes, and needs (VWN) of patients in the palliative phase by hospital clinicians is essential for guiding appropriate palliative care.

Objective

To explore the barriers and facilitators concerning communication with patients in the palliative phase about their VWN as perceived by hospital clinicians.

Design

A mixed-methods systematic review following the Joanna Briggs Institute guidelines for mixed-method systematic reviews and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted (PROSPERO ID: CRD42021216693).

Data sources and methods

Eight databases, including PubMed, Embase, and CINAHL, were searched without time restrictions. The search string was built using the search Palliative cAre Literature rEview iTeraTive mEthod (PALETTE) framework. Eligible studies focused on (1) hospital clinicians and (2) perceived barriers and facilitators regarding the exploration and monitoring of the VWN of adult patients in the palliative phase. Two researchers independently selected articles and evaluated the quality. Findings were synthesized using a convergent integrated approach.

Results

In total, 29 studies were included: 14 quantitative, 13 qualitative, and 2 mixed methods. Five synthesized findings were identified: (1) the clinician's professional manners, (2) the image formed of the patient and loved ones, (3) the human aspect of being a clinician, (4) the multidisciplinary collaboration, and (5) the contextual preconditions. Most studies seemed focused on communication about treatment decision making.

Conclusion

A patient-centered approach seems lacking when clinicians discuss the patient's VWN, since most studies focused on treatment decision making rather than on the exploration and monitoring of the multidimensional well-being of patients. This review emphasizes the need for the development and integration of a systematic approach to explore and monitor the patients' VWN to improve appropriate palliative care in hospitals.

Fundamentals of end-of-life communication as part of advance care planning from the perspective of nursing staff, older people, and family caregivers: a scoping review

BACKGROUND

Nursing staff is ideally positioned to play a central role in end-of-life communication as part of advance care planning for older people. However, this requires specific skills and competences. Only fragmented knowledge is available concerning important fundamentals in end-of-life communication performed by nursing staff.

OBJECTIVE

This review aimed to explore the fundamentals of end-of-life communication as part of advance care planning in the hospital, nursing home and home care setting, from the perspective of the nursing staff, the older person, and the family caregiver.

DESIGN

Scoping review.

METHODS

A literature search in PubMed, PsycINFO, CINAHL and Google (Scholar) was conducted on August 20, 2022. The search strategy followed the sequential steps as described in the Joanna Briggs Institute Manual. Peer-reviewed articles of empirical research and gray literature written in English or Dutch and published from 2010 containing fundamentals of end-of-life communication as part of advance care planning from the perspective of nursing staff, older people, and family caregivers in the hospital nursing home or home care setting were considered eligible for review.

RESULTS

Nine studies were included, and four themes were composed, reflecting 11 categories. Nursing staff attunes end-of-life communication to the values and needs of older people to approach the process in a person-centered manner. This approach requires additional fundamentals: building a relationship, assessing readiness, timing and methods to start the conversation, communication based on information needs, attention to family relationships, a professional attitude, improving communication skills, listening and non-verbal observation skills, and verbal communication skills.

CONCLUSIONS

This review is the first to compile an overview of the fundamentals of end-of-life communication performed by nursing staff. Building a nursing staff-older-person relationship is the most important foundation for engaging in a person-centered end-of-life communication process. Knowing each other enables nursing staff to have a sense of older people's readiness, determine the right timing to initiate an end-of-life conversation, identify specific needs, and accurately apply (non-)verbal observation skills. end-of-life communication is not a one-time conversation, but a complex process that takes time, effort, and genuine interest in each other.

End-of-life communication strategies for healthcare professionals: A scoping review

BACKGROUND

Timely and effective communication about end-of-life issues, including conversations about prognosis and goals of care, are extremely beneficial to terminally ill patients and their families. However, given the context, healthcare professionals may find it challenging to initiate and facilitate such conversations. Hence, it is critical to improving the available communication strategies to enhance end-of-life communication practices.

AIM

To summarise the end-of-life communication strategies recommended for healthcare professionals, identify research gaps and inform future research.

DESIGN

A scoping review performed in accordance with the Arksey and O'Malley framework.

DATA SOURCES

A literature search was conducted between January 1990 and January 2022 using PubMed, CINAHL, Embase, PsycINFO, Web of Science, Scopus, Cochrane Library and China National Knowledge Infrastructure databases and Google, Google Scholar and ProQuest Dissertations & Theses Global. Studies that described recommended end-of-life communication strategies for healthcare professionals were included.

RESULTS

Fifty-nine documents were included. Seven themes of communication strategies were found: (a) preparation; (b) exploration and assessment; (c) family involvement; (d) provision and tailoring of information; (e) empathic emotional responses; (f) reframing and revisiting the goals of care; and (g) conversation closure.

CONCLUSIONS

The themes of communication strategies found in this review provide a framework to integrally promote end-of-life communication. Our results will help inform healthcare professionals, thereby promoting the development of specialised training and education on end-of-life communication.

"What are my options?": How to have a goals-of-care conversation

ABSTRACT

Patients may choose to have a conversation with their providers about their care options. This article presents a guide for NPs for these goals-of-care conversations. NPs having these conversations can follow the strategies presented to plan the discussion, overcome barriers, and offer useful resources and support.

How can social workers be meaningfully involved in palliative care? A scoping review on the prerequisites and how they can be realised in practice

Palliative care is a holistic practice using a multidisciplinary approach in addressing multidimensional needs. Although the social aspects surrounding the end-of-life phase suggest a place for social work in it, the profession is often inadequately involved in daily practice. This contrasts strongly with the potential meaningful contributions of social workers in this field. To date, no comprehensive list of prerequisites for meaningful social work involvement in palliative care exists. This review aims to gain more insight on the prerequisites for meaningful social work involvement in palliative care and how to realise them in practice. It could therefore provide pathways for future intervention development in enhancing the involvement of social workers and maximising their contributions in palliative care. A scoping review methodology was used. A systematic selection of peer-reviewed articles ranged from 2000 to April 2021 - out of the electronic databases Web of Science, Scopus and Pubmed - was conducted. The 170 articles that met the eligibility criteria were analysed for relevant content using open and axial coding processes. The findings are reported according to the PRISMA-ScR checklist. The nine prerequisites listed in this review concern the level of individual social work capacities and the level of contextual factors structuring social work practices. A majority of articles have, however, focused on the level of individual social work capacities in a rather specialist view on palliative care. Future research should further address the contextual level of social work involvement in the broader practice of death, dying and bereavement.