Hope and therapeutic privilege: time for shared prognosis communication

Communication and support of patients and caregivers in chronic cancer care: ESMO Clinical Practice Guideline

•ESMO Clinical Practice Guideline with key recommendations for communication and support of cancer patients and caregivers. •The guideline discusses training in communication of oncology clinicians and research on communication in cancer care. •Practical recommendations aim to support oncology clinicians in their communication with patients and caregivers. •Figures summarising the responsibilities of the clinician, the oncology team and the health care institution are provided.

Health care professionals’ experiences with goal setting during initial rehabilitation after newly acquired spinal cord injury/ disorder – a qualitative focus group study

Introduction

Goal setting (GS) is an important aspect of initial spinal cord injury/ disorder (SCI/D) rehabilitation. However, because expected outcomes are individual and often difficult to determine, GS is not straightforward. The aim of this study was to explore the health care professionals' (HCP's) experiences with and perspectives on the goal-setting process (GSP) during initial SCI/D rehabilitation.

Method

Five semi-structured focus groups (FG) (22 purposively sampled HCP, mostly in leadership positions, six different professions). The FG were transcribed verbatim. We analyzed the transcripts for qualitative content analysis following Braun and Clarke (2013).

Results

HCP described GS-influencing aspects at the macro, meso and micro levels. At the macro level, participants spoke about restrictions imposed by health insurers or difficulties in planning the post-inpatient setting. Regarding the meso level, HCP spoke of institutional structures and culture that facilitated the GSP. At the micro level, knowledge of the diagnosis, expected outcomes, and individual patient characteristics were mentioned as important to the rehabilitation process. It was important for HCP to be patient and empathetic, to endure negative emotions, to accept that patients need time to adjust to their new situation, and to ensure that they do not lose hope. Open communication and interprofessional collaboration helped overcome barriers in the GSP.

Discussion

This paper shows the complex relationship between external (e.g., health insurers), emotional, and communication aspects. It calls for a comprehensive approach to optimizing the GSP, so that patients' experiences can be fully considered as a basis to identify the most appropriate care pathway.

'I Don't Like Uncertainty, I Like to Know': How and why uveal melanoma patients consent to life expectancy prognostication

BACKGROUND

Technological advances have led to cancer prognostication that is increasingly accurate but often unalterable. However, a reliable prognosis of limited life expectancy can cause psychological distress. People should carefully consider offers of prognostication, but little is known about how and why they decide on prognostication. Using uveal melanoma (UM) patients, we aimed to identify (i) how and why do people with UM decide to accept prognostication and (ii) alignment and divergence of their decision-making from conceptualizations of a 'well-considered' decision.

METHODS

UM provides a paradigm to elucidate clinical and ethical perspectives on prognostication, because prognostication is reliable but prognoses are largely nonameliorable. We used qualitative methods to examine how and why 20 UM people with UM chose prognostication. We compared findings to a template of 'well-considered' decision-making, where 'well-considered' decisions involve consideration of all likely outcomes.

RESULTS

Participants wanted prognostication to reduce future worry about uncertain life expectancy. They spontaneously spoke of hoping for a good prognosis when making their decisions, but largely did not consider the 50% possibility of a poor prognosis. When pressed, they argued that a poor outcome at least brings certainty.

CONCLUSIONS

While respecting decisions as valid expressions of participants' wishes, we are concerned that they did not explicitly consider the realistic possibility of a poor outcome and how this would affect them. Thus, it is difficult to see their decisions as 'well-considered'. We propose that nondirective preference exploration techniques could help people to consider the possibility of a poor outcome.

PATIENT OR PUBLIC CONTRIBUTION

This paper is a direct response to a patient-identified and defined problem that arose in therapeutic and conversational discourse. The research was informed by the responses of patient participants, as we used the material from interviews to dynamically shape the interview guide. Thus, participants' ideas drove the analysis and shaped the interviews to come.

Palliative care and its own identity, through an autoethnography: do you recognize these patterns?

Introduction:

After more than 25 years working in palliative care (PC) observing thousands of patients and family behaviors, I use my long experience and notes as a source of data for a qualitative research study. The aim is to identify frequent families’ behavior patterns in PC and better describe the culture in PC.

Methods:

This article is part of a larger project, using autoethnography as methodology, with the aim of helping doctors and interested health professionals better understand the culture and reality of PC. The focus is not the author but patients and families’ patterns of social behavior – the social context – within the end-of-life period and how to deal with these professionally. Confidentiality and privacy of patients’ data were guaranteed.

Results:

The vast number of treated cases, the regular observation and recording, and the continuous reflection and analysis over many years have led to these results. Due to editorial restrictions, in this article I only describe four of at least eight typical scenarios I have identified. Each is given a short title and I explore some of their inside-issues, integrating previous knowledge, research, and explanations, with practical suggestions on how to deal with them.

Significance:

As far as we know, these scenarios/patterns have never been described in this way. This work expands knowledge, innovates, and contributes to better describing PC culture. The final goal is to create a set of scripts that can be used to help clinicians quickly identify the clinical situation and how to deal with it in clinical practice. Reflecting on how patients and families frequently behave in PC can be very useful and then teach other professionals to better deal with these challenges.