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Ozdemir S, Chaudhry I, Ng S, Teo I, Malhotra C, Finkelstein EA. Prognostic awareness and its association with health outcomes in the last year of life. Cancer Med 2023; 12:4801-4808. [PMID: 36200706 PMCID: PMC9972138 DOI: 10.1002/cam4.5286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/23/2022] [Accepted: 09/12/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Little research has examined changes in prognostic awareness (PA) in the last year of life and the extent PA change was associated with anxiety, depression, and spiritual well-being among metastatic cancer patients. METHODS Two surveys were administered in the last year of life to 176 conveniently sampled Singaporean patients with stage 4 solid cancers. PA was assessed by asking patients whether they were aware that their treatments were unlikely to cure their cancer. Multivariable linear regression models were used to investigate the association of PA change with anxiety, depression, and spiritual well-being. RESULTS The proportion of patients with accurate PA increased (39.2%-45.5%; p < 0.05) from the second-last assessment to the last assessment before death. Those with inaccurate PA decreased (26.1%-20.4%; p < 0.05) while a third of patients remained uncertain at both assessments (34.7% and 34.1%). Compared to patients with inaccurate PA at both assessments, patients who reported accurate PA at both assessments reported worsened anxiety (β = 2.08), depression (β = 3.87), and spiritual well-being (β = -4.45) while patients who reported being uncertain about their prognosis at both assessments reported worsened spiritual well-being (β = - 6.30) at the last assessment before death (p < 0.05 for all). CONCLUSIONS Interventions should dually focus on decreasing prognostic uncertainty at the end-of-life while minimising the psychological and spiritual sequelae associated with being prognostically aware. More research is needed to clarify the causes of prognostic uncertainty.
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Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Isha Chaudhry
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Sean Ng
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Irene Teo
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,National Cancer Centre Singapore, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Eric Andrew Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore.,Duke Global Health Institute, Duke University, Durham, North Carolina, USA
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Mcpherson CJ, Addington-Hall JM. How do Proxies’ Perceptions of Patients’ Pain, Anxiety, and Depression Change during the Bereavement Period? J Palliat Care 2019. [DOI: 10.1177/082585970402000104] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Christine J. Mcpherson
- Department of Palliative Care and Policy, Guy's King's and St. Thomas’ School of Medicine, King's College London, London, U.K
| | - Julia M. Addington-Hall
- Department of Palliative Care and Policy, Guy's King's and St. Thomas’ School of Medicine, King's College London, London, U.K
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Abstract
Although 80% of the deaths worldwide occur in middle- and low-income countries such as India, there is less awareness of end-of-life care (EOLC) for people with chronic, serious, progressive, or advanced life-limiting illnesses, including dementia. EOLC involves good communication, clinical decision-making, liaison with medical teams and families, comprehensive assessment of and specialized interventions for physical, psychological, spiritual, and social needs of patients and their caregivers. The psychiatrist can play a significant role in each of the above domains in EOLC. The current trends in India are examined, including ambiguities between EOLC and euthanasia. Future directions include formulating a national EOLC policy, providing appropriate services and training. The psychiatrist should get involved in this process, with major responsibilities in providing good quality EOLC for patients with both life-limiting physical illnesses and severe mental disorders, supporting their caregivers, and ensuring dignity in death.
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Affiliation(s)
- Jayita K Deodhar
- MD (Psych), DPM, DNB (Psych), MRCPsych. Associate Professor, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
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Low JA, Kwek SK, Pang WS. The Psychopathology of Depression in the Advanced Cancer Patient. PROGRESS IN PALLIATIVE CARE 2016. [DOI: 10.1080/09699260.2001.11746910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Gagnon P, Fillion L, Robitaille MA, Girard M, Tardif F, Cochrane JP, Le Moignan Moreau J, Breitbart W. A cognitive-existential intervention to improve existential and global quality of life in cancer patients: A pilot study. Palliat Support Care 2015; 13:981-90. [PMID: 25050872 PMCID: PMC5485259 DOI: 10.1017/s147895151400073x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE We developed a specific cognitive-existential intervention to improve existential distress in nonmetastatic cancer patients. The present study reports the feasibility of implementing and evaluating this intervention, which involved 12 weekly sessions in both individual and group formats, and explores the efficacy of the intervention on existential and global quality of life (QoL) measures. METHOD Some 33 nonmetastatic cancer patients were randomized between the group intervention, the individual intervention, and the usual condition of care. Evaluation of the intervention on the existential and global QoL of patients was performed using the existential well-being subscale and the global scale of the McGill Quality of Life (MQoL) Questionnaire. RESULTS All participants agreed that their participation in the program helped them deal with their illness and their personal life. Some 88.9% of participants agreed that this program should be proposed for all cancer patients, and 94.5% agreed that this intervention helped them to reflect on the meaning of their life. At post-intervention, both existential and psychological QoL improved in the group intervention versus usual care (p = 0.086 and 0.077, respectively). At the three-month follow-up, global and psychological QoL improved in the individual intervention versus usual care (p = 0.056 and 0.047, respectively). SIGNIFICANCE OF RESULTS This pilot study confirms the relevance of the intervention and the feasibility of the recruitment and randomization processes. The data strongly suggest a potential efficacy of the intervention for existential and global quality of life, which will have to be confirmed in a larger study.
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Affiliation(s)
- Pierre Gagnon
- Faculty of Pharmacy,Laval University,Québec City,Quebec,Canada
| | - Lise Fillion
- Équipe de recherche Michel-Sarrazin en Oncologie psychosociale et Soins palliatifs,Research Center,Oncology Division,CHU de Québec - L'Hôtel-Dieu de Québec,Québec City,Quebec,Canada
| | - Marie-Anik Robitaille
- Équipe de recherche Michel-Sarrazin en Oncologie psychosociale et Soins palliatifs,Research Center,Oncology Division,CHU de Québec - L'Hôtel-Dieu de Québec,Québec City,Quebec,Canada
| | - Michèle Girard
- Department of Palliative Care,CHU de Québec - L'Hôtel-Dieu de Québec,Québec City,Quebec,Canada
| | - François Tardif
- Équipe de recherche Michel-Sarrazin en Oncologie psychosociale et Soins palliatifs,Research Center,Oncology Division,CHU de Québec - L'Hôtel-Dieu de Québec,Québec City,Quebec,Canada
| | - Jean-Philippe Cochrane
- Équipe de recherche Michel-Sarrazin en Oncologie psychosociale et Soins palliatifs,Research Center,Oncology Division,CHU de Québec - L'Hôtel-Dieu de Québec,Québec City,Quebec,Canada
| | - Joanie Le Moignan Moreau
- Équipe de recherche Michel-Sarrazin en Oncologie psychosociale et Soins palliatifs,Research Center,Oncology Division,CHU de Québec - L'Hôtel-Dieu de Québec,Québec City,Quebec,Canada
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences,Memorial Sloan Kettering Cancer Center,New York
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Udo C. The concept and relevance of existential issues in nursing. Eur J Oncol Nurs 2014; 18:347-54. [DOI: 10.1016/j.ejon.2014.04.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 01/12/2014] [Accepted: 04/09/2014] [Indexed: 12/30/2022]
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Abstract
AbstractObjectives: Psychiatric disorders are common and frequently undetected and under treated in the palliative care population. The aims of this pilot study were determine to: (1) the incidence of psychiatric co-morbidity; (2) the patient's current insight; (3) future fears regarding symptom control; and finally (4) the degree of satisfaction with their doctors level of communication, at the time of their diagnosis.Methods: Over a six-month period, 100 consecutive hospice admissions were assessed by AP, within 72 hours of their arrival. This patient group all had advanced malignant disease. A semi-structured questionnaire was used as a guide (see Table 1) to interview. A full history, cognitive and Mental State Examination (MSE) were performed on each patient.Results: Sixty-four patients were interviewed, 36 were excluded. Sixteen (25%) had a depressive illness, six (9%) had anxiety, 56 (88%) had full or partial insight into their illness. Only eight (12%) were unaware of the nature or implications of their disease. Of those who responded, 19 (30%) felt dissatisfied with how their doctors communicated their diagnosis. A significant proportion, 30 (47%) felt that eventually their symptoms would become out of control.Conclusions: This was a pilot study by a psychiatrist at the bedside in the hospice setting. We found that by concentrating on psychological symptoms rather than the biological, a diagnosis of depression was possible even in these complex medical patients. However, recognition of treatable anxiety in this population is a challenge. Even though 30 (47%) felt that their most distressing symptoms would become out of control during the course of their illness, we found an incidence of anxiety of only six (9%). This suggests that our interview underestimates the true level of anxiety in these patients, and highlights the need for a low threshold for diagnosis and possibly an objective screening mechanism. Regarding the ‘breaking of bad news’, 19 (31%) of patients were dissatisfied and unhappy with this experience and there is clearly room for improvement in communicating a diagnosis of malignancy.
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Seymour J. Needs and preferences of patients with diseases other than cancer: the UK experience. PROGRESS IN PALLIATIVE CARE 2013. [DOI: 10.1179/096992607x196042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Medikamentöse Therapie der Angst bei Patienten mit fortgeschrittenen Tumorerkrankungen bzw. Patienten in der palliativen Situation. Schmerz 2013; 26:537-49. [DOI: 10.1007/s00482-012-1241-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ciaramella A, Spiegel D. Psychiatric disorders among cancer patients. HANDBOOK OF CLINICAL NEUROLOGY 2012; 106:557-72. [PMID: 22608644 DOI: 10.1016/b978-0-444-52002-9.00033-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Mystakidou K, Tsilika E, Parpa E, Panagiotou I, Galanos A, Gouliamos A. The mediation effect of anxiety between post-traumatic stress symptoms and preparatory grief in advanced cancer patients. J Pain Symptom Manage 2011; 41:511-21. [PMID: 21146355 DOI: 10.1016/j.jpainsymman.2010.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 06/08/2010] [Accepted: 06/09/2010] [Indexed: 10/18/2022]
Abstract
CONTEXT The relationship between anxiety and preparatory grief is complex and poorly understood. OBJECTIVES To investigate the relationship between anxiety, post-traumatic stress symptoms, and preparatory grief in a sample of patients with advanced cancer. METHODS Ninety-four patients with advanced cancer completed the Greek version of the Impact of Events Scale-Revised (IES-R-Gr), the Anxiety subscale of the Greek Hospital Anxiety and Depression Scale, and the Preparatory Grief in Advanced Cancer Patients (PGAC) scale. RESULTS Statistically significant associations were found between IES-R-Gr subscales, anxiety (P<0.0005), and PGAC (P<0.0005). CONCLUSION Some of the effect of post-traumatic stress symptoms on preparatory grief is mediated by anxiety.
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Affiliation(s)
- Kyriaki Mystakidou
- Pain Relief and Palliative Care Unit, Department of Radiology, Areteion Hospital, School of Medicine, University of Athens, Athens, Greece.
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LEUNG D, ESPLEN M. Alleviating existential distress of cancer patients: can relational ethics guide clinicians? Eur J Cancer Care (Engl) 2010; 19:30-8. [DOI: 10.1111/j.1365-2354.2008.00969.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Cheng JOY, Lo RSK, Chan FMY, Kwan BHF, Woo J. An exploration of anticipatory grief in advanced cancer patients. Psychooncology 2009; 19:693-700. [DOI: 10.1002/pon.1613] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Distress in palliative care patients: developing patient-centred approaches to clinical management. Eur J Cancer 2008; 44:1133-8. [PMID: 18359621 DOI: 10.1016/j.ejca.2008.02.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2008] [Accepted: 02/25/2008] [Indexed: 11/20/2022]
Abstract
It is widely recognised by clinicians that depression is a difficult symptom to identify amongst patients with advanced illness. Many of the symptoms of depression are difficult to elicit in patients who are approaching the end of life. Additionally, many believe that a 'degree' of depression is almost normal as patients approach life's end. More recently the concept of demoralization as a separate entity to depression has been described which can be briefly described as a disorder of meaning and hope. In this paper, we review these diagnoses together with the latest screening tools which can help clinicians to recognise better such pathologies in their patients and discuss interventions that can be utilised to help patients with depression or demoralization to have a better quality of life.
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Gruneir A, Smith TF, Hirdes J, Cameron R. Depression in patients with advanced illness: An examination of Ontario complex continuing care using the Minimum Data Set 2.0. Palliat Support Care 2005; 3:99-105. [PMID: 16594434 DOI: 10.1017/s1478951505050170] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objective: In this study, we examined the prevalence of depression, its recognition, and its treatment in continuing care patients with advanced illness (AI).Methods: All data were obtained from the Ontario (Canada) provincially-mandated MDS 2.0 form for chronic care. Of 3,801 patients, 524 met our empiric definition of AI, which was predicated on a previously validated algorithm. The MDS-embedded Depression Rating Scale (DRS) was used to measure psychological well-being and a score of 3 or greater indicated potential depression.Results: Twenty-nine percent of patients with AI scored greater than 3, making them nearly twice as likely to be potentially depressed as other patients (OR 1.8, 95% CI 1.5–2.2). Despite this patients with AI were less likely to have received antidepressants (28.9% vs. 38.2%), even among those with a diagnosis (45.3% vs. 58.4%). Using logistic regression, correlates of potential depression were identified and surprisingly patients with cancer were substantially less likely to be depressed (AOR 0.37, 95% CI 0.2–0.6). Further investigation revealed that cancer patients were more likely to be treated for depression and to be recognized as being within the terminal phase of illness.Significance of results: These findings suggest that a high proportion of terminally ill patients had unmet needs for psychological support. As well, they suggest that cancer patients received better targeted end-of-life care, which resulted in an overall decrease in psychological distress when compared to other patients with similarly advanced illness.
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Affiliation(s)
- Andrea Gruneir
- Department of Community Health, Brown University, Providence, Rhode Island, USA
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Chochinov HM. Palliative care: an opportunity for mental health professionals. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2004; 49:347-9. [PMID: 15283528 DOI: 10.1177/070674370404900601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
Depression, anxiety and delirium are relatively common during the final stages of terminal disease, and each can profoundly impact the quality of those last days for both patient and involved family. In this article the authors review the assessment and treatment of each syndrome in the context of palliative care for older adults. Treatment of mental disorders at the end of life warrants special consideration due to the need to balance the benefits of treatment against the potential burden of the intervention, especially those that might worsen quality of life. Dementia and the complications of depression and behavioral disturbance within dementia are also discussed. Finally, caregivers of dying patients are vulnerable to stress, depression, grief, and complicated bereavement. Interventions for caregivers who are debilitated by these states are briefly summarized.
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Affiliation(s)
- Elizabeth Goy
- Portland Veterans Affairs Medical Center, Mental Health, P3MHDC, P.O. Box 1034, Portland, OR 97207, USA.
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Clark WG. Palliative Psychiatric Nursing Care: An Emerging Role? J Psychosoc Nurs Ment Health Serv 2003; 41:6-7. [PMID: 14571628 DOI: 10.3928/0279-3695-20031001-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Depressive disorders are common among 20% to 32% of people with HIV disease but are frequently unrecognized. Major depression is a recurring and disabling illness that typically responds to medications, cognitive psychotherapy, education, and social support. A large percentage of the emotional distress and major depression associated with HIV disease results from immunosuppression, treatment, and neuropsychiatric aspects of the disease. People with a history of intravenous drug use also have increased rates of depressive disorders. Untreated depression along with other comorbid conditions may increase costly clinic visits, hospitalizations, substance abuse, and risky behaviors and may reduce adherence to treatment and quality of life. HIV clinicians need not have psychiatric expertise to play a major role in depression. Screening tools improve case finding and encourage early treatment. Effective treatments can reduce major depression in 80% to 90% of patients. Clinicians who mistake depressive signs and symptoms for those of HIV disease make a common error that increases morbidity and mortality.
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Ringdal GI, Jordhøy MS, Kaasa S. Measuring quality of palliative care: psychometric properties of the FAMCARE Scale. Qual Life Res 2003; 12:167-76. [PMID: 12639063 DOI: 10.1023/a:1022236430131] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study measures quality of palliative care in 181 family members (i.e. spouse, child) to cancer victims with terminal disease 1 month after the time of death. The specific aim was to explore the underlying factor structure and dimensionality of the 20 items of the FAMCARE Scale, measuring family satisfaction with health care given to the patient and to them. The results from a factor analysis, a Mokken Scaling Program analysis, and a reliability analysis, showed that 19 out of the 20 items form a strong one-dimensional scale. Since the scale is one-dimensional, the possibility of reducing the number of items should be explored in future research. Our recommendation is to measure satisfaction with care 1-2 months after the death of the patient. One should also explore the possibilities of measuring satisfaction with care prospectively as an integral part of the palliative care program.
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Affiliation(s)
- Gerd Inger Ringdal
- Department of Psychology, Faculty of Social Sciences and Technology Management, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
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Abstract
It is common for health care providers to deal with the complex and difficult issue of withdrawing advanced life support. The patient is always the key source of authority in these decisions. The most important ingredient in end-of-life decision making is effective communication. It is important to try to ascertain what the patient thought about quality-of-life values before surrogate decisions can be made on the patient's behalf. The concepts of beneficence, nonmaleficence, autonomy, and justice are the foundation of ethical decision making. Numerous legal precedents have laid the groundwork for end-of-life decision making. Most state courts have supported withholding and withdrawing life support from patients who will not regain a reasonable quality of life. The recent Patient Self-Determination Act encourages patients to fill out advance directives that state their desires. When continued intensive care is futile, advanced life support should be withdrawn. However, a narrow definition of futility in this situation is the key, since the concept of futility could lead to inappropriate decisions. It is best to consider a situation futile when the patient is terminally ill, the condition is irreversible, and death is imminent. During the withdrawal of advanced life support, terminal or rapid weaning is preferable to extubation. Combinations of opiates, benzodiazepines, and other agents help provide comfort to patients who are suffering.
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Affiliation(s)
- N R Henig
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California 94305, USA.
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