1
|
Xia Q, Kularatna M, Virdun C, Button E, Close E, Carter HE. Preferences for Palliative and End-of-Life Care: A Systematic Review of Discrete Choice Experiments. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1795-1809. [PMID: 37543206 DOI: 10.1016/j.jval.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/20/2023] [Accepted: 07/22/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVES Understanding what matters most to patients and their caregivers is fundamental to delivering high-quality care. This systematic review aimed to characterize and appraise the evidence from discrete choice experiments eliciting preferences for palliative care. METHODS A systematic literature search was undertaken for publications up until August 2022. Data were synthesized narratively. Thematic analysis was applied to categorize attributes into groups. Attribute development, frequency, and relative importance were analyzed. Subgroup analyses were conducted to compare outcomes between patient and proxy respondents. RESULTS Seventeen studies spanning 11 countries were included; 59% of studies solely considered preferences for patients with cancer. A range of respondent groups were represented including patients (76%) and proxies (caregivers [35%], health providers [12%], and the public [18%]). A total of 117 individual attributes were extracted and thematically grouped into 8 broad categories and 21 subcategories. Clinical outcomes including quality of life, length of life, and pain control were the most frequently reported attributes, whereas attributes relating to psychosocial components were largely absent. Both patients and proxy respondents prioritized pain control over additional survival time. Nevertheless, there were differences between respondent cohorts in the emphasis on other attributes such as access to care, timely information, and low risk of adverse effects (prioritized by patients), as opposed to cost, quality, and delivery of care (prioritized by proxies). CONCLUSIONS Our review underscores the vital role of pain control in palliative care; in addition, it shed light on the complexity and relative strength of preferences for various aspects of care from multiple perspectives, which is useful in developing personalized, patient-centered models of care for individuals nearing the end of life.
Collapse
Affiliation(s)
- Qing Xia
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia.
| | - Mineth Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Claudia Virdun
- Cancer and Palliative Care Outcomes Centre, Centre for Healthcare Transformation, School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Elise Button
- Cancer and Palliative Care Outcomes Centre, Centre for Healthcare Transformation, School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Eliana Close
- Australian Centre for Health Law Research, School of Law, Faculty of Business and Law (Close), Queensland University of Technology, Brisbane, QLD, Australia
| | - Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| |
Collapse
|
2
|
Mulcahy Symmons S, Ryan K, Aoun SM, Selman LE, Davies AN, Cornally N, Lombard J, McQuilllan R, Guerin S, O'Leary N, Connolly M, Rabbitte M, Mockler D, Foley G. Decision-making in palliative care: patient and family caregiver concordance and discordance-systematic review and narrative synthesis. BMJ Support Palliat Care 2023; 13:374-385. [PMID: 35318213 PMCID: PMC10804031 DOI: 10.1136/bmjspcare-2022-003525] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/06/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Decision-making in palliative care usually involves both patients and family caregivers. However, how concordance and discordance in decision-making manifest and function between patients and family caregivers in palliative care is not well understood. OBJECTIVES To identify key factors and/or processes which underpin concordance and/or discordance between patients and family caregivers with respect to their preferences for and decisions about palliative care; and ascertain how patients and family caregivers manage discordance in decision-making in palliative care. METHODS A systematic review and narrative synthesis of original studies published in full between January 2000 and June 2021 was conducted using the following databases: Embase; Medline; CINAHL; AMED; Web of Science; PsycINFO; PsycARTICLES; and Social Sciences Full Text. RESULTS After full-text review, 39 studies were included in the synthesis. Studies focused primarily on end-of-life care and on patient and family caregiver preferences for patient care. We found that discordance between patients and family caregivers in palliative care can manifest in relational conflict and can result from a lack of awareness of and communication about each other's preferences for care. Patients' advancing illness and impending death together with open dialogue about future care including advance care planning can foster consensus between patients and family caregivers. CONCLUSIONS Patients and family caregivers in palliative care can accommodate each other's preferences for care. Further research is needed to fully understand how patients and family caregivers move towards consensus in the context of advancing illness.
Collapse
Affiliation(s)
- Sophie Mulcahy Symmons
- Discipline of Occupational Therapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Karen Ryan
- St Francis Hospice Dublin, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Samar M Aoun
- Palliative Care Unit, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
- Perron Institute for Neurological and Translational Science, Perth, Western Australia, Australia
| | - Lucy E Selman
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew Neil Davies
- Academic Department of Palliative Medicine, Our Lady's Hospice and Care Services, Dublin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Nicola Cornally
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - John Lombard
- School of Law, University of Limerick, Limerick, Ireland
| | - Regina McQuilllan
- St Francis Hospice Dublin, Dublin, Ireland
- Department of Palliative Care, Beaumont Hospital, Dublin, Ireland
| | - Suzanne Guerin
- School of Psychology, University College Dublin, Dublin, Ireland
| | - Norma O'Leary
- Our Lady's Hospice and Care Services, Dublin, Ireland
- Department of Palliative Care, St James's Hospital, Dublin, Ireland
| | - Michael Connolly
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
- Our Lady's Hospice and Care Services, Dublin, Ireland
| | - Mary Rabbitte
- All Ireland Institute of Hospice and Palliative Care, Dublin, Ireland
| | - David Mockler
- John Stearne Medical Library, Trinity College Dublin, Dublin, Ireland
| | - Geraldine Foley
- Discipline of Occupational Therapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| |
Collapse
|
3
|
Liao J, Wu B, Mao J, Ni P. Preference for Aggressive End-of-Life Care among Advanced Cancer Patients in Wuhan, China: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17186592. [PMID: 32927824 PMCID: PMC7560226 DOI: 10.3390/ijerph17186592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/05/2020] [Accepted: 09/08/2020] [Indexed: 11/21/2022]
Abstract
Life-sustaining treatments (LSTs) and end-of-life (EOL) care’s goal for prolonging one’s life are defined as aggressive EOL care among critically ill patients. They have limited effects and add unnecessary financial burden to advanced cancer patients. A questionnaire survey was conducted to collect information on demographics, disease conditions, preference for LSTs, and goal of EOL care among advanced cancer patients of comprehensive grade-A tertiary hospitals in Wuhan, mainland China. Most patients preferred to accept LSTs when they were in a critical condition, including cardiopulmonary resuscitation (89.9%), mechanical ventilation support (85.7%), nasogastric tube feeding (84.1%), blood transfusion (89.8%), general surgery (87.5%), and hemodialysis (85.8%). Most (88%) preferred prolonging life as the goal of EOL care. Logistic regression showed common influencing factors were participants who completed junior high/high school or below and were financially adequate had higher reference for aggressive EOL care. Patients whose physician had accurately disclosed prognosis; however, showed a decrease trend for aggressive EOL care. Most advanced cancer patients preferred to accept aggressive EOL care. Discussions about prognosis disclosure among physicians and patients should be improved. Education about LSTs’ limitations and comfort-oriented care’s benefits should be promoted among the advanced cancer patients in mainland China.
Collapse
Affiliation(s)
- Jing Liao
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
| | - Bei Wu
- Rory Meyers College of Nursing and NYU Aging Incubator, New York University, New York, NY 10010, USA;
| | - Jing Mao
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
| | - Ping Ni
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
- Correspondence: ; Tel.: +86-1387-154-0316
| |
Collapse
|
4
|
Wen FH, Chou WC, Chen JS, Chang WC, Hsieh CH, Tang ST. Evolution and Predictors of Patient–Caregiver Concordance on States of Life-Sustaining Treatment Preferences over Terminally Ill Cancer Patients' Last Six Months of Life. J Palliat Med 2019; 22:25-33. [DOI: 10.1089/jpm.2018.0307] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- School of Nursing, Chang Gung University, Taoyuan City, Taiwan
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung City, Taiwan
| |
Collapse
|
5
|
Waller A, Hall A, Sanson-Fisher R, Zdenkowski N, Douglas C, Walsh J. Do medical oncology patients and their support persons agree about end-of-life issues? Intern Med J 2018; 48:60-66. [PMID: 28980381 DOI: 10.1111/imj.13626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/07/2017] [Accepted: 09/22/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The perceptions of those called on to make decisions on behalf of patients who lack capacity at the end of life must accurately reflect patient preferences. AIMS To establish the extent to which the views of medical oncology outpatients are understood by their support persons, specifically with regards to (i) preferred type and location of end-of-life care, (ii) preferred level of involvement in end-of-life decision-making and (iii) whether the patient has completed an advance care plan or appointed an enduring guardian. METHODS Adults with a confirmed cancer diagnosis and their nominated support persons were approached between September 2015 and January 2016 in the waiting room of an Australian tertiary referral clinic. Consenting participants completed a pen-and-paper survey. Nominated support persons answered the same questions from the patient's perspective. RESULTS In total, 208 participants (39% of eligible dyads) participated. Observed agreement across the five outcomes ranged from 54% to 84%. Kappa values for concordance between patient-support person responses were fair to moderate (0.24-0.47) for enduring guardian, decision-making, advance care plan and care location outcomes. A slight level of concordance (k = 0.15; 95% confidence interval: -0.02, 0.32) was found for the type of care outcome. CONCLUSION Relying on support persons' views does not guarantee that patients' actual preferences will be followed. Strategies that make patient preferences known to healthcare providers and support persons while they still have the capacity to do so is a critical next step in improving quality cancer care.
Collapse
Affiliation(s)
- Amy Waller
- Health Behaviour Research Collaborative, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Alix Hall
- Clinical Research Design and Statistics Support Unit, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Rob Sanson-Fisher
- Health Behaviour Research Collaborative, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Nicholas Zdenkowski
- Department of Medical Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Charles Douglas
- Clinical Ethics and Health Law, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Justin Walsh
- Health Behaviour Research Collaborative, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| |
Collapse
|
6
|
Waller A, Sanson-Fisher R, Brown SD, Wall L, Walsh J. Quality versus quantity in end-of-life choices of cancer patients and support persons: a discrete choice experiment. Support Care Cancer 2018; 26:3593-3599. [PMID: 29725803 DOI: 10.1007/s00520-018-4226-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 04/26/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To explore in a sample of medical oncology outpatients and their nominated support persons (SPs): (1) the relative influence of pain, consciousness and life extension on end-of-life choices using a discrete choice experiment (DCE); (2) the extent to which SPs can predict the choices of index patients and (3) whether having a previous end-of-life discussion was associated with dyad agreement. METHODS Adult medical oncology patients and their SPs were approached for consent to complete a survey containing a DCE. Participants chose between three unlabelled care scenarios characterised by three attributes: pain (mild, moderate or severe), consciousness (some, half or most of time) and extension of life (1, 2 or 3 weeks). Respondents selected (1) most-preferred and (2) least-preferred scenarios within each question. SPs answered the same questions but from patient's perspective. RESULTS A total of 110 patients and 64 SPs responded overall (42 matched patient-SP dyads). For patients, pain was the most influential predictor of most- and least-preferred scenarios (z = 12.5 and z = 12.9). For SPs, pain was the only significant predictor of most and least-preferred scenarios (z = 9.7 and z = 11.5). Dyad agreement was greater for choices about least- (69%) compared to most-preferred scenarios (55%). Agreement was slightly higher for dyads reporting a previous EOL discussion (68 versus 48%; p = 0.065). CONCLUSION Patients and SPs place significant value on avoiding severe pain when making end-of-life choices, over and above level of consciousness or life extension. People's views about end-of-life scenarios they most as well as least prefer should be sought.
Collapse
Affiliation(s)
- Amy Waller
- Health Behaviour Research Collaborative, Priority Research Centre for Health Behaviour, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia. .,Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.
| | - Rob Sanson-Fisher
- Health Behaviour Research Collaborative, Priority Research Centre for Health Behaviour, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | - Scott D Brown
- Department of Psychology, The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Laura Wall
- Department of Psychology, The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Justin Walsh
- Health Behaviour Research Collaborative, Priority Research Centre for Health Behaviour, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| |
Collapse
|
7
|
Miaris N, Samantas E, Siafaka I, Logothetis E, Iacovidou N, Chalkias A, Xanthos T. Views of cancer patients regarding cardiopulmonary resuscitation in Greece. Eur J Cancer Care (Engl) 2018; 27:e12850. [PMID: 29672984 DOI: 10.1111/ecc.12850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 11/28/2022]
Abstract
Cardiopulmonary resuscitation (CPR) in patients with cancer is an ethical issue of worldwide interest. A questionnaire-based study was carried out in a Greek oncology hospital aiming to explore the attitude of Greek cancer patients towards CPR. Overall, 200 patients (94 male, 106 female) of a mean age of 62.8 years took part in the study. Only 42 (21%) patients indicated that they knew what CPR really involves and only 20 (10%) patients thought that CPR has serious side effects, while the mean estimated in-hospital CPR survival rate to hospital discharge was 56.6% (minimum = 2%, maximum = 99%, standard deviation [SD] = 25.16) and 42.1% (minimum = 0%, maximum = 90%, SD = 24.56%) in case of unselected and cancer patients respectively. Despite their poor knowledge, 177 (88.5%) patients were willing to undergo CPR in case of an in-hospital arrest, 127 (63.5%) thought that they had the right to choose their CPR status and 141 (70.5%) believed that they should be asked about it when they enter the hospital. Most patients (36%) wanted their CPR status to be decided by themselves, their family and their doctor jointly. These findings indicate that specific measures should be applied to clinical practice in order to best manage this ethical issue, and consequently, improve cancer care.
Collapse
Affiliation(s)
- N Miaris
- Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Third Department of Medical Oncology, "Agioi Anargyroi" General Oncology Hospital of Kifisia, Athens, Greece.,Department of Cardiology, "Tzaneio" General Hospital of Piraeus, Piraeus, Greece
| | - E Samantas
- Third Department of Medical Oncology, "Agioi Anargyroi" General Oncology Hospital of Kifisia, Athens, Greece
| | - I Siafaka
- Pain Relief and Palliative Care Unit, Department of Anesthesiology and Pain Therapy, First Anesthesiology Clinic, Medical School, Aretaieio University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - E Logothetis
- Department of Biopathology, Aretaieio University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - N Iacovidou
- Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neonatology, Aretaieio University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - A Chalkias
- Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - T Xanthos
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece.,Medical School, European University Cyprus, Nicosia, Cyprus
| |
Collapse
|
8
|
Van den Block L, Ko W, Miccinesi G, Moreels S, Donker GA, Onwuteaka-Philipsen B, Alonso TV, Deliens L. Final transitions to place of death: patients and families wishes. J Public Health (Oxf) 2017; 39:e302-e311. [PMID: 27694347 DOI: 10.1093/pubmed/fdw097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 08/03/2016] [Indexed: 11/14/2022] Open
Abstract
Purpose This four-country study (Belgium, the Netherlands, Italy and Spain) examines prevalence and types of final transitions between care settings of cancer patients and the extent to which patient/family wishes are cited as a reason for the transition. Methods Data were collected from the EUROSENTI-MELC study over a 2-year period. General practitioners within existing Sentinel Networks registered weekly all deaths of patients within practices using a standardized questionnaire. This registration included place of care in the final 3 months and wishes for the final transition to place of death. All non-sudden deaths due to cancer (+18 years) were included in the analyses. Results We included 2048 non-sudden cancer deaths; 63% of patients had at least one transition between care settings in the final 3 months of life. 'Hospital death from home' (25-55%) and 'home death from hospital' (16-30%) were the most frequent types of final transitions in all countries. Patients' or families' wishes were mentioned as a reason for a final transition in 5-27% (P < 0.001) and 10-22% (P = 0.002) across countries. Conclusions 'Hospital deaths from home' is the most prevalent final transition in three of four countries studied, in a significant minority of cases because of patient/family wishes.
Collapse
Affiliation(s)
- Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Winne Ko
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Guido Miccinesi
- Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, ISPO, Florence, Italy
| | - Sarah Moreels
- Public Health and Surveillance, Scientific Institute of Public Health , Brussels, Belgium
| | - Ge A Donker
- NIVEL Primary Care Database, Sentinel Practices, Netherlands Institute for Health Services Research , Utrecht, the Netherlands
| | - Bregje Onwuteaka-Philipsen
- EMGO Institute for Health and Care Research, Department of Public and Occupational Health, and Palliative Care Expertise Centre, VU University Medical Centre, Amsterdam, the Netherlands
| | - Tomas V Alonso
- Public Health Directorate General, Health Department, Valladolid, Spain
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
9
|
El-Jawahri A, Lau-Min K, Nipp RD, Greer JA, Traeger LN, Moran SM, D'Arpino SM, Hochberg EP, Jackson VA, Cashavelly BJ, Martinson HS, Ryan DP, Temel JS. Processes of code status transitions in hospitalized patients with advanced cancer. Cancer 2017; 123:4895-4902. [PMID: 28881383 DOI: 10.1002/cncr.30969] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/06/2017] [Accepted: 08/08/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although hospitalized patients with advanced cancer have a low chance of surviving cardiopulmonary resuscitation (CPR), the processes by which they change their code status from full code to do not resuscitate (DNR) are unknown. METHODS We conducted a mixed-methods study on a prospective cohort of hospitalized patients with advanced cancer. Two physicians used a consensus-driven medical record review to characterize processes that led to code status order transitions from full code to DNR. RESULTS In total, 1047 hospitalizations were reviewed among 728 patients. Admitting clinicians did not address code status in 53% of hospitalizations, resulting in code status orders of "presumed full." In total, 275 patients (26.3%) transitioned from full code to DNR, and 48.7% (134 of 275 patients) of those had an order of "presumed full" at admission; however, upon further clarification, the patients expressed that they had wished to be DNR before the hospitalization. We identified 3 additional processes leading to order transition from full code to DNR acute clinical deterioration (15.3%), discontinuation of cancer-directed therapy (17.1%), and education about the potential harms/futility of CPR (15.3%). Compared with discontinuing therapy and education, transitions because of acute clinical deterioration were associated with less patient involvement (P = .002), a shorter time to death (P < .001), and a greater likelihood of inpatient death (P = .005). CONCLUSIONS One-half of code status order changes among hospitalized patients with advanced cancer were because of full code orders in patients who had a preference for DNR before hospitalization. Transitions due of acute clinical deterioration were associated with less patient engagement and a higher likelihood of inpatient death. Cancer 2017;123:4895-902. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Areej El-Jawahri
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Kelsey Lau-Min
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ryan D Nipp
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Lara N Traeger
- Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Samantha M Moran
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sara M D'Arpino
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ephraim P Hochberg
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Vicki A Jackson
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Holly S Martinson
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - David P Ryan
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
10
|
Liu TW, Wen FH, Wang CH, Hong RL, Chow JM, Chen JS, Chiu CF, Tang ST. Terminally Ill Taiwanese Cancer Patients' and Family Caregivers' Agreement on Patterns of Life-Sustaining Treatment Preferences Is Poor to Fair and Declines Over a Decade: Results From Two Independent Cross-Sectional Studies. J Pain Symptom Manage 2017; 54:35-45.e4. [PMID: 28450219 DOI: 10.1016/j.jpainsymman.2017.02.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/16/2017] [Accepted: 02/20/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT/OBJECTIVE Temporal changes have not been examined in patient-caregiver agreement on life-sustaining treatment (LST) preferences at end of life (EOL). We explored the extent of and changes in patient-caregiver agreement on LST-preference patterns for two independent cohorts of Taiwanese cancer patient-family caregiver dyads recruited a decade apart. METHODS We surveyed preferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, tube feeding, and dialysis among 1049 and 1901 dyads in 2003-2004 and 2011-2012, respectively. LST-preference patterns were examined by multi-group latent class analysis. Extent of patient-caregiver agreement on LST-preference patterns was determined by percentage agreement and kappa coefficients. RESULTS For both patients and family caregivers, we identified seven distinct LST-preference classes. Patient-caregiver agreement on LST-preference patterns was poor to fair across both study cohorts, indicated by 24.4%-43.5% agreement and kappa values of 0.06 (95% CI: 0.04, 0.09) to 0.27 (0.23, 0.30), and declined significantly over time. Agreement on LST-preference patterns was most likely when both patients and caregivers uniformly rejected LSTs. When patients disagreed with caregivers on LST-preference patterns, discrepancies were most likely when patients totally rejected LSTs but caregivers uniformly preferred LSTs or preferred nutritional support but rejected other treatments. CONCLUSION Patients and family caregivers had poor-to-fair agreement on LST-preference patterns, and agreement declined significantly over a decade. Encouraging an open dialogue between patients and their family caregivers about desired EOL care would facilitate patient-caregiver agreement on LST-preference patterns, thus honoring terminally ill cancer patients' wishes when they cannot make EOL-care decisions.
Collapse
Affiliation(s)
- Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Taipei, Taiwan
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Cheng-Hsu Wang
- Division of Hematology-Oncology and Director of Cancer Center, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Ruey-Long Hong
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jyh-Ming Chow
- Section of Hematology and Medical Oncology, Wan-Fang Hospital, Taipei, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Chang-Fang Chiu
- Division of Hematology-Oncology and Comprehensive Cancer Center, China Medical University Hospital, Taichung, Taiwan
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan.
| |
Collapse
|
11
|
Tang ST, Wen FH, Liu LN, Chiang MC, Lee SCK, Chou MC, Feng WL, Lin YC, Liu IP, Kuo YH, Chi SC, Lee KC. A Decade of Changes in Family Caregivers' Preferences for Life-Sustaining Treatments for Terminally Ill Cancer Patients at End of Life in the Context of a Family-Oriented Society. J Pain Symptom Manage 2016; 51:907-915.e2. [PMID: 26921491 DOI: 10.1016/j.jpainsymman.2015.12.326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 12/20/2015] [Accepted: 12/24/2015] [Indexed: 11/22/2022]
Abstract
CONTEXT Temporal changes in different family caregiver cohorts' preferences for life-sustaining treatments (LSTs) at end of life (EOL) have not been examined nor have the concept of whether caregivers' LST preferences represent a homogeneous or heterogeneous construct. Furthermore, LST preferences are frequently assessed from multiple treatments, making clinical applications difficult/infeasible. OBJECTIVES To identify parsimonious patterns and changes in the pattern of LST preferences for two independent cohorts of family caregivers for terminally ill Taiwanese cancer patients. METHODS Preferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, tube feeding, and dialysis were assessed among 1617 and 2056 family caregivers in 2003-2004 and 2011-2012, respectively. Patterns and changes in LST preferences were examined by multigroup latent class analysis. RESULTS Five distinct classes were identified: uniformly preferring, uniformly rejecting, uniformly uncertain, and favoring nutritional support but rejecting or uncertain about other treatments. Class probability significantly decreased from 29.3% to 23.7% for the uniformly rejecting class, remained largely unchanged for the uniformly preferring (16.9%-18.6%), and favoring nutritional support but rejecting (37.1%-37.5%) or uncertain about other treatments (8.0%-10.4%) classes, but significantly increased from 7.0% to 11.5% for the uniformly uncertain class over time. CONCLUSION Family caregivers' LST preferences for terminally ill cancer patients are a heterogeneous construct and shifted from uniformly rejecting all LSTs toward greater uncertainty. Surrogate EOL-care decision making may be facilitated by earlier and thorough assessments of caregivers' LST preferences and tailoring interventions to the unique needs of caregivers in each class identified in this study.
Collapse
Affiliation(s)
- Siew Tzuh Tang
- Chang Gung University School of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China.
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Li Ni Liu
- Department of Nursing, Fu Jen Catholic University, New Taipei City, Taiwan, Republic of China
| | - Ming-Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China
| | - Shiuyu C K Lee
- School of Nursing, National Taipei University of Nursing and Health Science, Taipei City, Taiwan, Republic of China
| | - Man Chun Chou
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China
| | - Wei-Lien Feng
- National Institute of Cancer Research, National Health Research Institutes, Taipei, Taiwan, Republic of China
| | - Yu-Chuan Lin
- Department of Nursing, Tzu Chi University, Hualien City, Taiwan, Republic of China
| | - I-Ping Liu
- Chi-Mei Hospital, Chi Ali, Taiwan, Republic of China
| | - Ya-Hui Kuo
- Chia-Yi Christian Hospital, Chiayi City, Taiwan, Republic of China
| | - Shu Ching Chi
- Department of Nursing, E-Da Hospital and I-Shou University, Kaohsiung City, Taiwan, Republic of China
| | - Kwo C Lee
- School of Nursing, China Medical University, Taichung, Taiwan, Republic of China; Department of Nursing, China Medical University Hospital, Taichung, Taiwan, Republic of China
| |
Collapse
|