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Suh KJ, Jung EH, Seo J, Ji SY, Hwang K, Han JH, Kim CY, Kim IA, Kim YJ. Current status of advance care planning, palliative care consultation, and end-of-life care in patients with glioblastoma in South Korea. Oncologist 2024:oyae159. [PMID: 38940449 DOI: 10.1093/oncolo/oyae159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/17/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Given the typical trajectory of glioblastoma, many patients lose decision-making capacity over time, which can lead to inadequate advance care planning (ACP) and end-of-life (EOL) care. We aimed to evaluate patients' current ACP and EOL care status. PATIENTS AND METHODS We conducted a cohort study on 205 patients referred to oncologists at a Korean tertiary hospital between 2017 and 2022. We collected information on sociodemographic factors, cancer treatment, palliative care consultation, ACP, legal documents on life-sustaining treatment (LST) decisions, and aggressiveness of EOL care. RESULTS With a median follow-up time of 18.3 months: 159 patients died; median overall survival: 20.3 months. Of the 159 patients, 11 (6.9%) and 63 (39.6%) had advance directive (AD) and LST plans, respectively, whereas 85 (53.5%) had neither. Among the 63 with LST plans, 10 (15.9%) and 53 (84.1%) completed their forms through self-determination and family determination, respectively. Of the 159 patients who died, 102 (64.2%) received palliative care consultation (median time: 44 days from the first consultation to death) and 78 (49.1%) received aggressive EOL care. Those receiving palliative care consultations were less likely to receive aggressive EOL care (83.3% vs 32.4%, P < .001), and more likely to use more than 3 days of hospice care at EOL (19.6% vs 68.0%, P < .001). CONCLUSIONS The right to self-determination remains poorly protected among patients with glioblastoma, with nearly 90% not self-completing AD or LST plan. As palliative care consultation is associated with less aggressive EOL care and longer use of hospice care, physicians should promptly introduce patients to ACP conversations and palliative care consultations.
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Affiliation(s)
- Koung Jin Suh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Hee Jung
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeongmin Seo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - So Young Ji
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kihwan Hwang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Ho Han
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chae-Yong Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In Ah Kim
- Department. of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yu Jung Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Dow LA, Kapo J, Boyle F, Shin JA. Framework for Considering Primary and Subspecialty Palliative Care and Guiding Serious Illness Communication for Patients With Breast Cancer. Am Soc Clin Oncol Educ Book 2024; 44:e432554. [PMID: 39018514 DOI: 10.1200/edbk_432554] [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: 07/19/2024]
Abstract
Palliative care is a comprehensive approach aimed at enhancing the quality of life of patients and their families living with serious illnesses such as breast cancer. This approach includes assessing and managing pain and other physical symptoms, attending to psychosocial and spiritual aspects of care, fostering effective communication and decision making, and providing support in coordinating care that upholds a person's values and preferences from the time of diagnosis throughout the illness trajectory. This type of care can be provided by palliative care specialists (ideally an interprofessional team) working alongside the oncology team, referred to as subspecialty palliative care. Conversely, the fundamental aspects of this approach, which we sometimes call primary palliative care, are provided by all clinicians caring for patients with breast cancer. Given that access to subspecialty palliative care can vary globally, especially in rural and resource-constrained settings, it is imperative for all oncology clinicians to receive training in the core components of palliative care. This study aims to provide a basic framework to recognize what the core primary palliative care skills are in routine oncology practice, to delineate basic serious illness communication strategies, and to introduce when to consider the integration of subspecialty palliative care into the care of patients with breast cancer.
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Velasquez DA, Dhiman A, Brottman C, Eng OS, Fenton E, Herlitz J, Lozano E, McDonald E, Reynolds V, Wall E, Whitridge J, Semrad C, Turaga K, Micic D. Outcomes of parenteral nutrition in patients with advanced cancer and malignant bowel obstruction. Support Care Cancer 2024; 32:206. [PMID: 38433169 DOI: 10.1007/s00520-024-08403-8] [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: 10/17/2023] [Accepted: 02/21/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Malignant bowel obstruction (MBO) affects 3% to 15% of all cancer patients. In patients with advanced cancer and inoperable MBO, the average survival varies between four to nine weeks. Parenteral nutrition (PN) may improve survival in specific patient populations with malignant bowel obstruction. AIMS This retrospective, single-center cohort study aimed to review individual patient outcomes on PN in the setting of advanced cancer with a diagnosis of MBO and identify clinical and laboratory markers predictive of short- and long-term survival to further highlight patients that would benefit from PN in the setting of an inoperable MBO. RESULTS In a retrospective analysis of 68 patients receiving PN for inoperable MBO, the median survival was 142 (IQR: 63.3-239.5) days. Patients experienced a median number of two hospital readmissions (range: 0-10) and spent a median of 29 days (range: 0-105) in the hospital after starting PN. Eighteen (26.5%) patients developed a catheter-related bloodstream infection (CRBSI). A diagnosis of appendiceal cancer was identified as a predictive marker of improved survival (HR: 0.53, 95% CI: 0.29-0.92, p = 0.023). CONCLUSIONS The use of PN in the context of end-of-life cancer care is a practice that necessitates improvement. Recognizing the outcomes and patient experiences of PN utilization is essential to physicians and patients.
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Affiliation(s)
- David A Velasquez
- University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Ankit Dhiman
- Section of General Surgery and Surgical Oncology, University of Chicago Medicine, Chicago, IL, USA
| | - Colette Brottman
- Section of General Surgery and Surgical Oncology, University of Chicago Medicine, Chicago, IL, USA
| | - Oliver S Eng
- Section of General Surgery and Surgical Oncology, University of Chicago Medicine, Chicago, IL, USA
| | - Emily Fenton
- Section of General Surgery and Surgical Oncology, University of Chicago Medicine, Chicago, IL, USA
| | - Jean Herlitz
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Edward Lozano
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Edwin McDonald
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Valerie Reynolds
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Elizabeth Wall
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Jeffrey Whitridge
- Section of General Surgery and Surgical Oncology, University of Chicago Medicine, Chicago, IL, USA
| | - Carol Semrad
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Kiran Turaga
- Section of General Surgery and Surgical Oncology, University of Chicago Medicine, Chicago, IL, USA
| | - Dejan Micic
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA.
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Liu SY, Amato SS, Lahey TP, Malhotra AK. Association of COVID-19 Visitor Limitations and Goals of Care Discussions in the Intensive Care Unit. J Surg Res 2024; 295:407-413. [PMID: 38070254 DOI: 10.1016/j.jss.2023.11.020] [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] [Received: 03/01/2023] [Revised: 10/28/2023] [Accepted: 11/12/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION The COVID-19 pandemic led to visitor restrictions in many hospitals. Since care in the surgical intensive care unit (SICU) often engages visitors as surrogate decision-makers, we investigated whether there was an association between COVID-19-related visitor restrictions, goals of care discussions (GOCD), and patient outcomes in SICU patients. METHODS We conducted a retrospective review of trauma and emergency general surgery (EGS) patients admitted to a rural tertiary SICU between July 2019 and April 2021, dividing patients into those admitted during COVID-19 visitor restrictions and those admitted at other times. Using univariate and multivariate logistic regression analyses, we compared the primary outcome, incidence of GOCD, and incidence of prolonged hospital (> 14 d) and intensive care unit length of stay (LOS, > 7 d) between the two groups. RESULTS One hundred seventy nine of 368 study patients (48.6%) presented during restricted visitation. The proportion of GOCD was 38.0% and 36.5% in the restricted and nonrestricted visitation cohorts, respectively (P = 0.769). GOCD timing and outcomes were similar in both groups. The use of telecommunication increased during restricted visitation, as did the proportion of trauma patients admitted to the SICU. On multivariable logistic regression, age and patient category were independent predictors of GOCD. On outcomes analysis, visitor restriction was associated with prolonged hospital LOS for EGS patients (odds ratio 2.44, 95% confidence interval 1.01-5.91, P value 0.048). CONCLUSIONS Restricted visitation was not associated with changes in frequency or outcome of GOCD, but was associated with prolonged hospital LOS among EGS patients who had SICU admissions. Further investigation of patient/surrogate satisfaction with virtual GOCD in the SICU setting is needed.
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Affiliation(s)
- Sarah Y Liu
- Department of Surgery, University of Vermont Medical Center, Burlington, Vermont.
| | - Stas S Amato
- Department of Surgery, University of Vermont Medical Center, Burlington, Vermont
| | - Timothy P Lahey
- Departments of Infectious Disease and Clinical Ethics, University of Vermont Medical Center, Burlington, Vermont
| | - Ajai K Malhotra
- Department of Surgery, University of Vermont Medical Center, Burlington, Vermont
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Leung C, Andersen CR, Wilson K, Nortje N, George M, Flowers C, Bruera E, Hui D. The impact of a multidisciplinary goals-of-care program on unplanned readmission rates at a comprehensive cancer center. Support Care Cancer 2023; 32:66. [PMID: 38150077 DOI: 10.1007/s00520-023-08265-6] [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: 08/14/2023] [Accepted: 12/17/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE This study examined the 30-day unplanned readmission rate in the medical oncology population before and after the implementation of an institution-wide multicomponent interdisciplinary goals of care (myGOC) program. METHODS This retrospective study compared the 30-day unplanned readmission rates in consecutive medical patients during the pre-implementation period (May 1, 2019, to December 31, 2019) and the post-implementation period (May 1, 2020, to December 31, 2020). Secondary outcomes included 7-day unplanned readmission rates, inpatient do-not-resuscitate (DNR) orders, and palliative care consults. We randomly selected a hospitalization encounter for each unique patient during each study period for statistical analysis. A multivariate analysis model was used to examine the association between 30-day unplanned readmission rates and implementation of the myGOC program. RESULTS There were 7028 and 5982 unique medical patients during the pre- and post-implementation period, respectively. The overall 30-day unplanned readmission rate decreased from 24.0 to 21.3% after implementation of the myGOC program. After adjusting for covariates, the myGOC program implementation remained significantly associated with a reduction in 30-day unplanned readmission rates (OR [95% CI] 0.85 [0.77, 0.95], p = 0.003). Other factors significantly associated with a decreased likelihood of a 30-day unplanned readmission were an inpatient DNR order, advanced care planning documentation, and an emergent admission type. We also observed a significant decrease in 7-day unplanned readmission rates (OR [95% CI] 0.75 [0.64, 0.89]) after implementation of the myGOC program. CONCLUSION The 30-day and 7-day unplanned readmission rates decreased in our hospital after implementation of a system-wide multicomponent GOC intervention.
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Affiliation(s)
- Cerena Leung
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Clark R Andersen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kaycee Wilson
- Department of Inpatient Analytics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nico Nortje
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina George
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher Flowers
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Buma S, van Klinken M, van der Noort V. A Targeted Discharge Pathway to Reduce Hospital Readmission and Dying in Hospital in Cancer Patients at the End of Life. Semin Oncol Nurs 2023; 39:151506. [PMID: 37813728 DOI: 10.1016/j.soncn.2023.151506] [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] [Received: 04/13/2023] [Revised: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 10/11/2023]
Abstract
OBJECTIVES There is a need for better information exchange between primary and secondary care healthcare professionals in cancer patients with limited life expectancy, most of whom prefer to be at home but are admitted frequently at the end of life (EoL). We conducted a file search to assess this among our patients and developed a discharge pathway to decrease readmission rate and dying in hospital. DATA SOURCES We performed an in-depth file search among 150 patients who died within 1 month after hospital admission (July 2013 to January 2014); 60 were admitted once, and 90 were admitted twice or more. Mean time spent in hospital at EoL was 12 days; 37% died in hospital, and 49% died at home. We included 31 admitted cancer patients at the EoL in whom home-discharge was planned for the intervention (February 2017 to December 2018). Median survival was 24 days, time spent in hospital decreased from 15.5 to 2.5 days, and number of readmissions fell from 2.8 to 0.57. One patient (3.1%) died in hospital, and 77% died at home. And 78% of general practitioners found the provided information useful. CONCLUSION A proactive discharge pathway may reduce hospital readmission rates, time spent in hospital, and in-hospital death. IMPLICATIONS FOR NURSING PRACTICE Ever more patients with complex care needs at the EoL are being discharged early. Being informed about patients' wishes, preferences, and treatment options for symptom management at home is essential for doctors and nurses in primary care. A systematic discharge pathway can be useful for information transfer when admitted patients are discharged home.
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Affiliation(s)
| | - Merel van Klinken
- Specialist nurse Palliative Care, MSc, Research Nurse. Department of Anesthesiology, Intensive Care and Pain Medicine, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Vincent van der Noort
- Statistician PhD. Department of Biometrics, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Velasquez DA, Dhiman A, Brottman C, Eng OS, Fenton E, Herlitz J, Lozano E, McDonald E, Reynolds V, Wall E, Whitridge J, Semrad C, Turaga K, Micic D. Outcomes of parenteral nutrition in patients with advanced cancer and malignant bowel obstruction. RESEARCH SQUARE 2023:rs.3.rs-3455273. [PMID: 38014195 PMCID: PMC10680932 DOI: 10.21203/rs.3.rs-3455273/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Background Malignant bowel obstruction (MBO) affects 3-15% of all cancer patients. In patients with advanced cancer and inoperable MBO, the average survival varies between four to nine weeks. Parenteral nutrition (PN) may improve survival in specific patient populations with malignant bowel obstruction. Aims This retrospective, single-center cohort study aimed to review individual patient outcomes on PN in the setting of advanced cancer with a diagnosis of MBO and identify clinical and laboratory markers predictive of short- and long-term survival to further highlight patients that would benefit from PN in the setting of an inoperable MBO. Results In a retrospective analysis of 68 patients receiving PN for inoperable MBO, the median survival was 142 (IQR: 63.3-239.5) days. Patients experienced a median number of two hospital readmissions (range: 0-10) and spent a median of 29 days (range: 0-105) in the hospital after starting PN. Eighteen (26.5%) patients developed a catheter-related bloodstream infection (CRBSI). A diagnosis of appendiceal cancer was identified as a predictive marker of improved survival (HR: 0.53, 95% CI: 0.29-0.92, p = 0.023). Conclusions The use of PN in the context of end-of-life cancer care is a practice that necessitates improvement. Recognizing the outcomes and patient experiences of PN utilization is essential to physicians and patients.
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8
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Wheless M, Lee JJ, Domenico HJ, Martin BJ, Bennett ML, Martin SF, Berlin J, Green JK, Agarwal R. Factors and Barriers to Goals-of-Care Conversations for Patients With Cancer and Inpatient Mortality. JCO Oncol Pract 2023; 19:767-776. [PMID: 37390380 PMCID: PMC10538893 DOI: 10.1200/op.23.00095] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/02/2023] [Accepted: 05/25/2023] [Indexed: 07/02/2023] Open
Abstract
PURPOSE Conversations about personal values and goals of care (GOC) at the end of life are essential in caring for patients with advanced cancer. However, GOC conversations may be influenced by patient and oncologist factors during transitions of care. METHODS We electronically administered surveys to medical oncologists of inpatients who died from May 1, 2020, to May 31, 2021. Primary outcomes included oncologists' knowledge of inpatient death, anticipation of patient death, and recollection of GOC discussions. Secondary outcomes, including GOC documentation and advance directives (ADs), were collected retrospectively from electronic health records. Outcomes were analyzed for association with patient, oncologist, and patient-oncologist relationship factors. RESULTS For 75 patients who died, 104/158 (66%) surveys were completed by 40 inpatient and 64 outpatient oncologists. Eighty-one oncologists (77.9%) were aware of patients' deaths, 68 (65.4%) anticipated patients' deaths within 6 months, and 67 (64.4%) recalled having GOC discussions before or during the terminal hospitalization. Outpatient oncologists were more likely to report knowledge of patient death (P < .001), as were those with longer therapeutic relationships (P < .001). Inpatient oncologists were more likely to correctly anticipate patient death (P = .014). Secondary outcomes revealed 21.3% of patients had documented GOC discussions before admission and 33.3% had ADs; patients with a longer duration of cancer diagnosis were more likely to have ADs (P = .003). Oncologist-reported barriers to GOC included unrealistic expectations from patients or family (25%) and decreased patient participation because of clinical conditions (15%). CONCLUSION Most oncologists recalled having GOC discussions for patients with inpatient mortality, yet documentation of serious illness conversations remained suboptimal. Further studies are needed to examine barriers to GOC conversations and documentation during transitions of care and across health care settings.
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Affiliation(s)
- Margaret Wheless
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Julie J. Lee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Henry J. Domenico
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Office of Quality, Safety, and Risk Prevention, Vanderbilt University Medical Center, Nashville, TN
| | - Barbara J. Martin
- Vanderbilt Office of Quality, Safety, and Risk Prevention, Vanderbilt University Medical Center, Nashville, TN
| | - Marc L. Bennett
- Vanderbilt Office of Quality, Safety, and Risk Prevention, Vanderbilt University Medical Center, Nashville, TN
- Department of Otolaryngology Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Sara F. Martin
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jordan Berlin
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jennifer K. Green
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Office of Quality, Safety, and Risk Prevention, Vanderbilt University Medical Center, Nashville, TN
| | - Rajiv Agarwal
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Nashville, TN
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Brown J, Myers H, Eng D, Kilshaw L, Abraham J, Buchanan G, Eggimann L, Kelly M. Evaluation of the 'Talking Together' simulation communication training for 'goals of patient care' conversations: a mixed-methods study in five metropolitan public hospitals in Western Australia. BMJ Open 2022; 12:e060226. [PMID: 35922109 PMCID: PMC9353005 DOI: 10.1136/bmjopen-2021-060226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION In partnership with Cancer Council Western Australia (WA), the East Metropolitan Health Service in Perth, WA has developed a clinical simulation training programme 'Talking Together' using role play scenarios with trained actors as patients/carers. The aim of the training is to improve clinicians' communication skills when having challenging conversations with patients, or their carers, in relation to goals of care in the event of clinical deterioration. METHODS AND ANALYSIS A multisite, longitudinal mixed-methods study will be conducted to evaluate the impact of the communication skills training programme on patient, family/carer and clinician outcomes. Methods include online surveys and interviews. The study will assess outcomes in three areas: evaluation of the 'Talking Together' workshops and their effect on satisfaction, confidence and integration of best practice communication skills; quality of goals of patient care conversations from the point of view of clinicians, carers and family/carers; and investigation of the nursing/allied role in goals of patient care. ETHICS AND DISSEMINATION This study has received ethical approval from the Royal Perth Hospital, St John of God and Curtin University Human Research Ethics Committees. The outputs from this project will be a series of research papers and conference presentations.
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Affiliation(s)
- Janie Brown
- Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
| | - Helen Myers
- Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
| | - Derek Eng
- Palliative Care, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Lucy Kilshaw
- Aged Care, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Jillian Abraham
- East Metropolitan Health Service Executive, East Metropolitan Health Service, Perth, Western Australia, Australia
| | - Grace Buchanan
- Cancer Council Western Australia, Subiaco, Western Australia, Australia
| | - Liz Eggimann
- Cancer Council Western Australia, Subiaco, Western Australia, Australia
| | - Michelle Kelly
- Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
- Clinical & Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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When does early palliative care influence aggressive care at the end of life? Support Care Cancer 2022; 30:5371-5379. [PMID: 35290511 DOI: 10.1007/s00520-022-06954-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 03/03/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Early palliative care improves patient quality of life and influences cancer care. The time frame of early has not been established. Eight quality measures reflect aggressive care at the end of life. We retrospectively reviewed patients who died with cancer between January 1, 2018, through December 31, 2019, and compared the timing of palliative care consultation, advance directives (AD), and home palliative care with aggressive care at the end of life (ACEOL). METHODS Patients without ACEOL indicators were compared to patients with one or more than one indicator of ACEOL. The proportion of patients who received palliative care, completed AD, and the timing of palliative care and AD (less than 30 days, 30-90 days, and greater than 90 days prior to death) was compared for patients who had ACEOL versus those who did not. Chi-square analysis was used for categorical data, one-way ANOVA for continuous variables, and odds ratio (OR) with confidence intervals (CI) was reported as a measure of effect size. A p value ≤ 0.05 was considered significant. RESULTS 1727 patients died, 46% were female, and the mean age was 69 (SD 11.91). Seventy-one percent had a palliative care consult, 26% completed AD, and 888 (51.4%) had at least one indicator of ACEOL. The most common indicator of ACEOL was new chemotherapy within 30 days of death, in 571 of 888 (64%) of patients experiencing ACEOL. ADs completed at any time reduced ACEOL (OR 0.80, 95%CI 0.64-0.99). Palliative care initiated at 30 days was associated with a greater risk of ACEOL (OR 5.32, 95% CI 3.94-7.18) and initiated between 30 and 90 days (OR 1.39, 95% CI 1.07-1.80) compared to no palliative care but was associated with reduced chemotherapy as an indicator of ACEOL when > 90 days (OR 0.46, 95% CI 0.38-0.57) before death. DISCUSSION Completed ADs were associated with reduced chemotherapy in the last 30 days of life and reduced ICU admissions. This may reflect goals of care and end-of-life discussions and transition of care to comfort measures. Palliative care paradoxically when initiated within 90 days before death was associated with greater ACEOL compared to no palliative care. This may be due to consultation late in the course of illness with a focus on crisis management in patients frequently utilizing the health care system. There is an associated reduction in the use of chemotherapy in the last 30 days of life if palliative care is consulted 90 days prior to death. CONCLUSIONS An initial palliative care consult greater than 90 days before death and ADs completed at any time during the disease trajectory was associated only with reduced chemotherapy in the last 30 days of life compared with no palliative care among the 7 ACEOL indicators. ADs were associated with reduced ICU admissions. Most palliative care consults occurred within 90 days of death and a palliative care consult within 90 days of death is not an optimal utilization of services.
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Serious Illness Discussion in Palliative Care—A Case Study Approach in an African American Patient with Cancer. Crit Care Nurs Clin North Am 2022; 34:79-90. [DOI: 10.1016/j.cnc.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Hong D, Das LC, Daily E, Levine SK, Hahn OM, Liauw SL, Golden DW, Son CH. Goals of care discussions: perceptions of radiation and medical oncologists. Support Care Cancer 2021; 29:7279-7288. [PMID: 34031753 DOI: 10.1007/s00520-021-06258-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 04/28/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Goals of care discussions (GOCD) are essential when counseling patients with cancer. Respective roles of radiation oncologists (RO) and medical oncologists (MO) in GOCD can be unclear. This study aims to clarify the dynamics and barriers to GOCD. METHODS Five hundred and fifty-four ROs and 1604 MOs at NCI-designated comprehensive cancer centers were sent an anonymous electronic survey regarding demographics, opinions, training in GOCD, GOCD frequency, and three vignettes. Response formats were Yes/No, Likert-type, and free response. Chi-square and Wilcoxon rank-sum tests were performed. Likert-type scores were reported as median [interquartile range]. RESULTS There were 76 (13.7%) RO and 153 (9.5%) MO who completed surveys. Sixty-three percent of RO and 66% of MO reported GOCD with > 50% of patients (p = 0.90). GOCD were initiated for declining performance status (74%) and poor life expectancy (69%). More MO (42%) received formal GOCD training compared to RO (18%) (p < 0.01). MO were more comfortable conducting GOCD than RO (p < 0.01). RO-conducted GOCD were rated to be less important by MO compared to RO (p < 0.05). Thirty-six percent of MO reported being "not at all" or "somewhat" comfortable with RO-conducted GOCD. RO-initiated GOCD with new patients were rated less appropriate by RO compared to MO perceptions of RO-initiated GOCD (p < 0.01). CONCLUSIONS While MO and RO conduct GOCD with similar frequency, MO are more comfortable conducting GOCD and are more likely to have formal training. MO rate importance of RO involvement lower than RO. Further research is needed to understand interdisciplinary dynamics that may impact GOCD and subsequent patient care outcomes.
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Affiliation(s)
- Daniel Hong
- College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Ellen Daily
- Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Stacie K Levine
- Department of Medicine, Section of Geriatrics and Palliative Medicine, The University of Chicago, Chicago, IL, USA
| | - Olwen M Hahn
- Department of Medicine, Section of Hematology-Oncology, The University of Chicago, Chicago, IL, USA
| | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, The University of Chicago, 5758 S. Maryland Ave MC 9006, Chicago, IL, 60637, USA
| | - Daniel W Golden
- Department of Radiation and Cellular Oncology, The University of Chicago, 5758 S. Maryland Ave MC 9006, Chicago, IL, 60637, USA
| | - Christina H Son
- Department of Radiation and Cellular Oncology, The University of Chicago, 5758 S. Maryland Ave MC 9006, Chicago, IL, 60637, USA.
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Ye S, Williams CP, Gilbert AD, Huang CH, Salter TL, Rocque GB. The Impact of Depression on Health Care Utilization in Patients with Cancer. J Palliat Med 2021; 24:755-759. [PMID: 33481660 DOI: 10.1089/jpm.2020.0329] [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: 11/13/2022] Open
Abstract
Background: Depression is common in the oncology patient population. Little data exist on the impact of depression on health care utilization. Objectives: We evaluated the prevalence of depression and the relationship between depression and health care utilization in patients with cancer. Design: This cross-sectional study utilized patient-reported outcome data from predominately Medicare beneficiaries with cancer. We examined the emergency department visits and inpatient admissions within 3 months from survey. The relationship between depression and hospital visits was assessed using generalized linear models. Results: Of 1038 patients included in the study, 13% had moderate to severe depression. In adjusted models, patients with moderate or severe depression trended toward increased risk of hospitalizations compared with patients without depression (risk ratio: 1.25, 95% confidence interval: 0.97-1.62). Conclusions: Clinically significant depression is not uncommon in cancer patients. Further research is needed evaluating the relationship between depression, health care utilization, and early psychiatric intervention in oncology.
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Affiliation(s)
- Star Ye
- Divisions of General Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Courtney P Williams
- Divisions of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Aidan D Gilbert
- College of Medicine, University of South Alabama, Mobile, Alabama, USA
| | - Chao-Hui Huang
- Division of Gerontology, Geriatrics, and Palliative Care, and University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Terri L Salter
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gabrielle B Rocque
- Divisions of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Gerontology, Geriatrics, and Palliative Care, and University of Alabama at Birmingham, Birmingham, Alabama, USA.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
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14
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Living with Metastatic Cancer: A Roadmap for Future Research. Cancers (Basel) 2020; 12:cancers12123684. [PMID: 33302472 PMCID: PMC7763639 DOI: 10.3390/cancers12123684] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/03/2020] [Accepted: 12/05/2020] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Although people with metastatic cancer are living longer with their disease, they are faced with challenges that can interfere with their quality of life. These challenges include worsening disease, survival time, symptoms, distress, and financial problems. The aim of this review paper is to describe a framework to guide future efforts to address these challenges. The framework includes the risk factors (predisposing factors), triggers (precipitating factors), and responses (perpetuating factors) that contribute to the onset and maintenance of problems in living with metastatic cancer. We conclude by suggesting areas for future work to prevent problems, manage triggers, and reduce unhelpful responses. Abstract Living with metastatic cancer, or metavivorship, differs from cancer survivorship and has changed as novel treatments have increased survival time. The purpose of this narrative review is to describe factors that impact challenges in metavivorship within a conceptual framework to guide future research. This review focuses on the specific metavivorship outcomes of progressive disease, survival time, symptoms, distress, financial toxicity, and quality of life. We describe the predisposing, precipitating, and perpetuating (3P) model of metavivorship. Understanding the biological, psychological, and social 3P factors that contribute to the development and maintenance of challenges in metavivorship provides a roadmap for future research. Implications of this model include prevention by targeting predisposing factors, management of precipitating factors after onset of metastatic disease, and treatment of perpetuating factors to reduce symptoms and improve quality of life during the chronic phase of metavivorship. This can be accomplished through biopsychosocial screening efforts, monitoring of patient-reported outcomes, education and communication interventions, interdisciplinary symptom management, advance care planning, and behavioral interventions to cultivate psychological resilience.
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15
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Starr LT, Ulrich CM, Junker P, Huang L, O'Connor NR, Meghani SH. Patient Risk Factor Profiles Associated With the Timing of Goals-of-Care Consultation Before Death: A Classification and Regression Tree Analysis. Am J Hosp Palliat Care 2020; 37:767-778. [PMID: 32602349 PMCID: PMC8962013 DOI: 10.1177/1049909120934292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Early palliative care consultation ("PCC") to discuss goals-of-care benefits seriously ill patients. Risk factor profiles associated with the timing of conversations in hospitals, where late conversations most likely occur, are needed. OBJECTIVE To identify risk factor patient profiles associated with PCC timing before death. METHODS Secondary analysis of an observational study was conducted at an urban, academic medical center. Patients aged 18 years and older admitted to the medical center, who had PCC, and died July 1, 2014 to October 31, 2016, were included. Patients admitted for childbirth or rehabilitationand patients whose date of death was unknown were excluded. Classification and Regression Tree modeling was employed using demographic and clinical variables. RESULTS Of 1141 patients, 54% had PCC "close to death" (0-14 days before death); 26% had PCC 15 to 60 days before death; 21% had PCC >60 days before death (median 13 days before death). Variables associated with receiving PCC close to death included being Hispanic or "Other" race/ethnicity intensive care patients with extreme illness severity (85%), with age <46 or >75 increasing this probability (98%). Intensive care patients with extreme illness severity were also likely to receive PCC close to death (64%) as were 50% of intensive care patients with less than extreme illness severity. CONCLUSIONS A majority of patients received PCC close to death. A complex set of variable interactions were associated with PCC timing. A systematic process for engaging patients with PCC earlier in the care continuum, and in intensive care regardless of illness severity, is needed.
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Affiliation(s)
- Lauren T Starr
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Center for Bioethics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Connie M Ulrich
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Junker
- Program for Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Liming Huang
- BECCA Lab, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Nina R O'Connor
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Cui P, Ping Z, Wang P, Bie W, Yeh CH, Gao X, Chen Y, Dong S, Chen C. Timing of do-not-resuscitate orders and health care utilization near the end of life in cancer patients: a retrospective cohort study. Support Care Cancer 2020; 29:1893-1902. [PMID: 32803724 DOI: 10.1007/s00520-020-05672-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/03/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE The objectives are to explore the prevalence of DNR orders, the factors influencing them, and the association between DNR signing and health care utilization among advanced cancer patients. METHODS This was a retrospective cohort study. Data from cancer decedents in three hospitals in China from January 2016 to December 2017 during their last hospitalization before death were obtained from the electronic medical records system. RESULTS In total, 427 cancer patients were included; 59.0% had a DNR order. Patients who had solid tumors, lived in urban areas, had more than one comorbidity, and had more than five symptoms were more likely to have DNR orders. The cut-off of the timing of obtaining a DNR order was 3 days, as determined by the median number of days from the signing of a DNR order to patient death. Patients with early DNR orders (more than 3 days before death) were less likely to be transferred to the intensive care unit and undergo cardiopulmonary resuscitation, tracheal intubation, and ventilation, while they were more likely to be given morphine and psychological support compared with those with late (within 3 days before death) and no orders. CONCLUSIONS Advanced cancer patients with solid tumors living in urban areas with more symptoms and comorbidities are relatively more likely to have DNR orders. Early DNR orders are associated with less aggressive procedures and more comfort measures. However, these orders are always signed late. Future studies are needed to better understand the timing of DNR orders.
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Affiliation(s)
- Panpan Cui
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China.,The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhiguang Ping
- College of Public Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Panpan Wang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Wenqian Bie
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Chao Hsing Yeh
- Johns Hopkins School of Nursing, 525 N. Wolfe Street, Baltimore, USA
| | - Xinyi Gao
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yiyang Chen
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shiqi Dong
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Changying Chen
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China. .,The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.
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