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Barlet MH, Barks MC, Ubel PA, Davis JK, Pollak KI, Kaye EC, Weinfurt KP, Lemmon ME. Characterizing the Language Used to Discuss Death in Family Meetings for Critically Ill Infants. JAMA Netw Open 2022; 5:e2233722. [PMID: 36197666 PMCID: PMC9535532 DOI: 10.1001/jamanetworkopen.2022.33722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/09/2022] [Indexed: 12/03/2022] Open
Abstract
Importance Communication during conversations about death is critical; however, little is known about the language clinicians and families use to discuss death. Objective To characterize (1) the way death is discussed in family meetings between parents of critically ill infants and the clinical team and (2) how discussion of death differs between clinicians and family members. Design, Setting, and Participants This longitudinal qualitative study took place at a single academic hospital in the southeast US. Patients were enrolled from September 2018 to September 2020, and infants were followed up longitudinally throughout their hospitalization. Participants included families of infants with neurologic conditions who were hospitalized in the intensive care unit and had a planned family meeting to discuss neurologic prognosis or starting, not starting, or discontinuing life-sustaining treatment. Family meetings were recorded, transcribed, and deidentified before being screened for discussion of death. Main Outcomes and Measures The main outcome was the language used to reference death during family meetings between parents and clinicians. Conventional content analysis was used to analyze data. Results A total of 68 family meetings involving 36 parents of 24 infants were screened; 33 family meetings (49%) involving 20 parents (56%) and 13 infants (54%) included discussion of death. Most parents involved in discussion of death identified as the infant's mother (13 [65%]) and as Black (12 [60%]). Death was referenced 406 times throughout the family meetings (275 times by clinicians and 131 times by family members); the words die, death, dying, or stillborn were used 5% of the time by clinicians (13 of 275 references) and 15% of the time by family members (19 of 131 references). Four types of euphemisms used in place of die, death, dying, or stillborn were identified: (1) survival framing (eg, not live), (2) colloquialisms (eg, pass away), (3) medical jargon, including obscure technical terms (eg, code event) or talking around death with physiologic terms (eg, irrecoverable heart rate drop), and (4) pronouns without an antecedent (eg, it). The most common type of euphemism used by clinicians was medical jargon (118 of 275 references [43%]). The most common type of euphemism used by family members was colloquialism (44 of 131 references [34%]). Conclusions and Relevance In this qualitative study, the words die, death, dying, or stillborn were rarely used to refer to death in family meetings with clinicians. Families most often used colloquialisms to reference death, and clinicians most often used medical jargon. Future work should evaluate the effects of euphemisms on mutual understanding, shared decision-making, and clinician-family relationships.
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Affiliation(s)
| | - Mary C. Barks
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Peter A. Ubel
- Duke University School of Medicine, Durham, North Carolina
- Fuqua School of Business, Duke University, Durham, North Carolina
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - J. Kelly Davis
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Kathryn I. Pollak
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Erica C. Kaye
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Monica E. Lemmon
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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Lee SH, Lee JG, Choi YJ, Seol YM, Kim H, Kim YJ, Yi YH, Tak YJ, Kim GL, Ra YJ, Lee SY, Cho YH, Park EJ, Lee Y, Choi J, Lee SR, Kwon RJ, Son SM. Prognosis palliative care study, palliative prognostic index, palliative prognostic score and objective prognostic score in advanced cancer: a prospective comparison. BMJ Support Palliat Care 2021:bmjspcare-2021-003077. [PMID: 34215569 DOI: 10.1136/bmjspcare-2021-003077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/14/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Predicting how long a patient with far advanced cancer has to live is a significant part of hospice and palliative care. Various prognostic models have been developed, but have not been fully compared in South Korea. OBJECTIVES We aimed to compare the accuracy of the Prognosis in Palliative Care Study (PiPS), Palliative Prognostic Index (PPI), Palliative Prognostic Score (PaP) and Objective Prognostic Score (OPS) for patients with far advanced cancer in a palliative care unit in South Korea. METHODS This prospective study included patients with far advanced cancer who were admitted to a single palliative care unit at the National University Hospital. Variables for calculating the prognostic models were recorded by a palliative care physician. The survival rate was estimated using the Kaplan-Meier method. The sensitivity, specificity, positive predictive value and negative predictive value of each model were calculated. RESULTS A total of 160 patients participated. There was a significant difference in survival rates across all groups, each categorised through the five prognostic models. The overall accuracy (OA) of the prognostic models ranged between 54.5% and 77.6%. The OA of clinicians' predictions of survival ranged between 61.9% and 81.3%. CONCLUSION The PiPS, PPI, PaP and OPS were successfully validated in a palliative care unit of South Korea. There was no difference in accuracy between the prognostic models, and OA tended to be lower than in previous studies.
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Affiliation(s)
- Seung Hun Lee
- Family Medicine, Pusan National University Hospital, Busan, Korea (the Republic of)
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea (the Republic of)
- Department of Family Medicine, Pusan National University School of Medicine, Busan, Korea (the Republic of)
| | - Jeong Gyu Lee
- Family Medicine, Pusan National University Hospital, Busan, Korea (the Republic of)
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea (the Republic of)
- Department of Family Medicine, Pusan National University School of Medicine, Busan, Korea (the Republic of)
| | - Young Jin Choi
- Division of Hemato-oncology, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea (the Republic of)
| | - Young Mi Seol
- Division of Hemato-oncology, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea (the Republic of)
| | - Hyojeong Kim
- Division of Hemato-oncology, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea (the Republic of)
| | - Yun Jin Kim
- Family Medicine, Pusan National University Hospital, Busan, Korea (the Republic of)
- Department of Family Medicine, Pusan National University School of Medicine, Busan, Korea (the Republic of)
| | - Yu Hyeon Yi
- Family Medicine, Pusan National University Hospital, Busan, Korea (the Republic of)
- Department of Family Medicine, Pusan National University School of Medicine, Busan, Korea (the Republic of)
| | - Young Jin Tak
- Family Medicine, Pusan National University Hospital, Busan, Korea (the Republic of)
- Department of Family Medicine, Pusan National University School of Medicine, Busan, Korea (the Republic of)
| | - Gyu Lee Kim
- Family Medicine, Pusan National University Hospital, Busan, Korea (the Republic of)
| | - Young Jin Ra
- Family Medicine, Pusan National University Hospital, Busan, Korea (the Republic of)
| | - Sang Yeoup Lee
- Department of Family Medicine, Pusan National University School of Medicine, Busan, Korea (the Republic of)
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea (the Republic of)
- Department of Medical Education, Pusan National University School of Medicine, Yangsan, Korea (the Republic of)
| | - Young Hye Cho
- Department of Family Medicine, Pusan National University School of Medicine, Busan, Korea (the Republic of)
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea (the Republic of)
| | - Eun Ju Park
- Department of Family Medicine, Pusan National University School of Medicine, Busan, Korea (the Republic of)
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea (the Republic of)
| | - Youngin Lee
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea (the Republic of)
| | - Jungin Choi
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea (the Republic of)
| | - Sae Rom Lee
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea (the Republic of)
| | - Ryuk Jun Kwon
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea (the Republic of)
| | - Soo Min Son
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea (the Republic of)
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Yoon SJ, Suh SY, Hui D, Choi SE, Tatara R, Watanabe H, Otani H, Morita T. Accuracy of the Palliative Prognostic Score With or Without Clinicians' Prediction of Survival in Patients With Far Advanced Cancer. J Pain Symptom Manage 2021; 61:1180-1187. [PMID: 33096217 DOI: 10.1016/j.jpainsymman.2020.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Previous studies suggest that clinicians' prediction of survival (CPS) may have reduced the accuracy of objective indicators for prognostication in palliative care. OBJECTIVES We aimed to examine the accuracy of CPS alone, compared to the original Palliative Prognostic Score (PaP), and five clinical/laboratory variables of the PaP in patients with far advanced cancer. METHODS We compared the discriminative accuracy of three prediction models (the PaP-CPS [the score of the categorical CPS of PaP], PaP without CPS [sum of the scores of only the objective variables of PaP], and PaP total score) across 3 settings: inpatient palliative care consultation team, palliative care unit, and home palliative care. We computed the area under receiver operating characteristic curve (AUROC) for 30-day survival and concordance index (C-index) to compare the discriminative accuracy of these three models. RESULTS We included a total of 1534 subjects with median survival of 34.0 days. The AUROC and C-index in the three settings were 0.816-0.896 and 0.732-0.799 for the PaP total score, 0.808-0.884 and 0.713-0.782 for the PaP-CPS, and 0.726-0.815 and 0.672-0.728 for the PaP without CPS, respectively. The PaP total score and PaP-CPS showed similar AUROCs and C-indices across the three settings. The PaP total score had significantly higher AUROCs and C-indices than the PaP without CPS across the three settings. CONCLUSION Overall, the PaP total score, PaP-CPS, and PaP without CPS showed good discriminative performances. However, the PaP total score and PaP-CPS were significantly more accurate than the PaP without CPS.
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Affiliation(s)
- Seok-Joon Yoon
- Department of Family Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Sang-Yeon Suh
- Department of Medicine, Dongguk University-Seoul, Seoul, South Korea; Department of Family Medicine, Hospice and Palliative Care Center, Dongguk University Ilsan Hospital, Goyang-si, South Korea.
| | - David Hui
- Division of Cancer Medicine, Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sung-Eun Choi
- Department of Statistics, Dongguk University-Seoul, Seoul, South Korea
| | - Ryohei Tatara
- Department of Palliative Medicine, Osaka City General Hospital, Osaka, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Hiroyuki Otani
- Department of Palliative Care Team and Palliative and Supportive Care, National Kyushu Cancer Center, Fukuoka, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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Yoon SJ, Suh SY, Lee YJ, Park J, Hwang S, Lee SS, Ahn HY, Koh SJ, Park KU. Prospective Validation of Objective Prognostic Score for Advanced Cancer Inpatients in South Korea: A Multicenter Study. J Palliat Med 2017; 20:65-68. [DOI: 10.1089/jpm.2016.0044] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Seok Joon Yoon
- Department of Family Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Sang-Yeon Suh
- Department of Medicine, Dongguk University-Seoul, Seoul, South Korea
- Department of Family Medicine, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Yong Joo Lee
- Department of Palliative Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jeanno Park
- Palliative Care and Hospice Center, Bobath Memorial Hospital, Sungnam, South Korea
| | - Sunwook Hwang
- Department of Family Medicine, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sanghee Shiny Lee
- Department of Statistics, Dongguk University-Seoul, Seoul, South Korea
| | - Hong Yup Ahn
- Department of Statistics, Dongguk University-Seoul, Seoul, South Korea
| | - Su-Jin Koh
- Department of Hemato-oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Keon Uk Park
- Department of Hemato-oncology, Keimyung University Dongsan Hospital, Daegu, South Korea
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Bruggeman AR, Heavey SF, Ma JD, Revta C, Roeland EJ. Lack of documentation of evidence-based prognostication in cancer patients by inpatient palliative care consultants. J Palliat Med 2015; 18:382-5. [PMID: 25608220 DOI: 10.1089/jpm.2014.0331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Prognostication plays a key role in palliative care (PC). It is critical for advance care planning, determining hospice eligibility, and communication. In contrast to subjective clinical prognostication, evidence-based prognostication (EBP) uses existing validated data to quantify prognosis; however, the extent to which PC providers use EBP is limited. OBJECTIVE The objective was to analyze documentation of EBP by PC providers in the absence of an inpatient consultation note template at a single academic medical center. METHODS We retrospectively evaluated prognostic documentation of inpatient PC consultations on oncology patients at a single academic hospital. Ratings of Eastern Cooperative Oncology Group (ECOG) Scale, Karnofsky Performance Scale (KPS), Palliative Performance Scale, and/or activities of daily living (ADLs) were considered documentation of functional status. PC-specific documentation of EBP included the Palliative Prognostic Index and/or Palliative Prognostic Score. RESULTS There were 412 inpatient PC consultations for oncology patients (2012-2013). Reasons for consultation included goals of care (n=108), symptom management (n=181), or both (n=123). In the absence of a note template, functional status was documented in 6% (n=24) of consultation notes, while no consultation notes contained EBP documentation of the Palliative Prognostic Index and Palliative Prognostic Score. CONCLUSION This retrospective analysis conducted at a single academic medical center suggests poor documentation by PC providers of EBP in the absence of a consultation note template. Research and educational opportunities exist to evaluate barriers to EBP utilization and documentation by PC providers.
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Affiliation(s)
- Andrew R Bruggeman
- 1 Department of Medicine, UC San Diego Moores Cancer Center , La Jolla, California
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Netuveli G. Thinking fast and slow in pneumonia. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2014; 22:139-40. [PMID: 23708112 PMCID: PMC6442796 DOI: 10.4104/pcrj.2013.00051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Gopalakrishnan Netuveli
- Professor of Public Health, Institute of Health and Human Development, University of East London
- International Centre for Life Course Studies, University College London
- Professor of Public Health, Institute for Health and Human Development, University of East London, Suite 250, University House, The Green, Water Lane, London E15 4LZ, UK Tel: +44 (0)208 223 6342 Fax: +44 (0)208 223 4282 E-mail:
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7
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Fields A, Finucane AM, Oxenham D. Discussing preferred place of death with patients: staff experiences in a UK specialist palliative care setting. Int J Palliat Nurs 2014; 19:558-65. [PMID: 24263900 DOI: 10.12968/ijpn.2013.19.11.558] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND National end-of-life care policies propose that health professionals regularly discuss matters such as preferred place of death (PPD) with patients. AIM To explore clinician experiences of discussing PPD with palliative care patients. METHOD Six clinicians from a Scottish hospice each participated in a semi-structured interview. Interview data was analysed using interpretative phenomenological analysis. RESULTS Four themes were integral to the participants' accounts: the importance of discussing preferences at the end of life (staff recognise the value of discussing patients' final wishes), identifying how and when to discuss PPD (discussions are tailored to the individual), reflecting on the emotional aspects of discussing PPD (discussing PPD is challenging but rewarding), and a journey from expectations to experience (discussing PPD becomes easier with time). CONCLUSION Although potentially difficult, the participants believed that advance care planning is important and beneficial. With time, they had developed communication strategies enabling them to discuss PPD in an effective, patient-centred way.
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Affiliation(s)
- Anna Fields
- Medical Student, The University of Edinburgh, College of Medicine and Veterinary Medicine, Edinburgh, Scotland
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8
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Hui D, Nooruddin Z, Didwaniya N, Dev R, De La Cruz M, Kim SH, Kwon JH, Hutchins R, Liem C, Bruera E. Concepts and definitions for "actively dying," "end of life," "terminally ill," "terminal care," and "transition of care": a systematic review. J Pain Symptom Manage 2014; 47:77-89. [PMID: 23796586 PMCID: PMC3870193 DOI: 10.1016/j.jpainsymman.2013.02.021] [Citation(s) in RCA: 196] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 02/22/2013] [Accepted: 02/25/2013] [Indexed: 11/23/2022]
Abstract
CONTEXT The terms "actively dying," "end of life," "terminally ill," "terminal care," and "transition of care" are commonly used but rarely and inconsistently defined. OBJECTIVES We conducted a systematic review to examine the concepts and definitions for these terms. METHODS We searched MEDLINE, PsycINFO, Embase, and CINAHL for published peer-reviewed articles from 1948 to 2012 that conceptualized, defined, or examined these terms. Two researchers independently reviewed each citation for inclusion and then extracted the concepts/definitions when available. We also searched 10 dictionaries, four palliative care textbooks, and 13 organization Web sites, including the U.S. Federal Code. RESULTS One of 16, three of 134, three of 44, two of 93, and four of 17 articles defined or conceptualized actively dying, end of life, terminally ill, terminal care, and transition of care, respectively. Actively dying was defined as "hours or days of survival." We identified two key defining features for end of life, terminally ill, and terminal care: life-limiting disease with irreversible decline and expected survival in terms of months or less. Transition of care was discussed in relation to changes in 1) place of care (e.g., hospital to home), 2) level of professions providing the care (e.g., acute care to hospice), and 3) goals of care (e.g., curative to palliative). Definitions for these five terms were rarely found in dictionaries, textbooks, and organizational Web sites. However, when available, the definitions were generally consistent with the concepts discussed previously. CONCLUSION We identified unifying concepts for five commonly used terms in palliative care and developed a preliminary conceptual framework toward building standardized definitions.
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Affiliation(s)
- David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
| | - Zohra Nooruddin
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Neha Didwaniya
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Maxine De La Cruz
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Sun Hyun Kim
- Department of Family Medicine, Myong Ji Hospital, Kwandong University, College of Medicine, Gyeonggi, Republic of Korea
| | - Jung Hye Kwon
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
| | - Ronald Hutchins
- Research Medical Library, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Christiana Liem
- Research Medical Library, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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9
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Interleukin-6 but not tumour necrosis factor-alpha predicts survival in patients with advanced cancer. Support Care Cancer 2013; 21:3071-7. [DOI: 10.1007/s00520-013-1878-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 06/05/2013] [Indexed: 10/26/2022]
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10
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Singh P, Germain MJ, Cohen L, Unruh M. The elderly patient on dialysis: geriatric considerations. Nephrol Dial Transplant 2013; 29:990-6. [PMID: 23787545 DOI: 10.1093/ndt/gft246] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The burgeoning population of older dialysis patients presents opportunities to provide personalized care. The older dialysis population has a high burden of chronic health conditions, decrements in quality of life and a high risk of death. In order to address these challenges, this review will recommend routinely establishing prognosis through the use of prediction instruments and communicating these findings to older patients. The challenges to prognosis in adults with end-stage renal disease (ESRD) include the subjective nature of clinical judgment, application of appropriate prognostic tools and communication of findings to patients and caregivers. There are three reasons why we believe these conversations occur infrequently with the dialysis population. First, there have previously been no clinically practical instruments to identify individuals undergoing maintenance hemodialysis (HD) who are at highest risk for death. Second, nephrologists have not been trained to have conversations about prognosis and end-of-life care. Third, other than hospitalizations and accrual of new diagnoses, there are no natural milestone guidelines in place for patients supported by dialysis. The prognosis can be used in shared decision-making to establish goals of care, limits on dialysis support or parameters for withdrawal from dialysis. As older adults with ESRD benefit from kidney transplantation, prognosis can also be used to determine who should be referred for evaluation by a kidney transplant team. The use of prognosis in older adults may determine approaches to optimize well-being and personalize care among older adults ranging from hospice to kidney transplantation.
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Affiliation(s)
- Pooja Singh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
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11
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Yoon SJ, Jung JG, Kim JS, Kim SS, Kim S. Retrospective Assessment of Objective Prognostic Score in Terminally Ill Korean Patients With Cancer. Am J Hosp Palliat Care 2013; 31:435-40. [DOI: 10.1177/1049909113492557] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We conducted a retrospective study by reviewing the medical records of 104 patients to assess the usefulness of the objective prognostic score (OPS) in an independent population of Korea. The median survival time (±standard error) of the high OPS group (≥3) was 9.0 ± 1.31 days and that of the low OPS group (<3) was 26.0 ± 3.3 days. The former was significantly shorter than the latter ( P < .001). Only delirium (hazard ratio 1.751, P = .032) was related to shorter survival time independent of the OPS. This study demonstrates that the OPS is a valid and useful prognostic tool for predicting survival in terminally ill Korean patients with cancer, and that inclusion of delirium into the OPS may improve its prognostic value.
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Affiliation(s)
- Seok-Joon Yoon
- Department of Family Medicine, Research Institute for Medical Sciences, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jin-Gyu Jung
- Department of Family Medicine, Research Institute for Medical Sciences, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jong-Sung Kim
- Department of Family Medicine, Research Institute for Medical Sciences, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sung-Soo Kim
- Department of Family Medicine, Research Institute for Medical Sciences, Chungnam National University School of Medicine, Daejeon, Korea
| | - Samyong Kim
- Department of Internal Medicine, Cancer Research Institute, Chungnam National University School of Medicine, Daejeon, Korea
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Shuman AG, Fins JJ, Prince ME. Improving end-of-life care for head and neck cancer patients. Expert Rev Anticancer Ther 2012; 12:335-43. [PMID: 22369325 DOI: 10.1586/era.12.6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite improvements in the treatment of head and neck cancer, many patients still succumb to their disease. A litany of medical, psychosocial and ethical challenges arise in managing the end-of-life experiences within this patient population. In this article, we attempt to review existing data about the end-of-life experiences of this cohort, extrapolate relevant data from other cancer patients, and suggest the most promising avenues for additional research and practice improvement for terminal head and neck cancer patients. Clinical decision-making for patients dying of head and neck cancer requires proactive consideration of quality of life, functionality, symptom control and other patient-centered objectives, and frequently benefits from palliative care team involvement. Additional research aimed toward optimizing the end of life experience of head and neck cancer patients and their families is greatly needed.
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Affiliation(s)
- Andrew G Shuman
- Division of Head and Neck Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA.
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13
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Borreani C, Brunelli C, Bianchi E, Piva L, Moro C, Miccinesi G. Talking about end-of-life preferences with advanced cancer patients: factors influencing feasibility. J Pain Symptom Manage 2012; 43:739-46. [PMID: 22464353 DOI: 10.1016/j.jpainsymman.2011.05.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 05/03/2011] [Accepted: 05/12/2011] [Indexed: 11/30/2022]
Abstract
CONTEXT The End-of-Life Preferences Interview (ELPI) was developed with the purpose of supporting physicians in communicating with advanced cancer patients. OBJECTIVES This study aimed to evaluate ELPI feasibility and compare home care/hospice (HC-H) vs. outpatient (OU) care settings. METHODS Twenty-eight physicians were trained in the use of the ELPI and were asked to apply the new instrument in their daily clinical practice for two months. ELPI feasibility was evaluated through three indices: the percentage of eligible patients, the percentage of patients to whom the ELPI was proposed, and the percentage of completed interviews. RESULTS The 23 physicians participating in the data collection screened 633 patients, and 156 of them (25%, 95% confidence interval 21%-28%) were judged to be eligible. Eligibility in HC-H was lower than that in the OU setting (18% vs. 46%; P<0.0001), whereas the differences were reduced when looking at patients to whom the ELPI was proposed (12% vs. 20%; P=0.017) and who completed the ELPI (8% vs. 18%; P<0.001). The percentage of eligible patients refusing the interview was very low in the entire sample (1.9%). CONCLUSION Results indicate that discussing end-of-life preferences in an earlier disease phase, such as in the OU setting, could be preferable but that its accomplishment in this setting may be more difficult, mainly as a result of organizational reasons. This observation could indicate that the system is not yet ready to offer patients such an opportunity and although communication on these sensitive issues cannot be reduced to a procedure, the ELPI can become a useful tool to help physicians in accomplishing this difficult task.
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Affiliation(s)
- Claudia Borreani
- Clinical Psychology Unit, IRCCS Foundation, National Cancer Institute, Milan, Italy.
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Yun YH, Lee MK, Kim SY, Lee WJ, Jung KH, Do YR, Kim S, Heo DS, Choi JS, Park SY, Jeong HS, Kang JH, Kim SY, Ro J, Lee JL, Park SR, Park S. Impact of awareness of terminal illness and use of palliative care or intensive care unit on the survival of terminally ill patients with cancer: prospective cohort study. J Clin Oncol 2011; 29:2474-80. [PMID: 21576638 DOI: 10.1200/jco.2010.30.1184] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We conducted this study to evaluate the validity of the perception that awareness of their terminal prognosis and use of palliative care or nonuse of an intensive care unit (ICU) causes patients to die sooner than they would otherwise. PATIENTS AND METHODS In this prospective cohort study at 11 university hospitals and the National Cancer Center in Korea, we administered questionnaires to 619 consecutive patients immediately after they were determined by physicians to be terminally ill. We followed patients during 6 months after enrollment and assessed how their survival was affected by the disclosure of terminal illness and administration of palliative care or nonuse of the ICU. RESULTS In a follow-up of 481 patients and 163.8 person-years, we identified 466 deceased patients. Nineteen percent of the patients died within 1 month, while 41.3% lived for 3 months, and 17.7% lived for 6 months. Once the cancer was judged terminal, the median survival time was 69 days. On multivariate analysis, neither patient awareness of terminal status at baseline (adjusted hazard ratio [aHR], 1.20; 95% CI, 0.96 to 1.51), use of a palliative care facility (aHR, 0.96; 95% CI, 0.76 to 1.21), nor general prostration (aHR, 1.23; 95% CI, 0.96 to 1.57) was associated with reduced survival. Use of the ICU (aHR, 1.47; 95% CI, 1.06 to 2.05) and poor Eastern Cooperative Oncology Group performance status (aHR, 1.37; 95% CI, 1.10 to 1.71) were significantly associated with poor survival. CONCLUSION Patients' being aware that they are dying and entering a palliative care facility or ICU does not seem to influence patients' survival.
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Affiliation(s)
- Young Ho Yun
- Cancer Management Branch, Research Institute, National Cancer Center, 809, Madu-dong, Ilsan-gu, Goyang-si, Gyeonggi-do, 411-769, Korea.
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15
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Hwang IC, Choi CH, Kim KK, Lee KS, Suh HS, Shim JY. Predictability of Impending Events for Death within 48 Hours in Terminal Cancer Patients. ACTA ACUST UNITED AC 2011. [DOI: 10.14475/kjhpc.2011.14.1.28] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- In-Cheol Hwang
- Department of Family Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Chung-Hyun Choi
- Clinical Trial Center, Yonsei University Health System, Korea
| | - Kyoung-Kon Kim
- Department of Family Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Kyoung-Shik Lee
- Department of Family Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Heuy-Sun Suh
- Department of Family Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Jae-Yong Shim
- Department Family Medicine, Yonsei University College of Medicine, Seoul, Korea
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Loprinzi CL, Schapira L, Moynihan T, Kalemkerian GP, von Gunten C, Steensma D. Compassionate Honesty. J Palliat Med 2010; 13:1187-91. [DOI: 10.1089/jpm.2010.9777] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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17
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Hui D, Bruera E. Palliative Care for Patients with Lung Cancer. Lung Cancer 2010. [DOI: 10.1007/978-1-60761-524-8_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Eliott JA, Olver IN. Hope, life, and death: a qualitative analysis of dying cancer patients' talk about hope. DEATH STUDIES 2009; 33:609-638. [PMID: 19623763 DOI: 10.1080/07481180903011982] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Although deemed vital to patient well-being, hope in persons who are terminally ill is often thought to be problematic, particularly when centered on cure. As part of a study on end-of-life decision-making, we asked 28 patients with cancer, believed to be within weeks of their death, to talk about hope. Responses were transcribed and discursively analyzed, with 3 versions of hope, each of which connected hope and life, identified--hope as essential to, and for, life; hope, life, death, and others; and, hope/s changing during (or in) life. Hope for cure was common. Rather than death-denying, patients' hope appeared life-affirming, functioning to value patients, their lives, and connections with others.
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Affiliation(s)
- Jaklin A Eliott
- Cancer Council Australia, Sydney and School of Psychology, University of Adelaide, Adelaide SA 5005, Australia.
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19
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Construction of a new, objective prognostic score for terminally ill cancer patients: a multicenter study. Support Care Cancer 2009; 18:151-7. [PMID: 19381691 DOI: 10.1007/s00520-009-0639-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Accepted: 04/02/2009] [Indexed: 10/20/2022]
Abstract
GOALS OF WORK The goal of this study was to develop a new, objective prognostic score (OPS) for terminally ill cancer patients based on an integrated model that includes novel objective prognostic factors. MATERIALS AND METHODS A multicenter study of 209 terminally ill cancer patients from six training hospitals in Korea were prospectively followed until death. The Cox proportional hazard model was used to adjust for the influence of clinical and laboratory variables on survival time. The OPS was calculated from the sum of partial scores obtained from seven significant predictors determined by the final model. The partial score was based on the hazard ratio of each predictor. The accuracy of the OPS was evaluated. MAIN RESULTS The overall median survival was 26 days. On the multivariate analysis, reduced oral intake, resting dyspnea, low performance status, leukocytosis, elevated bilirubin, elevated creatinine, and elevated lactate dehydrogenase (LDH) were identified as poor prognostic factors. The range of OPS was from 0.0 to 7.0. For the above cutoff point of 3.0, the 3-week prediction sensitivity was 74.7%, the specificity was 76.5%, and the overall accuracy was 75.5%. CONCLUSIONS We developed the new OPS, without clinician's survival estimates but including a new prognostic factor (LDH). This new instrument demonstrated accurate prediction of the 3-week survival. The OPS had acceptable accuracy in this study population (training set). Further validation is required on an independent population (testing set).
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20
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Chaturvedi SK, Loiselle CG, Chandra PS. Communication with relatives and collusion in palliative care: a cross-cultural perspective. Indian J Palliat Care 2009; 15:2-9. [PMID: 20606848 PMCID: PMC2886207 DOI: 10.4103/0973-1075.53485] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Handling collusion among patients and family members is one of the biggest challenges that palliative care professionals face across cultures. Communication with patients and relatives can be complex particularly in filial cultures where families play an important role in illness management and treatment decision-making. Collusion comes in different forms and intensity and is often not absolute. Some illness-related issues may be discussed with the patient, whereas others are left unspoken. Particularly in palliative care, the transition from curative to palliative treatment and discussion of death and dying are often topics involving collusion. Communication patterns may also be influenced by age, gender, age, and family role. This paper outlines different types of collusion and how collusion manifests in Indian and Western cultures. In addition, promising avenues for future research are presented.
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Affiliation(s)
- Santosh K. Chaturvedi
- Department of Psychiatry, Professor & Head, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Carmen G. Loiselle
- Department of McGill University Oncology Nursing, Associate Professor, McGill School of Nursing, CIHR PORT Program Leader, Montreal, Quebec, Canada
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Abstract
Prognostication, along with diagnosis and treatment, is a traditional core clinical skill of the physician. Many patients and families receiving palliative care want information about life expectancy to help plan realistically for their futures. Although underappreciated, prognosis is, or at least should be, part of every clinical decision. Despite this crucial role, expertise in the art and science of prognostication diminished during the twentieth century, due largely to the ascendancy of accurate diagnostic tests and effective therapies. Consequently, "Doctor, how long do I have?" is a question most physicians find unprepared to answer effectively. As we focus on palliative care in the twenty-first century, prognostication will need to be restored as a core clinical proficiency. The discipline of palliative medicine can provide leadership in this direction. This paper begins by discussing a framework for understanding prognosis and how its different domains might be applied to all patients with life limiting illness, although the main focus of the paper is predicting survival in patients with cancer. Examples of prognostic tools are provided, although the subjective assessment of prognosis remains important in the terminally ill. Other issues addressed include: the importance of prognostication in terms of clinical decision-making, discharge planning, and care planning; the impact of prognosis on hospice referrals and patient/family satisfaction; and physicians' willingness to prognosticate.
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Affiliation(s)
- Paul A Glare
- Department of Palliative Care, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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22
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Affiliation(s)
- Scott R. Berry
- From the Division of Medical Oncology/Hematology, Sunnybrook Health Sciences Centre; Department of Medicine, University of Toronto; and University of Toronto Joint Centre for Bioethics, Toronto, Ontario, Canada
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23
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Gripp S, Moeller S, Bölke E, Schmitt G, Matuschek C, Asgari S, Asgharzadeh F, Roth S, Budach W, Franz M, Willers R. Survival Prediction in Terminally Ill Cancer Patients by Clinical Estimates, Laboratory Tests, and Self-Rated Anxiety and Depression. J Clin Oncol 2007; 25:3313-20. [PMID: 17664480 DOI: 10.1200/jco.2006.10.5411] [Citation(s) in RCA: 202] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To study how survival of palliative cancer patients relates to subjective prediction of survival, objective prognostic factors (PFs), and individual psychological coping. Patients and Methods Survival was estimated according to three categories (< 1 month, 1 to 6 months, and > 6 months) by two physicians (A and B) and the institutional tumor board (C) for 216 patients recently referred for palliative radiotherapy. After 6 months, the accuracy of these estimates was assessed. The prognostic relevance of clinical symptoms, performance status, laboratory tests, and self-reported emotional distress (Hospital Anxiety and Depression Scale) was investigated. Results In 61%, 55%, and 63% of the patients, prognoses were correctly estimated by A, B, and C, respectively. κ statistic showed fair agreement of the estimates, which proved to be overly optimistic. Accuracy of the three estimates did not improve with increasing professional experience. In particular, the survival of 96%, 71%, and 87% of patients who died in less than 1 month was overestimated by A, B, and C, respectively. On univariate analysis, 11 of 27 parameters significantly affected survival, namely performance status, primary cancer, fatigue, dyspnea, use of strong analgesics, brain metastases, leukocytosis, lactate dehydrogenase (LDH), depression, and anxiety. On multivariate analysis, colorectal and breast cancer had a favorable prognosis, whereas brain metastases, Karnofsky performance status less than 50%, strong analgesics, dyspnea, LDH, and leukocytosis were associated with a poor prognosis. Conclusion This study revealed that physicians' survival estimates were unreliable, especially in the case of patients near death. Self-reported emotional distress and objective PFs may improve the accuracy of survival estimates.
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Affiliation(s)
- Stephan Gripp
- Department of Radiation Oncology, University Hospital Düsseldorf at Heinrich-Heine-University, Düsseldorf, Germany.
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Kistler CE, Lewis CL, Amick HR, Bynum DL, Walter LC, Watson LC. Older adults' beliefs about physician-estimated life expectancy: a cross-sectional survey. BMC FAMILY PRACTICE 2006; 7:9. [PMID: 16472399 PMCID: PMC1386682 DOI: 10.1186/1471-2296-7-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2005] [Accepted: 02/11/2006] [Indexed: 11/10/2022]
Abstract
Background Estimates of life expectancy assist physicians and patients in medical decision-making. The time-delayed benefits for many medical treatments make an older adult's life expectancy estimate particularly important for physicians. The purpose of this study is to assess older adults' beliefs about physician-estimated life expectancy. Methods We performed a mixed qualitative-quantitative cross-sectional study in which 116 healthy adults aged 70+ were recruited from two local retirement communities. We interviewed them regarding their beliefs about physician-estimated life expectancy in the context of a larger study on cancer screening beliefs. Semi-structured interviews of 80 minutes average duration were performed in private locations convenient to participants. Demographic characteristics as well as cancer screening beliefs and beliefs about life expectancy were measured. Two independent researchers reviewed the open-ended responses and recorded the most common themes. The research team resolved disagreements by consensus. Results This article reports the life-expectancy results portion of the larger study. The study group (n = 116) was comprised of healthy, well-educated older adults, with almost a third over 85 years old, and none meeting criteria for dementia. Sixty-four percent (n = 73) felt that their physicians could not correctly estimate their life expectancy. Sixty-six percent (n = 75) wanted their physicians to talk with them about their life expectancy. The themes that emerged from our study indicate that discussions of life expectancy could help older adults plan for the future, maintain open communication with their physicians, and provide them knowledge about their medical conditions. Conclusion The majority of the healthy older adults in this study were open to discussions about life expectancy in the context of discussing cancer screening tests, despite awareness that their physicians' estimates could be inaccurate. Since about a third of participants perceived these discussions as not useful or even harmful, physicians should first ascertain patients' preferences before discussing their life expectancies.
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Affiliation(s)
- Christine E Kistler
- Family Medicine, University of Michigan, 200 Arnet St., Suite 200, Ypsilanti, MI 48198-HCA, USA
| | - Carmen L Lewis
- Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Halle R Amick
- Medicine Administration, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Debra L Bynum
- Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Louise C Walter
- Medicine, University of California, San Francisco, San Francisco, USA
| | - Lea C Watson
- Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, USA
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Clayton JM, Butow PN, Arnold RM, Tattersall MHN. Discussing life expectancy with terminally ill cancer patients and their carers: a qualitative study. Support Care Cancer 2005; 13:733-42. [PMID: 15761699 DOI: 10.1007/s00520-005-0789-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2004] [Accepted: 02/02/2005] [Indexed: 10/25/2022]
Abstract
GOALS OF WORK There is uncertainty regarding the preferred content and phrasing of information when discussing life expectancy with terminally ill cancer patients and their carers. The objective of this study was to explore the various stakeholders' perceptions about these issues. SUBJECTS AND METHODS We conducted focus groups and individual interviews with 19 patients with advanced cancer and 24 carers from three different palliative care (PC) services in Sydney and 22 PC health professionals (HPs) from ten different sites in Australia. The focus groups and individual interviews were audiotaped and fully transcribed. Further focus groups and/or individual interviews were conducted until no additional topics were raised. Participants' narratives were analysed using qualitative methodology. MAIN RESULTS Participants' suggestions regarding the content of prognostic discussions included: explaining uncertainty and limitations, explaining the process involved with making survival predictions, and avoiding being too exact. Those patients and carers who wanted to be given a time frame mostly wanted to know how long the average person with their condition would live and/or be given a rough range. HPs had various views regarding ways to phrase life expectancy: days versus weeks versus months, likelihood of the patients being alive for certain events, a rough quantitative range and probabilities (e.g. 10% and 50% survival). However, most HPs said they would rarely if ever give statistical information to patients. CONCLUSIONS This paper provides some potential strategies, words and phrases which may inform discussions about life expectancy. Further research is needed to determine the generalizability of these findings.
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Affiliation(s)
- Josephine M Clayton
- Medical Psychology Research Unit, University of Sydney, NSW 2006, Australia.
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Glare PA, Eychmueller S, McMahon P. Diagnostic accuracy of the palliative prognostic score in hospitalized patients with advanced cancer. J Clin Oncol 2005; 22:4823-8. [PMID: 15570085 DOI: 10.1200/jco.2004.12.056] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the predictive accuracy of the Palliative Prognostic (PaP) score in patients with advanced cancer under the care of an oncologist. PATIENTS AND METHODS The PaP score was calculated in 100 consecutive patients with advanced cancer hospitalized under the care of a medical or radiation oncologist at a university teaching hospital in Australia. The attending oncologist predicted the survival duration for the purpose of the scoring. The positive predictive value of the PaP score was evaluated. Survival analysis was performed to compare the survival of the three prognostic groups. RESULTS Assessable survival data were available for 98 patients. The overall median survival was 12 weeks (interquartile range, 7 to 25 weeks). The PaP score divided the heterogeneous patient sample into three isoprognostic groups related to the chance of surviving 1 month, with 64 patients in group A (> 70% chance), 32 patients in group B (30% to 70% chance), and four patients in group C (< 30% chance). The estimated median survival of the three groups was 17 weeks (95% CI, 12 to 26 weeks), 7 weeks (95% CI, 4 to 12 weeks), and less than 1 week (95% CI, < 1 to 3 weeks), respectively. These survival differences were highly significant (log-rank test of trend, chi1(2) = 25.65; P < .0001). The 1-month survival of the groups was 97%, 59%, and 25%, respectively. CONCLUSION When oncologists' survival estimates are used, the PaP score is able to identify accurately three isoprognostic patient groups, irrespective of the cancer type. The PaP score may help reduce the uncertainty of formulating a prognosis in patients with advanced cancer.
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Affiliation(s)
- Paul A Glare
- Royal Prince Alfred Hospital, Sydney, Australia.
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Belvedere O, Minisini A, Ramello M, Sobrero A, Grossi F. Information given to cancer patients on diagnosis, prognosis and treatment: the clinical oncologist's perspective. Eur J Cancer 2004; 40:1850-4. [PMID: 15288286 DOI: 10.1016/j.ejca.2004.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2004] [Revised: 04/15/2004] [Accepted: 04/20/2004] [Indexed: 10/26/2022]
Abstract
The extent of information to cancer patients is, in general, culture-dependent. Information mainly refers to three aspects, namely diagnosis (Dx), prognosis (Px) and treatment (Rx), but the relative contribution of each domain to the information given overall is not available. To address this issue, we e-mailed a questionnaire to 9893 members of the American Society of Clinical Oncology (ASCO) asking whether they agree that information about Dx, Px and Rx contribute differently to the information given to the cancer patient overall and, if so, to what extent, both in the adjuvant and advanced settings. 857 questionnaires were evaluable. There was no statistically significant difference between the contribution of these 3 domains in the adjuvant setting (33%, 34% and 33%, respectively). In subgroup analysis, medical oncologists and haematologists attributed a significantly higher contribution of Px information compared with other specialists (P < 0.05). In the advanced setting, respondents estimated a higher contribution of Px (41%) to patient information overall compared with Dx and Rx (28% and 31%, respectively; P < 0.05). This finding was more pronounced in North America than in Europe (P < 0.0001), and in Germanic-language than in Romance-language countries (P = 0.005). In conclusion, information on Dx, Px and Rx are believed to contribute differently to the information delivered to cancer patients overall, depending on the stage of disease, the cultural environment and the specialty of the physician.
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Affiliation(s)
- Ornella Belvedere
- Department of Medical Oncology, University of Udine, P.le S.M. Misericordia, 33100 Udine, Italy.
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Yabroff KR, Mandelblatt JS, Ingham J. The quality of medical care at the end-of-life in the USA: existing barriers and examples of process and outcome measures. Palliat Med 2004; 18:202-16. [PMID: 15198133 DOI: 10.1191/0269216304pm880oa] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
CONTEXT Cancer is a leading cause of morbidity and mortality in the USA and despite many recent advances in detection and treatment, over half a million cancer patients in this country will die from their disease each year. OBJECTIVE Using cancer as a prototype, we provide a conceptual framework to identify and review barriers to optimal end-of-life care and propose examples of linked process and outcome measures that could be used to evaluate whether standards of optimal end-of-life care are being achieved. METHODS We propose a conceptual model of end-of-life care and use this model to review the published literature to identify the key goals of optimal end-of-life care and summarize existing barriers to optimal end-of-life care. We then provide examples of process and outcome measures linked to the goals of optimal end-of-life care and domains within the conceptual framework. RESULTS Within all components of care at the end-of-life--societal attitudes, health care system(s), providers, and patients and their families--there are significant barriers to the quality of care. Some of the most critical barriers to optimal care at the end-of-life in the USA are limited availability, and coverage of, co-ordinated service delivery; poor provider communication and diagnostic skills; limited opportunities for training in palliative care; patient fears and attitudes towards the sick role, and a lack of, or inadequate health insurance. Proposed patient, provider, and system level measures of the quality of care were guided by goals of optimal end-of-life care, and focus on communication about prognosis and risks and benefits of treatment, development of clear and informed treatment goals, delivery of services consistent with treatment goals, and promotion of quality of life. CONCLUSIONS At present, there are substantial societal, health care system, provider, and patient barriers to obtaining optimal cancer care at the end-of-life. Ongoing discussions about appropriate measures of the quality of end-of-life care are gaining momentum, however. The proposed process and outcome measures for assessing optimal end-of-life care use cancer as a prototype, but are broadly applicable to other patient populations with life-threatening disease.
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Affiliation(s)
- K Robin Yabroff
- Cancer Control Program, Department of Human Oncology, Lombardi Cancer Center, Georgetown University Medical Center, Washington, DC, USA.
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Bansal M, Patel FD, Mohanti BK, Sharma SC. Setting up a palliative care clinic within a radiotherapy department: a model for developing countries. Support Care Cancer 2003; 11:343-7. [PMID: 12730727 DOI: 10.1007/s00520-002-0418-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Nearly 50% of all newly diagnosed cancer patients in India (and other developing countries) are terminally ill with advanced disease. These patients are usually neglected or often receive futile anticancer treatment(s), whereas what they really need is maximum medical management in the form of palliative care and psychosocial support. Since advanced and incurable cancer cases are mostly referred for radiotherapy (RT), a palliative care (PC) clinic was started in the Department of Radiotherapy, PGIMER, Chandigarh. The PC clinic staff consisted of one specialist doctor, a nurse and volunteers. Previous disease and treatment records maintained by the RT colleagues were noted. Proforma-based assessments were done in the PC clinic and focused on patients' Karnofsky Performance Status, physical symptoms, drugs prescribed, and the doctor's or patient's/relative's response to/satisfaction with the treatment in each case. Prospective data on 100 patients (March to August 2001) revealed that various distressing physical symptoms (cachexia, dyspnoea, constipation) had not been routinely assessed earlier. Despite previous treatment, adequate pain management as per the WHO ladder was needed in 67 of 88 (76%) patients when they were seen by the PC team. On the regular follow-up visits to the PC clinic, 42% and 50% of the patients/relatives reported a response to and satisfaction with the treatment at their second and third visits. We believe two conclusions are justified. (1) Attention to palliative care needs could result in good treatment outcome and high level of patients' and doctors' satisfaction. (2) Since a specialist PC set-up is lacking in most medical institutions in India, the RT department is the best suited to delivery of palliative care for patients with advanced cancer.
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Affiliation(s)
- M Bansal
- Department of Radiotherapy, Postgraduate Institute of Medical Education and Research, 160012 Chandigarh, India.
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Chow E, Andersson L, Wong R, Vachon M, Hruby G, Franssen E, Fung KW, Harth T, Pach B, Pope J, Connolly R, Schueller T, Stefaniuk K, Szumacher E, Hayter C, Finkelstein J, Danjoux C. Patients with advanced cancer: a survey of the understanding of their illness and expectations from palliative radiotherapy for symptomatic metastases. Clin Oncol (R Coll Radiol) 2002; 13:204-8. [PMID: 11527297 DOI: 10.1053/clon.2001.9255] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We conducted a pilot study to examine patients' understanding of their illness and their expectations for palliative radiotherapy for symptomatic metastases. Participants were asked to complete a survey consisting of seven questions prior to the initial consultation. Demographic details and information on extent of disease were collected. Patients were asked to score their symptom distress using the modified Edmonton Symptom Assessment System. Sixty patients participated in the pilot study between January and April 1999. Their median age was 68 years (range 46-90). The most common primary tumours were lung, prostate and breast. Twenty-one patients (35%) believed that their cancer was curable. Twelve (20%) expected that palliative radiotherapy would cure their advanced cancer and 23 (38%) believed that palliative radiotherapy would prolong their lives. Twenty-one patients (35%) had concerns about the effectiveness of radiation therapy and twenty (33%) had concerns about the side-effects of radiotherapy. Fifty-two (87%) were not familiar with the concept of radiation treatment. Forty-seven patients (78%) reported that they were not given information about the radiation treatment; 51 (85%) were not satisfied with the information that their own doctors had provided regarding radiation treatment prior to the consultation at our clinic. A significant proportion of the patients in this pilot study had misconceptions regarding their illness and unrealistic expectations from palliative radiotherapy. We plan to provide educational pamphlets for use in referring doctors' surgeries and clinics in order to inform patients of the nature, rationale and anticipated benefits and side-effects of palliative radiotherapy.
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Affiliation(s)
- E Chow
- Department of Radiation Oncology, Toronto-Sunnybrook Regional Cancer Centre, University of Toronto, Canada.
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Baider L, Wein S. Reality and fugues in physicians facing death: confrontation, coping, and adaptation at the bedside. Crit Rev Oncol Hematol 2001; 40:97-103. [PMID: 11682316 DOI: 10.1016/s1040-8428(01)00135-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
This paper addresses the psychological effects and fears of physicians in their private and professional lives. It specifically looks at their experiences, perceptions, behavior, and vulnerability, especially when confronted with death and dying. The concepts of empathy, fears of oncologists, the mechanisms used for adaptation and coping, recommendations and interventions are presented. The success of a physician can be measured by the empathic yet objective relationship he/she establishes with the patient, while simultaneously building clear emotional and professional boundaries.
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Affiliation(s)
- L Baider
- Department of Psycho-Oncology, Sharett Institute of Oncology, Hadassah Hospital, Ein Kerem, 91120, Jerusalem, Israel.
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Schapira L, Eisenberg PD, MacDonald N, Mumber MP, Loprinzi C. A revisitation of "Doc, how much time do I have?". J Clin Oncol 2000; 18:2640-3. [PMID: 10893300 DOI: 10.1200/jco.2000.18.13.2640] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- L Schapira
- Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline, MA, USA
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