The needs and experiences of critically ill patients and family members in intensive care unit of a tertiary hospital in Malaysia: a qualitative study

BACKGROUND

Admission to an intensive care unit (ICU) is a stressful experience for patients and their family members. While the focus of management is primarily on medical care, there can be other areas which are overlooked. The purpose of this study was to investigate the needs and experiences of ICU patients and family members.

METHOD

This qualitative study involved four trained researchers conducting in-depth interviews (IDI) based on a semi-structured interview guide. The participants were ICU patients and family members. All IDIs were audio-recorded and transcribed verbatim. Four researchers independently analyzed the data via thematic analysis with the aid of QDA Miner Lite®. The themes and subthemes were generated and confirmed by literature and expert opinion.

RESULTS

Six IDIs were conducted with three patients and three family members, whose ages ranged from 31 to 64 years old. One pair of participants consisted of a patient and his respective family member, while the other four participants did not have a familial relationship with each other. Three main themes emerged from the analysis: (I) critical care services; (II) physical spaces; and (III) monitoring technology. Medical, psychological, physical, and social needs for critical care services were expressed by both patients and family members. Patients' needs in clinical spaces were highlighted as a conducive ICU environment with ambient temperature and controlled noise levels. In non-clinical spaces, family members expressed a need for more chairs in the waiting area. Participants expressed the need for call bells as well as patients' negative perceptions of medical equipment alarms in the ICU when it pertained to monitoring technology.

CONCLUSION

This study provides an in-depth view at the needs and experiences of ICU patients and family members who have a variety of unmet needs. This understanding is critical for guiding ICU personnel and stakeholders in their efforts to humanize ICU care.

Current Status and Cardinal Features of Patient Autonomy after Enactment of the Life-Sustaining Treatment Decisions Act in Korea

Purpose

The main purpose of the Life-Sustaining Treatment Decisions Act recently enacted in Korea is to respect the patient’s self-determination. We aimed to investigate the current status and features of patient self-determination after implementation of the law.

Materials and Methods

Between February 2018 and January 2019, 54,635 cancer deaths were identified from the National Health Insurance Service (NHIS) database. We analyzed the characteristics of decedents who complied with the law process by self-determination compared with decedents with family determination and with decedents who did not comply with the law process.

Results

In multivariable analysis, patients with self-determination were younger, were less likely to live in rural areas, were less likely to belong to the highest income quintile, were less likely to be treated in general hospitals, and were more likely to show a longer time from cancer diagnosis compared with patients with family determination. Compared with patients who did not comply with the law process, patients with self-determination were younger, lived in Seoul or capital area, were less likely to belong to the highest income quintile, were treated in general hospitals, were less likely to have genitourinary or hematologic malignancies, scored higher on the Charlson comorbidity index, and showed a longer time from cancer diagnosis. Patients with self-determination were more likely to use hospice and less likely to use intensive care units (ICUs) at the end-of-life (EOL).

Conclusion

Decedents with self-determination were more likely to be younger, reside in the Seoul or capital area, show a longer time from cancer diagnosis, and were less likely to belong to the highest income quintile. They utilized hospice more frequently, and received less ICU care at the EOL.

eTRIO trial: study protocol of a randomised controlled trial of online education modules to facilitate effective family caregiver involvement in oncology

OBJECTIVE

Informal family caregivers play a crucial role in cancer care. Effective caregiver involvement in cancer care can improve both patient and caregiver outcomes. Despite this, interventions improving the caregiver involvement are sparse. This protocol describes a randomised controlled trial evaluating the combined effectiveness of novel online caregiver communication education modules for: (1) oncology clinicians (eTRIO) and (2) patients with cancer and caregivers (eTRIO-pc).

METHODS AND ANALYSIS

Thirty medical/radiation/surgical oncology or haematology doctors and nurses will be randomly allocated to either intervention (eTRIO) or control (an Australian State Government Health website on caregivers) education conditions. Following completion of education, each clinician will recruit nine patient-caregiver pairs, who will be allocated to the same condition as their recruiting clinician. Eligibility includes any new adult patient diagnosed with any type/stage cancer attending consultations with a caregiver. Approximately 270 patient-caregiver pairs will be recruited. The primary outcome is caregiver self-efficacy in triadic (clinician-patient-caregiver) communication. Patient and clinician self-efficacy in triadic communication are secondary outcomes. Additional secondary outcomes for clinicians include preferences for caregiver involvement, perceived module usability/acceptability, analysis of module use, satisfaction with the module, knowledge of strategies and feedback interviews. Secondary outcomes for caregivers and patients include preferences for caregiver involvement, satisfaction with clinician communication, distress, quality of life, healthcare expenditure, perceived module usability/acceptability and analysis of module use. A subset of patients and caregivers will complete feedback interviews. Secondary outcomes for caregivers include preparedness for caregiving, patient-caregiver communication and caring experience. Assessments will be conducted at baseline, and 1 week, 12 weeks and 26 weeks post-intervention.

ETHICS AND DISSEMINATION

Ethical approval has been received by the Sydney Local Health District Human Research Ethics Committee (REGIS project ID number: 2019/PID09787), with site-specific approval from each recruitment site. Protocol V.7 (dated 1 September 2020) is currently approved and reported in this manuscript. Findings will be disseminated via presentations and peer-reviewed publications. Engagement with clinicians, media, government, consumers and peak cancer groups will facilitate widespread dissemination and long-term availability of the educational modules.

TRIAL REGISTRATION NUMBER

ACTRN12619001507178.

What Should Clinicians Do When a Patient's Autonomy Undermines Her Being Treated Equitably?

Language and cultural barriers can impede communication between patients and clinicians, exacerbating health inequity. Additional complications can arise when family members, intending to protect their loved ones, ask clinicians to lie or not disclose to patients their diagnoses, prognoses, or intervention options. Clinicians must express respect for patients' and families' cultural, religious, and social norms regarding health care decision making, but they might also be ethically troubled by some decisions' effects on patients' health outcomes. This article suggests strategies for clinicians trying to overcome linguistic and cultural barriers to equitable patient care.

Palliative care: needs of advanced breast cancer patients

Advanced breast cancer is characterized by many physical manifestations with the potential to undermine the quality of life (most related to the cancer and some to treatments), as well as substantial impact on psychosocial well-being. Patients with advanced breast cancer and their families have complex needs that have to be addressed in order to minimize severe distress and deterioration in the quality of life of patients and their family members. This task requires the full engagement of an interdisciplinary approach to palliative care with strong emphasis on the assessment of needs and anticipated needs, patient expectations, skilled therapeutics, and commitment to continuity of care. In this review, we address four issues: 1) organizational and conceptual issues in palliative care of patients with breast cancer, 2) common physical symptoms among patients with breast cancer and their management, 3) common psychological issues among patients with breast cancer, and 4) common challenging palliative care problems in breast cancer.

Attitudes of cancer patients and their families toward disclosure of cancer diagnosis in Saudi Arabia: a Middle Eastern population example

OBJECTIVES

Particularly in the Middle East, few studies have explored the attitude of cancer patients and their families toward cancer diagnosis disclosure (CDD). This study was conducted to investigate the preference and attitude of a sample of cancer patients and their families in Saudi Arabia toward CDD.

METHODS

We constructed a questionnaire based on previous studies. The questionnaire assessed preference and attitude toward CDD. Participants were recruited from the King Abdullah Medical City, which has one of the largest cancer centers in Saudi Arabia.

RESULTS

Three hundred and four cancer patients and 277 of their family members participated in the study. The patient group preferred CDD more than the family group (82.6% vs 75.3%, P<0.05). This preference is especially more evident toward disclosure of detailed cancer information (status, prognosis, and treatment) (83.6% vs 59.9%, P<0.001). In a binary logistic regression, factors associated with preference toward CDD included having information about cancer (odds ratio [OR] 1.8; 95% confidence interval [CI], 1.15-2.84) and being employed (OR, 1.77; 95% CI, 1-2.82) while being from the patient group was the only factor associated with preference toward detailed cancer information (OR, 3.25; 95% CI, 2.11-5.05). In terms of patient reaction after CDD, "fear" was the attitude expected by the family group more than the patient group (56.3% vs 70.4%, P<0.001) while "acceptance" was the attitude anticipated by the patient group more than the family group (38% vs 15.2%, P<0.001).

CONCLUSION

Patients preferred CDD and disclosure of related information, while their families were more inclined toward scarce disclosure. Family members seem to experience negative attitudes more than the patients themselves.

Knowledge, Perception, and Attitudes of Cancer Patients Towards Cancer and Cancer Care: Local Perspective from Saudi Arabia

Understanding the attitudes of cancer patients towards different cancer-related issues is very important for the health care provider in order to deliver an optimal care. This survey was designed to collect data about the initial patient's perception and reaction to the diagnosis of cancer, the patient's preference regarding the disclosure of diagnosis, and prevalence and pattern of complementary and alternative medicine (CAM) use. Between January and December 2011, of 234 cancer patients, 42.2 % believed that eye of evil/envy was the cause of their cancers. In 18.3 % of cases, relatives refused to inform the patient about the diagnosis. Participants liked to be the first to be informed, either with relatives at the same time (44.21 %) or alone (33.48 %). Only 7.7 % of participants liked to totally leave decisions to their doctors and/or relatives. There were 53.4 % tried CAM before starting treatment, and 46.7 % continued using CAM during treatment and most of them used more than one type of CAM. Treatment with the Holy Qur'an or Ruqia was widely reported by the study population (92 %). Our survey confirmed that the patient's preference is towards disclosure while the public attitude is, relatively, still against full disclosure. This situation poses a special challenge to the physicians in Kingdom of Saudi Arabia (KSA) when it comes to discussing the disease and treatment. Educational efforts are required to emphasize the curative role of conventional treatment, especially surgery, in many cases. Such efforts should also address the wrong beliefs and misconceptions regarding CAM.

The difficulties experienced by nurses and healthcare staff involved in the process of breaking bad news

AIMS

The aim of this study was to explore the difficulties experienced by nurses and healthcare professionals when engaging in the process of breaking bad news.

BACKGROUND

The challenges faced by staff when breaking bad news have previously been researched in relation to particular settings or participants. This study involved staff from diverse settings and roles to develop broader insights into the range of difficulties experienced in clinical practice.

DESIGN

The study used a descriptive survey design involving self-reported written accounts and framework analysis.

METHODS

Data were collected using a structured questionnaire containing a free text section that asked participants to describe a difficult experience they had encountered when involved in the process of breaking bad news. Data were collected from healthcare staff from hospital, community, hospice and care home settings attending training days on breaking bad news between April 2011 and April 2014.

FINDINGS

Multiple inter-related factors presented challenges to staff engaging in activities associated with breaking bad news. Traditional subjects such as diagnostic and treatment information were described but additional topics were identified such as the impact of illness and care at the end of life. A descriptive framework was developed that summarizes the factors that contribute to creating difficult experiences for staff when breaking bad news.

CONCLUSION

The framework provides insights into the scope of the challenges faced by staff when they engage in the process of breaking bad news. This provides the foundation for developing interventions to support staff that more closely matches their experiences in clinical practice.

The patient who 'must not be told': demographic factors associated with collusion in a retrospective study in South India

BACKGROUND

Patients with cancer need adequate information about diagnosis, treatment options, and possible outcomes and prognosis to make therapeutic decisions. In cultures where the family plays the dominant role in healthcare decisions, doctors are often requested to collude in withholding distressing information from the patient. This challenging situation has not been well studied and there is limited knowledge on the different factors that may contribute to collusion.

OBJECTIVE

To study the prevalence of collusion among adult cancer patients attending a palliative care outpatient clinic and the contributing factors.

METHODS

The healthcare records of 306 adult cancer patients who had visited the palliative care outpatient clinic at least three times with follow-up until death were retrospectively reviewed. Details on information shared and why it was not shared were retrieved from the documentation in the communication sheet in the patient chart. The prevalence, sociodemographic and clinical factors that could contribute to collusion in doctor-patient communication were studied.

RESULTS

Collusion was present in 40% of cases at the time of referral to the palliative care outpatient clinic (collusion regarding diagnosis in 18%; collusion regarding prognosis in 40%). Collusion was later addressed in 35%. Collusion was significantly higher among female patients (p=0.005), manual workers (p=0.035), those not accompanied by a spouse (p=0.000) and with no oncological treatment (p=0.001).

CONCLUSIONS

Collusion regarding diagnosis or prognosis is common among cancer patients referred for palliative care. It was more prevalent among female patients, manual workers, patients who had not received oncological treatment, and patients not accompanied by a spouse.

Discordance among patient preferences, caregiver preferences, and caregiver predictions of patient preferences regarding disclosure of terminal status and end-of-life choices

BACKGROUND

The complexity of end-of-life (EOL) communication in cancer care is often increased by family caregivers, who frequently affect the information and decision-making process. We assessed cancer patient preferences (PP), family caregiver preferences (FCP), and family caregiver predictions of patient preferences (FCPPP) regarding the disclosure of terminal status, family involvement in the disclosure process, and EOL choices, and we evaluated the concordances among them.

METHODS

A national, multicenter, cross-sectional survey of 990 patient-caregiver dyads (participation rate = 76.2%) was performed. A set of paired questionnaires was independently administered to patients and their caregivers.

RESULTS

While patients and family caregivers had wide spectra of preferences, patients significantly preferred disclosure, direct disclosure by a physician, and palliative care options (all P < 0.001). Family caregiver predictions were similar to PP with regard to terminal disclosure (P = 0.35) but significantly different with regard to family involvement in the disclosure process and EOL choices (P < 0.001). The concordances of PP and FCP (κ = 0.08-0.13), and those of PP and FCPPP (κ = 0.09-0.17), were poor. The concordances of FCP and FCPPP were fair to moderate (κ = 0.35-0.67). Discrepancies between PP and FCP and between PP and FCPPP were associated with dysfunctional family communication.

CONCLUSIONS

Family caregivers do not generally concur with patients in their preferences, nor do they reliably predict PP. Open dialogue between patient and family caregivers would reduce the discrepancy. More emphasis on incorporating family caregivers in EOL communication is needed from clinical, research, and training perspectives.

Health care decision making: cross-cultural analysis of the shift from the autonomous to the relational staff

This paper addresses three factors that have contributed to shifts in decision making in health care. First, the notion of patient autonomy, which has changed due to the rise of patient-centred approaches in contemporary health care and the re-conceptualization of the physician-patient relationship. Second, the understanding of patient autonomy has broadened to better engage patient participation. Third, the need to develop cross-cultural health care ethics. Our paper shows that the shift in the West from the individual to the relational self indicates an important change in the understanding of autonomy through the lens of culture. Practices that recognize the notion of the relational self allow for a more balanced view of autonomy and a richer conception of moral agency.

When the family requests withholding the diagnosis: who owns the truth?

Patient autonomy has extended beyond providing sufficient, understandable information before obtaining consent for treatment to the practice of telling patients the truth about their diagnoses and prognoses.

Novel molecular targets for the therapy of urothelial carcinoma

INTRODUCTION

First-line platinum-based combinations are active in locally advanced and metastatic urothelial carcinoma; however, long-term outcomes including disease-specific and overall survival remain suboptimal. In addition, approximately 40 - 50% of patients with advanced urothelial carcinoma have coexisting medical issues that preclude the use of cisplatin-based therapy. Improvements in our understanding of the molecular mechanisms of urothelial tumorigenesis have led to first-generation clinical trials evaluating novel agents targeting molecular pathways. These are particularly relevant in regard to subpopulations. Novel trial designs warrant consideration to accelerate accrual.

AREAS COVERED

In this review, novel molecular targets for the therapy of urothelial carcinoma, as well as recently completed and ongoing clinical trials utilizing novel targeted agents, are discussed. A Medline search with key words, abstracts reported at national conferences on urothelial carcinoma and NCI clinical trial identifiers was used for this review.

EXPERT OPINION

Improved understanding of molecular biology has identified a number of new molecular targets, but there is a seeming absence of one dominant molecular driver for urothelial cancer. An adaptive and biomarker-derived strategy may be warranted. Clinical trials utilizing targeted agents are ongoing and results are awaited.

Current treatment of metastatic bladder cancer and future directions

Metastatic urothelial carcinoma portends a very poor long-term prognosis, with 5-year survival at approximately 5%. The overall survival of metastatic bladder cancer has not improved over the last 20 years. The first-line therapy is cisplatin-based chemotherapy with the response rate approximately 50%. Approximately 30-50% of the patients are unsuitable for cisplatin, and there is no standard of care for this patient population. There is no standard second-line treatment. Several signaling pathways are activated in bladder urothelial carcinoma, but no targeted therapy, either alone or in combination with conventional cytotoxic chemotherapy, has been shown to significantly improve the treatment outcomes. The future of metastatic urothelial carcinoma treatment lies in the ability to deliver personalized therapy. This area remains an active research field today.

Value of current chemotherapy and surgery in advanced and metastatic bladder cancer

The aim of the present paper was to review findings from the most relevant studies and to evaluate the value of current chemotherapy and surgery in advanced unresectable and metastatic bladder cancer. Studies were identified by searching the MEDLINE® and PubMed® databases up to 2011 using both medical subject heading (Mesh) and a free text strategy with the name of the known individual chemotherapeutic drug and the following key words: 'muscle-invasive bladder cancer', 'chemotherapeutics agents', and 'surgery in advanced bladder cancer'. At the end of our literature research we selected 141 articles complying with the aim of the review. The results showed that it has been many years since the MVAC (methotrexate, vinblastine, adriamycin, cisplatin) regimen was first developed. The use of cisplatin-based combination chemotherapy is associated with significant toxicity and produces long-term survival in only approximately 15-20% of patients. Gemcitabine + cisplatin represents the gold standard in the treatment of metastatic bladder cancer. In conclusion, the optimal approach in the management of advanced urothelial cancer continues to evolve. Further progress relies on the expansion of research into tumor biology and an understanding of the underlying molecular 'fingerprints' that can be used to enhance diagnostic and therapeutic strategies. Cisplatin-based therapy has had the best track record thus far.

Use of a Decision Aid to Help Caregivers Discuss Terminal Disease Status With a Family Member With Cancer: A Randomized Controlled Trial

Purpose

We tested whether a decision aid explaining how to discuss the approach of death with a family member with cancer would help family caregivers decide to discuss a terminal prognosis.

Patients and Methods

We randomly assigned caregivers of terminally ill patients with cancer to a group that received a video and a companion workbook that showed either how they can discuss the prognosis with their patient (experimental arm) or how cancer pain can be controlled (control arm). At baseline and 1 month, we evaluated the decision to discuss terminal prognosis as the primary outcome. At 0, 1, 3, and 6 months, we assessed the caregivers' decisional conflict and satisfaction as secondary outcomes using a Decision Conflict Scale (DCS).

Results

We found no difference in changes in the decision to discuss terminal prognosis between the two groups. Conflict (P = .003), uncertainty (P = .019), and value clarity (P = .007) subscale scores and total DCS score (P = .008) improved from baseline to 1 month significantly more in the experimental arm than in the control arm. Over 6 months, the significant between-group differences continued for the conflict (P = .031), uncertainty (P = .014), and value clarity (P = .039) subscale scores and total DCS score (P = .040).

Conclusion

Decision aids can help caregivers, with the aid of trained professionals, to communicate with patients about their terminal illness.

Cultural perspectives in cancer care: impact of Islamic traditions and practices in Middle Eastern countries

People's attitudes to cancer and its treatment are influenced by the patient's and his family's faith, beliefs, societal traditions, and cultural taboos and stigmatism. In most Middle Eastern countries Islam is the dominant religion, yet there are differences as to people's acceptance of cancer, starting with the realization of the diagnosis and the subsequent treatment planning. In many societies in the Middle East, patients prefer that their families will be the first to know about the disease and to agree to the planned treatment protocols. Whereas in Western societies the patient is usually the first to know, understand, and agree to the proposed therapeutic procedures; this is not the case in various Muslim societies. Health care professionals have to accept these kinds of practices and find ways to cope with their patients' sensitivities, thereby preserving their dignity and faith.

Experiences and Attitudes of Patients With Terminal Cancer and Their Family Caregivers Toward the Disclosure of Terminal Illness

Purpose

We investigated the experiences of cancer patients and their family caregivers who became aware that the cancer was terminal, how they became aware, and how they felt about disclosure of the information.

Patients and Methods

In this cohort study, we administered questionnaires to 619 consecutive patients determined by physicians to be terminally ill and to their family caregivers.

Results

A total of 481 patients and 381 family caregivers completed the questionnaire. A majority of patients (58.0%) and caregivers (83.4%) were aware of the patient's terminal status. Approximately 28% of patients and 23% of caregivers reported that they guessed it from the patient's worsening condition. The patient group was more likely than the caregiver group (78.6% v 69.6%) to prefer that patients be informed of their terminal status. Patients informed of their terminal diagnosis had a significantly better quality of life and fewer symptoms and had a lower rate of emotional distress than patients who guessed it from their worsening condition. Younger patients and patients who paid the treatment costs themselves were significantly more likely to want to be told when their illness was terminal. If the patient paid the treatment cost and was employed at the time of the cancer diagnosis, the family caregivers were more likely to prefer disclosure of terminal illness.

Conclusion

Most patients with terminal cancer and their family caregivers preferred disclosure, and patients who knew of their terminal diagnosis had a lower rate of emotional distress and a higher health-related quality of life.

The attitude towards disclosure of bad news to cancer patients in Saudi Arabia

Disclosing the diagnosis or prognosis to cancer patients in Saudi Arabia can be a serious challenge to the physician in his daily clinic practice. The public attitude towards full disclosure is still conservative, and in order to appropriately deal with such an attitude, physicians need to deeply understand its sociocultural background. This article attempts to look into what governs the public attitude towards disclosure in Saudi Arabia as an example of what may affect attitudes in developing countries. It also brings some data from local surveys among physicians and patients as well as from public surveys to describe the changing trend in attitude over the years with a comparative analysis of the Western literature.

Disclosure of Incurable Illness to Spouses: Do They Want to Know? A Swedish Population-Based Follow-Up Study

Purpose

Awareness of the cancer patient's terminal state decreases the risk of psychological morbidity of the bereaved. We wanted to determine whether male spouses of cancer patients who died from their disease had received information that the illness was incurable and to determine their preferences of disclosure.

Participants and Methods

The study included 907 widowers whose wives had died of cancer. In an anonymous questionnaire, we asked whether the widower had received information that his wife's illness was incurable and about his attitudes towards receiving this information.

Results

Six hundred ninety-one widowers (76%) participated. Eighty percent of the widowers reported that they were told that the wife's cancer was incurable, and 21% reported that they had been informed within 1 week before the patient's death. Although 14% of the widowers did not think the next of kin should be told immediately when the patient's cancer is beyond cure, 39% of the men did not want the patient to be immediately informed. Furthermore, 71% of the men who were never informed about the incurable illness believed that the next of kin should receive that information immediately.

Conclusion

Although a large majority of men prefer an immediate disclosure about the incurable stage of their wife's illness, 41% of the husbands received this information during the last week of the patient's life or not at all. These findings indicate that there is room for improvement in the level of communication between health providers and the husbands of women with incurable cancer.