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Gotanda H, Ikesu R, Walling AM, Zhang JJ, Xu H, Reuben DB, Wenger NS, Damberg CL, Zingmond DS, Jena AB, Gross N, Tsugawa Y. Association between physician age and patterns of end-of-life care among older Americans. J Am Geriatr Soc 2024; 72:2070-2081. [PMID: 38721884 PMCID: PMC11226372 DOI: 10.1111/jgs.18939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND End-of-life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age. METHODS We conducted a cross-sectional study of a 20% sample of Medicare fee-for-service beneficiaries aged ≥66 years who died in 2016-2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary-level outcomes by physician age (<40, 40-49, 50-59, or ≥60) in two areas: (1) advance care planning (ACP) and palliative care; and (2) high-intensity care at the EOL. RESULTS Beneficiaries attributed to younger physicians had slightly higher proportions of billed ACP (adjusted proportions, 17.1%, 16.1%, 15.5%, and 14.0% for physicians aged <40, 40-49, 50-59, and ≥60, respectively; p-for-trend adjusted for multiple comparisons <0.001) and palliative care counseling or hospice use in the last 180 days of life (64.5%, 63.6%, 61.9%, and 60.8%; p-for-trend <0.001). Similarly, physicians' younger age was associated with slightly lower proportions of emergency department visits (57.4%, 57.0%, 57.4%, and 58.1%; p-for-trend <0.001), hospital admissions (51.2%, 51.1%, 51.4%, and 52.1%; p-for-trend <0.001), intensive care unit admissions (27.8%, 27.9%, 28.2%, and 28.3%; p-for-trend = 0.03), or mechanical ventilation or cardiopulmonary resuscitation (14.2, 14.9%, 15.2%, and 15.3%; p-for-trend <0.001) in the last 30 days of life, and in-hospital death (20.2%, 20.6%, 21.3%, and 21.5%; p-for-trend <0.001). CONCLUSIONS We found that differences in patterns of EOL care between beneficiaries cared for by younger and older physicians were small, and thus, not clinically meaningful. Future research is warranted to understand the factors that can influence patterns of EOL care provided by physicians, including initial and continuing medical education.
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Affiliation(s)
- Hiroshi Gotanda
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ryo Ikesu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Anne M. Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Jessica J. Zhang
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Neil S. Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - David S. Zingmond
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Anupam B. Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
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Hsieh TC, Yeo YH, Zou G, Zhou C, Ash A. Disparities in Palliative Care Use for Patients With Blood Cancer Who Died in the Hospital. Am J Hosp Palliat Care 2024:10499091241254523. [PMID: 38803232 DOI: 10.1177/10499091241254523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
Background: Palliative care can enhance quality of life during a terminal hospitalization. Despite advances in diagnostic and treatment tools, blood cancers lag behind solid malignancies in palliative use. It is not clear what factors affect palliative care use in blood cancer. Methods: We used the 2016 to 2019 National Inpatient Sample to identify demographic and socioeconomic factors associated with receiving palliative care among patients over age 18 with any malignant hematological diagnosis during a terminal hospitalization lasting at least 3 days, excluding those receiving a stem cell transplant. Results: Palliative care use was documented 54% of the time among 49,720 weighted cases (9944 distinct individual hospitalizations), approximately evenly distributed across the years 2016-2019. Palliative care use was lowest in 2016 (51%) and highest in 2018 (58%), and increased with age, reaching 58% for those 80 years and older. Men and women were similarly likely to receive care. Patients of Hispanic ethnicity and African Americans received less palliative care (47% and 49%, respectively), as did those insured by Medicaid (48%), and those admitted to small or rural hospitals (52% and 47%, respectively). Charges for hospitalizations with palliative care were 19% lower than for those without it. Conclusions: This study highlights disparities in palliative care use among blood-cancer patients who died in the hospital. It seems likely that many of the 46% who did not receive palliative care could have benefitted from it. Interventions are likely needed to achieve equitable access to ideal levels of palliative care services in late-stage blood cancer.
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Affiliation(s)
- Tien-Chan Hsieh
- Division of Hematology-Oncology, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Yee Hui Yeo
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Guangchen Zou
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chan Zhou
- Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Program in Bioinformatics and Integrative Biology, University of Massachusetts Chan Medical School, Worcester, MA, USA
- The RNA Therapeutics Institute, University of Massachusetts Chan Medical School, Worcester, MA, USA
- UMass Cancer Center, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Arlene Ash
- Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
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Shih YA, Lu Q. Oncology nurses' knowledge, attitudes, and practice behaviours towards advance care planning: A nationwide cross-sectional study. NURSE EDUCATION TODAY 2024; 134:106076. [PMID: 38159386 DOI: 10.1016/j.nedt.2023.106076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 12/07/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND With the increasing cancer prevalence in China, discussions surrounding end-of-life care have become more frequent within the purview of oncology nursing. Nonetheless, limited research has explored the current state of Advance Care Planning (ACP) among oncology nurses in China. Hence, it is essential to comprehensively assesses oncology nurses' ACP knowledge, attitudes, and practice behaviours, addressing existing literature gaps and revealing China's oncology nursing ACP status. OBJECTIVES To explore oncology nurses' knowledge, attitudes, and practice behaviours regarding ACP and identify factors impacting ACP practice behaviours. DESIGN A multi-centre, observational, cross-sectional study. SETTINGS The research is conducted in oncology hospitals across 22 provinces, 4 municipalities, and 5 autonomous regions across China. PARTICIPANTS Convenience sampling was used to recruit 1800 registered oncology nurses. METHODS Data were collected via an electronic questionnaire between December 2021 and January 2022. Univariate and hierarchical multiple regression analyses were used for data prediction (P < 0.05). RESULTS In the knowledge section, respondents achieved an average accuracy rate of 51.94 % and demonstrated moderate positive attitudes towards ACP. Their practice behaviour scores were moderately graded. Sociodemographic characteristics and attitude were included as predictors of practice behaviour in the hierarchical multiple regression analysis, explaining 12.2 % and 31.1 % of the variance, respectively. The final model accounted for 43.3 % of the variance. The results indicated that attitudes had a significant and positive impact on practice behaviours, indicating that nurses with more positive attitudes were more likely to engage in ACP practice. CONCLUSIONS Chinese oncology nurses seem to have more positive attitudes towards ACP, but they do not prepare adequately in practice. By enhancing workplace values, beliefs, and policies, it is feasible to enhance the attitudes of oncology nurses towards ACP and, consequently, promote practice behaviours. Furthermore, this study underscores the need for targeted interventions to bridge the gap between positive attitudes and actual ACP implementation among oncology nurses in China.
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Affiliation(s)
- Yi-An Shih
- School of Nursing, Peking University, Beijing, China
| | - Qian Lu
- School of Nursing, Peking University, Beijing, China.
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4
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Bandieri E, Borelli E, Bigi S, Mucciarini C, Gilioli F, Ferrari U, Eliardo S, Luppi M, Potenza L. Positive Psychological Well-Being in Early Palliative Care: A Narrative Review of the Roles of Hope, Gratitude, and Death Acceptance. Curr Oncol 2024; 31:672-684. [PMID: 38392043 PMCID: PMC10888238 DOI: 10.3390/curroncol31020049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/11/2024] [Accepted: 01/19/2024] [Indexed: 02/24/2024] Open
Abstract
In the advanced cancer setting, low psychological functioning is a common symptom and its deleterious impact on health outcomes is well established. Yet, the beneficial role of positive psychological well-being (PPWB) on several clinical conditions has been demonstrated. Early palliative care (EPC) is a recent value-based model consisting of the early integration of palliative care into standard care for solid tumors and hematologic malignancies. While the late palliative care primary offers short-term interventions, predominantly pharmacological in nature and limited to physical symptom reduction, EPC has the potential to act over a longer term, enabling specific interventions aimed at promoting PPWB. This narrative review examines nine English studies retrieved from MEDLINE/PubMed, published up to October 2023, focusing on EPC and three dimensions of PPWB: hope, gratitude, and death acceptance. These dimensions consistently emerge in our clinical experience within the EPC setting for advanced cancer patients and appear to contribute to its clinical efficacy. The choice of a narrative review reflects the novelty of the topic, the limited existing research, and the need to incorporate a variety of methodological approaches for a comprehensive exploration.
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Affiliation(s)
- Elena Bandieri
- Oncology and Palliative Care Units, Civil Hospital Carpi, Unità Sanitaria Locale (USL), 41012 Carpi, Italy; (E.B.); (C.M.); (F.G.); (U.F.); (S.E.)
| | - Eleonora Borelli
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy; (M.L.); (L.P.)
| | - Sarah Bigi
- Department of Linguistic Sciences and Foreign Literatures, Catholic University of the Sacred Heart, 20123 Milan, Italy;
| | - Claudia Mucciarini
- Oncology and Palliative Care Units, Civil Hospital Carpi, Unità Sanitaria Locale (USL), 41012 Carpi, Italy; (E.B.); (C.M.); (F.G.); (U.F.); (S.E.)
| | - Fabio Gilioli
- Oncology and Palliative Care Units, Civil Hospital Carpi, Unità Sanitaria Locale (USL), 41012 Carpi, Italy; (E.B.); (C.M.); (F.G.); (U.F.); (S.E.)
| | - Umberto Ferrari
- Oncology and Palliative Care Units, Civil Hospital Carpi, Unità Sanitaria Locale (USL), 41012 Carpi, Italy; (E.B.); (C.M.); (F.G.); (U.F.); (S.E.)
| | - Sonia Eliardo
- Oncology and Palliative Care Units, Civil Hospital Carpi, Unità Sanitaria Locale (USL), 41012 Carpi, Italy; (E.B.); (C.M.); (F.G.); (U.F.); (S.E.)
| | - Mario Luppi
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy; (M.L.); (L.P.)
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena, 41124 Modena, Italy
| | - Leonardo Potenza
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy; (M.L.); (L.P.)
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena, 41124 Modena, Italy
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Epner DE, Reddy SK, Hui D, Fellman B, Bruera E. Doing the hard work of learning: oncologists' enduring impressions of a year-long communication skills training program. Support Care Cancer 2023; 32:71. [PMID: 38158427 DOI: 10.1007/s00520-023-08285-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE Few studies have examined the long-term impact of communication skills training for oncologists. We developed a year-long communication skills curriculum for medical oncology fellows with the primary goals of fostering life-long learning of patient-centered communication skills and internalization of associated attitudes and beliefs. We engaged learners through reflection, narrative methods, and action methods, thereby creating a non-threatening, team-based environment. The purpose of the current study was to determine whether learners perceived that they had acquired enduring skills, attitudes, and knowledge years after they participated. METHODS Former fellows completed an online cross-sectional survey from June to July 2019 that included demographic information, 21 items on a numerical scale, and 3 narrative prompts. Survey items pertained to 4 domains, including skills, attitudes, confidence with specific scenarios, and overall impressions. The numerical scale ranged from "strongly agree" = 1 to "strongly disagree" = 5. RESULTS A total of 114 fellows, including 27 teaching assistants, participated in the communication skills training over 8 years. The average time between the end of the training program and completion of the survey was 5.2 years. The response rate was 68/114 (64%). Forty-one (60%, 95% CI: 49.3-73.8) fellows agreed or strongly agreed that the curriculum profoundly impacted their practice of medicine. Forty-three (64%, 95% CI: 51.5-75.5) fellows strongly agreed or agreed that they often found themselves informally sharing lessons they learned during the series. Overall average domain scores were 1.89 (SD = 0.84) for skills, 2.16 (0.79) for attitudes, 2.05 (0.81) for confidence with specific challenges, and 2.38 (0.94) for lasting impressions. Results were significantly more favorable for teaching assistants than for others. CONCLUSION Engaging, interactive, safe, and learner-centered communication skills training has an enduring and favorable impact on oncologists' self-perceived skills, confidence with specific challenges, and attitudes.
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Affiliation(s)
- Daniel E Epner
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1414, Houston, TX, 77030, USA.
| | - Suresh K Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1414, Houston, TX, 77030, USA
| | - David Hui
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1414, Houston, TX, 77030, USA
| | - Bryan Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. / Unit 1411, Houston, TX, 77030, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1414, Houston, TX, 77030, USA
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Laughlin BS, Langley N, Patel SH, Kough K, Ernst B, Ashman JB, Rule WG, Vern-Gross TZ. Attitudes and Perception of the REFLECT Communication Curriculum for Clinical Oncology Graduate Medical Education. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2023; 38:1786-1791. [PMID: 37349641 PMCID: PMC10656312 DOI: 10.1007/s13187-023-02333-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 06/24/2023]
Abstract
Communication and interpersonal skills are essential components of oncology patient care. The REFLECT (Respect, Empathy, Facilitate Effective Communication, Listen, Elicit Information, Compassion, and Teach Others) curriculum is a novel framework to improve and refine physician/patient interactions for oncology graduate medical trainees. We seek to evaluate the attitudes and perceptions of the REFLECT communication curriculum among oncology trainees. Seven-question and 8-question Likert scale surveys (1 = not beneficial and 5 = beneficial) were distributed to resident/fellow participants and faculty mentors, respectively. Questions asked trainees and faculty about their perceptions of improvement in communication, handling of stressful situations, the value of the curriculum, and overall impression of the curriculum. Descriptive statistics determined the survey's baseline characteristics and response rates. Kruskal-Wallis rank sum tests were used to compare the distribution of continuous variables. Thirteen resident/fellow participants completed the participant survey. Six (43.6%) Radiation Oncology trainees and 7 (58.3%) Hematology/Oncology fellows completed the trainee survey. Eight (88.9%) Radiation Oncologists and 1 (11.1%) Medical Oncologist completed the observer survey. Faculty and trainees generally felt that the curriculum increased communication skills. Faculty responded more favorably to the program's impact on communication skills (median 5.0 vs. 4.0, p = 0.008). Faculty were more assertive about the curriculum's capabilities to improve a learner's ability to handle stressful situations (median 5.0 vs. 4.0, p = 0.003). Additionally, faculty had a more favorable overall impression of the REFLECT curriculum than the residents/fellows (median 5.0 vs. 4.0, p < 0.001). Radiation Oncology residents felt more strongly that the curriculum enhanced their ability to handle stressful topics, compared to Heme/Onc fellows (median 4.5 vs. 3.0, range 1-5, p = 0.379). Radiation Oncology trainees felt more consistently that the workshops improved their communication skills, compared to Heme/Onc fellows (median 4.5 vs. 3.5, range 1-5, p = 0.410). The overall impression between Rad Onc resident and Heme/Onc fellows was similar (median 4.0, p = 0.586). Conclusions: Overall, the REFLECT curriculum enhanced communication skills of trainees. Oncology trainees and faculty physicians feel that the curriculum was beneficial. As interactive skills and communication is critical to build positive interactions, further work is needed to improve the REFLECT curriculum.
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Affiliation(s)
- Brady S Laughlin
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, 85054, USA.
| | - Natalie Langley
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, AZ, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, 85054, USA
| | | | - Brenda Ernst
- Department of Hematology/Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Jonathan B Ashman
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, 85054, USA
| | - William G Rule
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Tamara Z Vern-Gross
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, 85054, USA
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We were in the fight together: The expectations of bereaved caregivers of patients with acute myeloid leukemia from diagnosis to death. Leuk Res 2023; 124:106994. [PMID: 36481729 DOI: 10.1016/j.leukres.2022.106994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/09/2022] [Accepted: 11/24/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Patients with hematologic malignancies are more optimistic than their oncologists and their expectations may be a barrier to timely hospice care. Patient expectations toward the end of life (EOL), however, have not been characterized. In this study, we analyzed interviews of bereaved caregivers to understand the expectations of patients diagnosed with acute myeloid leukemia and the factors that influenced those expectations, from diagnosis until death. METHODS Bereaved caregivers (n = 19) participated in an in-depth interview that included open-ended and semi-structured prompts, within 18 months following patient death. Interviews were analyzed using a modified grounded theory qualitative approach and constant comparative methods. RESULTS We identified three themes relevant to expectations: Taking Stock, Being Stuck, and Disruption. Caregivers described clear and optimistic early expectations that AML is treatable. It was understood that treatment was required to survive. Later, when treatment options were limited, patients and caregivers became stuck in a belief that the patient could continue to live indefinitely on supportive care or at least until new more effective treatments were available. Caregivers often realized that the patient was at the end of life only when faced with a disruption, an event or conversation that changed their expectations for indefinite patient survival. CONCLUSIONS Caregivers described continued expectations for patient survival until presented with irrefutable evidence to the contrary. The study suggests patients and caregivers may make better EOL care decisions if their early optimism is deliberately moderated by ongoing conversations with clinicians that highlight the sentinel events that signal treatment failure and explain how expectations and goals are changing from living a longer life to dying a more comfortable death.
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van der Velden NC, van Laarhoven HW, Nieuwkerk PT, Kuijper SC, Sommeijer DW, Ottevanger PB, Fiebrich HB, Dohmen SE, Creemers GJ, de Vos FY, Smets EM, Henselmans I. Attitudes Toward Striving for Quality and Length of Life Among Patients With Advanced Cancer and a Poor Prognosis. JCO Oncol Pract 2022; 18:e1818-e1830. [DOI: 10.1200/op.22.00185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE: When deliberating palliative cancer treatment, insight into patients' attitudes toward striving for quality of life (QL) and length of life (LL) may facilitate goal-concordant care. We investigated the (1) attitudes of patients with advanced cancer toward striving for QL and/or LL and whether these change over time, and (2) characteristics associated with these attitudes (over time). METHODS: We performed a secondary analysis of a randomized controlled trial on improving shared decision making (SDM), without differentiation between intervention arms. Patients (n = 173) with advanced cancer, a median life expectancy of < 12 months without anticancer treatment, and a median survival benefit of < 6 months from systemic therapy were included in seven Dutch hospitals. We used audio-recorded consultations and surveys at baseline (T0), shortly after the consultation (T2), at 3 and 6 months (T3 and T4). Primary outcomes were patients' attitudes toward striving for QL and LL (Quality Quantity Questionnaire; T2, T3, and T4). RESULTS: Overall, patients' attitudes toward striving for QL became less positive over 6 months ( P < .01); attitudes toward striving for LL did not change on group level. Studying individual patients, 76% showed changes in their attitudes toward striving for QL and/or LL at some point during the study, which occurred in various directions. More helplessness/hopelessness ( P < .001), less fighting spirit ( P < .05), less state anxiety ( P < .001), and more observed SDM ( P < .05) related to more positive attitudes toward striving for QL. Lower education, less helplessness/hopelessness, more fighting spirit, and more state anxiety ( P < .001) related to more positive attitudes toward striving for LL. CONCLUSION: Oncologists may explore patients' attitudes toward striving for QL and LL repeatedly and address patients' coping style and emotions during SDM to facilitate goal-concordant care throughout the last phase of life.
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Affiliation(s)
- Naomi C.A. van der Velden
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Hanneke W.M. van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Pythia T. Nieuwkerk
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Steven C. Kuijper
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Dirkje W. Sommeijer
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Department of Medical Oncology, Flevoziekenhuis, Almere, the Netherlands
| | - Petronella B. Ottevanger
- Department of Medical Oncology, Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands
| | | | - Serge E. Dohmen
- Department of Medical Oncology, BovenIJ Ziekenhuis, Amsterdam, the Netherlands
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Filip Y.F.L. de Vos
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ellen M.A. Smets
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Inge Henselmans
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
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9
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van der Velden NCA, van Laarhoven HWM, Burgers SA, Hendriks LEL, de Vos FYFL, Dingemans AMC, Jansen J, van Haarst JMW, Dits J, Smets EM, Henselmans I. Characteristics of patients with advanced cancer preferring not to know prognosis: a multicenter survey study. BMC Cancer 2022; 22:941. [PMID: 36050628 PMCID: PMC9434918 DOI: 10.1186/s12885-022-09911-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/14/2022] [Indexed: 12/14/2022] Open
Abstract
Background For some patients with advanced cancer not knowing prognosis is essential. Yet, in an era of informed decision-making, the potential protective function of unawareness is easily overlooked. We aimed to investigate 1) the proportion of advanced cancer patients preferring not to know prognosis; 2) the reasons underlying patients’ prognostic information preference; 3) the characteristics associated with patients’ prognostic information preference; and 4) the concordance between physicians’ perceived and patients’ actual prognostic information preference. Methods This is a cross-sectional study with structured surveys (PROSPECT). Medical and thoracic oncologists included patients (n = 524), from seven Dutch hospitals, with metastatic/inoperable cancer and an expected median overall survival of ≤ 12 months. For analysis, descriptive statistics and logistic regression models were used. Results Twenty-five to 31% of patients preferred not to know a general life expectancy estimate or the 5/2/1-year mortality risk. Compared to patients preferring to know prognosis, patients preferring unawareness more often reported optimism, avoidance and inability to comprehend information as reasons for wanting limited information; and less often reported expectations of others, anxiety, autonomy and a sense of control as reasons for wanting complete information. Females (p < .05), patients receiving a further line of systemic treatment (p < .01) and patients with strong fighting spirit (p < .001) were more likely to prefer not to know prognosis. Concordance between physicians’ perceived and patients’ actual prognostic information preference was poor (kappa = 0.07). Conclusions We encourage physicians to explore patients’ prognostic information preferences and the underlying reasons explicitly, enabling individually tailored communication. Future studies may investigate changes in patients’ prognostic information preferences over time and examine the impact of prognostic disclosure on patients who prefer unawareness. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09911-8.
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Affiliation(s)
- Naomi C A van der Velden
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Sjaak A Burgers
- Department of Thoracic Oncology, Netherlands Cancer Institute, Antoni Van Leeuwenhoek Ziekenhuis, Amsterdam, The Netherlands
| | - Lizza E L Hendriks
- Department of Pulmonary Diseases, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Filip Y F L de Vos
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anne-Marie C Dingemans
- Department of Pulmonary Diseases, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joost Jansen
- Department of Pulmonary Diseases, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan-Maarten W van Haarst
- Department of Respiratory Medicine and Department of Surgery, Tergooi Ziekenhuis, Hilversum, The Netherlands
| | - Joyce Dits
- Department of Pulmonology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Ellen Ma Smets
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Inge Henselmans
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Cripe LD, Vater LB, Lilly JA, Larimer A, Hoffmann ML, Frankel RM. Goals of care communication and higher-value care for patients with advanced-stage cancer: A systematic review of the evidence. PATIENT EDUCATION AND COUNSELING 2022; 105:1138-1151. [PMID: 34489147 DOI: 10.1016/j.pec.2021.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/23/2021] [Accepted: 08/20/2021] [Indexed: 06/13/2023]
Abstract
CONTEXT Goals-of-care communication (GOCC) is recommended to increase the value of cancer care near the end of life (EOL). OBJECTIVES Conduct a systematic review of the evidence that GOCC is associated with higher-value care. METHODS We searched PubMed, Scopus, Ovid MEDLINE, EMBASE, EMB Reviews, CINAHL, and PsycInfo from inception to July 2019. We analyzed the population,design, and results and the authors' definitions of GOCC. Risk of bias was assessed. RESULTS Thirty-two articles were selected. Ten articles reported results from 8 interventions; 17 characterized participants' perspectives; and 5 were retrospective The topics, behaviors, timing, and anticipated outcomes of GOCC varied significantly and were indistinguishable from practices such as advance care planning. GOCC typically focused on treatment outcomes rather than patients' goals. Four of 5 interventions increased evidence of GOCC after clinician training. Only one reported improved patient outcomes. CONCLUSION No consensus exists about what GOCC entails. There is limited evidence that GOCC increases the value of EOL care. PRACTICE IMPLICATIONS Future studies should focus on how to engage patients in conversations about their personal goals and integrate their goals into care planning. Clinicians can encourage GOCC by explaining how patients' goals influence decisions especially as treatment options become limited.
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Affiliation(s)
- Larry D Cripe
- Indiana University School of Medicine, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Simon Cancer Center, 473 Barnhill Drive, Indianapolis, IN 46202, USA.
| | - Laura B Vater
- Indiana University School of Medicine, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Simon Cancer Center, 473 Barnhill Drive, Indianapolis, IN 46202, USA.
| | - Jason A Lilly
- Indiana University Health, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Medical Library, 473 Barnhill Drive, Indianapolis, IN 46202, USA.
| | - Angeline Larimer
- Indiana University Purdue University at Indianapolis (IUPUI), 473 Barnhill Drive, Indianapolis, IN 46202, USA.
| | - Mary Lynn Hoffmann
- Indiana University School of Medicine, 473 Barnhill Drive, Indianapolis, IN 46202, USA.
| | - Richard M Frankel
- Indiana University School of Medicine, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Simon Cancer Center, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Regenstrief Institute, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Purdue University at Indianapolis (IUPUI), 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Health, 473 Barnhill Drive, Indianapolis, IN 46202, USA; Indiana University Medical Library, 473 Barnhill Drive, Indianapolis, IN 46202, USA.
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11
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Swillens JEM, Voorham QJM, Nagtegaal ID, Hermens RPMG. Improving Interdisciplinary Communication: Barriers and Facilitators for Implementation of Standardized Structured Reporting in Oncology. J Natl Compr Canc Netw 2021; 19:1-11. [PMID: 34653965 DOI: 10.6004/jnccn.2021.7002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 01/06/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Standardized structured reporting (SSR) improves quality of diagnostic cancer reporting and interdisciplinary communication in multidisciplinary team (MDT) meetings, resulting in more adequate treatment decisions and better health outcomes. However, use of SSR varies widely among pathologists, but might be encouraged by MDT members (MDTMs). Our objectives were to identify barriers and facilitators (influencing factors) for SSR implementation in oncologic pathology from the perspective of MDTMs and their determinants. METHODS In a multimethod design, we identified influencing factors for SSR implementation related to MDT meetings, using 5 domains: (1) innovation factors, (2) individual professional factors, (3) social setting factors, (4) organizational factors, and (5) political and legal factors. Four focus groups with MDTMs in urologic, gynecologic, and gastroenterologic oncology were conducted. We used an eSurvey among MDTMs to quantify the qualitative findings and to analyze determinants affecting these influencing factors. RESULTS Twenty-three MDTMs practicing in 9 oncology-related disciplines participated in the focus groups and yielded 28 barriers and 28 facilitators in all domains. The eSurvey yielded 211 responses. Main barriers related to lack of readability of SSR: difficulties with capturing nuances (66%) and formulation of the conclusion (43%); lack of transparency in the development (50%) and feedback processes of SSR templates (38%); and lack of information exchange about SSR between pathologists and other MDTMs (45%). Main facilitators were encouragement of pathologists' SSR use by MDTMs (90%) and expanding the recommendation of SSR use in national guidelines (80%). Oncology-related medical discipline and MDT type were the most relevant determinants for SSR implementation barriers. CONCLUSIONS Although SSR makes diagnostic reports more complete, this study shows important barriers in implementing SSR in oncologic pathology. The next step is to use these factors for developing and testing implementation tools to improve SSR implementation.
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Affiliation(s)
- Julie E M Swillens
- 1Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen
| | | | - Iris D Nagtegaal
- 3Department of Pathology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Rosella P M G Hermens
- 1Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen
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12
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Prater LC, O'Rourke B, Schnell P, Xu W, Li Y, Gustin J, Lockwood B, Lustberg M, White S, Happ MB, Retchin SM, Wickizer TM, Bose-Brill S. Examining the Association of Billed Advance Care Planning With End-of-Life Hospital Admissions Among Advanced Cancer Patients in Hospice. Am J Hosp Palliat Care 2021; 39:504-510. [PMID: 34427154 DOI: 10.1177/10499091211039449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Advance care planning (ACP), or the consideration and communication of care preferences for the end-of-life (EOL), is a critical process for improving quality of care for patients with advanced cancer. The incorporation of billed service codes for ACP allows for new inquiries on the association between systematic ACP and improved EOL outcomes. OBJECTIVE Using the IBM MarketScan® Database, we conducted a retrospective medical claims analysis for patients with an advanced cancer diagnosis and referral to hospice between January 2016 and December 2017. We evaluated the association between billed ACP services and EOL hospital admissions in the final 30 days of life. DESIGN This is a cross-sectional retrospective cohort study. PARTICIPANTS A total of 3,705 patients met the study criteria. MAIN MEASURES ACP was measured via the presence of a billed ACP encounter (codes 99497 and 99498) prior to the last 30 days of life; hospital admissions included a dichotomous indicator for inpatient admission in the final 30 days of life. KEY RESULTS Controlling for key covariates, patients who received billed ACP were less likely to experience inpatient hospital admissions in the final 30 days of life compared to those not receiving billed ACP (OR: 0.34; p < 0.001). CONCLUSION The receipt of a billed ACP encounter is associated with reduced EOL hospital admissions in a population of patients with advanced cancer on hospice care. Strategies for consistent, anticipatory delivery of billable ACP services prior to hospice referral may prevent potentially undesired late-life hospital admissions.
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Affiliation(s)
- Laura C Prater
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.,Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Brian O'Rourke
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Patrick Schnell
- Division of Biostatistics, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Wendy Xu
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Yiting Li
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Jillian Gustin
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Bethany Lockwood
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Maryam Lustberg
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus OH, USA.,James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Susan White
- James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary Beth Happ
- The Ohio State University College of Nursing, Columbus, OH, USA
| | - Sheldon M Retchin
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.,Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Thomas M Wickizer
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Seuli Bose-Brill
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Facilitating communication for critically ill patients and their family members: Study protocol for two randomized trials implemented in the U.S. and France. Contemp Clin Trials 2021; 107:106465. [PMID: 34091062 DOI: 10.1016/j.cct.2021.106465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/14/2021] [Accepted: 05/31/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Critically-ill patients and their families suffer a high burden of psychological symptoms due, in part, to many transitions among clinicians and settings during and after critical illness, resulting in fragmented care. Communication facilitators may help. DESIGN AND INTERVENTION We are conducting two cluster-randomized trials, one in the U.S. and one in France, with the goal of evaluating a nurse facilitator trained to support, model, and teach communication strategies enabling patients and families to secure care consistent with patients' goals, beginning in ICU and continuing for 3 months. PARTICIPANTS We will randomize 376 critically-ill patients in the US and 400 in France to intervention or usual care. Eligible patients have a risk of hospital mortality of greater than15% or a chronic illness with a median survival of approximately 2 years or less. OUTCOMES We assess effectiveness with patient- and family-centered outcomes, including symptoms of depression, anxiety, and post-traumatic stress, as well as assessments of goal-concordant care, at 1-, 3-, and 6-months post-randomization. The primary outcome is family symptoms of depression over 6 months. We also evaluate whether the intervention improves value by reducing utilization while improving outcomes. Finally, we use mixed methods to explore implementation factors associated with implementation outcomes (acceptability, fidelity, acceptability, penetration) to inform dissemination. Conducting the trial in U.S. and France will provide insights into differences and similarities between countries. CONCLUSIONS We describe the design of two randomized trials of a communication facilitator for improving outcomes for critically ill patients and their families in two countries.
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14
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Kuusisto A, Santavirta J, Saranto K, Haavisto E. Healthcare professionals' perceptions of advance care planning in palliative care unit: a qualitative descriptive study. J Clin Nurs 2020; 30:633-644. [PMID: 33275801 DOI: 10.1111/jocn.15578] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/12/2020] [Accepted: 11/21/2020] [Indexed: 01/10/2023]
Abstract
AIMS AND OBJECTIVES To describe healthcare professionals' perceptions of advance care planning (ACP) in palliative care unit in hospital ward or outpatient clinic. BACKGROUND Clinical guidelines recommend timely ACP as a central component of patient-centred palliative care. However, the ACP concept and terminology have been judged to be confusing, and practices are not established. Professionals' views are needed for ACP adoption and usage. DESIGN Qualitative descriptive design. METHODS The study used purposive sampling. The data were collected through focus group interviews with registered nurses and practical nurses and individual or couple interviews with physicians and social workers. The data (n = 33) were analysed by inductive content analysis. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. RESULTS Three main categories emerged: Information content of ACP, coordination of care activities through ACP, and support for patients' and family members' coping. The information content of ACP included assessment of need for patient care, preparing for changes in patient's state of health and proactive medication. Coordination of care activities through ACP contained ACP care planning, cooperation and work practices between healthcare professionals. Support for patients' and family members' coping included communication between patient, family members and professionals and promoting patient self-care. CONCLUSIONS ACP is a useful and proactive tool for integrating patient-centred information, care and services as well as support for patients' and family members' coping. Palliative care activities can be coordinated through ACP in a multidisciplinary manner. ACP is significant and relevant for both professionals' work and patient care throughout the service system. RELEVANCE TO CLINICAL PRACTICE Results highlight the importance of proactive, concrete and holistic ACP. ACP should be up to date to reflect patient's current wishes. Raising professional awareness and implementing ACP into work processes are essential. Results can be utilised in planning and implementing interprofessional in-service training.
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Affiliation(s)
- Anne Kuusisto
- Department of Nursing Science, University of Turku, Turku, Finland.,Satakunta Hospital District, Pori, Finland
| | | | - Kaija Saranto
- Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland
| | - Elina Haavisto
- Department of Nursing Science, University of Turku, Turku, Finland.,Satakunta Hospital District, Pori, Finland
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Joung SY, Lee CW, Choi YS, Kim SM, Park SW, Mo ES, Park JH, Shin J, Lee HJ, Park HS. Analysis of the Time Interval between the Physician Order for Life-Sustaining Treatment Completion and Death. Korean J Fam Med 2020; 41:392-397. [PMID: 32429012 PMCID: PMC7700825 DOI: 10.4082/kjfm.19.0077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/11/2019] [Accepted: 10/04/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND This study aimed to explore the time interval distribution pattern between the Physicians Order for Life-Sustaining Treatment (POLST) form completion and death at a tertiary hospital in South Korea. It also examined the association between various independent parameters and POLST form completion timing. METHODS A total of 150 critically ill patients admitted to Korea University Guro Hospital between June 1, 2018 and December 31, 2018 who completed the POLST form were retrospectively analyzed and included in this study. Data were analyzed with descriptive statistics, and group comparisons were performed using the chi-square test for categorical variables. Fisher's exact test was also used to compare cancer versus non-cancer groups. RESULTS More than half the decedents (54.7%) completed their POLST within 15 days of death and 73.4% within 30 days. The non-cancer group had the highest percentage of patients (77.8%) who died within 15 days of POLST form completion while the colorectal (39.1%) and other cancer (37.5%) groups had the lowest (P=0.336). CONCLUSION Our findings demonstrated a current need for more explicit guidance to assist physicians with initiating more timely, proactive end-of-life discussions.
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Affiliation(s)
- Sung Yoon Joung
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Chung-woo Lee
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Youn Seon Choi
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Seon Mee Kim
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Seok Won Park
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Eun Shik Mo
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Jae Hyun Park
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Jean Shin
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Hyun Jin Lee
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Hong Seok Park
- Department of Urology, Korea University Guro Hospital, Seoul, Korea
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16
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Resick JM, Arnold RM, Sudore RL, Farrell D, Belin S, Althouse AD, Ferrell B, Hammes BJ, Chu E, White DB, Rak KJ, Schenker Y. Patient-centered and efficacious advance care planning in cancer: Protocol and key design considerations for the PEACe-compare trial. Contemp Clin Trials 2020; 96:106071. [PMID: 32739493 PMCID: PMC7510772 DOI: 10.1016/j.cct.2020.106071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/05/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Failure to deliver care near the end of life that reflects the needs, values and preferences of patients with advanced cancer remains a major shortcoming of our cancer care delivery system. METHODS A mixed-methods comparative effectiveness trial of in-person advance care planning (ACP) discussions versus web-based ACP is currently underway at oncology practices in Western Pennsylvania. Patients with advanced cancer and their caregivers are invited to enroll. Participants are randomized to either (1) in-person ACP discussions via face-to-face visits with a nurse facilitator following the Respecting Choices® Conversation Guide or (2) web-based ACP using the PREPARE for your care™ web-based ACP tool. The trial compares the effect of these two interventions on patient and family caregiver outcomes (engagement in ACP, primary outcome; ACP discussions; advance directive (AD) completion; quality of end-of-life (EOL) care; EOL goal attainment; caregiver psychological symptoms; healthcare utilization at EOL) and assesses implementation costs. Factors influencing ACP effectiveness are assessed via in-depth interviews with patients, caregivers and clinicians. DISCUSSION This trial will provide new and much-needed empirical evidence about two patient-facing ACP approaches that successfully overcome limitations of traditional written advance directives but entail very different investments of time and resources. It is innovative in using mixed methods to evaluate not only the comparative effectiveness of these approaches, but also the contexts and mechanisms influencing effectiveness. Data from this study will inform clinicians, payers and health systems seeking to adopt and scale the most effective and efficient ACP strategy in real-world oncology settings.
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Affiliation(s)
- Judith M Resick
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
| | - Robert M Arnold
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA; San Francisco Veterans Affairs Health Care System, SFVAMC 4150 Clement Street, #151R, San Francisco, CA 94121, USA.
| | - David Farrell
- People Designs, Inc., 1304 Broad Street, Durham, NC 27705, USA.
| | - Shane Belin
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
| | - Andrew D Althouse
- Center for Research on Health Care Data Center, University of Pittsburgh School of Medicine, 200 Meyran Avenue, Suite 300, Pittsburgh, PA 15213, USA.
| | - Betty Ferrell
- Division of Nursing Research and Education, Department of Population Sciences, City of Hope Medical Center, 1500 Duarte Road, Duarte, CA 91010, USA.
| | - Bernard J Hammes
- Respecting Choices, A Division of C-TAC Innovations, PO Box 258, Oregon, WI 53575-0258, USA.
| | - Edward Chu
- Department of Medicine, Division of Hematology-Oncology and Cancer Therapeutics Program, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Douglas B White
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, USA.
| | - Kimberly J Rak
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 3520 Fifth Ave, Suite100, Pittsburgh, PA 15213, USA.
| | - Yael Schenker
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
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17
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Detering KM, Sellars M, Kelly H, Clayton JM, Buck K, Nolte L. Prevalence of advance care planning documentation and self-reported uptake in older Australians with a cancer diagnosis. J Geriatr Oncol 2020; 12:274-281. [PMID: 32739354 DOI: 10.1016/j.jgo.2020.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/26/2020] [Accepted: 07/18/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Advance care planning (ACP) and completion advance care directives (ACDs) is recommended for patients with cancer. Documentation needs to be available at the point of care. OBJECTIVE(S) To describe the prevalence of ACDs in health records and the self-reported awareness of and engagement in ACP as reported by older Australians with cancer, and to examine the concordance between self-reported completion of and presence of documentation in participants' health records. DESIGN/SETTING/PARTICIPANTS Prospective multi-center audit of health records, and a self-report survey of eligible participants in 51 Australian health and residential aged care services. The audit included 458 people aged ≥65 years with cancer. RESULTS 30% had ≥ ACD located in their record. 218 people were eligible for survey completion; 97 (44% response rate) completed it. Of these, 81% had a preference to limit some/all treatments, 10% wanted to defer decision-making to someone else, and 9% wanted all treatments. Fifty-eight percent of survey completers reported having completed an ACP document. Concordance between documentation in the participant's record and self-report of completion was 61% (k = 0.269), which is only fair agreement. CONCLUSION(S) Whilst 30% of participants had at least one ACD in their record, 58% self-reported document completion, and concordance between self-reported completion and presence in records was only fair. This is significant given most people had a preference for some/all limitation of treatment. Further ACP implementation strategies are required. These include a systematic approach to embedding ACP into routine care, workforce education, increasing community awareness, and looking at e-health solutions to improve accessibility at the point of care.
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Affiliation(s)
- Karen M Detering
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Sciences, Melbourne University, Melbourne, Victoria, Australia; Faculty of Health, Arts and Innovation, Swinburne University, Australia.
| | - Marcus Sellars
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
| | - Helana Kelly
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
| | - Josephine M Clayton
- Centre for Learning & Research in Palliative Care, HammondCare, Greenwich Hospital, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kim Buck
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
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Kawamura A, Harris I, Thomas K, Mema B, Mylopoulos M. Exploring How Pediatric Residents Develop Adaptive Expertise in Communication: The Importance of "Shifts" in Understanding Patient and Family Perspectives. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1066-1072. [PMID: 31464732 DOI: 10.1097/acm.0000000000002963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Communication with patients and families can be complex, especially in challenging discussions. To communicate effectively, expert physicians must often use flexible approaches. This innovative use of knowledge to handle complexity is an essential capability of adaptive expertise. Despite its importance for effective communication and implications for medical education, little is known about how adaptive expertise develops in trainees. The purpose of this study was to explore how pediatric residents developed adaptive expertise in communication. METHOD A constructivist grounded theory study, using observations of physician-patient communication and semistructured interviews as data sources and purposeful sampling of 10 pediatric subspecialty residents at the University of Toronto, was conducted in 2016-2017. Data collection and analysis occurred iteratively, and themes were identified through the research team's constant comparative analysis. RESULTS Residents navigated challenging discussions with patients and families by enabling them to express their own narratives and integrating these with their medical knowledge to provide care. At times, a "shift" in the residents' understanding of the families' perspectives was needed to effectively navigate the discussion. Residents used this shift purposefully to create new communication strategies, resulting in an opportunity for learning. CONCLUSIONS "Shifts" are defined as adjustments in the resident's understanding of a family's perspective that affect clinical care. Analysis suggests that these "shifts" can be understood to support development of adaptive expertise. The workplace learning environment promoted this development by providing opportunities that prepared residents for future learning through active experimentation, offering multiple perspectives and enhancing deeper conceptual learning.
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Affiliation(s)
- Anne Kawamura
- A. Kawamura is associate professor, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. I. Harris is professor, Department of Medical Education, University of Illinois at Chicago, Chicago, Illinois. K. Thomas is a resident, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. B. Mema is associate professor, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. M. Mylopoulos is associate professor, Department of Pediatrics, University of Toronto, Faculty of Medicine, and scientist, Wilson Centre for Research in Education, University of Toronto, Toronto, Ontario, Canada
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19
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de Moor JS, Kent EE, McNeel TS, Virgo KS, Swanberg J, Tracy JK, Banegas MP, Han X, Qin J, Yabroff KR. Employment Outcomes Among Cancer Survivors in the United States: Implications for Cancer Care Delivery. J Natl Cancer Inst 2020; 113:641-644. [PMID: 32533839 DOI: 10.1093/jnci/djaa084] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 05/19/2020] [Accepted: 06/08/2020] [Indexed: 11/14/2022] Open
Abstract
The national prevalence of employment changes after a cancer diagnosis has not been fully documented. Cancer survivors who worked for pay at or since diagnosis (n = 1490) were identified from the 2011, 2016, and 2017 Medical Expenditure Panel Survey and Experiences with Cancer supplement. Analyses characterized employment changes due to cancer and identified correlates of those employment changes. Employment changes were made by 41.3% (95% confidence interval [CI] = 38.0% to 44.6%) of cancer survivors, representing more than 3.5 million adults in the United States. Of these, 75.4% (95% CI = 71.3% to 79.2%) took extended paid time off and 46.1% (95% CI = 41.6% to 50.7%) made other changes, including switching to part-time or to a less demanding job. Cancer survivors who were younger, female, non-White, or multiple races and ethnicities, and younger than age 20 years since last cancer treatment were more likely to make employment changes. Findings highlight the need for patient-provider communication about the effects of cancer and its treatment on employment.
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Affiliation(s)
- Janet S de Moor
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Erin E Kent
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | | | | | - Jennifer Swanberg
- Department of Health Policy & Management, School of Professional Studies, Providence College, Providence, RI, USA
| | | | - Matthew P Banegas
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Xuesong Han
- Surveillance and Health Services Research Program, Department of Intramural Research, American Cancer Society, Atlanta, GA, USA
| | - Jin Qin
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - K Robin Yabroff
- Surveillance and Health Services Research Program, Department of Intramural Research, American Cancer Society, Atlanta, GA, USA
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Kross EK, Rosenberg AR, Engelberg RA, Curtis JR. Postdoctoral Research Training in Palliative Care: Lessons Learned From a T32 Program. J Pain Symptom Manage 2020; 59:750-760.e8. [PMID: 31775020 PMCID: PMC7029795 DOI: 10.1016/j.jpainsymman.2019.11.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 12/20/2022]
Abstract
Our aging population and advances in chronic disease management that prolong the time that patients live with a chronic illness have combined to create an enormous need for improved palliative care research across diverse diseases. In this article, we describe the structure and processes of a National Institutes of Health-funded T32 postdoctoral research fellowship at the University of Washington and our experiences in developing and implementing the program. We recognize a broad definition of palliative care research, including research focused on improving quality of life, minimizing symptoms, providing psychological and spiritual support, and improving communication about patients' values and goals of care, all in the context of a serious illness. We describe our four core principles for postdoctoral training in palliative care research, each with a number of specific approaches: 1) mastering a set of essential content and research skills; 2) structured mentoring and academic career development; 3) creating and supporting early success; and 4) interdisciplinary training and team science. In addition, we also describe our framework for the essential competencies necessary for a palliative care research training program, our methods for identification and selection of applicants, our outcomes to date, and our processes of continuous quality assessment and improvement. Our goal is to describe our successful postdoctoral research training program in palliative care to promote development of new programs and share information between programs to continue to build the field of collaborative and interdisciplinary palliative care research.
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Affiliation(s)
- Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Abby R Rosenberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Hematology/Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.
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Yun YH, Kang E, Park S, Koh SJ, Oh HS, Keam B, Do YR, Chang WJ, Jeong HS, Nam EM, Jung KH, Kim HR, Choo J, Lee J, Sim JA. Efficacy of a Decision Aid Consisting of a Video and Booklet on Advance Care Planning for Advanced Cancer Patients: Randomized Controlled Trial. J Pain Symptom Manage 2019; 58:940-948.e2. [PMID: 31442484 DOI: 10.1016/j.jpainsymman.2019.07.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 11/15/2022]
Abstract
CONTEXT Few randomized controlled trials of advance care planning (ACP) with a decision aid (DA) show an effect on patient preferences for end-of-life (EOL) care over time, especially in racial/ethnic settings outside the U.S. OBJECTIVES The objective of this study was to examine the effect of a decision aid consisting of a video and an ACP booklet for EOL care preferences among patients with advanced cancer. METHODS Using a computer-generated sequence, we randomly assigned (1:1) patients with advanced cancer to a group that received a video and workbook that both discussed either ACP (intervention group) or cancer pain control (control group). At baseline, immediately after intervention, and at 7 weeks, we evaluated the subjects' preferences. The primary outcome was preference for EOL care (active treatment, life-prolonging treatment, or hospice care) on the assumption of a fatal disease diagnosis and the expectation of death 1) within 1 year, 2) within several months, and 3) within a few weeks. We used Bonferroni correction methods for multiple comparisons with an adjusted P level of 0.005. RESULTS From August 2017 to February 2018, we screened 287 eligible patients, of whom 204 were enrolled to the intervention (104 patients) or the control (100 patients). At postintervention, the intervention group showed a significant increase in preference for active treatment, life-prolonging treatment, and hospice care on the assumption of a fatal disease diagnosis and the expectation of death within 1 year (P < 0.005). Assuming a life expectancy of several months, the change in preferences was significant for active treatment and hospice care (P < 0.005) but not for life-prolonging treatment. The intervention group showed a significant increase in preference for active treatment, life-prolonging treatment, and hospice care on the assumption of a fatal disease diagnosis and the expectation of death within a few weeks (P < 0.005). From baseline to 7 weeks, the decrease in preference in the intervention group was not significant for active treatment, life-prolonging treatment, and hospice care in the intervention group in the subset expecting to die within 1 year, compared with the control group. Assuming a life expectancy of several months and a few weeks, the change in preferences was not significant for active treatment and for life-prolonging treatment but was significantly greater for hospice care in the intervention group (P < 0.005). CONCLUSION ACP interventions that included a video and an accompanying book improved preferences for EOL care.
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Affiliation(s)
- Young Ho Yun
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, South Korea; Department of Family Medicine, Seoul National University College of Medicine, Seoul, South Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea.
| | - EunKyo Kang
- Department of Family Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Sohee Park
- Department of Biostatics, Graduate School of Public Health, Yonsei University, Seoul, South Korea
| | - Su-Jin Koh
- Department of Hematology and Oncology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, South Korea
| | - Ho-Suk Oh
- Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, South Korea
| | - Bhumsuk Keam
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Young Rok Do
- Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea
| | - Won Jin Chang
- Division of Hemato-Oncology, Department of Internal medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Hyun Sik Jeong
- Department of Internal Medicine, G Sam Hospital, Gunpo, South Korea
| | - Eun Mi Nam
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hak Ro Kim
- Department of Hematology and Oncology, Pohang Semyeng Christianity Hospital, Pohang, Kyeongbuk, South Korea
| | - Jiyeon Choo
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, South Korea
| | - Jihye Lee
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin-Ah Sim
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, South Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
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George LS, Breitbart W, Prigerson HG. "My Family Wants Something Different": Discordance in Perceived Personal and Family Treatment Preference and Its Association With Do-Not-Resuscitate Order Placement. J Oncol Pract 2019; 15:e942-e947. [PMID: 31509484 DOI: 10.1200/jop.19.00250] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients make treatment decisions based not only on what they want, but what they think their families want. Discordance in such perceived preferences may therefore pose challenges for advance care planning. This study examines discordance in preference for life-extending care versus comfort-focused care and its association with do-not-resuscitate (DNR) order placement. METHODS One hundred eighty-nine patients with advanced cancers refractory to at least one chemotherapy regimen were enrolled in a multisite observational study. In structured interviews, patients reported their preference for treatment maximizing either life extension or comfort; patients also indicated their perception of their families' preference. DNR placement was reported by patients and verified using medical records. RESULTS Approximately 23% of patients (n = 43) perceived discordance between their preference and their families' preference. Patients who perceived discordance were less likely to have completed a DNR compared with those who perceived concordance, even after controlling for relevant confounds (odds ratio = .35; P = .02). Subgroups of discordance and concordance showed varying DNR placement rates (χ2, 19.95; P < .001). DNR placement rate was lowest among discordant subgroups, where there was either a personal (26.7%; four of 15) or family preference for comfort care (28.6%; eight of 28), followed by patients who perceived concordance for wanting life-extending care (34.5%; 29 of 84) and by patients who perceived concordance in wanting comfort-focused care (66.1%; 41 of 62). CONCLUSION Many patients may perceive discordance between personal and family treatment preferences, posing impediments to advance care planning. Such patients may benefit from additional decision support.
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Johns SA, Beck-Coon K, Stutz PV, Talib TL, Chinh K, Cottingham AH, Schmidt K, Shields C, Stout ME, Stump TE, Monahan PO, Torke AM, Helft PR. Mindfulness Training Supports Quality of Life and Advance Care Planning in Adults With Metastatic Cancer and Their Caregivers: Results of a Pilot Study. Am J Hosp Palliat Care 2019; 37:88-99. [PMID: 31378080 DOI: 10.1177/1049909119862254] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Emotional distress often causes patients with cancer and their family caregivers (FCGs) to avoid end-of-life discussions and advance care planning (ACP), which may undermine quality of life (QoL). Most ACP interventions fail to address emotional barriers that impede timely ACP. AIM We assessed feasibility, acceptability, and preliminary effects of a mindfulness-based intervention to facilitate ACP for adults with advanced-stage cancer and their FCGs. DESIGN A single-arm pilot was conducted to assess the impact of a 6-week group mindfulness intervention on ACP behaviors (patients only), QoL, family communication, avoidant coping, distress, and other outcomes from baseline (T1) to post-intervention (T2) and 1 month later (T3). PARTICIPANTS Eligible patients had advanced-stage solid malignancies, limited ACP engagement, and an FCG willing to participate. Thirteen dyads (N = 26 participants) enrolled at an academic cancer center in the United States. RESULTS Of eligible patients, 59.1% enrolled. Attendance (70.8% across 6 sessions) and retention (84.6% for patients; 92.3% for FCGs) through T3 were acceptable. Over 90% of completers reported high intervention satisfaction. From T1 to T3, patient engagement more than doubled in each of 3 ACP behaviors assessed. Patients reported large significant decreases in distress at T2 and T3. Family caregivers reported large significant improvements in QoL and family communication at T2 and T3. Both patients and FCGs reported notable reductions in sleep disturbance and avoidant coping at T3. CONCLUSIONS The mindfulness intervention was feasible and acceptable and supported improvements in ACP and associated outcomes for patients and FCGs. A randomized trial of mindfulness training for ACP is warranted. The study is registered at ClinicalTrials.gov with identifier NCT02367508 ( https://clinicaltrials.gov/ct2/show/NCT02367508 ).
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Affiliation(s)
- Shelley A Johns
- Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Inc, Indianapolis, IN, USA.,Charles Warren Fairbanks Center for Medical Ethics, Indianapolis, IN, USA.,Indiana University-Purdue University Indianapolis RESPECT Center, Indianapolis, IN, USA
| | - Kathleen Beck-Coon
- Indiana University School of Medicine, Indianapolis, IN, USA.,Indiana University School of Nursing, Indianapolis, IN, USA
| | - Patrick V Stutz
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Kelly Chinh
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
| | - Ann H Cottingham
- Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Karen Schmidt
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cleveland Shields
- Department of Human Development and Family Studies, Purdue University, West Lafayette, IN, USA
| | | | - Timothy E Stump
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Alexia M Torke
- Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Inc, Indianapolis, IN, USA.,Charles Warren Fairbanks Center for Medical Ethics, Indianapolis, IN, USA.,Indiana University-Purdue University Indianapolis RESPECT Center, Indianapolis, IN, USA
| | - Paul R Helft
- Indiana University School of Medicine, Indianapolis, IN, USA.,Charles Warren Fairbanks Center for Medical Ethics, Indianapolis, IN, USA.,Indiana University-Purdue University Indianapolis RESPECT Center, Indianapolis, IN, USA.,Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
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24
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Ghose S, Radhakrishnan V, Bhattacharya S. Ethics of cancer care: beyond biology and medicine. Ecancermedicalscience 2019; 13:911. [PMID: 31123494 PMCID: PMC6467456 DOI: 10.3332/ecancer.2019.911] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Indexed: 11/23/2022] Open
Abstract
Treatable cancers are on the rise due to improved early diagnosis and more innovative treatments, and preventative strategies against cancer are becoming a global concern. With the rapidly increasing complexity of cancer treatment, a clear definition of what constitutes ethical cancer care has become a matter of great debate. This situation is more complex in a developing country where healthcare resources are limited. Doctors, nurses and public health professionals engaged in the prevention, screening, diagnosis, treatment and research of cancers are often posed with ethical dilemmas while making complex choices. With a special focus on low- and middle-income countries, this paper is intended to highlight these real-world ethical concerns facing those involved in the management of cancer patients. While taking a neutral view, this paper has adopted a theme-wise approach to discuss barriers in cancer care.
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Affiliation(s)
- Soumita Ghose
- Administration and Policy, Tata Medical Centre, Kolkata 700156, India
| | - Vivek Radhakrishnan
- Department of Clinical Haematology and Hematopoietic Cell Therapy, Tata Medical Centre, Kolkata 700156, India
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Chan A, Chien I, Moseley E, Salman S, Kaminer Bourland S, Lamas D, Walling AM, Tulsky JA, Lindvall C. Deep learning algorithms to identify documentation of serious illness conversations during intensive care unit admissions. Palliat Med 2019; 33:187-196. [PMID: 30427267 DOI: 10.1177/0269216318810421] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Timely documentation of care preferences is an endorsed quality indicator for seriously ill patients admitted to intensive care units. Clinicians document their conversations about these preferences as unstructured free text in clinical notes from electronic health records. Aim: To apply deep learning algorithms for automated identification of serious illness conversations documented in physician notes during intensive care unit admissions. Design: Using a retrospective dataset of physician notes, clinicians annotated all text documenting patient care preferences (goals of care or code status limitations), communication with family, and full code status. Clinician-coded text was used to train algorithms to identify documentation and to validate algorithms. The validated algorithms were deployed to assess the percentage of intensive care unit admissions of patients aged ⩾75 that had care preferences documented within the first 48 h. Setting/participants: Patients admitted to one of five intensive care units. Results: Algorithm performance was calculated by comparing machine-identified documentation to clinician-coded documentation. For detecting care preference documentation at the note level, the algorithm had F1-score of 0.92 (95% confidence interval, 0.89 to 0.95), sensitivity of 93.5% (95% confidence interval, 90.0% to 98.0%), and specificity of 91.0% (95% confidence interval, 86.4% to 95.3%). Applied to 1350 admissions of patients aged ⩾75, we found that 64.7% of patient intensive care unit admissions had care preferences documented within the first 48 h. Conclusion: Deep learning algorithms identified patient care preference documentation with sensitivity and specificity approaching that of clinicians and computed in a tiny fraction of time. Future research should determine the generalizability of these methods in multiple healthcare systems.
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Affiliation(s)
- Alex Chan
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,2 Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Isabel Chien
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,3 Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Edward Moseley
- 4 College of Science and Mathematics, University of Massachusetts Boston, Boston, MA, USA
| | - Saad Salman
- 2 Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | | | - Daniela Lamas
- 5 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Anne M Walling
- 6 Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.,7 Palliative Care, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - James A Tulsky
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,8 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Charlotta Lindvall
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,8 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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26
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Step MM, Ferber GA, Downs-Holmes C, Silverman P. Feasibility of a team based prognosis and treatment goal discussion (T-PAT) with women diagnosed with advanced breast cancer. PATIENT EDUCATION AND COUNSELING 2019; 102:77-84. [PMID: 30150125 DOI: 10.1016/j.pec.2018.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 08/06/2018] [Accepted: 08/10/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To assess the feasibility of a team-based prognosis and treatment goal discussion for women living with advanced breast cancer. METHODS Female patients diagnosed with advanced breast cancer (n = 25) participated in a mixed methods study that evaluated the feasibility and effects of a planned and structured prognosis discussion. Audio analysis of the intervention appointments was conducted to assess intervention feasibility. Patient self-reports of prognosis related beliefs and treatment preferences were compared across intervention and usual care groups. RESULTS Most patients found the T-PAT appointment challenging but worthwhile. Intervention uptake by clinicians was good, but some fidelity disruptions were noted. T-PAT participants were more likely to hold realistic beliefs about disease curability after the appointment. CONCLUSION Productive prognosis discussions can be delivered effectively by a practice-based clinical team within a semi-structured patient education appointment. It was perceived by patients with advanced breast cancer as both valuable and acceptable. T-PAT clinicians found the intervention easy to deliver. PRACTICE IMPLICATIONS Regular implementation of T-PAT may help clinicians' build prognosis discussion communication skills. T-PAT documentation provides valuable information that can be used to tailor ongoing care.
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Affiliation(s)
- Mary M Step
- College of Public Health at Kent State University, Lowry Hall, 750 Hilltop Dr., Kent, OH, 44242, USA.
| | - Gretchen A Ferber
- Northeast Ohio Medical University, 4209 OH-44, Rootstown, OH, 44272, USA
| | - Catherine Downs-Holmes
- University Hospitals Seidman Cancer Center, 11100 Euclid Ave., Cleveland, OH, 44106, USA
| | - Paula Silverman
- School of Medicine at Case Western Reserve University, 11000 Cedar Ave, Cleveland, OH, USA
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Maté-Méndez J, González-Barboteo J, Calsina-Berna A, Mateo-Ortega D, Codorniu-Zamora N, Limonero-García JT, Trelis-Navarro J, Serrano-Bermúdez G, Gómez-Batiste X. The Institut Català D'Oncologia model of Palliative Care: An Integrated and Comprehensive Framework to Address the Essential needs of Patients with Advanced Cancer. J Palliat Care 2018. [DOI: 10.1177/082585971302900406] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jorge Maté-Méndez
- X Gómez-Batiste (corresponding author) Department of Palliative Care, University of Vic, Vic and QUALY Observatory/WHO Collaborating Center for Public Health Palliative Care Programs, Institut Català d'Oncologia, Avinguda Gran Via de l’ Hospitalet 199–203, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jesús González-Barboteo
- Psycho-oncology Unit, Institut Català d'Oncologia, L'Hospitalet de Llobregat and Research Group on Stress and Health, Faculty of Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Agnès Calsina-Berna
- Palliative Care Service, Institut Català d'Oncologia, L'Hospitalet de Llobregat and Department of Palliative Care, University of Vic, Barcelona, Spain
| | - Dolors Mateo-Ortega
- Department of Palliative Care, University of Vic and QUALY Observatory/WHO Collaborating Center for Public Health Palliative Care Programs, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain; N Codorniu-Zamora, G Serrano-Bermúdez: Palliative Care Service, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain; JT Limonero-García: Research Group on Stress and Health, Faculty of Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain; J Trelis-Navarro:
| | - Núria Codorniu-Zamora
- Palliative Care Service, Institut Català d'Oncologia, L'Hospitalet de Llobregat and Department of Palliative Care, University of Vic, Barcelona, Spain
| | - Joaquín T. Limonero-García
- Psycho-oncology Unit, Institut Català d'Oncologia, L'Hospitalet de Llobregat and Research Group on Stress and Health, Faculty of Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Jordi Trelis-Navarro
- Department of Palliative Care, University of Vic and QUALY Observatory/WHO Collaborating Center for Public Health Palliative Care Programs, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain; N Codorniu-Zamora, G Serrano-Bermúdez: Palliative Care Service, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain; JT Limonero-García: Research Group on Stress and Health, Faculty of Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain; J Trelis-Navarro:
| | - Gala Serrano-Bermúdez
- Palliative Care Service, Institut Català d'Oncologia, L'Hospitalet de Llobregat and Department of Palliative Care, University of Vic, Barcelona, Spain
| | - Xavier Gómez-Batiste
- X Gómez-Batiste (corresponding author) Department of Palliative Care, University of Vic, Vic and QUALY Observatory/WHO Collaborating Center for Public Health Palliative Care Programs, Institut Català d'Oncologia, Avinguda Gran Via de l’ Hospitalet 199–203, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
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Steiner JM, Kirkpatrick JN, Heckbert SR, Sibley J, Fausto JA, Engelberg RA, Randall Curtis J. Hospital resource utilization and presence of advance directives at the end of life for adults with congenital heart disease. CONGENIT HEART DIS 2018; 13:721-727. [PMID: 30230232 DOI: 10.1111/chd.12638] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/16/2018] [Accepted: 05/29/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Overall health care resource utilization by adults with congenital heart disease has increased dramatically in the past two decades, yet little is known about utilization patterns at the end of life. The objective of this study is to better understand the patterns and influences on end-of-life care intensity for adults with congenital heart disease. METHODS We identified a sample of adults with congenital heart disease (n = 65), cancer (n = 10 784), or heart failure (n = 3809) who died between January 2010 and December 2015, cared for in one multi-hospital health care system. We used multivariate analysis to evaluate markers of resource utilization, location of death, and documentation of advance care planning among patients with congenital heart disease versus those with cancer and those with heart failure. RESULTS Approximately 40% of adults with congenital heart disease experienced inpatient and intensive care unit (ICU) hospitalizations in the last 30 days of life; 64% died in the hospital. Compared to patients with cancer, patients with adult congenital heart disease (ACHD) were more likely to have inpatient (adjusted risk ratio 1.57; 95% CI 1.12-2.18) and ICU admissions in the last 30 days of life (adjusted risk ratio 2.56; 95% CI 1.83-3.61), more likely to die in the hospital (adjusted risk ratio 1.75; 95% CI 1.43-2.13), and more likely to have documentation of advance care planning (adjusted risk ratio 1.46; 95% CI 1.09-1.96). Compared to patients with heart failure (HF), patients with ACHD were less likely to have an ICU admission in the last 30 days of life (adjusted risk ratio 0.73; 95% CI 0.54-0.99). CONCLUSIONS Adults with congenital heart disease have significant hospital resource utilization near the end of life compared to patients with cancer, notable for more hospitalizations and a higher likelihood of death in the hospital. This population represents an important opportunity for the application of palliative and supportive care.
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Affiliation(s)
- Jill M Steiner
- Division of Cardiology, School of Medicine, University of Washington, Seattle, Washington
| | - James N Kirkpatrick
- Division of Cardiology, School of Medicine, University of Washington, Seattle, Washington
| | - Susan R Heckbert
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
| | - James Sibley
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
| | - James A Fausto
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
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29
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Jimenez G, Tan WS, Virk AK, Low CK, Car J, Ho AHY. Overview of Systematic Reviews of Advance Care Planning: Summary of Evidence and Global Lessons. J Pain Symptom Manage 2018; 56:436-459.e25. [PMID: 29807158 DOI: 10.1016/j.jpainsymman.2018.05.016] [Citation(s) in RCA: 295] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/16/2018] [Accepted: 05/18/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Advance care planning (ACP) involves important decision making about future medical needs. The high-volume and disparate nature of ACP research makes it difficult to grasp the evidence and derive clear policy lessons for policymakers and clinicians. AIM The aim of this study was to synthesize ACP research evidence and identify relevant contextual elements, program features, implementation principles, and impacted outcomes to inform policy and practice. DESIGN An overview of systematic reviews using the Cochrane Handbook of Systematic Reviews of Interventions was performed. Study quality was assessed using a modified version of the AMSTAR (A MeaSurement Tool to Assess Reviews) tool. DATA SOURCES MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE were searched for ACP-related research from inception of each database to April 2017. Searches were supplemented with gray literature and manual searches. Eighty systematic reviews, covering over 1660 original articles, were included in the analysis. RESULTS Legislations, institutional policies, and cultural factors influence ACP development. Positive perceptions toward ACP do not necessarily translate into more end-of-life conversations. Many factors related to patients' and providers' attitudes, and perceptions toward life and mortality influence ACP implementation, decision making, and completion. Limited, low-quality evidence points to several ACP benefits, such as improved end-of-life communication, documentation of care preferences, dying in preferred place, and health care savings. Recurring features that make ACP programs effective include repeated and interactive discussion sessions, decision aids, and interventions targeting multiple stakeholders. CONCLUSIONS Preliminary evidence highlights several elements that influence the ACP process and provides a variety of features that could support successful, effective, and sustainable ACP implementation. However, this evidence is compartmentalized and limited. Further studies evaluating ACP as a unified program and assessing the impact of ACP for different populations, settings, and contexts are needed to develop programs that are able to unleash ACP's full potential.
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Affiliation(s)
- Geronimo Jimenez
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| | - Woan Shin Tan
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; NTU Institute of Health Technologies (HealthTech), Interdisciplinary Graduate School, Nanyang Technological University, Singapore, Singapore; Health Services and Outcomes Research Department, National Healthcare Group, Singapore, Singapore
| | - Amrit K Virk
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Chan Kee Low
- Economics Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore
| | - Josip Car
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Andy Hau Yan Ho
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Psychology Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore; Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
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Foglia MB, Lowery J, Sharpe VA, Tompkins P, Fox E. A Comprehensive Approach to Eliciting, Documenting, and Honoring Patient Wishes for Care Near the End of Life: The Veterans Health Administration's Life-Sustaining Treatment Decisions Initiative. Jt Comm J Qual Patient Saf 2018; 45:47-56. [PMID: 30126715 DOI: 10.1016/j.jcjq.2018.04.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/18/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is an emerging consensus that clinicians should initiate a proactive "goals of care conversation" (GoCC) with patients whose serious illness is likely to involve decisions about life-sustaining treatments (LSTs) such as artificial nutrition, ventilator support, or cardiopulmonary resuscitation. This conversation is intended to elicit the patient's values, goals, and preferences as a basis for shared decisions about treatment planning. LST decisions are often postponed until the patient is within days or even hours of death and no longer able to make his or her goals and preferences known. Decisions then fall to surrogates who may be uncertain about what the patient would have wanted. LIFE-SUSTAINING TREATMENT DECISIONS INITIATIVE (LSTDI) The Veterans Health Administration's Life-Sustaining Treatment Decisions Initiative (LSTDI) was designed to ensure that patients' goals, values, and preferences for LSTs are elicited, documented, and honored across the continuum of care. The LSTDI includes a coordinated set of evidence-based strategies that consists of enterprisewide practice standards for conducting, documenting, and supporting high-quality GoCCs; staff training to enhance proficiency in conducting, documenting, and supporting GoCCs; standardized, durable electronic health record tools for documenting GoCCs; monitoring and information technology tools to support implementation and improvement; a two-year multifacility demonstration project conducted to test and refine strategies and tools and to identify strong practices; and a program of study to evaluate the LSTDI and identify strategies critical to improving care for patients with serious illness. CONCLUSION The LSTDI moves beyond traditional advance care planning by addressing well-documented barriers to goal-concordant care for seriously ill patients.
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State of advance care planning research: A descriptive overview of systematic reviews. Palliat Support Care 2018; 17:234-244. [PMID: 30058506 DOI: 10.1017/s1478951518000500] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To provide an overview of the current state of research of advance care planning (ACP), highlighting most studied topics, publication time, quality of studies and reported outcomes, and to identify gaps to improve ACP receptivity, utilization, implementation, and outcomes. METHOD Cochrane methodology for conducting overviews of systematic reviews. Study quality was assessed using a modified version of the Assessing the Methodological Quality of Systematic Reviews tool. The following databases were searched from inception to April 2017: MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE. Searches were supplemented with gray literature and manual searches. RESULT Eighty systematic reviews, covering 1,662 single articles, show that ACP-related research focuses on nine main topics: (1) ACP as part of end-of-life or palliative care interventions, (2) care decision-making; (3) communication strategies; (4) factors influencing ACP implementation; (5) ACP for specific patient groups, (6) ACP effectiveness; (7) ACP experiences; (8) ACP cost; and (9) ACP outcome measures. The majority of this research was published since 2014, its quality ranges from moderate to low, and reports on documentation, concordance, preferences, and resource utilization outcomes. SIGNIFICANCE OF RESULTS Despite the surge of ACP research, there are major knowledge gaps about ACP initiation, timeliness, optimal content, and impact because of the low quality and fragmentation of the available evidence. Research has mostly focused on discrete aspects within ACP instead of using a holistic evaluative approach that takes into account its intricate working mechanisms, the effects of systems and contexts, and the impacts on multilevel stakeholders. Higher quality studies and innovative interventions are needed to develop effective ACP programs and address research gaps.
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Gómez-Batiste X, Blay C, Broggi MA, Lasmarias C, Vila L, Amblàs J, Espaulella J, Costa X, Martínez-Muñoz M, Robles B, Quintana S, Bertran J, Torralba F, Benito C, Terribas N, Busquets JM, Constante C. Ethical Challenges of Early Identification of Advanced Chronic Patients in Need of Palliative Care. J Palliat Care 2018; 33:247-251. [DOI: 10.1177/0825859718788933] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Palliative care must be early applied to all types of advanced chronic and life limited prognosis patients, present in all health and social services. Patients' early identification and registry allows introducing palliative care gradually concomitant with other measures. Patients undergo a systematic and integrated care process, meant to improve their life quality, which includes multidimensional assessment of their needs, recognition of their values and preferences for advance care planning purposes, treatments review, family care, and case management. Leaded by the National Department of Health, a program for the early identification of these patients has been implemented in Catalonia (Spain). Although the overall benefits expected, the program has raised some ethical issues. In order to address these challenges, diverse institutions, including bioethics and ethics committees, have elaborated a proposal for the program's advantages. This paper describes the process of evaluation, elaboration of recommendations, and actions done in Catalonia.
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Affiliation(s)
- Xavier Gómez-Batiste
- Chair of Palliative Care, University of Vic/WHO Collaborating Center for Palliative Care Public Health Programs, Catalan Institute of Oncology, Barcelona, Spain
| | - Carles Blay
- Chair of Palliative Care, University of Vic/WHO Collaborating Center for Palliative Care Public Health Programs, Catalan Institute of Oncology, Barcelona, Spain
- Program for Prevention and Care of Persons With Chronic Conditions, Department of Health, Government of Catalonia, Barcelona, Spain
| | - Marc Antoni Broggi
- Bioethics Committee of Catalonia, Department of Health, Government of Catalonia, Barcelona, Spain
| | - Cristina Lasmarias
- Chair of Palliative Care, University of Vic/WHO Collaborating Center for Palliative Care Public Health Programs, Catalan Institute of Oncology, Barcelona, Spain
| | - Laura Vila
- Chair of Palliative Care, University of Vic/WHO Collaborating Center for Palliative Care Public Health Programs, Catalan Institute of Oncology, Barcelona, Spain
- SAP Osona, Institut Català de la Salut, Vic, Barcelona, Spain
| | - Jordi Amblàs
- Chair of Palliative Care, University of Vic/WHO Collaborating Center for Palliative Care Public Health Programs, Catalan Institute of Oncology, Barcelona, Spain
- Geriatric Unit, Hospital de Sta Creu/Consorci Hospitalari de Vic, Vic, Barcelona, Spain
| | - Joan Espaulella
- Chair of Palliative Care, University of Vic/WHO Collaborating Center for Palliative Care Public Health Programs, Catalan Institute of Oncology, Barcelona, Spain
- Geriatric Unit, Hospital de Sta Creu/Consorci Hospitalari de Vic, Vic, Barcelona, Spain
| | - Xavier Costa
- Chair of Palliative Care, University of Vic/WHO Collaborating Center for Palliative Care Public Health Programs, Catalan Institute of Oncology, Barcelona, Spain
- SAP Osona, Institut Català de la Salut, Vic, Barcelona, Spain
| | - Marisa Martínez-Muñoz
- Chair of Palliative Care, University of Vic/WHO Collaborating Center for Palliative Care Public Health Programs, Catalan Institute of Oncology, Barcelona, Spain
| | - Bernabé Robles
- Bioethics Committee, Parc Sanitari St Joan de Deu, St Boi Llobregat, Barcelona, Spain
| | - Salvador Quintana
- Bioethics Committee, Hospital Universitari Mútua de Terrassa, Barcelona, Spain
| | - Joan Bertran
- Bioethics Committee, Hospital San Rafael, Barcelona, Spain
| | | | - Carmen Benito
- Bioethics Committee, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | - Josep Maria Busquets
- Bioethics Committee of Catalonia, Department of Health, Government of Catalonia, Barcelona, Spain
| | - Carles Constante
- General Planning and Research Management, Department of Health, Government of Catalonia, Barcelona, Spain
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Abstract
Introduction There has been a growing emphasis on the use of integrated care plans to deliver cancer care. However little is known about how integrated care plans for cancer patients are developed including featured core activities, facilitators for uptake and indicators for assessing impact. Methods Given limited consensus around what constitutes an integrated care plan for cancer patients, a scoping review was conducted to explore the components of integrated care plans and contextual factors that influence design and uptake. Results Five types of integrated care plans based on the stage of cancer care: surgical, systemic, survivorship, palliative and comprehensive (involving a transition between stages) are described in current literature. Breast, esophageal and colorectal cancers were common disease sites. Multi-disciplinary teams, patient needs assessment and transitional planning emerged as key features. Provider buy-in and training alongside informational technology support served as important facilitators for plan uptake. Provider-level measurement was considerably less robust compared to patient and system-level indicators. Conclusions Similarities in design features, components and facilitators across the various types of integrated care plans indicates opportunities to leverage shared features and enable a management lens that spans the trajectory of a patient's journey rather than a phase-specific silo approach to care.
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Gilligan T, Coyle N, Frankel RM, Berry DL, Bohlke K, Epstein RM, Finlay E, Jackson VA, Lathan CS, Loprinzi CL, Nguyen LH, Seigel C, Baile WF. Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline. J Clin Oncol 2017; 35:3618-3632. [PMID: 28892432 DOI: 10.1200/jco.2017.75.2311] [Citation(s) in RCA: 329] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Purpose To provide guidance to oncology clinicians on how to use effective communication to optimize the patient-clinician relationship, patient and clinician well-being, and family well-being. Methods ASCO convened a multidisciplinary panel of medical oncology, psychiatry, nursing, hospice and palliative medicine, communication skills, health disparities, and advocacy experts to produce recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. The systematic review focused on guidelines, systematic reviews and meta-analyses, and randomized controlled trials published from 2006 through October 1, 2016. Results The systematic review included 47 publications. With the exception of clinician training in communication skills, evidence for many of the clinical questions was limited. Draft recommendations underwent two rounds of consensus voting before being finalized. Recommendations In addition to providing guidance regarding core communication skills and tasks that apply across the continuum of cancer care, recommendations address specific topics, such as discussion of goals of care and prognosis, treatment selection, end-of-life care, facilitating family involvement in care, and clinician training in communication skills. Recommendations are accompanied by suggested strategies for implementation. Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki .
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Affiliation(s)
- Timothy Gilligan
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nessa Coyle
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Richard M Frankel
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Donna L Berry
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kari Bohlke
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ronald M Epstein
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Esme Finlay
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vicki A Jackson
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher S Lathan
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles L Loprinzi
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lynne H Nguyen
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carole Seigel
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Walter F Baile
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
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El-Jawahri A, Lau-Min K, Nipp RD, Greer JA, Traeger LN, Moran SM, D'Arpino SM, Hochberg EP, Jackson VA, Cashavelly BJ, Martinson HS, Ryan DP, Temel JS. Processes of code status transitions in hospitalized patients with advanced cancer. Cancer 2017; 123:4895-4902. [PMID: 28881383 DOI: 10.1002/cncr.30969] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/06/2017] [Accepted: 08/08/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although hospitalized patients with advanced cancer have a low chance of surviving cardiopulmonary resuscitation (CPR), the processes by which they change their code status from full code to do not resuscitate (DNR) are unknown. METHODS We conducted a mixed-methods study on a prospective cohort of hospitalized patients with advanced cancer. Two physicians used a consensus-driven medical record review to characterize processes that led to code status order transitions from full code to DNR. RESULTS In total, 1047 hospitalizations were reviewed among 728 patients. Admitting clinicians did not address code status in 53% of hospitalizations, resulting in code status orders of "presumed full." In total, 275 patients (26.3%) transitioned from full code to DNR, and 48.7% (134 of 275 patients) of those had an order of "presumed full" at admission; however, upon further clarification, the patients expressed that they had wished to be DNR before the hospitalization. We identified 3 additional processes leading to order transition from full code to DNR acute clinical deterioration (15.3%), discontinuation of cancer-directed therapy (17.1%), and education about the potential harms/futility of CPR (15.3%). Compared with discontinuing therapy and education, transitions because of acute clinical deterioration were associated with less patient involvement (P = .002), a shorter time to death (P < .001), and a greater likelihood of inpatient death (P = .005). CONCLUSIONS One-half of code status order changes among hospitalized patients with advanced cancer were because of full code orders in patients who had a preference for DNR before hospitalization. Transitions due of acute clinical deterioration were associated with less patient engagement and a higher likelihood of inpatient death. Cancer 2017;123:4895-902. © 2017 American Cancer Society.
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Affiliation(s)
- Areej El-Jawahri
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Kelsey Lau-Min
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ryan D Nipp
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Lara N Traeger
- Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Samantha M Moran
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sara M D'Arpino
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ephraim P Hochberg
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Vicki A Jackson
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Holly S Martinson
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - David P Ryan
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
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Sasaki A, Hiraoka E, Homma Y, Takahashi O, Norisue Y, Kawai K, Fujitani S. Association of code status discussion with invasive procedures among advanced-stage cancer and noncancer patients. Int J Gen Med 2017; 10:207-214. [PMID: 28769583 PMCID: PMC5529109 DOI: 10.2147/ijgm.s136921] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Code status discussion is associated with a decrease in invasive procedures among terminally ill cancer patients. We investigated the association between code status discussion on admission and incidence of invasive procedures, cardiopulmonary resuscitation (CPR), and opioid use among inpatients with advanced stages of cancer and noncancer diseases. Methods We performed a retrospective cohort study in a single center, Ito Municipal Hospital, Japan. Participants were patients who were admitted to the Department of Internal Medicine between October 1, 2013 and August 30, 2015, with advanced-stage cancer and noncancer. We collected demographic data and inquired the presence or absence of code status discussion within 24 hours of admission and whether invasive procedures, including central venous catheter placement, intubation with mechanical ventilation, and CPR for cardiac arrest, and opioid treatment were performed. We investigated the factors associated with CPR events by using multivariate logistic regression analysis. Results Among the total 232 patients, code status was discussed with 115 patients on admission, of which 114 (99.1%) patients had do-not-resuscitate (DNR) orders. The code status was not discussed with the remaining 117 patients on admission, of which 69 (59%) patients had subsequent code status discussion with resultant DNR orders. Code status discussion on admission decreased the incidence of central venous catheter placement, intubation with mechanical ventilation, and CPR in both cancer and noncancer patients. It tended to increase the rate of opioid use. Code status discussion on admission was the only factor associated with the decreased use of CPR (P<0.001, odds ratio =0.03, 95% CI =0.004–0.21), which was found by using multivariate logistic regression analysis. Conclusion Code status discussion on admission is associated with a decrease in invasive procedures and CPR in cancer and noncancer patients. Physicians should be educated about code status discussion to improve end-of-life care.
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Affiliation(s)
| | | | - Yosuke Homma
- Department of Emergency Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu City, Chiba
| | - Osamu Takahashi
- Department of Internal Medicine, St. Luke's International Hospital, Chuo-ku, Tokyo
| | - Yasuhiro Norisue
- Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu City, Chiba
| | - Koji Kawai
- Department of Gastroenterology, Ito Municipal Hospital, Ito City, Shizuoka, Japan
| | - Shigeki Fujitani
- Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu City, Chiba
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Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, Matlock DD, Rietjens JAC, Korfage IJ, Ritchie CS, Kutner JS, Teno JM, Thomas J, McMahan RD, Heyland DK. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. J Pain Symptom Manage 2017; 53:821-832.e1. [PMID: 28062339 PMCID: PMC5728651 DOI: 10.1016/j.jpainsymman.2016.12.331] [Citation(s) in RCA: 887] [Impact Index Per Article: 126.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/21/2016] [Accepted: 12/23/2016] [Indexed: 11/18/2022]
Abstract
CONTEXT Despite increasing interest in advance care planning (ACP) and previous ACP descriptions, a consensus definition does not yet exist to guide clinical, research, and policy initiatives. OBJECTIVE The aim of this study was to develop a consensus definition of ACP for adults. METHODS We convened a Delphi panel of multidisciplinary, international ACP experts consisting of 52 clinicians, researchers, and policy leaders from four countries and a patient/surrogate advisory committee. We conducted 10 rounds using a modified Delphi method and qualitatively analyzed panelists' input. Panelists identified several themes lacking consensus and iteratively discussed and developed a final consensus definition. RESULTS Panelists identified several tensions concerning ACP concepts such as whether the definition should focus on conversations vs. written advance directives; patients' values vs. treatment preferences; current shared decision making vs. future medical decisions; and who should be included in the process. The panel achieved a final consensus one-sentence definition and accompanying goals statement: "Advance care planning is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal of advance care planning is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness." The panel also described strategies to best support adults in ACP. CONCLUSIONS A multidisciplinary Delphi panel developed a consensus definition for ACP for adults that can be used to inform implementation and measurement of ACP clinical, research, and policy initiatives.
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Affiliation(s)
- Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA; San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.
| | - Hillary D Lum
- VA Eastern Colorado Geriatrics Research Education and Clinical Center (GRECC), Denver, Colorado, USA; Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - John J You
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Diane E Meier
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Steven Z Pantilat
- Palliative Care Program, Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Daniel D Matlock
- VA Eastern Colorado Geriatrics Research Education and Clinical Center (GRECC), Denver, Colorado, USA; Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Judith A C Rietjens
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Joan M Teno
- Division of Gerontology and Geriatrics, University of Washington, Seattle, Washington, USA
| | - Judy Thomas
- Coalition for Compassionate Care of California, Sacramento, California, USA
| | - Ryan D McMahan
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University; Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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Park EM, Deal AM, Yopp JM, Edwards T, Stephenson EM, Hailey CE, Nakamura ZM, Rosenstein DL. End-of-life parental communication priorities among bereaved fathers due to cancer. PATIENT EDUCATION AND COUNSELING 2017; 100:1019-1023. [PMID: 28012678 PMCID: PMC5400699 DOI: 10.1016/j.pec.2016.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 11/22/2016] [Accepted: 12/12/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To elicit widowed fathers' perspectives on which domains of parenting-related communication they consider most important for dying parents to discuss at the end of life (EOL). METHODS Two hundred seventy nine fathers widowed by cancer completed a survey about their own depression and bereavement symptoms, their wife's illness, and EOL parental communication priorities. Chi square and Fisher's exact tests and logistic regression were used to evaluate relationships between maternal EOL characteristics and fathers' responses to parenting-related EOL communication priorities. RESULTS Fathers identified raising children in a manner that reflected maternal wishes, whether/how to talk with children about their mother's death, and how the mother wanted to be remembered as the most important EOL communication domains. Fathers who reported that their dying wives were worried about the children were more likely to prioritize raising children in ways that reflect her wishes (p=0.01). Other EOL characteristics were not associated with communication domains. CONCLUSIONS Communicating with children and maintaining emotional connection with the deceased parent are important priorities for bereaved fathers who lost a spouse to cancer. PRACTICE IMPLICATIONS Health care providers working with seriously ill parents may improve family outcomes by supporting communication at the EOL between co-parents.
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Affiliation(s)
- Eliza M Park
- Department of Psychiatry, University of North Carolina, 170 Manning Drive, CB 7305, Chapel Hill, NC 27599, USA.
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center Biostatistics Core Facility, University of North Carolina, 450 West Drive, Chapel Hill, NC 27514, USA
| | - Justin M Yopp
- Department of Psychiatry, University of North Carolina, 170 Manning Drive, CB 7305, Chapel Hill, NC 27599, USA
| | - Teresa Edwards
- H. W. Odum Institute for Research in Social Science, University of North Carolina at Chapel Hill, 208 N. Raleigh St., CB3355, Chapel Hill, NC 27599, USA
| | - Elise M Stephenson
- School of Medicine, University of North Carolina, 321 S. Columbia St., Chapel Hill, NC 27516, USA
| | - Claire E Hailey
- School of Medicine, University of North Carolina, 321 S. Columbia St., Chapel Hill, NC 27516, USA
| | - Zev M Nakamura
- Department of Psychiatry, University of North Carolina, 170 Manning Drive, CB 7305, Chapel Hill, NC 27599, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina, 170 Manning Drive, CB 7305, Chapel Hill, NC 27599, USA; Department of Medicine, University of North Carolina, 125 MacNider Hall, CB7005, Chapel Hill NC 27599, USA
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Palliative Care Quality Indicators for Patients with End-Stage Liver Disease Due to Cirrhosis. Dig Dis Sci 2017; 62:84-92. [PMID: 27804005 PMCID: PMC5384571 DOI: 10.1007/s10620-016-4339-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 10/03/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS There are guidelines for the medical management of cirrhosis and associated quality indicators (QIs), but QIs focusing on standards for palliative aspects of care are needed. METHODS We convened a 9-member, multidisciplinary expert panel and used RAND/UCLA modified Delphi methods to develop palliative care quality indicators for patients with cirrhosis. Experts were provided with a report based on a systematic review of the literature that contained evidence concerning the proposed candidate QIs. Panelists rated QIs prior to a planned meeting using a standard 9-point RAND appropriateness scale. These ratings guided discussion during a day-long phone conference meeting, and final ratings were then provided by panel members. Final QI scores were computed and QIs with a final median score of greater than or equal to 7, and no disagreement was included in the final set. RESULTS Among 28 candidate QIs, the panel rated 19 as valid measures of quality care. These 19 quality indicators cover care related to information and care planning (13) and supportive care (6). CONCLUSIONS These QIs are evidence-based process measures of care that may be useful to improve the quality of palliative care. Research is needed to better understand the quality of palliative care provided to patients with cirrhosis.
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Brown CE, Back AL, Ford DW, Kross EK, Downey L, Shannon SE, Curtis JR, Engelberg RA. Self-Assessment Scores Improve After Simulation-Based Palliative Care Communication Skill Workshops. Am J Hosp Palliat Care 2016; 35:45-51. [PMID: 28273752 DOI: 10.1177/1049909116681972] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND We conducted a randomized trial of a simulation-based multisession workshop to improve palliative care communication skills (Codetalk). Standardized patient assessments demonstrated improved communication skills for trainees receiving the intervention; however, patient and family assessments failed to demonstrate improvement. This article reports findings from trainees' self-assessments. AIM To examine whether Codetalk resulted in improved self-assessed communication competence by trainees. DESIGN Trainees were recruited from the University of Washington and the Medical University of South Carolina. Internal medicine residents, medicine subspecialty fellows, nurse practitioner students, or community-based advanced practice nurses were randomized to Codetalk, a simulation-based workshop, or usual education. The outcome measure was self-assessed competence discussing palliative care needs with patients and was assessed at the start and end of the academic year. We used robust linear regression models to predict self-assessed competency, both as a latent construct and as individual indicators, including randomization status and baseline self-assessed competency. RESULTS We randomized 472 trainees to the intervention (n = 232) or usual education (n = 240). The intervention was associated with an improvement in trainee's overall self-assessment of competence in communication skills ( P < .001). The intervention was also associated with an improvement in trainee self-assessments of 3 of the 4 skill-specific indicators-expressing empathy, discussing spiritual issues, and eliciting goals of care. CONCLUSION Simulation-based communication training was associated with improved self-assessed competency in overall and specific communication skills in this randomized trial. Further research is needed to fully understand the importance and limitations of self-assessed competence in relation to other outcomes of improved communication skill.
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Affiliation(s)
- Crystal E Brown
- 1 Division of Pulmonary and Critical Care, Department of Medicine, Harborview Medical Center, University of Washington, Seattle WA, USA
| | - Anthony L Back
- 2 Division of Medical Oncology, Department of Medicine, Seattle Cancer Care Alliance, University of Washington and Fred Hutchinson Cancer Research Center, Seattle WA, USA
| | - Dee W Ford
- 3 Division of Pulmonary and Critical Care, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Erin K Kross
- 1 Division of Pulmonary and Critical Care, Department of Medicine, Harborview Medical Center, University of Washington, Seattle WA, USA
| | - Lois Downey
- 1 Division of Pulmonary and Critical Care, Department of Medicine, Harborview Medical Center, University of Washington, Seattle WA, USA
| | - Sarah E Shannon
- 4 School of Nursing, Oregon Health & Sciences University, Portland, OR, USA
| | - J Randall Curtis
- 1 Division of Pulmonary and Critical Care, Department of Medicine, Harborview Medical Center, University of Washington, Seattle WA, USA
| | - Ruth A Engelberg
- 1 Division of Pulmonary and Critical Care, Department of Medicine, Harborview Medical Center, University of Washington, Seattle WA, USA
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Peyre M, Gauchet A, Roustit M, Leclercq P, Epaulard O. Influence of the First Consultation on Adherence to Antiretroviral Therapy for HIV-infected Patients. Open AIDS J 2016; 10:182-189. [PMID: 27708747 PMCID: PMC5037933 DOI: 10.2174/1874613601610010182] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 06/29/2016] [Accepted: 08/05/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Physician attitude influences the way patients cope with diagnosis and therapy in chronic severe diseases such as cancer. Previous studies showed that such an effect exists in HIV care; it is likely that it begins with the first contact with a physician. OBJECTIVE We aimed to explore in HIV-infected persons their perception of the first consultation they had with an HIV specialist (PFC-H), and whether this perception correlates with adherence to antiretroviral therapy. METHOD The study was conducted in Grenoble University Hospital, France, a tertiary care center. Every antiretroviral-experienced patient was asked to freely complete a self-reported, anonymous questionnaire concerning retrospective PFC-H, present adherence (Morisky scale), and present perceptions and beliefs about medicine (BMQ scale). RESULTS One hundred and fifty-one questionnaires were available for evaluation. PFC-H score and adherence were correlated, independently from age, gender, and numbers of pill(s) and of pill intake(s) per day. BMQ score also correlated with adherence; structural equation analysis suggested that the effect of PFC-H on adherence is mediated by positive beliefs. CONCLUSION These results suggest that for HIV-infected persons, the perceptions remaining from the first consultation with an HIV specialist physician influence important issues such as adherence and perception about medicine. Physicians must be aware of this potentially long-lasting effect.
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Affiliation(s)
- Marion Peyre
- Service des Maladies Infectieuses, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
- Université Grenoble Alpes, Grenoble,France
| | - Aurélie Gauchet
- Université Grenoble Alpes, Grenoble,France
- Laboratoire Inter-Universitaire de Psychologie - Personnalité, Cognition, Changement Social (LIP/PC2S) EA 4145, Université Grenoble Alpes, Grenoble, France
| | - Matthieu Roustit
- Université Grenoble Alpes, Grenoble,France
- Pharmacologie Clinique - CIC1406, Pôle Recherche, Centre Hospitalier Universitaire de Grenoble,
Grenoble, France
- Inserm, HP2, 38000 Grenoble, France
| | - Pascale Leclercq
- Service des Maladies Infectieuses, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Olivier Epaulard
- Service des Maladies Infectieuses, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
- Université Grenoble Alpes, Grenoble,France
- Team “HIV and other human persistent viruses”, Institut de Biologie Structurale, UMR 5075 UGA-CEA-CNRS, Grenoble, France
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Singer AE, Goebel JR, Kim YS, Dy SM, Ahluwalia SC, Clifford M, Dzeng E, O'Hanlon CE, Motala A, Walling AM, Goldberg J, Meeker D, Ochotorena C, Shanman R, Cui M, Lorenz KA. Populations and Interventions for Palliative and End-of-Life Care: A Systematic Review. J Palliat Med 2016; 19:995-1008. [PMID: 27533892 PMCID: PMC5011630 DOI: 10.1089/jpm.2015.0367] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2016] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Evidence supports palliative care effectiveness. Given workforce constraints and the costs of new services, payers and providers need help to prioritize their investments. They need to know which patients to target, which personnel to hire, and which services best improve outcomes. OBJECTIVE To inform how payers and providers should identify patients with "advanced illness" and the specific interventions they should implement, we reviewed the evidence to identify (1) individuals appropriate for palliative care and (2) elements of health service interventions (personnel involved, use of multidisciplinary teams, and settings of care) effective in achieving better outcomes for patients, caregivers, and the healthcare system. EVIDENCE REVIEW Systematic searches of MEDLINE, EMBASE, PsycINFO, Web of Science, and Cochrane Database of Systematic Reviews databases (1/1/2001-1/8/2015). RESULTS Randomized controlled trials (124) met inclusion criteria. The majority of studies in cancer (49%, 38 of 77 studies) demonstrated statistically significant patient or caregiver outcomes (e.g., p < 0.05), as did those in congestive heart failure (CHF) (62%, 13 of 21), chronic obstructive pulmonary disease (COPD; 58%, 11 of 19), and dementia (60%, 15 of 25). Most prognostic criteria used clinicians' judgment (73%, 22 of 30). Most interventions included a nurse (70%, 69 of 98), and many were nurse-only (39%, 27 of 69). Social workers were well represented, and home-based approaches were common (56%, 70 of 124). Home interventions with visits were more effective than those without (64%, 28 of 44; vs. 46%, 12 of 26). Interventions improved communication and care planning (70%, 12 of 18), psychosocial health (36%, 12 of 33, for depressive symptoms; 41%, 9 of 22, for anxiety), and patient (40%, 8 of 20) and caregiver experiences (63%, 5 of 8). Many interventions reduced hospital use (65%, 11 of 17), but most other economic outcomes, including costs, were poorly characterized. Palliative care teams did not reliably lower healthcare costs (20%, 2 of 10). CONCLUSIONS Palliative care improves cancer, CHF, COPD, and dementia outcomes. Effective models include nurses, social workers, and home-based components, and a focus on communication, psychosocial support, and the patient or caregiver experience. High-quality research on intervention costs and cost outcomes in palliative care is limited.
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Affiliation(s)
- Adam E. Singer
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
- RAND Corporation, Santa Monica, California
| | - Joy R. Goebel
- School of Nursing, California State University, Long Beach, Long Beach, California
| | - Yan S. Kim
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sydney M. Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - Elizabeth Dzeng
- Division of Hospital Medicine, University of California at San Francisco, San Francisco, California
| | - Claire E. O'Hanlon
- RAND Corporation, Santa Monica, California
- Pardee RAND Graduate School, RAND Corporation, Santa Monica, California
| | | | - Anne M. Walling
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
- RAND Corporation, Santa Monica, California
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Jaime Goldberg
- Supportive Care Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniella Meeker
- Department of Preventive Medicine, University of Southern California, Los Angeles, California
| | | | | | - Mike Cui
- RAND Corporation, Pittsburgh, Pennsylvania
| | - Karl A. Lorenz
- RAND Corporation, Santa Monica, California
- Stanford University School of Medicine, Stanford, California
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Abstract
The current state of the science in the fields of patient safety and palliative and end-of-life care have many issues in common. This article synthesizes recent systematic reviews and additional research on improving patient safety and end-of-life care and compares each field’s perspective on common issues, both in traditional patient safety frameworks and in other areas, and how current approaches in each field can inform the other. The article then applies these overlapping concepts to a key example area: improving documentation of patient preferences for life-sustaining treatment. The synthesis demonstrates how end-of-life issues should be incorporated into patient safety initiatives. In addition, evaluating overlap and comparable issues between patient safety and end-of-life care and comparing different perspectives and improvement strategies can benefit both fields.
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Affiliation(s)
- Sydney Morss Dy
- Department of Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins University and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
- Harry J. Duffey Family Pain and Palliative Care Program, Baltimore, MD, USA
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Zafar W, Ghafoor I, Jamshed A, Gul S, Hafeez H. Outcomes of In-Hospital Cardiopulmonary Resuscitation Among Patients With Cancer. Am J Hosp Palliat Care 2016; 34:212-216. [PMID: 26589879 DOI: 10.1177/1049909115617934] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To review all episodes where an emergency code was called in a cancer-specialized hospital in Pakistan and to assess survival to discharge among patients who received a cardiopulmonary resuscitation (CPR). METHODS We reviewed demographic and clinical data related to all "code blue" calls over 3 years. Multivariate logistic regression analyses were used to test the association of clinical characteristics with the primary outcome of survival to discharge. RESULTS A total of 646 code blue calls were included in the analysis. The CPR was performed in 388 (60%) of these calls. For every 20 episodes of CPR among patients with cancer of all ages, only 1 resulted in a patient's survival to discharge, even though in 52.2% episodes there was a return of spontaneous circulation. No association was found between the type of rhythm at initiation of CPR and likelihood of survival to discharge. CONCLUSIONS The proportion of patients with advanced cancer surviving to discharge after in-hospital CPR in a low-income country was in line with the reported international experience. Most patients with cancer who received in-hospital CPR did not survive to discharge and did not appear to benefit from resuscitation. Advance directives by patients with cancer limiting aggressive interventions at end of life and proper documentation of these directives will help in provision of care that is humane and consonant with patients' wishes for a dignified death. Patients' early appreciation of the limited benefits of CPR in advanced cancer is likely to help them formulate such advance directives.
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Affiliation(s)
- Waleed Zafar
- 1 Department of Cancer Registry and Clinical Data Management, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Irum Ghafoor
- 2 Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Arif Jamshed
- 3 Department of Radiation Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Sabika Gul
- 2 Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Haroon Hafeez
- 2 Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
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Fu AZ, Graves KD, Jensen RE, Marshall JL, Formoso M, Potosky AL. Patient preference and decision-making for initiating metastatic colorectal cancer medical treatment. J Cancer Res Clin Oncol 2016; 142:699-706. [PMID: 26577827 PMCID: PMC4752940 DOI: 10.1007/s00432-015-2073-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Some medical treatment for metastatic colorectal cancer (CRC) may have marginal survival benefit, but cause toxicities. The purpose of this study is to determine metastatic CRC patients' tradeoffs in making a decision to undergo new medical treatment. METHODS We conducted a survey of patients with a diagnosis of advanced CRC who were currently receiving or completed one chemotherapy regimen. First, patients were asked to rate the importance of 15 medical treatment-related adverse events that may arise as a consequence of chemotherapy or biological therapy in their treatment decision-making. Then, the patient identified his or her top five most important events and solicited preferences in hypothetical metastatic CRC treatment vignettes using the standard gamble technique. RESULTS A total of 107 patients responded to the survey. From the list of medical treatment-related adverse events, patients identified clinically serious ones such as stroke, heart attack, and gastrointestinal perforation as the most important in their medical treatment decision-making, yet placed lower willingness to tolerate symptom-related events such as pain, fatigue, and depression. Generally, patients who were older, stage III versus IV and who had prior radiotherapy, lower educational attainment, and lower household income (all p <0.05) were less willing to tolerate any medical treatment-related adverse events after adjusting for other demographic and clinical characteristics. CONCLUSIONS Variations in patients' willingness to tolerate different treatment-related adverse events underscore the need for improved communications between physicians and patients about the risks and benefits of their medical treatment, which helps make a more personalized decision for metastatic CRC treatment.
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Affiliation(s)
- Alex Z Fu
- Department of Oncology, Georgetown University, Washington, DC, USA.
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA.
| | - Kristi D Graves
- Department of Oncology, Georgetown University, Washington, DC, USA
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Roxanne E Jensen
- Department of Oncology, Georgetown University, Washington, DC, USA
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - John L Marshall
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Margaret Formoso
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Arnold L Potosky
- Department of Oncology, Georgetown University, Washington, DC, USA
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
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Neubauer MA, Taniguchi CB, Hoverman JR. Improving incidence of code status documentation through process and discipline. J Oncol Pract 2016; 11:e263-6. [PMID: 25784582 DOI: 10.1200/jop.2014.001438] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Documentation of a patient's preferred code status is a critical outcome of advance care planning. Although there is agreement that code status is valuable information, little progress has been made to increase the incidence of documented code status within the medical record in an outpatient setting. Incidence of code status documentation in the community oncology setting has not been studied. In April 2013, the US Oncology Network and McKesson Specialty Health launched a new advance care planning initiative for the purpose of promoting conversations between clinicians and patients regarding end-of-life care preferences. The program-My Choices, My Wishes-provides a systematic approach for learning about and documenting a patient's values and goals for care in the electronic health record. Code status documentation is one of several program performance measures. During the 14-month period from August 1, 2013, through September 30, 2014, collective sites participating in My Choices, My Wishes included discrete code status documentation within the medical record for 5,467 patients with metastatic disease. Although much work remains, early results show promise for improvement in incidence of code status documentation within health records in the outpatient setting.
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Affiliation(s)
- Marcus A Neubauer
- US Oncology Network; and McKesson Specialty Health, The Woodlands, TX
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Dy SM, Herr K, Bernacki RE, Kamal AH, Walling AM, Ersek M, Norton SA. Methodological Research Priorities in Palliative Care and Hospice Quality Measurement. J Pain Symptom Manage 2016; 51:155-62. [PMID: 26596877 DOI: 10.1016/j.jpainsymman.2015.10.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/17/2015] [Accepted: 10/22/2015] [Indexed: 11/26/2022]
Abstract
Quality measurement is a critical tool for improving palliative care and hospice, but significant research is needed to improve the application of quality indicators. We defined methodological priorities for advancing the science of quality measurement in this field based on discussions of the Technical Advisory Panel of the Measuring What Matters consensus project of the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association and a subsequent strategy meeting to better clarify research challenges, priorities, and quality measurement implementation strategies. In this article, we describe three key priorities: 1) defining the denominator(s) (or the population of interest) for palliative care quality indicators, 2) developing methods to measure quality from different data sources, and 3) conducting research to advance the development of patient/family-reported indicators. We then apply these concepts to the key quality domain of advance care planning and address relevance to implementation of indicators in improving care. Developing the science of quality measurement in these key areas of palliative care and hospice will facilitate improved quality measurement across all populations with serious illness and care for patients and families.
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Affiliation(s)
- Sydney Morss Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Keela Herr
- University of Iowa College of Nursing, Iowa City, Iowa, USA
| | - Rachelle E Bernacki
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Ariadne Labs, Boston, Massachusetts, USA; Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard School of Public Health, Boston, Massachusetts, USA
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Anne M Walling
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Mary Ersek
- Corporal Michael J. Crescenz VA Medical Center-Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA; School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sally A Norton
- University of Rochester School of Nursing, Rochester, New York, USA
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Rhodes SM, Gabbard J, Chaudhury A, Ketterer B, Lee EM. Palliative Care. SUPPORTIVE CANCER CARE 2016:77-95. [DOI: 10.1007/978-3-319-24814-1_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2023]
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Clark MA, Ott M, Rogers ML, Politi MC, Miller SC, Moynihan L, Robison K, Stuckey A, Dizon D. Advance care planning as a shared endeavor: completion of ACP documents in a multidisciplinary cancer program. Psychooncology 2015; 26:67-73. [PMID: 26489363 DOI: 10.1002/pon.4010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 07/16/2015] [Accepted: 09/25/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We examined the roles of oncology providers in advance care planning (ACP) delivery in the context of a multidisciplinary cancer program. METHODS Semi-structured interviews were conducted with 200 women with recurrent and/or metastatic breast or gynecologic cancer. Participants were asked to name providers they deemed important in their cancer care and whether they had discussed and/or completed ACP documentation. Evidence of ACP documentation was obtained from chart reviews. RESULTS Fifty percent of participants self-reported completing an advance directive (AD) and 48.5% had named a healthcare power of attorney (HPA), 38.5% had completed both, and 39.0% had completed neither document. Among women who self-reported completion of the documents, only 24.0% and 14.4% of women respectively had documentation of an AD and HPA in their chart. Completion of an AD was associated with number (adjusted odds ratio [AOR] = 1.49) and percentage (AOR = 6.58) of providers with whom the participant had a conversation about end-of-life decisions. Participants who named a social worker or nurse practitioner were more likely to report having completed an AD. Participants who named at least one provider in common (e.g., named the same oncologist) were more likely to have comparable behaviors related to naming a HPA (AOR = 1.13, p = 0.011) and completion of an AD (AOR = 1.06, p = 0.114). CONCLUSIONS Despite the important role of physicians in facilitating ACP discussions, involvement of other staff was associated with a greater likelihood of completion of ACP documentation. Patients may benefit from opportunities to discuss ACP with multiple members of their cancer care team. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Melissa A Clark
- Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA.,Center for Population Health and Clinical Epidemiology, Brown University, Providence, RI, USA.,Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Miles Ott
- Department of Mathematics, Augsburg College, Minneapolis, MN, USA
| | - Michelle L Rogers
- Center for Population Health and Clinical Epidemiology, Brown University, Providence, RI, USA
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University, St. Louis, MO, USA
| | - Susan C Miller
- Department of Health Services, Policy, and Practice, Brown University, Providence, RI, USA.,Center for Gerontology and Health Care Research, Brown University, Providence, RI, USA
| | | | - Katina Robison
- Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI, USA.,Program in Women's Oncology, Women & Infants Hospital, Providence, RI, USA
| | - Ashley Stuckey
- Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI, USA.,Program in Women's Oncology, Women & Infants Hospital, Providence, RI, USA
| | - Don Dizon
- Departments of Hematology and Oncology and Medicine, Massachusetts General Hospital, Boston, MA, USA
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Johnson S, Butow P, Kerridge I, Tattersall M. Advance care planning for cancer patients: a systematic review of perceptions and experiences of patients, families, and healthcare providers. Psychooncology 2015; 25:362-86. [PMID: 26387480 DOI: 10.1002/pon.3926] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/10/2015] [Accepted: 07/07/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients with advanced cancer may benefit from end of life (EOL) planning, but there is evidence that their willingness and desire to engage in advance care planning (ACP) varies. The reasons for this remain poorly understood. Previous reviews on ACP most commonly report outcome measures related to medical interventions and type of care. Synthesis of the literature, which aims to illuminate the salient characteristics of ACP and investigates the psychological and social features of preparation for the EOL, is required. METHODS We searched Medline, EMBASE, PsychINFO, CINAHL, and the Cochrane Central Register of Controlled Trials for studies on perceptions or experiences regarding ACP of adults with cancer, family, friends, or professionals caring for this group. Databases were searched from earliest records to 19 November 2014. A thematic analysis of the literature generated conceptual themes. RESULTS Of the 2483 studies identified, 40 were eligible for inclusion. Studies addressed the relational nature of ACP, fear surrounding ACP, the conceptual complexity of autonomy, and the influence of institutional culture and previous healthcare experiences on ACP. CONCLUSIONS The complex social and emotional environments within which EOL planning is initiated and actioned are not sufficiently embedded within standardized ACP. The notion that ACP is concerned principally with the 'right' to self-determination through control over treatment choices at the EOL may misrepresent the way that ACP actually occurs in cancer care and ultimately conflict with the deeper concerns and needs of patients, who experience ACP as relational, emotional, and social.
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Affiliation(s)
- Stephanie Johnson
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology and Department of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Phyllis Butow
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology and Department of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Ian Kerridge
- Centre for Values, Ethics and the Law in Medicine (Velim), School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Martin Tattersall
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology and Department of Medicine, University of Sydney, Sydney, NSW, Australia
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