1
|
Bolek H, Arslan C, Basaran M, Cicin İ, Ozguroglu M, Tural D, Ürün Y. Perceptions and Expectations: A Study on Prognostic Perception and Quality of Life in Patients With Metastatic Renal and Bladder Cancer. JCO Glob Oncol 2024; 10:e2400201. [PMID: 39208383 DOI: 10.1200/go.24.00201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 06/29/2024] [Accepted: 07/25/2024] [Indexed: 09/04/2024] Open
Abstract
PURPOSE Durable complete response rates for metastatic renal cell carcinoma (mRCC) and metastatic bladder cancer (mBC) are low despite new therapy. Palliative care focuses on life extension and quality of life (QoL), not cure. This study aims to investigate patients' perceptions of treatment outcomes in mRCC and mBC and to assess the influence of QoL and optimism levels on these perceptions. METHODS From March 15, 2023, to January 15, 2024, a multicenter, cross-sectional online survey was carried out, targeting patients diagnosed with mRCC and mBC. The survey comprised structured questions aimed at evaluating perceptions concerning disease cure, symptom improvement, daily activity performance, and life extension due to treatment. Additionally, to evaluate optimism and QoL, the European Organization for Research and Treatment of Cancer 30.3 QoL questionnaire and life orientation test were implemented. Study on patients' perceptions of treatment outcomes in metastatic kidney and bladder cancer shows high optimism, inaccurate cure beliefs. RESULTS In total, 169 patients participated in the survey; the majority of the patients stated their general health status as good (72.2%) and excellent (13.6%). Patients who rated their overall health status as good-excellent had a higher median general QoL and optimism score compared with those who rated it as fair-poor. In all, 85.2% of patients considered the possibility of a cure very likely or likely. Most participants believed treatment could provide symptom relief (30.2% very likely, 49.1% likely), enhanced ability to perform daily activities (28.4% very likely, 55.6% likely), and life extension (32.5% very likely, 53.3% likely). Patients responding very likely and likely to these questions regarding treatment outcomes had higher QoL and optimism scores than those responding a little likely and not possible. CONCLUSION The majority of patients with mRCC and mBC held inaccurate beliefs about treatment outcomes. Better QoL and optimism were associated with increased inaccuracy.
Collapse
Affiliation(s)
- Hatice Bolek
- Department of Medical Oncology, Ankara University School of Medicine, Ankara, Turkey
- Ankara University Cancer Institute, Ankara, Turkey
| | - Cagatay Arslan
- Department of Medical Oncology, Izmir University of Economics, Medical Point Hospital, Izmir, Turkey
| | - Mert Basaran
- Department of Medical Oncology, Istanbul University School of Medicine, Istanbul, Turkey
| | - İrfan Cicin
- Department of Medical Oncology, Trakya University School of Medicine, Edirne, Turkey
| | - Mustafa Ozguroglu
- Department of Medical Oncology, Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Deniz Tural
- Department of Medical Oncology, University of Health Science, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Yüksel Ürün
- Department of Medical Oncology, Ankara University School of Medicine, Ankara, Turkey
- Ankara University Cancer Institute, Ankara, Turkey
| |
Collapse
|
2
|
Naher SK, Mercieca-Bebber R, Siu D, Stockler MR, Kiely BE, Grimison P. Estimating survival scenarios in advanced or metastatic gastric and oesophageal adenocarcinoma: a systematic review of randomized-controlled trials. Curr Med Res Opin 2024; 40:1357-1367. [PMID: 38961804 DOI: 10.1080/03007995.2024.2376129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 06/24/2024] [Accepted: 07/01/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND We aimed to summarize survival data from RCTs in patients with GO adenocarcinoma; estimate and explain worst-, typical-, and best-case-scenarios of survival time; and determine if simple multiples of median overall survival (mOS) could estimate these percentiles. METHODS We systematically searched RCTs of systemic therapies for GO adenocarcinoma published 2000-2022. The following key percentiles were extracted from overall survival curves: 90th (worst-case), 75th (lower-typical), 25th (upper-typical), and 10th (best-case). We tested if these percentiles could be estimated by simple multiples of mOS: 0.25 of the median for the 90th percentile, 0.5 for the 75th, 2 for the 25th, and 3 for the 10th. RESULTS We identified 44 trials (22,447 participants). For first line chemotherapy and immunotherapy combined (CI) trials (n = 3) worst-to-best case survival time ranged from 4 months to not reached, compared to 3-30 months for other trials (n = 27) and 1-23 months for subsequent lines (n = 14). Simple multiples of mOS accurately estimated the following survival percentiles: 90th (n = 3/3 trials), 75th (n = 3/3), and 25th (n = 2/3) in first line CI trials. In other first line trials, the mOS accurately estimated the 90th survival percentile in n = 22/27 trials, 75th percentile in n = 26/27, 25th percentile in 27/27 trials, and 10th percentile in 22/27 trials. Simple multiples of the mOS accurately predicted the 90th, 75th, 25th, and 10th survival percentiles in the majority of trials of second and subsequent lines apart from chemotherapy and immunotherapy only trials. CONCLUSION We provide realistic, evidence-based prognostic information as scenarios for survival time which can inform clinical decision-making. Simple multiples of the mOS accurately estimated the percentiles for most groups.
Collapse
Affiliation(s)
- Sayeda K Naher
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre (CTC), University of Sydney, Camperdown, NSW, Australia
- Illawarra and Shoalhaven Local Health District, Warrawong, NSW, Australia
| | - Rebecca Mercieca-Bebber
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre (CTC), University of Sydney, Camperdown, NSW, Australia
| | - Derrick Siu
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre (CTC), University of Sydney, Camperdown, NSW, Australia
| | - Martin R Stockler
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre (CTC), University of Sydney, Camperdown, NSW, Australia
| | - Belinda E Kiely
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre (CTC), University of Sydney, Camperdown, NSW, Australia
| | | |
Collapse
|
3
|
Papadimos TJ. Prognostication: A fading Hippocratic art? Explore (NY) 2024; 20:103026. [PMID: 39002395 DOI: 10.1016/j.explore.2024.103026] [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: 06/05/2024] [Revised: 06/18/2024] [Accepted: 06/29/2024] [Indexed: 07/15/2024]
Abstract
Over the past 75 years modern medicine has advanced in its ability to diagnose and treat many diseases. However, the medical profession's ability to prognosticate the course and outcome of an illness has not satisfied the needs of many patients. Physicians must not lose the ability, or desire, to consider the whole person in relation to a patient's disease. We need to ask ourselves what person has the disease, not what disease the person has. Here I endeavor to demonstrate why Hippocrates valued prognostication highly, how its importance may have faded from the consciousness of current medical practice, and how modern technology is attempting to reinvent or revise it.
Collapse
Affiliation(s)
- Thomas John Papadimos
- Departments of Anesthesiology and Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH 43614, United States.
| |
Collapse
|
4
|
van der Velden NCA, Smets EMA, van Vliet LM, Brom L, van Laarhoven HWM, Henselmans I. Effects of Prognostic Communication Strategies on Prognostic Perceptions, Treatment Decisions and End-Of-Life Anticipation in Advanced Cancer: An Experimental Study among Analogue Patients. J Pain Symptom Manage 2024; 67:478-489.e13. [PMID: 38428696 DOI: 10.1016/j.jpainsymman.2024.02.563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 02/15/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
CONTEXT Evidence-based guidance for oncologists on how to communicate prognosis is scarce. OBJECTIVES To investigate the effects of prognostic communication strategies (prognostic disclosure vs. communication of unpredictability vs. non-disclosure; standard vs. standard and best-case vs. standard, best- and worst-case survival scenarios; numerical vs. word-based estimates) on prognostic perceptions, treatment decision-making and end-of-life anticipation in advanced cancer. METHODS This experimental study used eight videos of a scripted oncological consultation, varying only in prognostic communication strategies. Cancer-naive individuals, who imagined being the depicted patient, completed surveys before and after watching one video (n = 1036). RESULTS Individuals generally perceived dying within 1 year as more likely after prognostic disclosure, compared to communication of unpredictability or non-disclosure (P < 0.001), and after numerical versus word-based estimates (P < 0.001). Individuals felt better informed about prognosis to decide about treatment after prognostic disclosure, compared to communication of unpredictability or non-disclosure (P < 0.001); after communication of unpredictability versus non-disclosure (P < 0.001); and after numerical versus word-based estimates (P = 0.017). Chemotherapy was more often favored after prognostic disclosure versus non-disclosure (P = 0.010), but less often after numerical versus word-based estimates (P < 0.001). Individuals felt more certain about the treatment decision after prognostic disclosure, compared to communication of unpredictability or non-disclosure (P < 0.001). Effects of different survival scenarios were absent. No effects on end-of-life anticipation were observed. Evidence for moderating individual characteristics was limited. CONCLUSION If and how oncologists discuss prognosis can influence how individuals perceive prognosis, which treatment they prefer, and how they feel about treatment decisions. Communicating numerical estimates may stimulate prognostic understanding and informed treatment decision-making.
Collapse
Affiliation(s)
- Naomi C A van der Velden
- Department of Medical Psychology (N.C.A.V., E.M.A.S., I.H.), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health (N.C.A.V., E.M.A.S., I.H.), Quality of Care, Amsterdam, The Netherlands; Cancer Center Amsterdam (N.C.A.V., E.M.A.S., I.H., H.W.M.L.), Cancer Treatment and Quality of Life, Amsterdam, The Netherlands.
| | - Ellen M A Smets
- Department of Medical Psychology (N.C.A.V., E.M.A.S., I.H.), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health (N.C.A.V., E.M.A.S., I.H.), Quality of Care, Amsterdam, The Netherlands; Cancer Center Amsterdam (N.C.A.V., E.M.A.S., I.H., H.W.M.L.), Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Liesbeth M van Vliet
- Department of Health, Medical and Neuropsychology (L.M.V.), University of Leiden, Leiden, The Netherlands
| | - Linda Brom
- Department of Research and Development (L.B.), Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands; Netherlands Association for Palliative Care (PZNL) (L.B.), Utrecht, The Netherlands
| | - Hanneke W M van Laarhoven
- Cancer Center Amsterdam (N.C.A.V., E.M.A.S., I.H., H.W.M.L.), Cancer Treatment and Quality of Life, Amsterdam, The Netherlands; Department of Medical Oncology (H.W.M.L.), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Inge Henselmans
- Department of Medical Psychology (N.C.A.V., E.M.A.S., I.H.), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health (N.C.A.V., E.M.A.S., I.H.), Quality of Care, Amsterdam, The Netherlands; Cancer Center Amsterdam (N.C.A.V., E.M.A.S., I.H., H.W.M.L.), Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| |
Collapse
|
5
|
van der Velden NCA, Smets EMA, van Vliet LM, Brom L, van Laarhoven HWM, Henselmans I. Effects of prognostic communication strategies on emotions, coping, and appreciation of consultations: An experimental study in advanced cancer. Palliat Support Care 2024:1-13. [PMID: 38533613 DOI: 10.1017/s1478951524000403] [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: 03/28/2024]
Abstract
OBJECTIVES We aimed to investigate effects of prognostic communication strategies on emotions, coping, and appreciation of consultations in advanced cancer. METHODS For this experimental study, we created 8 videos of a scripted oncological consultation, only varying in prognostic communication strategies. Disease-naive individuals (n = 1036) completed surveys before and after watching 1 video, while imagining being the depicted cancer patient. We investigated effects of the type of disclosure (prognostic disclosure vs. communication of unpredictability vs. non-disclosure) and content of disclosure (standard vs. standard and best-case vs. standard, best- and worst-case survival scenarios; numerical vs. word-based estimates) on emotions, coping, and appreciation of consultations. Moderating effects of individual characteristics were tested. RESULTS Participants generally reported more satisfaction (p < .001) after prognostic disclosure versus communication of unpredictability and less uncertainty (p = .042), more satisfaction (p = .005), and more desirability (p = .016) regarding prognostic information after numerical versus word-based estimates. Effects of different survival scenarios were absent. Prognostic communication strategies lacked effects on emotions and coping. Significant moderators included prognostic information preference and uncertainty tolerance. SIGNIFICANCE OF RESULTS In an experimental setting, prognostic disclosure does not cause more negative emotions than non-disclosure and numerical estimates are more strongly appreciated than words. Oncologists' worries about harming patients should not preclude disclosing (precise) prognostic information, yet sensitivity to individual preferences and characteristics remains pivotal.
Collapse
Affiliation(s)
- Naomi C A van der Velden
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Quality of Care, Amsterdam Public Health, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Quality of Care, Amsterdam Public Health, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Liesbeth M van Vliet
- Department of Health, Medical and Neuropsychology, University of Leiden, Leiden, The Netherlands
| | - Linda Brom
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
- Netherlands Association for Palliative Care (PZNL), Utrecht, The Netherlands
| | - Hanneke W M van Laarhoven
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Inge Henselmans
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Quality of Care, Amsterdam Public Health, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
6
|
Ramchandani A, Mihic-Góngora L, Hernández R, Zafra-Poves M, Muñoz MM, Ferreira E, Cruz-Castellanos P, Fernández-Montes A, Pacheco-Barcia V, Jiménez-Fonseca P, Calderon C. Psychological factors and prognostic communication preferences in advanced cancer: multicentre study. BMJ Support Palliat Care 2024; 13:e1342-e1350. [PMID: 37491146 DOI: 10.1136/spcare-2023-004221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/09/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVES Communication regarding prognosis to patients with advanced cancer is fundamental for informed medical decision making. Our objective was to analyse (1) the proportion of subjects with advanced cancer who prefer to know their prognosis, (2) the characteristics associated with patients' preference for prognostic information, (3) the psychological factors that impact the preference to know prognosis and 4) the concordance between preference for prognostic information perceived among physicians and patients. METHODS A prospective, cross-sectional design was adopted. Data were collected from 748 participants with advanced cancer at 15 tertiary hospitals in Spain. Participants completed the following questionnaires: Mental Adjustment to Cancer; Trust in the Physician; Uncertainty in Illness Scale Patient's Prognostic Preferences. RESULTS Fifty-two per cent of advanced cancer sufferers preferred to know the prognosis of their disease. Compared with participants who preferred not to know, those who did reported more uncertainty, greater satisfaction with their physician and higher scores on positive attitude (all p=0.001). Thirty-seven per cent of the physicians believed that patients want to know their prognosis, indicating that they underestimate the number of such patients. No significant differences were found regarding preference to know prognosis as a function of sociodemographic and clinical variables. CONCLUSIONS A substantial proportion of individuals with advanced cancer prefer to know the prognosis of their disease. It appears that knowing their prognosis was mainly motivated by a need to maintain a positive attitude, lessen uncertainty and by satisfaction with the physician. It is important to explore patients' preferences for information to offer more personalised communication.
Collapse
Affiliation(s)
- Avinash Ramchandani
- Department of Medical Oncology, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Luka Mihic-Góngora
- Department of Medical Oncology, Hospital Universitario Central de Asturias, Instituto de Investigación del Principado de Asturias, ISPA, Oviedo, Spain
| | - Raquel Hernández
- Department of Medical Oncology, Hospital Universitario de Canarias, La Laguna, Canarias, Spain
| | - Marta Zafra-Poves
- Department of Medical Oncology, Hospital General Universitario José M Morales Meseguer, Murcia, Spain
| | - María M Muñoz
- Department of Medical Oncology, Hospital General Virgen de la Luz, Cuenca, Spain
| | - Estrella Ferreira
- Department of Clinical Psychology and Psychobiology, University of Barcelona, Barcelona, Spain
| | | | - Ana Fernández-Montes
- Department of Medical Oncology, Complejo Hospitalario de Orense, Ourense, Galicia, Spain
| | - Vilma Pacheco-Barcia
- Department of Medical Oncology, Hospital Central de la Defensa Gomez Ulla, Madrid, Spain
| | | | - Caterina Calderon
- Department of Clinical Psychology and Psychobiology, University of Barcelona, Barcelona, Spain
| |
Collapse
|
7
|
Henderson AW, Turner AP, Leonard C, Sayre G, Suckow B, Williams SL, Norvell DC, Czerniecki JM. Mortality Conversations Between Male Veterans and Their Providers Prior to Dysvascular Lower Extremity Amputation. Ann Vasc Surg 2023; 92:313-322. [PMID: 36746270 PMCID: PMC10121889 DOI: 10.1016/j.avsg.2023.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND Among patients facing lower extremity amputation due to dysvascular disease, the mortality risk is very high. Given this, as well as the importance of a patient-centered approach to medical care, informing patients about their possible risk of dying may be important during preoperative shared decision-making. The goal of this investigation was to gain an understanding of patient and provider experiences discussing mortality within the context of amputation within the Veterans Health Administration. METHODS Semistructured interviews were performed with Veterans with peripheral arterial disease and/or diabetes, vascular and podiatric surgeons, and physical medicine and rehabilitation physicians. Interviews were analyzed using team-based content analysis to identify themes related to amputation-level decisions. RESULTS We interviewed 22 patients and 21 surgeons and physicians and identified 3 themes related to conversations around mortality: (1) both patients and providers report that mortality conversations are not common prior to amputation; (2) while most providers find value in mortality conversations, some express concerns around engaging in these discussions with patients; and (3) some patients perceive mortality conversations as unnecessary, but many are open to engaging in the conversation. CONCLUSIONS Providers may benefit from introducing the topic with patients, including providing the context for why mortality conversations may be valuable, with the understanding that patients can always decline to participate should they not be interested or comfortable discussing this issue.
Collapse
Affiliation(s)
- Alison W Henderson
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA.
| | - Aaron P Turner
- VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Chelsea Leonard
- VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA; Denver Seattle COIN, VA Eastern Colorado Healthcare System, Aurora, CO; Health Systems, Management and Policy, University of Colorado, School of Public Health, Aurora, CO
| | - George Sayre
- VA Puget Sound Health Care System, Seattle, WA; Qualitative Research Core, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA; VA Collaborative Evaluation Center (VACE), Seattle, WA; Department of Health Services, University of Washington, Seattle, WA
| | - Bjoern Suckow
- Department of Vascular Surgery, White River Junction VA Medical Center, White River Junction, VT; Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Sienna L Williams
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA
| | - Daniel C Norvell
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Joseph M Czerniecki
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| |
Collapse
|
8
|
Sun S, Krishnan M, Alcorn S. Prognostication for Patients Receiving Palliative Radiation Therapy. Semin Radiat Oncol 2023; 33:104-113. [PMID: 36990628 DOI: 10.1016/j.semradonc.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Estimation of patient prognosis plays a central role in guiding decision making for the palliative management of metastatic disease, and a number of statistical models have been developed to provide survival estimates for patients in this context. In this review, we discuss several well-validated survival prediction models for patients receiving palliative radiotherapy to sites outside of the brain. Key considerations include the type of statistical model, model performance measures and validation procedures, studies' source populations, time points used for prognostication, and details of model output. We then briefly discuss underutilization of these models, the role of decision support aids, and the need to incorporate patient preference in shared decision making for patients with metastatic disease who are candidates for palliative radiotherapy.
Collapse
|
9
|
Harnischfeger N, Rath H, Alt-Epping B, Brand H, Haller K, Letsch A, Rieder N, Thuss-Patience P, Bokemeyer C, Bergelt C, Oechsle K. Effects of a communication training for oncologists on early addressing palliative and end-of-life care in advanced cancer care (PALLI-COM): a randomized, controlled trial. ESMO Open 2022; 7:100623. [PMID: 36356411 PMCID: PMC9808464 DOI: 10.1016/j.esmoop.2022.100623] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 09/28/2022] [Accepted: 10/05/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION In advanced cancer care, early communication about palliative care (PC) and end-of-life (EoL)-related issues is recommended, but is often impeded by physicians' communication insecurities. We investigated the effect of a newly developed compact communication skills training 'PALLI-COM' on oncologists' competencies to early address PC/EoL-related issues. MATERIALS AND METHODS We conducted a randomized, controlled trial (RCT) with an intervention group (IG; 2 × 90 min training) and a wait list control group (CG) at five sites. At two assessment points, participating oncologists led videotaped medical consultations with simulated patients (SPs) via a privacy compliant video conference platform. SPs were represented by trained actors. The taped conversations were rated for primary outcome (communication skills assessed by adapted COM-ON-checklist and COM-ON-coaching rating scales) by raters blinded for study group. Secondary outcomes included oncologists' self-reported communication skills (Self-Efficacy in Palliative Care Scale, Thanatophobia-Scale, Communication about End of Life Survey, study-specific items) as well as external rating of the SPs. Univariate analyses of covariance with baseline adjustment were used to analyze intervention effects. RESULTS A total of 141 oncologists [age: mean (standard deviation) = 32.7 (6.3) years, 60% female (nIG = 73, nCG = 68)] participated. Following intervention, the IG showed significantly more improvement in four out of five assessed communication skills: 'reacting to emotions and showing empathy', 'pointing out opportunities and giving hope', 'addressing the EoL' and 'explaining the concept of PC'. IG participants also improved more than CG participants in almost all secondary outcomes assessed by participants and SPs: oncologists' self-efficacy, attitudes towards caring for terminally ill patients, communication strategies and confidence in dealing with PC/EoL-related issues as well as communication quality from the SPs' perspective. CONCLUSION Findings indicate that the compact communication skills training PALLI-COM increases oncologists' competencies in early addressing PC/EoL-related issues from different perspectives. Implementation in routine oncology residency might improve advanced cancer care by strengthening these communication skills.
Collapse
Affiliation(s)
- N. Harnischfeger
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Correspondence to: Nele Harnischfeger, Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - H.M. Rath
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - B. Alt-Epping
- Department of Palliative Medicine, Heidelberg University Hospital, Heidelberg, Germany,Department of Palliative Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - H. Brand
- Department of Hematology, Oncology and Tumor Immunology, Campus Kiel, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - K. Haller
- Department of Hematology, Oncology and Cancer Immunology, Campus Virchow-Klinikum, Charité – University Medicine Berlin, Berlin, Germany
| | - A. Letsch
- Department of Hematology, Oncology and Tumor Immunology, Campus Kiel, University Medical Center Schleswig-Holstein, Kiel, Germany,Department of Hematology, Oncology and Cancer Immunology, Campus Benjamin Franklin, Charité – University Medicine Berlin, Berlin, Germany
| | - N. Rieder
- Department of Palliative Medicine, Heidelberg University Hospital, Heidelberg, Germany,Department of Palliative Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - P. Thuss-Patience
- Department of Hematology, Oncology and Cancer Immunology, Campus Virchow-Klinikum, Charité – University Medicine Berlin, Berlin, Germany
| | - C. Bokemeyer
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - C. Bergelt
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Department of Medical Psychology, University Medicine Greifswald, Greifswald, Germany
| | - K. Oechsle
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
10
|
Is It Worth Knowing That You Might Die Tomorrow? Revisiting the Ethics of Prognosis Disclosure. Clin Pract 2022; 12:803-808. [PMID: 36286070 PMCID: PMC9600686 DOI: 10.3390/clinpract12050084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/27/2022] [Accepted: 09/29/2022] [Indexed: 11/16/2022] Open
Abstract
Ethical discourse on prognosis disclosure is not yet well established. The core of the problem continues to be the dilemma between the right of self-determination and non-maleficence of patients. The prognosis disclosure policy based on Kantian autonomy provides a good solution for the problem. The policy includes demand for strict truth telling and its compatibility with patients' best interest. However, there remains a discrepancy between theory and practice, especially when prognosis is disclosed just prior to their death. Kantian theory of prognosis is supplemented by a moralistic perspective. The moralistic perspective places high importance on temporality and relationships with others, which all human beings inherently possess. From the moralistic viewpoint, decisions about prognosis disclosure at the final stages of life must be individualized in order to be authentically autonomous. The decision to disclose a prognosis or not can only be determined by the relationships fostered over time with patients.
Collapse
|
11
|
Bryant J, Hobden B, Waller A, Sanson-Fisher R, Shepherd J. Oncology nurse perceptions about life expectancy discussions: a cross-sectional study exploring what patients want to know, and why doctors don't disclose. Contemp Nurse 2022; 58:424-434. [PMID: 36373372 DOI: 10.1080/10376178.2022.2147848] [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: 11/16/2022]
Abstract
Background: Sensitive and patient-centred discussion about life expectancy has clear benefits for patients with advanced cancer and their families. The perceptions of oncology nurses about disclosure of life expectancy, and the barriers to disclosure, have rarely been explored. Objectives/Aims/Hypotheses: To examine oncology nurses' perceptions of the: (1) proportion of patients with advanced cancer who want, receive and understand estimates of life expectancy; (2) reasons why doctors may not provide estimates of life expectancy. Design: Cross-sectional survey. Methods: Australian oncology nurses who were members of a professional society or worked at a participating metropolitan cancer centre were emailed a link to an anonymous online survey. Participants provided socio-demographic characteristics and their perceptions about the proportion of patients with advanced cancer who (a) want, (b) are provided with, (c) receive and (d) understand estimates of life expectancy, as well as the reasons estimates of life expectancy may not be provided. Results: A total of 104 nurses participated. While 51% of nurses perceived that most patients (>75%) want to be provided with an estimate of their life expectancy, 63% of nurses reported that <50% of patients were provided with an estimate. Further, 85% of nurses indicated that <50% of patients understand the estimate. The most frequent reason nurses perceived doctors did not provide an estimate of life expectancy was because the doctor didn't have an accurate idea of life expectancy (80.8%). Almost one-fifth of nurses (18.3%) thought that doctors did not provide estimates because they felt it was not their responsibility to do so. Conclusions: Strategies to ensure a patient-centred approach to life expectancy discussions with patients with advanced cancer are urgently needed. Impact statement: Oncology nurses perceive that many patients with advanced cancer are not provided with an accurate estimate of their life expectancy and few understand the information provided to them.
Collapse
Affiliation(s)
- Jamie Bryant
- Health Behaviour Research Collaborative, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Breanne Hobden
- Health Behaviour Research Collaborative, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Amy Waller
- Health Behaviour Research Collaborative, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Rob Sanson-Fisher
- Health Behaviour Research Collaborative, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Jan Shepherd
- Health Behaviour Research Collaborative, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
| |
Collapse
|
12
|
Maeda S, Nakazawa E, Kamishiraki E, Ishikawa E, Murata M, Mori K, Akabayashi A. An Exploratory Study on Information Manipulation by Doctors: Awareness, Actual State, and Ethical Tolerance. Clin Pract 2022; 12:723-733. [PMID: 36136869 PMCID: PMC9498308 DOI: 10.3390/clinpract12050075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/17/2022] [Accepted: 09/06/2022] [Indexed: 11/26/2022] Open
Abstract
(1) Background: To what extent is information manipulation by doctors acceptable? To answer this question, we conducted an exploratory study aimed at obtaining basic data on descriptive ethics for considering this issue. (2) Methods: A self-administered questionnaire survey was conducted on a large sample (n = 3305) of doctors. The participants were queried on (1) whether they consider that information manipulation is necessary (awareness), (2) whether they have actually manipulated information (actual state), and (3) their ethical tolerance. (3) Result: The response rate was 28.7%. Sixty percent of the doctors responded that information manipulation to avoid harm to patients is necessary (awareness), that they have actually manipulated information (actual state), and that information manipulation is ethically acceptable. (4) Conclusion: While the present survey was conducted among doctors in Japan, previous studies have reported similar findings in the United States and Europe. Based on our analysis, we hypothesize that a relationship of trust between patients and medical personnel is crucial and that information manipulation is not needed when such a relationship has been established.
Collapse
Affiliation(s)
- Shoichi Maeda
- Department of Medical Ethics and Patient Safety, Keio University Keio Research Institute at SFC, 4411 Endo, Fujisawa 252-0883, Japan
- Course for Health Care Management and Public Health, Graduate School of Health Management, Keio University, 4411 Endo, Fujisawa 252-0883, Japan
| | - Eisuke Nakazawa
- Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Etsuko Kamishiraki
- Graduate School of Welfare and Health Sciences, Oita University, 700 Dannoharu, Oita 870-1192, Japan
| | - Eri Ishikawa
- Department of Medical Ethics and Patient Safety, Keio University Keio Research Institute at SFC, 4411 Endo, Fujisawa 252-0883, Japan
- Comprehensive Research Organization, Institute for Global Health, Waseda University, 1-3-10 Nishiwaseda Shinjyuku-ku, Tokyo 169-0051, Japan
| | - Maho Murata
- Department of Medical Ethics and Patient Safety, Keio University Keio Research Institute at SFC, 4411 Endo, Fujisawa 252-0883, Japan
- Department of Clinical Oral Oncology, Graduate School of Biomedical Sciences, Nagasaki University, Sakamoto1-7-1, Nagasaki 852-8588, Japan
| | - Katsumi Mori
- Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Akira Akabayashi
- Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
- Division of Medical Ethics, School of Medicine, New York University, 227 East 30th Street, New York, NY 10016, USA
- Correspondence: or ; Tel.: +81-35841-3511
| |
Collapse
|
13
|
Huepenbecker SP, Zhang X, Morgan MA, Haggerty AF. A prospective cross-sectional survey comparing patient and provider expectations regarding ovarian cancer prognosis. Gynecol Oncol Rep 2022; 42:101042. [PMID: 35874551 PMCID: PMC9303825 DOI: 10.1016/j.gore.2022.101042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 12/01/2022] Open
Abstract
Providers believe prognostic discussions are important for ovarian cancer patients. Providers report having prognostic conversations more often than patients. Ovarian cancer patients and providers have different expectations surrounding treatment, remission, and survival. Age, marital status, religion, and cancer stage may affect patient perceptions of ovarian cancer prognosis.
Introduction There is limited data comparing patient and physician expectations regarding ovarian cancer prognosis. Our primary objective was to compare physician and patient estimates of survival to 6 months, 1 year, and 5 years; secondary objectives included comparing provider and patient responses on the likelihood of requiring future treatments and categorizing patient and provider preferences regarding communication about prognosis. Methods A prospective cross-sectional survey was delivered to 10 gynecologic oncology providers and 50 adult ovarian cancer patients from November 2015-April 2016 at one institution. Descriptive statistics were used to categorize survey answers and compare survey answers between patients and providers; multivariable logistic regression evaluated patient survey responses. Results All providers (100%) believed treating providers should discuss prognosis and 90% reported having prognostic conversations with patients, compared to 63%, 37%, and 4% of patients who reported discussing prognosis, living wills/advance directives, and palliative care/hospice services, respectively, with their provider. Compared to their provider, patients gave significantly lower estimations of requiring any future therapy (mean score 84.6 vs 74, p <.001) and future chemotherapy (mean score 84.1 vs 69.8, p <.001) and significantly higher estimations of requiring future surgery (mean score 23.3 vs 40, p <.001), achieving remission (mean score 33.5 vs 47.5, p =.009), survival to 1 year (mean score 77.1 vs 86.4, p =.002), and survival to 5 years (mean score 40.5 vs 61.3, p <.001). Conclusions Although gynecologic oncology providers believe it is important to discuss prognosis and end-of-life care, there are gaps in communication, knowledge, and expectations between providers and ovarian cancer patients.
Collapse
Affiliation(s)
- Sarah P. Huepenbecker
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
- Corresponding author.
| | - Xiaochen Zhang
- Center for Research on Reproduction and Women’s Health, University of Pennsylvania, 3440 Market St, Philadelphia, PA 19104, USA
| | - Mark A. Morgan
- Division of Gynecologic Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Ashley F. Haggerty
- Division of Gynecologic Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| |
Collapse
|
14
|
Serey K, Cambriel A, Pollina-Bachellerie A, Lotz JP, Philippart F. Advance Directives in Oncology and Haematology: A Long Way to Go-A Narrative Review. J Clin Med 2022; 11:jcm11051195. [PMID: 35268299 PMCID: PMC8911354 DOI: 10.3390/jcm11051195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 12/04/2022] Open
Abstract
Patients living with cancer often experience serious adverse events due to their condition or its treatments. Those events may lead to a critical care unit admission or even result in death. One of the most important but challenging parts of care is to build a care plan according to the patient’s wishes, meeting their goals and values. Advance directives (ADs) allow everyone to give their preferences in advance regarding life sustaining treatments, continuation, and withdrawal or withholding of treatments in case one is not able to speak their mind anymore. While the absence of ADs is associated with a greater probability of receiving unwanted intensive care around the end of their life, their existence correlates with the respect of the patient’s desires and their greater satisfaction. Although progress has been made to promote ADs’ completion, they are still scarcely used among cancer patients in many countries. Several limitations to their acceptance and use can be detected. Efforts should be made to provide tailored solutions for the identified hindrances. This narrative review aims to depict the situation of ADs in the oncology context, and to highlight the future areas of improvement.
Collapse
Affiliation(s)
- Kevin Serey
- Anesthesiology and Intensive Care Medicine Department, APHP—Ambroise Paré University Hospital, 92100 Boulogne-Billancourt, France;
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
| | - Amélie Cambriel
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
- Anesthesiology and Intensive Care Medicine Department, APHP—Tenon University Hospital, 75020 Paris, France
| | - Adrien Pollina-Bachellerie
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
- Anesthesiology and Intensive Care Medicine Department, Toulouse Hospitals, 31000 Toulouse, France
| | - Jean-Pierre Lotz
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
- Pôle Onco-Hématologie, Service D’oncologie Médicale et de Thérapie Cellulaire, APHP—Hôpitaux Universitaires de L’est Parisien, 75020 Paris, France
| | - François Philippart
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
- Medical and Surgical Intensive Care Department, Groupe Hospitalier Paris Saint Joseph, 185 Rue R. Losserand, 75674 Paris, France
- Correspondence: ; Tel.: +33-1-44-12-30-85
| |
Collapse
|
15
|
Bloom JR, Marshall DC, Rodriguez-Russo C, Martin E, Jones JA, Dharmarajan KV. Prognostic disclosure in oncology - current communication models: a scoping review. BMJ Support Palliat Care 2022; 12:167-177. [PMID: 35144938 DOI: 10.1136/bmjspcare-2021-003313] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/08/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prognostic disclosure is essential to informed decision making in oncology, yet many oncologists are unsure how to successfully facilitate this discussion. This scoping review determines what prognostic communication models exist, compares and contrasts these models, and explores the supporting evidence. METHOD A protocol was created for this study using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols extension for Scoping Reviews. Comprehensive literature searches of electronic databases MEDLINE, EMBASE, PsycINFO and Cochrane CENTRAL were executed to identify relevant publications between 1971 and 2020. RESULTS In total, 1532 articles were identified, of which 78 met inclusion criteria and contained 5 communication models. Three of these have been validated in randomised controlled trials (the Serious Illness Conversation Guide, the Four Habits Model and the ADAPT acronym) and have demonstrated improved objective communication measures and patient reported outcomes. All three models emphasise the importance of exploring patients' illness understanding and treatment preferences, communicating prognosis and responding to emotion. CONCLUSION Communicating prognostic estimates is a core competency skill in advanced cancer care. This scoping review highlights available communication models and identifies areas in need of further assessment. Such areas include how to maintain learnt communication skills for lifelong practice, how to assess patient and caregiver understanding during and after these conversations, and how to best scale these protocols at the institutional and national levels.
Collapse
Affiliation(s)
- Julie Rachel Bloom
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Carlos Rodriguez-Russo
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Martin
- Palliative Care Program, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Joshua Adam Jones
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kavita Vyas Dharmarajan
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
16
|
Versteeg AL, Gal R, Charest-Morin R, Verlaan JJ, Wessels H, Fisher CG, Verkooijen HM. Expectations of treatment outcomes in patients with spinal metastases; what do we tell our patients? A qualitative study. BMC Cancer 2021; 21:1263. [PMID: 34814886 PMCID: PMC8611925 DOI: 10.1186/s12885-021-08993-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 11/02/2021] [Indexed: 01/23/2023] Open
Abstract
Background Realistic pre-treatment expectations are important and have been associated with post-treatment health related quality of life (HRQOL). Patient expectations are greatly influenced by physicians, as they are the primary resource for information. This study aimed to explore the communication practices of physicians regarding treatment outcomes for patients with spinal metastases, and physician experiences with patients’ pre-treatment expectations. Methods An international qualitative study using semi-structured interviews with physicians routinely involved in treating metastatic spine disease (spine surgeons, radiation and medical oncologists, and rehabilitation specialists) was conducted. Physicians were interviewed about the content and extent of information they provide to patients with spinal metastases regarding treatment options, risks and treatment outcomes. Interviews were transcribed verbatim and analyzed using a thematic coding network. Results After 22 interviews data saturation occurred. The majority of the physicians indicated that they currently do not establish patients’ pre-treatment expectations, despite acknowledging the importance of these expectations. Spine surgeons often believe that patient expectations are disproportionate. Physicians expressed they manage expectations by detailing the most common risks and providing a broad but nonspecific overview of treatment outcomes. While the palliative intent seems clear to the physicians, their perception is that the implications of a palliative treatment remains elusive to most patients. Conclusion This study highlights the current gap in patient-physician communication regarding expectations of treatment outcomes of patients with spinal metastases. These results warrant further research to improve communication practices and determine the effect of patient expectations on patient reported outcomes in this population. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08993-0.
Collapse
Affiliation(s)
- Anne L Versteeg
- Division of Imaging and Cancer, University Medical Center Utrecht, University of Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands. .,Division of Imaging and Cancer, Department of Radiotherapy, University Medical Center Utrecht, Universiteitsweg 100, 3584, CG, Utrecht, the Netherlands.
| | - Roxanne Gal
- Division of Imaging and Cancer, University Medical Center Utrecht, University of Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands
| | - Raphaele Charest-Morin
- Division of Spine, Department of Orthopaedics, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Jorrit-Jan Verlaan
- Department of Orthopaedic surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hester Wessels
- Department of Corporate Communications, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Charles G Fisher
- Division of Spine, Department of Orthopaedics, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Helena M Verkooijen
- Division of Imaging and Cancer, University Medical Center Utrecht, University of Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands
| |
Collapse
|
17
|
Janett-Pellegri C, Eychmüller AS. 'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication? PRAXIS 2021; 110:914-924. [PMID: 34814721 DOI: 10.1024/1661-8157/a003785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Uncertainty, fear to harm the patient, discomfort handling the discussion and lack of time are the most cited barriers to prognostic disclosure. Physicians can be reassured that patients desire the truth about prognosis and can manage the discussion without harm, including the uncertainty of the information, if approached in a sensitive manner. Conversational guides could provide support in preparing such difficult conversations. Communicating 'with realism and hope' is possible, and anxiety is normal for both patients and clinicians during prognostic disclosure. As a clinician pointed out: 'I had asked a mentor once if it ever got easier. - No. But you get better at it.'
Collapse
Affiliation(s)
- Camilla Janett-Pellegri
- Service de Médicine Interne, Hôpital Cantonal Fribourg, Fribourg
- Universitäres Zentrum für Palliative Care, Inselspital, Universitätsspital Bern, Bern
| | | |
Collapse
|
18
|
Sener U, Neil EC, Scharf A, Carver AC, Buthorn JB, Bossert D, Sigler AM, Voigt LP, Diamond EL. Ethics consultations in neuro-oncology. Neurooncol Pract 2021; 8:539-549. [PMID: 34594568 DOI: 10.1093/nop/npab038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Management of patients with brain tumors can lead to ethical and decisional dilemmas. The aim of this study was to characterize ethical conflicts encountered in neuro-oncologic patients. Methods Retrospective review of ethics consultations performed upon patients with primary and metastatic brain tumors at a tertiary cancer center. An ethics consultation database was examined to characterize ethical conflicts, contextual factors, and interventions by the consultation team. Results Fifty consultations were reviewed; 28 (56%) patients were women, median age 54 (range 4-86); 27 (54%) patients had a primary central nervous system malignancy; 20 (40%) had brain metastasis. At the time of consultations, 41 (82%) patients lacked decisional capacity; 48 (96%) had a designated surrogate decision maker; 3 (6%) had an advance directive outlining wishes regarding medical treatment; 12 (24%) had a Do Not Attempt Resuscitation (DNAR) order. Ethical conflicts centered upon management of end-of-life (EOL) circumstances in 37 (72%) of cases; of these, 30 did not have decisional capacity. The most common ethical issues were DNAR status, surrogate decision making, and request for nonbeneficial treatment. Consultants resolved conflicts by facilitating decision making for incapacitated patients in 30 (60%) cases, communication between conflicting parties in 10 (20%), and re-articulation of patients' previously stated wishes in 6 (12%). Conclusions Decisional capacity at EOL represents the primary ethical challenge in care of neuro-oncologic patients. Incomplete awareness among surrogate decision makers of patients' prognosis and preferences contributes to communication gaps and dilemmas. Early facilitation of communication between patients, caregivers, and medical providers may prevent or mitigate conflicts and allow the enactment of patients' goals and values.
Collapse
Affiliation(s)
- Ugur Sener
- Department of Neurology, West Virginia University, Morgantown, West Virginia, USA
| | - Elizabeth C Neil
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Amy Scharf
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alan C Carver
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Justin B Buthorn
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Dana Bossert
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Allison M Sigler
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Louis P Voigt
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Eli L Diamond
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| |
Collapse
|
19
|
van de Water LF, van den Boorn HG, Hoxha F, Henselmans I, Calff MM, Sprangers MAG, Abu-Hanna A, Smets EMA, van Laarhoven HWM. Informing Patients With Esophagogastric Cancer About Treatment Outcomes by Using a Web-Based Tool and Training: Development and Evaluation Study. J Med Internet Res 2021; 23:e27824. [PMID: 34448703 PMCID: PMC8433928 DOI: 10.2196/27824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/07/2021] [Accepted: 05/24/2021] [Indexed: 11/17/2022] Open
Abstract
Background Due to the increasing use of shared decision-making, patients with esophagogastric cancer play an increasingly important role in the decision-making process. To be able to make well-informed decisions, patients need to be adequately informed about treatment options and their outcomes, namely survival, side effects or complications, and health-related quality of life. Web-based tools and training programs can aid physicians in this complex task. However, to date, none of these instruments are available for use in informing patients with esophagogastric cancer about treatment outcomes. Objective This study aims to develop and evaluate the feasibility of using a web-based prediction tool and supporting communication skills training to improve how physicians inform patients with esophagogastric cancer about treatment outcomes. By improving the provision of treatment outcome information, we aim to stimulate the use of information that is evidence-based, precise, and personalized to patient and tumor characteristics and is communicated in a way that is tailored to individual information needs. Methods We designed a web-based, physician-assisted prediction tool—Source—to be used during consultations by using an iterative, user-centered approach. The accompanying communication skills training was developed based on specific learning objectives, literature, and expert opinions. The Source tool was tested in several rounds—a face-to-face focus group with 6 patients and survivors, semistructured interviews with 5 patients, think-aloud sessions with 3 medical oncologists, and interviews with 6 field experts. In a final pilot study, the Source tool and training were tested as a combined intervention by 5 medical oncology fellows and 3 esophagogastric outpatients. Results The Source tool contains personalized prediction models and data from meta-analyses regarding survival, treatment side effects and complications, and health-related quality of life. The treatment outcomes were visualized in a patient-friendly manner by using pictographs and bar and line graphs. The communication skills training consisted of blended learning for clinicians comprising e-learning and 2 face-to-face sessions. Adjustments to improve both training and the Source tool were made according to feedback from all testing rounds. Conclusions The Source tool and training could play an important role in informing patients with esophagogastric cancer about treatment outcomes in an evidence-based, precise, personalized, and tailored manner. The preliminary evaluation results are promising and provide valuable input for the further development and testing of both elements. However, the remaining uncertainty about treatment outcomes in patients and established habits in doctors, in addition to the varying trust in the prediction models, might influence the effectiveness of the tool and training in daily practice. We are currently conducting a multicenter clinical trial to investigate the impact that the combined tool and training have on the provision of information in the context of treatment decision-making.
Collapse
Affiliation(s)
- Loïs F van de Water
- Department of Medical Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Héctor G van den Boorn
- Department of Medical Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Florian Hoxha
- Department of Medical Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Inge Henselmans
- Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Mart M Calff
- Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Mirjam A G Sprangers
- Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
20
|
van der Velden NCA, van der Kleij MBA, Lehmann V, Smets EMA, Stouthard JML, Henselmans I, Hillen MA. Communication about Prognosis during Patient-Initiated Second Opinion Consultations in Advanced Cancer Care: An Observational Qualitative Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115694. [PMID: 34073341 PMCID: PMC8199300 DOI: 10.3390/ijerph18115694] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 11/16/2022]
Abstract
Prognostic communication is essential for patients with advanced cancer to enable informed medical decision-making and end-of-life planning. Discussing prognosis is challenging, and might be especially complex for oncologists conducting a second opinion (SO). Survival data are often lacking, and consulting oncologists need to consider previously conveyed information and patients’ relationship with the referring oncologist. We qualitatively investigated how advanced cancer patients and consulting oncologists discuss prognosis during audio-recorded SO consultations (N = 60), including prognostic information received from the referring oncologist. Our results show that patients regularly expressed implicit cues to discuss prognosis or posed explicit questions tentatively. Consulting oncologists were mostly unresponsive to patients’ cues and cautious to prognosticate. They also seemed cautious when patients brought up the referring oncologist. Consulting oncologists checked which prognostic information patients had received from the referring oncologist, before estimating prognosis. They agreed with the first opinion or rectified discrepancies carefully. Altogether, this study exposes missed opportunities for open prognostic discussions in SOs. Consulting oncologists could explicitly explore patients’ information preferences and perceptions of prognosis. If desired, they can provide tailored, independent information to optimise patients’ prognostic awareness and informed medical decision-making. They may additionally support patients in dealing with prognosis and the uncertainties associated with it.
Collapse
Affiliation(s)
- N. C. A. van der Velden
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
- Correspondence:
| | - M. B. A. van der Kleij
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
| | - V. Lehmann
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - E. M. A. Smets
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - J. M. L. Stouthard
- Department of Medical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands;
| | - I. Henselmans
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - M. A. Hillen
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| |
Collapse
|
21
|
Just J, Schmitz MT, Grabenhorst U, Joist T, Horn K, Engel B, Weckbecker K. Factors influencing length of survival in ambulatory palliative care - a cross sectional study based on secondary data. BMC Palliat Care 2021; 20:69. [PMID: 34001099 PMCID: PMC8130350 DOI: 10.1186/s12904-021-00762-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quality of life and patient self-determination are key elements in successful palliative care. To achieve these goals, a robust prediction of the remaining survival time is useful as it can provide patients and their relatives with information for individual goal setting including appropriate priorities. The Aim of our study was to assess factors that influence survival after enrollment into ambulatory palliative care. METHODS In this cross-sectional, multicenter study (n = 14 study centers) clinical records of all palliative care patients who were treated in 2017 were extracted and underwent statistical analysis. The main outcome criterion was the association of survival time with clinical characteristics such as age, type of disease, symptoms and performance status. RESULTS A total of 6282 cases were evaluated. Median time of survival was 26 days (95 % CI: 25-27 days). The strongest association for an increased hazard ratio was found for the following characteristics: moderate/severe weakness (aHR: 1.91; 95 % CI: 1.27-2.86) Karnofsky score 10-30 (aHR: 1.80; 95 % CI: 1.67-1.95), and age > 85 (aHR: 1.50; 95 % CI: 1.37-1.64). Surprisingly, type of disease (cancer vs. non-cancer) was not associated with a change in survival time (aHR: 1.03; 95 % CI: 0.96-1.10). CONCLUSIONS In this cross-sectional study, the most relevant predictor for a short survival time in specialized ambulatory palliative care was the performance status while type of disease was irrelevant to survival.
Collapse
Affiliation(s)
- Johannes Just
- Institute of General Practice and Interprofessional Care Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58453, Witten, Germany.
| | - Marie-Therese Schmitz
- Department of Medical Biometry, Informatics and Epidemiology (IMBIE), University Hospital Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Ulrich Grabenhorst
- VSTN e.V. (Association of SAPV Teams in North Rhine), Venloer Straße 40, 41751, Viersen, Germany
| | - Thomas Joist
- VSTN e.V. (Association of SAPV Teams in North Rhine), Venloer Straße 40, 41751, Viersen, Germany
| | - Kirsten Horn
- VSTN e.V. (Association of SAPV Teams in North Rhine), Venloer Straße 40, 41751, Viersen, Germany
| | - Bettina Engel
- Division of General Practice, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, 26129, Oldenburg, Germany
| | - Klaus Weckbecker
- Institute of General Practice and Interprofessional Care Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58453, Witten, Germany
| |
Collapse
|
22
|
Vasista A, Stockler MR, Martin A, Lawrence NJ, Kiely BE. Communicating prognostic information: what do oncologists think patients with incurable cancer should be told? Intern Med J 2021; 50:1492-1499. [PMID: 31904887 DOI: 10.1111/imj.14739] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/20/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND People with incurable cancer require information about their prognosis to make informed decisions about their future. AIMS To determine the frequency, form and documentation of prognostic discussions between oncologists and their patients with incurable cancer. METHODS We surveyed medical oncologists in Australia and New Zealand about their practices communicating prognosis. RESULTS A total of 206 medical oncologists completed the survey. Respondent characteristics were: median age 40 years (range 27-75), female 51%, trainee 22%; and 71% had completed specific training on communicating prognosis. Respondents reported discussing prognosis with a patient a median of 10 times per month (interquartile range 4-15); 88% reported explaining that 'the cancer is incurable' to all their patients with incurable cancer and 84% reported always or usually providing a quantitative estimate of survival time. The preferred method for explaining expected survival time (EST) was providing 'multiple ranges of time with probabilities, for example best-case, typical and worst-case scenarios' (52% of respondents). The most frequently reported barriers to discussing EST were: 'family members requesting that prognostic information not be discussed' (57% of respondents), and 'not knowing the EST' (46% of respondents). Twenty percent reported always documenting prognostic discussions and the EST in the patient's medical record, and 11% reported always documenting this information in their letters to other doctors. CONCLUSIONS Most oncologists reported providing quantitative estimates of EST to their patients with incurable cancer, but very few reported documenting this information. Methods to help oncologists estimate, explain and document survival time are needed to improve communication of prognosis.
Collapse
Affiliation(s)
- Anuradha Vasista
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Martin R Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Martin
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Nicola J Lawrence
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Belinda E Kiely
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
23
|
Marron JM. Communicating uncertainty: A step in the right direction? Pediatr Blood Cancer 2021; 68:e28849. [PMID: 33352005 PMCID: PMC7856024 DOI: 10.1002/pbc.28849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 11/30/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Jonathan M. Marron
- Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Harvard Medical School, Boston, MA,Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA,Center for Bioethics, Harvard Medical School, Boston, MA,Office of Ethics, Boston Children’s Hospital, Boston, MA,Division of Population Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| |
Collapse
|
24
|
Ramsey T, Lee B, Curran K, Desai V, Debiase C, Galati L, Gildener-Leapman N. Associations of insurance, urbanity, and comorbidity with types of palliative care received by patients with head and neck cancer. Head Neck 2021; 43:1499-1508. [PMID: 33599358 DOI: 10.1002/hed.26648] [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: 07/30/2020] [Revised: 01/08/2021] [Accepted: 02/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Our study examined some of the social and medical factors associated with receiving pain palliation alone over more aggressive cytoreductive palliative measures, such as surgery, chemotherapy, or radiation among patients with head and neck cancer. METHODS This retrospective study used the National Cancer Database 2016 for data analysis. Patient and tumor characteristics were examined using bivariate analysis and logistic regression to identify their association with receiving pain palliation alone versus cytoreductive palliation treatment. RESULTS Using multivariate logistic regression analysis, insurance status (odds ratio [OR]: 0.27, 95% confidence interval [CI]: 0.15-0.50, p < 0.001), urbanity (OR: 1.73, 95%CI: 1.21-2.46, p = 0.002), and Charlson-Deyo scores greater than 3 (OR: 2.49, 95%CI: 1.38-4.47, p = 0.002) were significantly associated with receipt of pain palliation alone. CONCLUSIONS Clinicians should be aware of non-health-related factors, such as insurance status, that may influence patients' receipt of treatments in head and neck cancer.
Collapse
Affiliation(s)
- Tam Ramsey
- Department of Otolaryngology - Head and Neck Surgery, Albany Medical Center, Albany, New York, USA
| | - Brian Lee
- Department of Otolaryngology - Head and Neck Surgery, Albany Medical Center, Albany, New York, USA
| | - Kent Curran
- Department of Otolaryngology - Head and Neck Surgery, Albany Medical Center, Albany, New York, USA
| | - Vilok Desai
- Department of Otolaryngology - Head and Neck Surgery, Albany Medical Center, Albany, New York, USA
| | - Carolyn Debiase
- Department of Otolaryngology - Head and Neck Surgery, Albany Medical Center, Albany, New York, USA
| | - Lisa Galati
- Department of Otolaryngology - Head and Neck Surgery, Albany Medical Center, Albany, New York, USA
| | - Neil Gildener-Leapman
- Department of Otolaryngology - Head and Neck Surgery, Albany Medical Center, Albany, New York, USA
| |
Collapse
|
25
|
Benedetti DJ, Marron JM. Ethical Challenges in Pediatric Oncology Care and Clinical Trials. Recent Results Cancer Res 2021; 218:149-173. [PMID: 34019168 DOI: 10.1007/978-3-030-63749-1_11] [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: 12/29/2022]
Abstract
The care of pediatric cancer patients is a vast departure from cancer care of adults. While the available treatment modalities-chemotherapy, radiation, and surgery-are the same, the diseases, care-delivery, and outcomes differ greatly. And just as 'children are not just little adults,' pediatric bioethics occupies a distinct place within the broader field of bioethics. In this chapter, we will begin with an introduction to fundamental principles and frameworks for understanding ethical issues in pediatrics, highlighting the triadic nature of medical decision-making between a physician, the child-patient, and the child's parent as the surrogate decision-maker. We will then delve into further details of how these principles and frameworks shape the care of children with cancer, examining specific ethical challenges commonly encountered by pediatric oncologists. We will traverse this landscape by examining issues involving (a) informed consent; (b) research involving children; (c) end of life; (d) genetic and genomic testing; and (e) professionalism. We also examine ethical challenges in clinical research, in children and more broadly. While not an exhaustive exploration of the myriad ethical issues one might encounter in pediatric cancer medicine and clinical trials, this chapter provides readers with a foundation for further reading.
Collapse
Affiliation(s)
- Daniel J Benedetti
- Division of Hematology-Oncology, Department of Pediatrics, Vanderbilt University Medical Center, 2220 Pierce Avenue 397 PRB, Nashville, TN, 37232-6310, USA.
| | - Jonathan M Marron
- Division of Pediatric Hematology/Oncology, Harvard Medical School, Center for Bioethics, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, 02215, USA
| |
Collapse
|
26
|
Enzinger AC, Uno H, McCleary N, Frank E, Sanoff H, Van Loon K, Matin K, Bullock A, Cronin C, Bagley J, Schrag D. The Effect of Disclosing Life Expectancy Information on Patients' Prognostic Understanding: Secondary Outcomes From a Multicenter Randomized Trial of a Palliative Chemotherapy Educational Intervention. J Pain Symptom Manage 2021; 61:1-11.e3. [PMID: 32777456 PMCID: PMC7769864 DOI: 10.1016/j.jpainsymman.2020.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/21/2020] [Accepted: 07/25/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT Many advanced patients with cancer have unrealistic prognostic expectations. OBJECTIVES We tested whether offering life expectancy (LE) statistics within palliative chemotherapy (PC) education promotes realistic expectations. METHODS In this multicenter trial, patients with advanced colorectal and pancreatic cancers initiating first or second line PC were randomized to usual care versus a PC educational tool with optional LE information. Surveys at two weeks and three months assessed patients' review of the LE module and their reactions; at three months, patients estimated their LE and reported occurrence of prognosis and end-of-life (EOL) discussions. Wilcoxon tests and proportional odds models evaluated between-arm differences in LE self-estimates, and how realistic those estimates were (based on cancer type and line of treatment). RESULTS From 2015 to 2017, 92 patients were randomized to the intervention and 94 to usual care. At baseline most patients (80.9%) wanted "a lot" or "as much information as possible" about the impact of chemotherapy on LE. Among patients randomized to the intervention, 52.0% reviewed the LE module by two weeks and 66.7% by three months-of whom 88.2% reported the information was important, 31.4% reported it was upsetting, and 3.9% regretted reviewing it. Overall, patients' LE self-estimates were very optimistic; 71.4% of patients with colorectal cancer estimated greater than five years; 50% pancreatic patients estimated greater than two years. The intervention had no effect on the length or realism of patients' LE self-estimates, or on the occurrence of prognostic or EOL discussions. CONCLUSIONS Offering LE information within a PC educational intervention had no effect on patients' prognostic expectations.
Collapse
Affiliation(s)
- Andrea C Enzinger
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA; Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA.
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Nadine McCleary
- Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Elizabeth Frank
- Susan F. Smith Center for Women's Cancers, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Hanna Sanoff
- Division of Medical Oncology, University of North Carolina Lineberger Cancer Center, Chapel Hill, North Carolina, USA
| | - Katherine Van Loon
- Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Khalid Matin
- Division of Medical Oncology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Andrea Bullock
- Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christine Cronin
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Janet Bagley
- Department of Nursing, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Deborah Schrag
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA; Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| |
Collapse
|
27
|
Harnischfeger N, Rath HM, Ullrich A, Alt-Epping B, Letsch A, Thuss-Patience P, Bokemeyer C, Oechsle K, Bergelt C. Evaluation of a communication skills training to facilitate addressing palliative care related topics in advanced cancer patients: study protocol of a multicenter randomized controlled trial (PALLI-KOM). Palliat Care 2020; 19:67. [PMID: 32398130 PMCID: PMC7218622 DOI: 10.1186/s12904-020-00568-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background Early integration of palliative care concurrently to standard cancer care is associated with several benefits for patients and their caregivers. However, communication barriers on part of the caring physicians often impede a timely referral to palliative care. This study describes the protocol of the evaluation of a communication skills training aiming to strengthen the ability of physicians to address palliative care related topics adequately and early during disease trajectory. Methods We will implement a communication skills training and evaluate it within a prospective, multi-centered, two-armed randomized controlled trial (RCT), which will be conducted at four sites in Germany. Eligible subjects are all physicians treating patients with advanced cancer in their daily routine. An intervention group (IG) receiving a group training will be compared to a wait-list control group (CG) receiving the training after completion of data collection. At pre- and post-measurement points, participants will conduct videotaped conversations with standardized simulated patients (SP). Primary outcome will be the external rating of communication skills and consulting competencies addressing palliative care related topics. Secondary outcomes on core concepts of palliative care, basic knowledge, attitudes, confidence and self-efficacy will be assessed by standardized questionnaires and self-developed items. A further external assessment of the quality of physician-patient-interaction will be conducted by the SP. Longitudinal quantitative data will be analyzed using covariate-adjusted linear mixed-models. Discussion If the communication skills training proves to be effective, it will provide a feasible intervention to promote an earlier communication of palliative care related topics in the care of advanced cancer patients. This would help to further establish early integration of palliative care as it is recommended by national and international guidelines. Trial registration German Clinical Trials Register DRKS00017025 (date of registration: 4 June 2019).
Collapse
|
28
|
LeBlanc TW. Hoping for the best and preparing for the worst: a forgotten maxim in the immunotherapy era? Palliat Med 2020; 34:1289-1290. [PMID: 32912076 DOI: 10.1177/0269216320954621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Thomas W LeBlanc
- Duke Cancer Institute, Durham, NC, USA.,Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
29
|
Hoesseini A, Offerman MPJ, van de Wall-Neecke BJ, Sewnaik A, Wieringa MH, Baatenburg de Jong RJ. Physicians' clinical prediction of survival in head and neck cancer patients in the palliative phase. BMC Palliat Care 2020; 19:176. [PMID: 33234115 PMCID: PMC7687732 DOI: 10.1186/s12904-020-00682-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/09/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The prognosis of patients with incurable head and neck cancer (HNC) is a relevant topic. The mean survival of these patients is 5 months but may vary from weeks to more than 3 years. Discussing the prognosis early in the disease trajectory enables patients to make well-considered end-of-life choices, and contributes to a better quality of life and death. However, physicians often are reluctant to discuss prognosis, partly because of the concern to be inaccurate. This study investigated the accuracy of physicians' clinical prediction of survival of palliative HNC patients. METHODS This study was part of a prospective cohort study in a tertiary cancer center. Patients with incurable HNC diagnosed between 2008 and 2011 (n = 191), and their treating physician were included. Analyses were conducted between July 2018 and February 2019. Patients' survival was clinically predicted by their physician ≤3 weeks after disclosure of the palliative diagnosis. The clinical prediction of survival in weeks (CPS) was based on physicians' clinical assessment of the patient during the outpatient visits. More than 25% difference between the actual survival (AS) and the CPS was regarded as a prediction error. In addition, when the difference between the AS and CPS was 2 weeks or less, this was always considered as correct. RESULTS In 59% (n = 112) of cases survival was overestimated. These patients lived shorter than predicted by their physician (median AS 6 weeks, median CPS 20 weeks). In 18% (n = 35) of the cases survival was correctly predicted. The remaining 23% was underestimated (median AS 35 weeks, median CPS 20 weeks). Besides the differences in AS and CPS, no other significant differences were found between the three groups. There was worse accuracy when predicting survival closer to death: out of the 66 patients who survived 6 weeks or shorter, survival was correctly predicted in only eight (12%). CONCLUSION Physicians tend to overestimate the survival of palliative HNC patients. This optimism can result in suboptimal use of palliative and end-of-life care. The future development of a prognostic model that provides more accurate estimates, could help physicians with personalized prognostic counseling.
Collapse
Affiliation(s)
- Arta Hoesseini
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Marinella P J Offerman
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Bojou J van de Wall-Neecke
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Marjan H Wieringa
- Department of Education and Research, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - Robert J Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| |
Collapse
|
30
|
Yoo SH, Choi W, Kim Y, Kim MS, Park HY, Keam B, Heo DS. Difficulties Doctors Experience during Life-Sustaining Treatment Discussion after Enactment of the Life-Sustaining Treatment Decisions Act: A Cross-Sectional Study. Cancer Res Treat 2020; 53:584-592. [PMID: 33211941 PMCID: PMC8053877 DOI: 10.4143/crt.2020.735] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/18/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose This study aimed to investigate difficulties doctors experience during life-sustaining treatment (LST) discussion with seriously ill patients and their families after enactment of the LST Decisions Act in February 2018. Materials and Methods A cross-sectional survey was conducted in a tertiary hospital in the Republic of Korea in August 2019. Six hundred eighty-six doctors who care for seriously ill patients were given a structured questionnaire, and difficulties during the discussion were examined. Results One hundred thirty-two doctors completed the questionnaire. Eighty-five percent answered they treat cancer patients. Most (86.4%) experienced considerable difficulties during LST discussions (mean score, 7.4±1.6/10). The two most common difficulties were communication with patients and family and determining when to discuss LST. Two-thirds of doctors found direct discussions with the patient difficult and said they would initiate LST discussions only with family. LST discussions were actually initiated later than considered appropriate. When medically assessing whether the patient is imminently dying, 56% of doctors experienced disagreements with other doctors, which could affect their decisions. Conclusion This study found that most doctors experienced serious difficulties regarding communication with patients and family and medical assessment of dying process during LST discussions. To alleviate these difficulties, further institutional support is needed to improve the LST discussion between doctors, patients, and family.
Collapse
Affiliation(s)
- Shin Hye Yoo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea
| | - Wonho Choi
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea
| | - Yejin Kim
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea
| | - Min Sun Kim
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea.,Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
| | - Hye Yoon Park
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea.,Department of Psychiatry, Seoul National University Hospital, Seoul, Korea
| | - Bhumsuk Keam
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dae Seog Heo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| |
Collapse
|
31
|
Messerotti A, Banchelli F, Ferrari S, Barbieri E, Bettelli F, Bandieri E, Giusti D, Catellani H, Borelli E, Colaci E, Pioli V, Morselli M, Forghieri F, Galeazzi GM, Marasca R, Bigi S, D'Amico R, Martin P, Efficace F, Luppi M, Potenza L. Investigating the association between physicians self-efficacy regarding communication skills and risk of "burnout". Health Qual Life Outcomes 2020; 18:271. [PMID: 32762755 PMCID: PMC7409639 DOI: 10.1186/s12955-020-01504-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 07/21/2020] [Indexed: 11/10/2022] Open
Abstract
Background Breaking bad news (BBN) may be associated with increasing risk of burnout in practising physicians. However, there is little research on the association between the way bad news is broken and burnout. We investigated the association between physicians’ self-efficacy regarding communication to patients and risk of burnout. Methods We performed a cross-sectional study by proposing an ad-hoc survey exploring attitudes and practice regarding BBN and the Maslach Burnout Inventory - Human Service Survey to 379 physicians from two University Hospitals in Italy. Associations were assessed by multivariable logistic regression models. Results Two-hundred twenty-six (60%) physicians returned the questionnaires. 76% of physicians acquired communication skills by observing mentors or colleagues, 64% considered BBN as discussing a poor prognosis, 56% reported discussing prognosis as the most difficult task, 38 and 37% did not plan a BBN encounter and considered it stressful. The overall burnout rate was 59%. Considering BBN a stressful task was independently associated with high risk of burnout (OR 3.01; p = 0.013). Planning the encounter (OR = 0.43, p = 0.037), mastering communication skills (OR = 0.19, p = 0.034) and the self-evaluation as good or very good at BBN (OR 0.32; 0.15 to 0.71; p = 0.0) were associated with low risk of burnout. Conclusions Our findings suggest that some physicians’ BBN attitudes and knowledge of conceptual frameworks may influence the risk of burnout and support the notion that increasing knowledge about communication skills may protect clinicians from burnout. Further research is needed in this area.
Collapse
Affiliation(s)
- Andrea Messerotti
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena and Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Federico Banchelli
- Department of Medical and Surgical Sciencesm, Statistic Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Silvia Ferrari
- Department of Biomedic and Metabolic Science and Neuroscience, section of Psychiatry, University of Modena and Reggio Emilia, Modena, Italy
| | - Emiliano Barbieri
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena and Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesca Bettelli
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena and Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Elena Bandieri
- Oncology and Palliative Care Units, Civil Hospital Carpi, Local Health Agency, Carpi (Modena), Italy
| | - Davide Giusti
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena and Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Hillary Catellani
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena and Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Eleonora Borelli
- Department of Biomedic and Metabolic Science and Neuroscience, University of Modena and Reggio Emilia, Modena, Italy
| | - Elisabetta Colaci
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena and Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Valeria Pioli
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena and Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Monica Morselli
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena and Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Forghieri
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena and Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Gian Maria Galeazzi
- Department of Biomedic and Metabolic Science and Neuroscience, section of Psychiatry, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Marasca
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena and Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Sarah Bigi
- Department of Linguistic Sciences and Foreign Literatures, Catholic University of the Sacred Heart, Milan, Italy
| | - Roberto D'Amico
- Department of Medical and Surgical Sciencesm, Statistic Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Peter Martin
- Centre for Organisational Change in Person-Centred Healthcare, Faculty of Health, Deakin University, Melbourne, Australia
| | - Fabio Efficace
- Italian Group for Adult Hematologic Disease (GIMEMA), Health Outcomes Research Unit, Rome, Italy
| | - Mario Luppi
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena and Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Leonardo Potenza
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di Modena and Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy.
| |
Collapse
|
32
|
O’Neill C, Hutchings HA, Abbott Z, Battle C. Prognostic prediction tools and clinician communication: a qualitative study of the effect of the STUMBL tool on clinical practice. BMC Emerg Med 2020; 20:36. [PMID: 32393174 PMCID: PMC7216548 DOI: 10.1186/s12873-020-00331-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 04/29/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND In recent years, researchers and clinicians have been developing prognostic prediction tools (PPTs) as a way of identifying patients at risk of deterioration. The use of PPTs in the clinical environment not only impacts the risk of adverse outcomes for patients, but the use of these tools also effect clinical practice. Much attention has been paid to the clinical performance of PPTs. But more insight is needed on how the use of PPTs impacts clinical practice. The objective of this study was to map some of the ways in which PPTs effect clinical practice. The STUMBL (STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients) feasibility trial evaluated the use of a new prognostic prediction tool (PPT) to guide the management blunt chest wall trauma patients in the emergency departments (ED). The trial was undertaken between October 2016 and September 2018 and conducted at four sites in England and Wales. Nested within the feasibility trial was a qualitative study aimed at understanding how ED clinicians experienced and used the PPT. The qualitative methods included a focus group and telephone interviews with 9 ED clinicians. This study focused on participant perceptions of the feasibility and use of the STUMBL tool on clinical practice in the ED. RESULTS Clinical practice is reshaped as a result of the introduction of the STUMBL PPT into the clinical environment. The PPT enhanced reflexive awareness of prognostic practice; facilitated communication between patients and professionals; helps to guide patient outcomes; and provides a common ground for clinician discussion on prognostication. CONCLUSIONS The qualitative data collected offered useful insights into the ways in which the tool changes clinical practice. This was a small study of the effect of one kind of PPT on clinical practice. Nevertheless, this study maps areas in which clinical practice is affected by the introduction of a PPT into the clinical environment. More research is needed to better understand these effects, and to understand how these tools become embedded in clinical practice over the longer term.
Collapse
Affiliation(s)
- Claire O’Neill
- grid.4827.90000 0001 0658 8800Institute of Life Science 2, Swansea University Medical School, Swansea University, Singleton Park, Swansea, SA2 8PP UK
| | - Hayley A. Hutchings
- grid.4827.90000 0001 0658 8800Institute of Life Science 2, Swansea University Medical School, Swansea University, Singleton Park, Swansea, SA2 8PP UK
| | - Zoe Abbott
- grid.5600.30000 0001 0807 5670Division of Population Medicine, Cardiff University, Fifth Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Ceri Battle
- grid.416122.20000 0004 0649 0266Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Heol Maes Eglwys, Swansea, SA6 6NL UK ,grid.4827.90000 0001 0658 8800Swansea University Medical School, Swansea University, Singleton Park, Swansea, SA2 8PP UK
| |
Collapse
|
33
|
Abstract
Prognostication is a vital aspect of decision making because it provides patients and families with information to establish realistic and achievable goals of care, is used in determining eligibility for certain benefits, and helps in targeting interventions to those likely to benefit. Prognostication consists of 3 components: clinicians use their clinical judgment or other tools to estimate the probability of an individual developing a particular outcome over a specific period of time; this prognostic estimate is communicated in accordance with the patient's information preferences; the prognostic estimate is interpreted by the patient or surrogate and used in clinical decision making.
Collapse
Affiliation(s)
- Emily J Martin
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles, 757 Westwood Plaza Suite 7501, Los Angeles, CA 90095, USA.
| | - Eric Widera
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, 4150 Clement Street, Box 181G, San Francisco, CA 94121, USA. https://twitter.com/EWidera
| |
Collapse
|
34
|
Sisk BA, Dobrozsi S, Mack JW. Teamwork in prognostic communication: Addressing bottlenecks and barriers. Pediatr Blood Cancer 2020; 67:e28192. [PMID: 31965719 PMCID: PMC7096274 DOI: 10.1002/pbc.28192] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/16/2019] [Accepted: 01/09/2020] [Indexed: 11/09/2022]
Abstract
Prognostic communication is essential to family-centered care in pediatric oncology. Yet, prognostic communication from the medical team to the family is often absent or incomplete. In our experience, many clinical groups view prognostic disclosure as the responsibility of the patient's primary oncologist, and nurses are often excluded from these conversations. This current individual-based model of prognostic disclosure lacks redundancy and creates a communication bottleneck. We propose that clinical groups should address prognostic communication with a multidisciplinary team-based approach that incorporates three critical components: shared team mental models, distribution and redundancy in role assignment, and high fidelity monitoring of communication milestones.
Collapse
Affiliation(s)
- Bryan A. Sisk
- Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Sarah Dobrozsi
- Division of Hematology and Oncology, Department of Pediatrics, Medical College of Wisconsin/Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | - Jennifer W. Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts; and Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, Massachusetts
| |
Collapse
|
35
|
Perez GK, Salsman JM, Fladeboe K, Kirchhoff AC, Park ER, Rosenberg AR. Taboo Topics in Adolescent and Young Adult Oncology: Strategies for Managing Challenging but Important Conversations Central to Adolescent and Young Adult Cancer Survivorship. Am Soc Clin Oncol Educ Book 2020; 40:1-15. [PMID: 32324424 PMCID: PMC7328818 DOI: 10.1200/edbk_279787] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
Research on adolescents and young adults (AYAs) with cancer has flourished over the past decade, underscoring the unique medical and psychosocial needs of this vulnerable group. A cancer diagnosis during adolescence and young adulthood intersects with the developmental trajectory of AYAs, derailing critical physical, social, and emotional development. AYAs face these abrupt life changes needing age-appropriate information and resources to offset these challenges. Greater attention is needed to address AYA-specific concerns on reproductive and sexual health, financial security and independence, emotional well-being, social support, and end-of-life care. If these unique needs are unaddressed, this can adversely affect AYAs' health care engagement and overall quality of life, increasing their risk for cancer-related morbidity and early mortality. In particular, health care decisions made during treatment have important implications for AYA patients' future health. Oncology clinicians are well positioned to address AYA patients' concerns by anticipating and addressing the challenges this age group is likely to face. In this paper, we explore several core topics that affect AYAs' quality of life and that can be challenging to address. Starting from the moment of diagnosis, through cancer treatment and post-treatment survivorship, and into end of life, each section highlights critical developmental-centric life domains that are affected by the cancer experience. Specifically, we discuss resources, tools, and strategies to navigate these challenging conversations. Taking a risk-reduction approach that invites two-way communication and facilitates referral to age-appropriate resources would help destigmatize these experiences and, in turn, would support the provision of compassionate and effective age-concordant care to this vulnerable group.
Collapse
Affiliation(s)
- Giselle K. Perez
- Harvard Medical School/Massachusetts General Hospital, Boston, MA
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, MA
| | - John M. Salsman
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC
| | - Kaitlyn Fladeboe
- Seattle Children’s Research Institute, University of Washington, Seattle, WA
| | - Anne C. Kirchhoff
- Huntsman Cancer Institute and Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Elyse R. Park
- Harvard Medical School/Massachusetts General Hospital, Boston, MA
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, MA
| | - Abby R. Rosenberg
- Seattle Children’s Research Institute, University of Washington, Seattle, WA
| |
Collapse
|
36
|
Kang E, Kang JH, Koh SJ, Song EK, Shim HJ, Keam B, Maeng CH, Kim YJ, Yun HJ, Jung KH, Kwon JH, Lee SN, Lee JL, Do YR, Min J, Lee J, Choo J, Yun YH. The Impacts of Prognostic Awareness on Mood and Quality of Life Among Patients With Advanced Cancer. Am J Hosp Palliat Care 2020; 37:904-912. [PMID: 32052654 DOI: 10.1177/1049909120905789] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Accurate awareness of the prognosis is an important factor in the treatment decision of patients with advanced cancer; however, prognostic disclosure is still subject to debate because it can reduce patient's satisfaction and increase depression. AIM The purpose of this study is to assess whether patients' prognostic awareness is associated with decreased quality of life (QoL) or increased depressive mood in patients with advanced cancer. DESIGN AND PARTICIPANTS In this cohort study, 386 patients with advanced cancer were recruited across 3 periods from December 2016 to August 2018. The outcome of this study was a change in QoL and depression according to the patients' prognostic awareness at baseline, 3 months, and 6 months. RESULTS This study found significant differences in changes of QoL based on patients' prognostic awareness. From baseline to 3 months, emotional functioning (P = .039), pain (P = .042), existential well-being (P = .025), and social support (P = .038) subscale scores improved significantly more in those with lack of prognostic awareness. Over 6 months, the group without prognostic awareness improved significantly in terms of physical functioning (P = .037), emotional functioning (P = .002), nausea/vomiting (P = .048), and constipation (P = .039) subscale scores and existential well-being scores (P = .025). No significant difference between the groups was found in terms of depression. CONCLUSION Accurate prognostic awareness may pose harm and may provide no additional benefits in terms of QoL and mood among patients with advanced cancer for a short period of time.
Collapse
Affiliation(s)
- EunKyo Kang
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea.,Institute for Public Health and Medical Service, Seoul National University Hospital, Seoul, Korea
| | - Jung Hun Kang
- Department of Internal Medicine, School of Medicine, Gyeongsang University, Jinju, Korea
| | - Su-Jin Koh
- Department of Hematology and Oncology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea
| | - Eun-Kee Song
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Hyun-Jeong Shim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Bhumsuk Keam
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chi-Hoon Maeng
- Division of Hemato-Oncology, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Yu Jung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hwan Jung Yun
- Department of Internal Medicine, Chungnam National University College of Medicine, Chungnam, Korea
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Hye Kwon
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Korea
| | - Soon Nam Lee
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jung Lim Lee
- Department of Hemato-Oncology, Daegu Fatima Hospital, Daegu, Korea
| | - Young Rok Do
- Department of Internal Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - JeongHee Min
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Korea
| | - Jihye Lee
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Korea
| | - Jiyeon Choo
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ho Yun
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
37
|
Niranjan SJ, Turkman Y, Williams BR, Williams CP, Halilova KI, Smith T, Knight SJ, Bhatia S, Rocque GB. "I'd Want to Know, Because a Year's Not a Long Time to Prepare for a Death": Role of Prognostic Information in Shared Decision Making among Women with Metastatic Breast Cancer. J Palliat Med 2020; 23:937-943. [PMID: 32043896 DOI: 10.1089/jpm.2019.0457] [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] [Indexed: 11/12/2022] Open
Abstract
Context: Increasing emphasis on patient-centered care has led to highlighted importance of shared decision making, which better aligns medical decisions with patient care preferences. Effective shared decision making in metastatic breast cancer (MBC) treatment requires prognostic understanding, without which patients may receive treatment inconsistent with personal preferences. Objectives: To assess MBC patient and provider perspectives on the role of prognostic information in treatment decision making. Methods: We conducted semi-structured interviews with MBC patients and community oncologists and separate focus groups involving lay navigators, nurses, and academic oncologists. Qualitative analysis utilized a content analysis approach that included a constant comparative method to generate themes. Results: Of 20 interviewed patients with MBC, 30% were African American. Academic oncologists were mostly women (60%), community oncologists were all Caucasian, and nurses were all women and 28% African American. Lay navigators were all African American and predominately women (86%). Five emergent themes were identified. (1) Most patients wanted prognostic information but differed in when they wanted to have this conversation, (2) Emotional distress and discomfort was a critical reason for not discussing prognosis, (3) Religious beliefs shaped preferences for prognostic information, (4) Health care professionals differed on prognostic information delivery timing, and (5) Providers acknowledged that an individualized approach taking into account patient values and preferences would be beneficial. Conclusion: Most MBC patients wanted prognostic information, yet varied in when they wanted this information. Understanding why patients want limited or unrestricted prognostic information can inform oncologists' efforts toward shared decision making.
Collapse
Affiliation(s)
- Soumya J Niranjan
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Yasemin Turkman
- School of Nursing, and University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Beverly R Williams
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Courtney P Williams
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Karina I Halilova
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tom Smith
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sara J Knight
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Smita Bhatia
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gabrielle B Rocque
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
38
|
Yamaji N, Sawaguchi M, Ota E. Talking with Children about Cancer: A Content Analysis of Text in Children’s Picture Books. Health (London) 2020. [DOI: 10.4236/health.2020.127055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
39
|
Malhotra C, Rajasekaran T, Kanesvaran R, Yee A, Bundoc FG, Singh R, Tulsky JA, Pollak KI. Pilot Trial of a Combined Oncologist-Patient-Caregiver Communication Intervention in Singapore. JCO Oncol Pract 2019; 16:e190-e200. [PMID: 31880975 DOI: 10.1200/jop.19.00412] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE High-quality end-of-life cancer care requires oncologists to communicate effectively and patients/caregivers to be participatory. However, most communication interventions target either but not both. We aimed to pilot a potentially disseminable combined oncologist-patient/caregiver intervention to improve oncologist empathic responses, discussions of prognosis and goals of care, and patient/caregiver participation. We assessed its feasibility, acceptability, and preliminary efficacy. METHODS Between June 2018 and January 2019, we conducted a pilot 2-arm cluster trial in Singapore, randomly assigning 10 oncologists in a 1:1 ratio to receive the combined intervention or usual care. Intervention arm oncologists received online communication skills training, and their patients received a brief prompt sheet before consultations. We audio recorded consultations with 60 patients with stage IV solid malignancy and analyzed 30 in the postintervention phase. The study was not powered for statistical significance. RESULTS Participation rates for oncologists and patients were 100% and 63%, respectively. All oncologists completed the online training within an average of 4.5 weeks; 73% of the patients selected at least 1 question in the prompt sheet. Compared with the control arm, intervention arm oncologists had more empathic responses in total (relative risk [RR], 1.66) and for every patient/caregiver negative emotion (RR, 2.01). Their consultations were more likely to involve discussions of prognosis (RR, 3.00) and goals of care, and their patients were more likely to ask a prognosis-related question (RR, 2.00; P > .05 for all). CONCLUSION The combined oncologist-patient/caregiver intervention is feasible and acceptable and has the potential to improve communication within consultations.
Collapse
Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | | | | | - Alethea Yee
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | | | - Ratna Singh
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - James A Tulsky
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke University School of Medicine, Singapore
| |
Collapse
|
40
|
Brassfield ER, Buchbinder M. Clinicians' Perspectives on the Duty to Inform Patients About Medical Aid-in-Dying. AJOB Empir Bioeth 2019; 11:53-62. [PMID: 31829903 DOI: 10.1080/23294515.2019.1695016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: As of 2019, ten jurisdictions in the United States have authorized physicians to prescribe a lethal dose of medication to a terminally ill patient for the purpose of hastening death. Relatively little bioethics scholarship has addressed the question of whether physicians have an obligation to inform qualifying patients about aid-in-dying (AID) in permissive jurisdictions and little is known about providers' actual communication practices with respect to this issue. Methods: One hundred and forty-four in-depth, semi-structured interviews were conducted and analyzed using an inductive analytic approach as part of the Vermont Study on Aid-in-Dying. Results: Seventeen respondents, 14 physicians and 3 nurse practitioners, met the inclusion criteria for this sub-study. Eleven respondents indicated that they at least sometimes inform patients about AID. Respondents described multiple factors that influence whether or not they might initiate discussions of AID, including the importance of informing patients of their options for end-of-life care, worries about undue influence, and worries about the potential effects on the patient-provider relationship. For those providers who do initiate discussion of AID at least some of the time, attention to the particulars of each individual patient's situation and the context of the discussion appear to play a role in shaping communication about AID. Conclusions: While initiating a clinical discussion of AID is undoubtedly challenging, our study provides compelling descriptive evidence that some medical providers who support AID do not unilaterally follow the conventional bioethics wisdom holding that they ought to wait for patients to introduce the topic of AID. Future research should investigate how to approach these discussions so as to minimize ethical worries about undue influence or potential negative consequences.
Collapse
Affiliation(s)
- Elizabeth R Brassfield
- Department of Philosophy and School of Medicine, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Mara Buchbinder
- Center for Bioethics, Department of Social Medicine, School of Medicine, University of North Carolina at Chapel Hill, North Carolina, USA
| |
Collapse
|
41
|
Modes ME, Engelberg RA, Downey L, Nielsen EL, Lee RY, Curtis JR, Kross EK. Toward Understanding the Relationship Between Prioritized Values and Preferences for Cardiopulmonary Resuscitation Among Seriously Ill Adults. J Pain Symptom Manage 2019; 58:567-577.e1. [PMID: 31228534 PMCID: PMC6754772 DOI: 10.1016/j.jpainsymman.2019.06.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Prioritizing among potentially conflicting end-of-life values may help patients discriminate among treatments and allow clinicians to align treatments with values. OBJECTIVES To investigate end-of-life values that patients prioritize when facing explicit trade-offs and identify predictors of patients whose values and treatment preferences seem inconsistent. METHODS Analysis of surveys from a multi-center cluster-randomized trial of patients with serious illness. Respondents prioritized end-of-life values and identified cardiopulmonary resuscitation (CPR) preferences in two health states. RESULTS Of 535 patients, 60% prioritized relief of discomfort over extending life, 17% prioritized extending life over relief of discomfort, and 23% were unsure. Patients prioritizing extending life were most likely to prefer CPR, with 93% preferring CPR in current health and 67% preferring CPR if dependent on others, compared with 69% and 21%, respectively, for patients prioritizing relief of discomfort, and 78% and 33%, respectively, for patients unsure of their prioritized value (P < 0.001 for all comparisons). Among patients prioritizing relief of discomfort, preference for CPR in current health was less likely among older patients (odds ratio 0.958 per year; 95% CI 0.935, 0.981) and more likely with better self-perceived health (odds ratio 1.402 per level of health; 95% CI 1.090, 1.804). CONCLUSION Clinicians face challenges as they clarify patient values and align treatments with values. Patients' values predicted CPR preferences, but a substantial proportion of patients expressed CPR preferences that appeared potentially inconsistent with their primary value. Clinicians should question assumptions about relationships between values and CPR preferences. Further research is needed to identify ways to use values to guide treatment decisions.
Collapse
Affiliation(s)
- Matthew E Modes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Lois Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Robert Y Lee
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| |
Collapse
|
42
|
Berger Z, Tung M, Yesantharao P, Zhou A, Blackford A, Smith TJ, Snyder C. Feasibility and perception of a question prompt list in outpatient cancer care. J Patient Rep Outcomes 2019; 3:53. [PMID: 31418088 PMCID: PMC6695465 DOI: 10.1186/s41687-019-0145-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 08/06/2019] [Indexed: 11/10/2022] Open
Abstract
Introduction Management of cancer is often characterized by difficult decisions. The National Coalition for Cancer Survivorship (NCCS) has developed the “Know Yourself” tool, a question prompt list (QPL) to enable patients to participate in these decisions. Methods We investigated the feasibility of using the NCCS tool by oncologists and their patients with cancer in a before-and-after pilot study at a tertiary medical center. We also measured patient reported decision preparedness, anxiety, satisfaction with care, trust in physician, discussion of care with their primary care physician (PCP), and general state of health, and solicited feedback from clinicians and patients on use of the form. Results Ninety patients and fifteen clinicians participated. Most patients reported the Tool was easy to use (91%) and would recommend it to others (73%) however fewer reported discussing the Tool at the visit (31%) or felt that it improved the quality of care (45%) or communication with the oncologist (56%). Clinicians reported Tool use in only 16 of 60 visits (27%); in these visits the Tool was helpful in identifying areas of concern (74%), guiding the clinical interaction (67%), promoting communication (62%), identifying areas of need (70%), and improving quality of care (71%). Decision preparedness, trust in physicians, uncertainty about care, anxiety, patient satisfaction and discussion of care with the PCP was unchanged with Tool use compared to non-use. Conclusions The Know Yourself tool had poor uptake but was favorably received among both patients and clinicians who used it. These findings suggest some patients could benefit from QPLs. Future work should test how implementation strategies might achieve greater use.
Collapse
Affiliation(s)
- Zackary Berger
- Johns Hopkins University School of Medicine and Johns Hopkins Berman Institute of Bioethics, Johns Hopkins Outpatient Center, 601 N Caroline St Suite 7143, Baltimore, MD, 2187, USA.
| | - Monica Tung
- Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD, 21205, USA
| | - Pooja Yesantharao
- Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD, 21205, USA
| | - Alice Zhou
- Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD, 21205, USA
| | - Amanda Blackford
- Johns Hopkins Division of Biostatistics and Bioinformatics, 550 N. Broadway, Suite 1111, Baltimore, MD, 21205, USA
| | - Thomas J Smith
- Johns Hopkins University Division of General Internal Medicine and Oncology, 2024 Monument St, Baltimore, MD, 21205, USA
| | - Claire Snyder
- Johns Hopkins University Division of General Internal Medicine, 2024 Monument St, Baltimore, MD, 21205, USA
| |
Collapse
|
43
|
Hirano H, Shimizu C, Kawachi A, Ozawa M, Higuchi A, Yoshida S, Shimizu K, Tatara R, Horibe K. Preferences Regarding End-of-Life Care Among Adolescents and Young Adults With Cancer: Results From a Comprehensive Multicenter Survey in Japan. J Pain Symptom Manage 2019; 58:235-243.e1. [PMID: 31077783 DOI: 10.1016/j.jpainsymman.2019.04.033] [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: 02/15/2019] [Revised: 04/29/2019] [Accepted: 04/30/2019] [Indexed: 12/31/2022]
Abstract
CONTEXT Patient preferences influence end-of-life (EOL) care which patients receive. However, preferences regarding EOL care among adolescent and young adult (AYA) cancer population remain unclear. OBJECTIVES The objective of the study was to evaluate preferences regarding EOL care among AYA cancer population. METHODS We evaluated preferences regarding EOL care as a part of a comprehensive multicenter questionnaire study investigating the experience and needs of Japanese AYA cancer population. RESULTS A total of 349 AYA cancer population (213 AYA cancer patients and 136 AYA cancer survivors) were evaluated. Eighty-six percent (296/344), 53% (180/338), 88% (301/341), and 61% (207/342) of participants with valid response preferred to have prognostic disclosure, receive palliative chemotherapy for incurable cancer with limited efficacy at the expense of considerable toxicity, actively use palliative care, and stay home at EOL, respectively. In multivariate analysis, the preference regarding prognostic disclosure was associated positively with no child status (odds ratio [OR] = 3.05, P = 0.003) and negatively with history of chemotherapy (OR = 0.23, P = 0.009), the preference regarding palliative chemotherapy for incurable cancer with limited efficacy at the expense of considerable toxicity was associated positively with status under active cancer treatment (OR = 1.74, P = 0.03), and the preference of staying home at EOL was positively associated with anxiety (OR = 1.72, P = 0.04). CONCLUSION This study elucidated preferences regarding EOL care among Japanese AYA cancer population. These findings may help health care practitioners to have better understanding of preferences regarding EOL care among this population.
Collapse
Affiliation(s)
- Hidekazu Hirano
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan; Department of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan; Department of Medicine, Keio University Graduate School of Medicine, Tokyo, Japan
| | - Chikako Shimizu
- Department of Breast Medical Oncology, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Asuka Kawachi
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Miwa Ozawa
- Department of Pediatrics, St. Luke's International Hospital, Tokyo, Japan
| | - Akiko Higuchi
- Children's Cancer Association of Japan, Tokyo, Japan
| | - Saran Yoshida
- Graduate School of Education, Tohoku University, Sendai, Miyagi, Japan
| | - Ken Shimizu
- Department of Psycho-oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Ryohei Tatara
- Department of Psycho-oncology, National Cancer Center Hospital, Tokyo, Japan; Clinical Department of Palliative Medicine, Osaka City General Hospital, Osaka, Japan
| | - Keizo Horibe
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| |
Collapse
|
44
|
|
45
|
Thomas JM, Cooney LM, Fried TR. Prognosis Reconsidered in Light of Ancient Insights-From Hippocrates to Modern Medicine. JAMA Intern Med 2019; 179:820-823. [PMID: 30958502 DOI: 10.1001/jamainternmed.2019.0302] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Whereas modern clinicians are often reluctant to discuss prognosis with their patients, such discussions were central to medical practice in ancient Greece. A historical analysis has the potential to explain the reasons for this difference in prognostic practices and provide insights into overcoming current challenges. Many scholars consider prognosis to be the principal scientific achievement of the Hippocratic tradition. The earliest treatise on the subject, On Prognostics, defines prognosis broadly as "foreseeing and foretelling, by the side of the sick, the present, the past, and the future." This definition makes clear that prognosis is not simply about predicting the future, but also involves an appreciation for the continuity of past, present, and future as sequences of connected events, or trajectories, that can be pieced together into a comprehensive story of the patient's health. In modern medicine, prognosis has lagged behind diagnosis and treatment in its establishment as a central component of medical care. An important basis for understanding this lies in the paradigm change that occurred with the discovery of pathogens as agents of disease, shifting attention toward individual diseases and away from diseased individuals. With this shift, diagnostics and treatments advanced dramatically and prognosis fell to the background. More recent attempts to advance prognosis have focused on narrower uses of the term, such as estimates of life expectancy and mortality risk. However, physicians have expressed a number of reservations about the use of such estimates in the care of patients, and patients have indicated the desire for a wide variety of predictive information. Adopting the broadness of the Hippocratic definition may allow clinicians to overcome their hesitancy and provide much-needed information to their patients.
Collapse
Affiliation(s)
- John M Thomas
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut (prior affiliation while this work was conducted).,Dominican House of Studies, Pontifical Faculty of the Immaculate Conception, Washington, DC
| | - Leo M Cooney
- Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut
| | - Terri R Fried
- Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut.,Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| |
Collapse
|
46
|
LeBlanc TW, Marron JM, Ganai S, McGinnis MM, Spence RA, Tenner L, Tap WD, Hlubocky FJ. Prognostication and Communication in Oncology. J Oncol Pract 2019; 15:208-215. [DOI: 10.1200/jop.18.00647] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Sabha Ganai
- Southern Illinois University School of Medicine, Springfield, IL
| | | | | | - Laura Tenner
- University of Texas Health Cancer Center at San Antonio, San Antonio, TX
| | | | | |
Collapse
|
47
|
Habib AR, Cronin AM, Earle CC, Tulsky JA, Mack JW, Abel GA, Odejide OO. How Do Blood Cancer Doctors Discuss Prognosis? Findings from a National Survey of Hematologic Oncologists. J Palliat Med 2019; 22:677-684. [PMID: 30907686 DOI: 10.1089/jpm.2018.0441] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Although blood cancers are accompanied by a high level of prognostic uncertainty, little is known about when and how hematologic oncologists discuss prognosis. Objectives: Characterize reported practices and predictors of prognostic discussions for a cohort of hematologic oncologists. Design: Cross-sectional mailed survey in 2015. Setting/Subjects: U.S.-based hematologic oncologists providing clinical care for adult patients with blood cancers. Measurements: We conducted univariable and multivariable analyses assessing the association of clinician characteristics with reported frequency of initiation of prognostic discussions, type of terminology used, and whether prognosis is readdressed. Results: We received 349 surveys (response rate = 57.3%). The majority of respondents (60.3%) reported conducting prognostic discussions with "most" (>95%) of their patients. More than half (56.8%) preferred general/qualitative rather than specific/numeric terms when discussing prognosis. Although 91.3% reported that they typically first initiate prognostic discussions at diagnosis, 17.7% reported routinely never readdressing prognosis or waiting until death is imminent to revisit the topic. Hematologic oncologists with ≤15 years since medical school graduation (odds ratio [OR] 0.51; confidence interval (95% CI) 0.30-0.88) and those who considered prognostic uncertainty a barrier to quality end-of-life care (OR 0.57; 95% CI 0.35-0.90) had significantly lower odds of discussing prognosis with "most" patients. Conclusions: Although the majority of hematologic oncologists reported discussing prognosis with their patients, most prefer general/qualitative terms. Moreover, even though prognosis evolves during the disease course, nearly one in five reported never readdressing prognosis or only doing so near death. These findings suggest the need for structured interventions to improve prognostic communication for patients with blood cancers.
Collapse
Affiliation(s)
- Anand R Habib
- 1 Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,2 Harvard Medical School, Boston, Massachusetts
| | - Angel M Cronin
- 1 Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Craig C Earle
- 3 Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - James A Tulsky
- 2 Harvard Medical School, Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,5 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jennifer W Mack
- 1 Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,2 Harvard Medical School, Boston, Massachusetts
| | - Gregory A Abel
- 1 Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,2 Harvard Medical School, Boston, Massachusetts
| | - Oreofe O Odejide
- 1 Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,2 Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
48
|
Adamson M, Cotoc C, Choi K, Notaro S. Cancer Communication Outside of the Physician-Patient Relationship: The Experience of Communicating and Understanding the Meaning of Prognosis. Am J Hosp Palliat Care 2019; 36:711-717. [PMID: 30818959 DOI: 10.1177/1049909119832811] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
RESEARCH QUESTION How does the process of engagement and integration of sources of information outside patient-physician interaction affect how individuals with cancer interpret their treatment experience and prognosis? BACKGROUND Studies of patient-physician communication of prognosis in oncology highlight areas where misunderstanding occurs: understanding consequences of treatment, likelihood of treatment success, probability of cure, status/progression of illness, and prognosis. Theories proposing mechanisms that underlie this discrepancy cannot account for all instances of misunderstanding, including when complete and direct physician disclosure occurs. Prior research focused on patient-physician communication event(s) and immediate antecedents and consequences. However, less is known about what happens to information once it has been communicated and how a patient's process to interpret the meaning of their experience affects their understanding of it. Our study explores this question by examining patient communication with sources of information other than treating physicians. METHODOLOGY We conducted 10 semi-structured qualitative interviews with individuals diagnosed with 4 types of cancer at different stages. The interviews were analyzed using inductive qualitative analysis. RESULTS Participants in our sample consulted a variety of additional sources to give context and understanding to their communicated prognosis. These were important contributors to how they understood their prognosis and incorporated that understanding. They included family, friends/acquaintances, cancer survivors, support/survivor groups, secondary health-care staff, and relevant informational materials. Different motivations for seeking out these sources were also expressed. Participants expressed a link between their understanding of their prognosis and the variety of outside sources they enlisted for input and support.
Collapse
Affiliation(s)
- Matthew Adamson
- 1 Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Crina Cotoc
- 1 Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Kelsey Choi
- 1 Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Stephen Notaro
- 1 Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| |
Collapse
|
49
|
Geerse OP, Lamas DJ, Sanders JJ, Paladino J, Kavanagh J, Henrich NJ, Berendsen AJ, Hiltermann TJN, Fromme EK, Bernacki RE, Block SD. A Qualitative Study of Serious Illness Conversations in Patients with Advanced Cancer. J Palliat Med 2019; 22:773-781. [PMID: 30724693 DOI: 10.1089/jpm.2018.0487] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: Conversations with seriously ill patients about their values and goals have been associated with reduced distress, a better quality of life, and goal-concordant care near the end of life. Yet, little is known about how such conversations are conducted. Objective: To characterize the content of serious illness conversations and identify opportunities for improvement. Design: Qualitative analysis of audio-recorded, serious illness conversations using an evidence-based guide and obtained through a cluster randomized controlled trial in an outpatient oncology setting. Setting/Measurements: Clinicians assigned to the intervention arm received training to use the "Serious Illness Conversation Guide" to have a serious illness conversation about values and goals with advanced cancer patients. Conversations were de-identified, transcribed verbatim, and independently coded by two researchers. Key themes were analyzed. Results: A total of 25 conversations conducted by 16 clinicians were evaluated. The median conversation duration was 14 minutes (range 4-37), with clinicians speaking half of the time. Thematic analyses demonstrated five key themes: (1) supportive dialogue between patients and clinicians; (2) patients' openness to discuss emotionally challenging topics; (3) patients' willingness to articulate preferences regarding life-sustaining treatments; (4) clinicians' difficulty in responding to emotional or ambiguous patient statements; and (5) challenges in discussing prognosis. Conclusions: Data from this exploratory study suggest that seriously ill patients are open to discussing values and goals with their clinician. Yet, clinicians may struggle when disclosing a time-based prognosis and in responding to patients' emotions. Such skills should be a focus for additional training for clinicians caring for seriously ill patients.
Collapse
Affiliation(s)
- Olaf P Geerse
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,2 Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Daniela J Lamas
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin J Sanders
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joanna Paladino
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jane Kavanagh
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Natalie J Henrich
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Annette J Berendsen
- 6 Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thijo J N Hiltermann
- 2 Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik K Fromme
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Rachelle E Bernacki
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Susan D Block
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,7 Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
50
|
Diamond EL, Prigerson HG, Correa DC, Reiner A, Panageas K, Kryza-Lacombe M, Buthorn J, Neil EC, Miller AM, DeAngelis LM, Applebaum AJ. Prognostic awareness, prognostic communication, and cognitive function in patients with malignant glioma. Neuro Oncol 2018. [PMID: 28645200 DOI: 10.1093/neuonc/nox117] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Malignant glioma (MG) is a devastating neuro-oncologic disease with almost invariably poor prognosis. Prognostic awareness (PA) is the awareness of incurable disease and shortened life expectancy (LE). Accurate PA is associated with favorable psychological outcomes at the end of life (EoL) for patients with cancer; however, little is known about PA or prognostic communication in MG. Moreover, research has yet to evaluate the impact of cognitive impairment on PA and preferred forms of communication. Methods Fifty MG patients and 32 paired caregivers were evaluated in this exploratory study with a semi-structured PA assessment aimed to measure their awareness of MG incurability and LE. Full PA was defined as awareness of MG incurability and accurate estimate of LE. The assessment included a survey about preferences for prognostic communication (items from the Prognosis and Treatment Perceptions Questionnaire), neurocognitive assessment (Hopkins Verbal Learning Test-Revised, Trail Making Test Parts A and B, and the Controlled Oral Word Association Test), and measurements of mood (Hospital Anxiety and Depression Scale) and quality of life (Functional Assessment of Cancer Therapy-Brain [FACT-Br]). Results Twenty (40%) patients and 22 (69%) caregivers had full PA. Thirty (60%) patients and 23 (72%) caregivers reported that prognostic information was extremely or very important, and 21 (42%) patients and 16 (50%) caregivers desired more prognostic information. Patients with memory impairment more frequently believed that prognostic information was important (P = 0.04, P = 0.03) and desired more information (P = 0.05, P = 0.003) as compared with those without impairment. Conclusions Most MG patients were unaware of their LE. Memory impairment may influence preferences for prognostic information.
Collapse
Affiliation(s)
- Eli L Diamond
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California; Department of Neurology, University of Minnesota, Minneapolis, Minnesota; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Holly G Prigerson
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California; Department of Neurology, University of Minnesota, Minneapolis, Minnesota; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Denise C Correa
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California; Department of Neurology, University of Minnesota, Minneapolis, Minnesota; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne Reiner
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California; Department of Neurology, University of Minnesota, Minneapolis, Minnesota; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine Panageas
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California; Department of Neurology, University of Minnesota, Minneapolis, Minnesota; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria Kryza-Lacombe
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California; Department of Neurology, University of Minnesota, Minneapolis, Minnesota; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Justin Buthorn
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California; Department of Neurology, University of Minnesota, Minneapolis, Minnesota; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elizabeth C Neil
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California; Department of Neurology, University of Minnesota, Minneapolis, Minnesota; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alex M Miller
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California; Department of Neurology, University of Minnesota, Minneapolis, Minnesota; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California; Department of Neurology, University of Minnesota, Minneapolis, Minnesota; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Allison J Applebaum
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California; Department of Neurology, University of Minnesota, Minneapolis, Minnesota; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|