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Herskovits AZ, Newman T, Nicholas K, Colorado-Jimenez CF, Perry CE, Valentino A, Wagner I, Egan B, Gorenshteyn D, Vickers AJ, Pessin MS. Comparing Clinician Estimates versus a Statistical Tool for Predicting Risk of Death within 45 Days of Admission for Cancer Patients. Appl Clin Inform 2024; 15:489-500. [PMID: 38925539 PMCID: PMC11208110 DOI: 10.1055/s-0044-1787185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/29/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVES While clinical practice guidelines recommend that oncologists discuss goals of care with patients who have advanced cancer, it is estimated that less than 20% of individuals admitted to the hospital with high-risk cancers have end-of-life discussions with their providers. While there has been interest in developing models for mortality prediction to trigger such discussions, few studies have compared how such models compare with clinical judgment to determine a patient's mortality risk. METHODS This study is a prospective analysis of 1,069 solid tumor medical oncology hospital admissions (n = 911 unique patients) from February 7 to June 7, 2022, at Memorial Sloan Kettering Cancer Center. Electronic surveys were sent to hospitalists, advanced practice providers, and medical oncologists the first afternoon following a hospital admission and they were asked to estimate the probability that the patient would die within 45 days. Provider estimates of mortality were compared with those from a predictive model developed using a supervised machine learning methodology, and incorporated routine laboratory, demographic, biometric, and admission data. Area under the receiver operating characteristic curve (AUC), calibration and decision curves were compared between clinician estimates and the model predictions. RESULTS Within 45 days following hospital admission, 229 (25%) of 911 patients died. The model performed better than the clinician estimates (AUC 0.834 vs. 0.753, p < 0.0001). Integrating clinician predictions with the model's estimates further increased the AUC to 0.853 (p < 0.0001). Clinicians overestimated risk whereas the model was extremely well-calibrated. The model demonstrated net benefit over a wide range of threshold probabilities. CONCLUSION The inpatient prognosis at admission model is a robust tool to assist clinical providers in evaluating mortality risk, and it has recently been implemented in the electronic medical record at our institution to improve end-of-life care planning for hospitalized cancer patients.
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Affiliation(s)
- Adrianna Z. Herskovits
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Tiffanny Newman
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Kevin Nicholas
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Cesar F. Colorado-Jimenez
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Claire E. Perry
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Alisa Valentino
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Isaac Wagner
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Barbara Egan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | | | - Andrew J. Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Melissa S. Pessin
- Department of Pathology, University of Chicago, Chicago, Illinois, United States
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2
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Svendsen SJ, Grov EK, Staats K. Patients' experiences with shared decision-making in home-based palliative care - navigation through major life decisions. BMC Palliat Care 2024; 23:101. [PMID: 38627710 PMCID: PMC11022472 DOI: 10.1186/s12904-024-01434-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/12/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND This study addresses the issue of shared decision-making (SDM) in a Norwegian home-based palliative care setting. The significance of patient involvement in SDM is widely acknowledged, and many patients want to participate in decisions about care and treatment. Yet, it remains a need for more knowledge regarding the initiators and approaches of SDM in the context of home-based palliative care, particularly from the patients' perspective. The aim of this study is to understand patients' experiences and preferences for SDM in home-based palliative care, seeking to enhance the quality of care and direct the planning of healthcare services. METHODS We used a qualitative explorative design. A hermeneutic approach was employed, and data was collected through in-dept interviews with 13 patients. RESULTS The study uncovered an overarching theme of "Navigating to reach own decisions," comprising three sub-themes: "To be trapped in life without decisions to act on"; "To surrender to others and let others deal with decisions"; "To continue to be oneself without focusing on disease and decision-making". CONCLUSIONS The findings underscore the need for flexible, person-centered approaches in SDM, tailored to the fluctuating health literacy and changing preferences of patients in palliative care settings. Our study contributes to the understanding of SDM in palliative care by highlighting how patients navigate the balance between autonomy and reliance on HCPs. Future research should explore how healthcare systems, including HCPs' roles in the system, can adapt to the patients' dynamic needs, to ensuring that SDM will remain a supportive and empowering process for patients at all stages of their disease.
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Affiliation(s)
- Sandra Jahr Svendsen
- Lillestrøm Municipality, Lillestrøm, Norway.
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Kjeller, Norway.
| | - Ellen Karine Grov
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Pilestredet, Norway
| | - Katrine Staats
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Kjeller, Norway
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3
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Shen MJ, Prigerson HG, Maciejewski PK, Daly B, Adelman R, McConnell Trevino KM. A communication intervention to improve prognostic understanding and engagement in advance care planning among diverse advanced cancer patient-caregiver dyads: A pilot study. Palliat Support Care 2024; 22:10-18. [PMID: 37526150 PMCID: PMC10901460 DOI: 10.1017/s1478951523000901] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
OBJECTIVES Accurate prognostic understanding among patients with advanced cancer and their caregivers is associated with greater engagement in advance care planning (ACP) and receipt of goal-concordant care. Poor prognostic understanding is more prevalent among racial and ethnic minority patients. The purpose of this study was to examine the feasibility, acceptability, and impact of a patient-caregiver communication-based intervention to improve prognostic understanding, engagement in ACP, and completion of advance directives among a racially and ethnically diverse, urban sample of patients and their caregivers. METHODS Patients with advanced cancer and their caregivers (n = 22 dyads) completed assessments of prognostic understanding, engagement in ACP, and completion of advance directives at baseline and post-intervention, Talking About Cancer (TAC). TAC is a 7-session intervention delivered remotely by licensed social workers that includes distress management and communication skills, review of prognosis, and information on ACP. RESULTS TAC met a priori benchmarks for feasibility, acceptability, and fidelity. Prognostic understanding and engagement in ACP did not change over time. However, patients showed increases in completion of advance directives. SIGNIFICANCE OF RESULTS TAC was feasible, acceptable, and delivered with high fidelity. Involvement of caregivers in TAC may provide added layers of support to patients facing advanced cancer diagnoses, especially among racial and ethnic minorities. Trends indicated greater completion of advance directives but not in prognostic understanding or engagement in ACP. Future research is needed to optimize the intervention to improve acceptability, tailor to diverse patient populations, and examine the efficacy of TAC in a randomized controlled trial.
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Affiliation(s)
- Megan J Shen
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Holly G Prigerson
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Paul K Maciejewski
- Department of Radiology, Weill Cornell Medical College, New York, NY, USA
| | - Bobby Daly
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ronald Adelman
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Kelly M McConnell Trevino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Golmohammadi M, Ebadi A, Ashrafizadeh H, Rassouli M, Barasteh S. Factors related to advance directives completion among cancer patients: a systematic review. BMC Palliat Care 2024; 23:3. [PMID: 38166983 PMCID: PMC10762918 DOI: 10.1186/s12904-023-01327-w] [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: 02/12/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person's future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients. METHODS A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior. RESULTS Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients' age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: "Lack of knowledge of the ADs concept" and "Previous experience of the disease", the subjective norm category includes three subcategories: "Social support and interaction with family", "Respecting the patient's wishes" and "EOL care choices". Also, the category of perceived control behavior was categorized into two sub-categories: "Decision-making" and "Access to the healthcare system", as well as external factors affecting the model, including "socio-demographic characteristics". CONCLUSION The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.
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Affiliation(s)
- Mobina Golmohammadi
- Student Research Committee, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Hadis Ashrafizadeh
- Student Research Committee, Faculty of Nursing, Dezful University of Medical Sciences, Dezful, Iran
| | - Maryam Rassouli
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Salman Barasteh
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran.
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
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Mercadante S, Lo Cascio A, Casuccio A. Mortality rate and palliative sedation in an acute palliative care unit. BMJ Support Palliat Care 2023:spcare-2023-004669. [PMID: 38154922 DOI: 10.1136/spcare-2023-004669] [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: 10/31/2023] [Accepted: 11/15/2023] [Indexed: 12/30/2023]
Abstract
AIM To assess the mortality rate and the use of palliative sedation (PS) in an advanced long-standing acute palliative care unit (APCU) METHODS: The charts of patients who died and eventually received PS, consecutively admitted to the APCU for 4 years, were reviewed. Patients' characteristics and symptom intensity were recorded at admission, 3 days before death and the day before death (T0, T-3, T-end, respectively). For patients who were administered midazolam for PS, initial and final doses of drugs, as well as duration of PS until death, were recorded. RESULTS One hundred and forty-eight patients died in APCU (8.9%), and 45 of them (30.4%) received PS. Younger patients and those reporting high levels of dyspnoea at T-3 and T-end were more likely to be sedated (p=0.002, p=0.013 and 0.002, respectively). The mean duration of PS was 27.47 hours. Mean initial and final doses of midazolam were 35.45 mg/day (SD 19.7) and 45.57 mg/day (SD 20.6), respectively (p=0.001). CONCLUSION Mortality rate in APCU was very low. As a percentage of the number of deaths, PS rate was similar to that reported in other settings. PS does not seem to accelerate impending death.
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Affiliation(s)
| | - Alessio Lo Cascio
- Pain Relief and Supportive Care, Private Hospital La Maddalena, Palermo, Italy
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Mercadante S, Bruera E. Acute palliative care units: characteristics, activities and outcomes - scoping review. BMJ Support Palliat Care 2023; 13:386-392. [PMID: 36653151 DOI: 10.1136/spcare-2022-004088] [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: 11/19/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023]
Abstract
Acute palliative care units (APCUs) are lacking in most cancer hospitals and even when palliative care units are present, they are predominantly based on a traditional hospice-like model for patients with short life expectancy. This scoping review examined the papers assessing the activities of APCU. Data from literature regarding APCU characteristics, activities and outcomes have shown important differences among different countries.In comparison with existing data on traditional hospices, APCU provided a whole range of palliative care interventions, from an early treatment of pain and symptoms at time diagnosis and during the oncological treatment, up to the advanced stage of disease when they may favour the transition to the best supportive care or palliative care only, also indicating the best palliative care service that may fits the clinical and social condition of individuals. Large differences in the characteristics of such units, including hospital stay and mortality, have been evidenced, in some cases resembling those of a traditional hospice. It likely that in some countries such units supply the lack of other palliative care services.Further studies on APCUs are needed, even on other outcome processes, to provide a more precise identification among the palliative care settings, which should not interchangeable, but complimentary to offer the full range of activities to be activated according to the different needs of the patients.
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Affiliation(s)
- Sebastiano Mercadante
- Main regional center for pain relief and supportive/palliative care, La Maddalena Cancer center, Palermo, Italy
| | - Eduardo Bruera
- Department of supportive care, MD Anderson, Houston, Texas, USA
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Prsic E, Morris JC, Adelson KB, Parker NA, Gombos EA, Kottarathara MJ, Novosel M, Castillo L, Gould Rothberg BE. Oncology hospitalist impact on hospice utilization. Cancer 2023; 129:3797-3804. [PMID: 37706601 DOI: 10.1002/cncr.35008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/02/2023] [Accepted: 07/15/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Unplanned hospitalizations among patients with advanced cancer are often sentinel events prompting goals of care discussions and hospice transitions. Late referrals to hospice, especially those at the end of life, are associated with decreased quality of life and higher total health care costs. Inpatient management of patients with solid tumor malignancies is increasingly shifting from oncologists to oncology hospitalists. However, little is known about the impact of oncology hospitalists on the timing of transition to hospice. OBJECTIVE To compare hospice discharge rate and time to hospice discharge on an inpatient oncology service led by internal medicine-trained hospitalists and a service led by oncologists. METHODS At Smilow Cancer Hospital, internal medicine-trained hospitalists were integrated into one of two inpatient medical oncology services allowing comparison between the new, hospitalist-led service (HS) and the traditional, oncologist-led service (TS). Discharges from July 26, 2021, through January 31, 2022, were identified from the electronic medical record. The odds ratio for discharge disposition by team was calculated by logistic regression using a multinomial distribution. Adjusted length of stay before discharge was assessed using multivariable linear regression. RESULTS The HS discharged 47/400 (11.8%) patients to inpatient hospice, whereas the TS service discharged 18/313 (5.8%), yielding an adjusted odds ratio of 1.94 (95% CI, 1.07-3.51; p = .03). Adjusted average length of stay before inpatient hospice disposition was 6.83 days (95% CI, 4.22-11.06) for the HS and 16.29 days (95% CI, 7.73-34.29) for the TS (p = .003). CONCLUSIONS Oncology hospitalists improve hospice utilization and time to inpatient hospice referral on an inpatient medical oncology service. PLAIN LANGUAGE SUMMARY Patients with advanced cancer are often admitted to the hospital near the end of life. These patients generally have a poor chance of long-term survival and may prefer comfort-focused care with hospice. In this study, oncology hospitalists discharged a higher proportion of patients to inpatient hospice with less time spent in the hospital before discharge.
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Affiliation(s)
- Elizabeth Prsic
- Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jensa C Morris
- Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Hospital Medicine Service, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Kerin B Adelson
- Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut, USA
- Yale University Yale Cancer Center, New Haven, Connecticut, USA
| | - Nathaniel A Parker
- Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut, USA
- Hospital Medicine Service, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Erin A Gombos
- Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut, USA
- Hospital Medicine Service, Yale New Haven Hospital, New Haven, Connecticut, USA
| | | | - Madison Novosel
- Yale University School of Public Health, New Haven, Connecticut, USA
| | - Lawrence Castillo
- Yale University School of Public Health, New Haven, Connecticut, USA
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Shalev Many Y, Shvartzman P, Wolf I, Silverman BG. Place of Death for Israeli Cancer Patients Over a 20-Year Period: Reducing Hospital Deaths, but Barriers Remain. Oncologist 2023; 28:e1092-e1098. [PMID: 37260398 PMCID: PMC10628558 DOI: 10.1093/oncolo/oyad141] [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: 01/11/2023] [Accepted: 04/19/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Cancer remains a leading cause of mortality worldwide. While the main focus of palliative care (PC) is quality of life, the elements that comprise the quality of death are often overlooked. Dying at home, with home-hospice-care (HHC) support, rather than in-hospital, may increase patient satisfaction and decrease the use of invasive measures. We examined clinical and demographic characteristics associated with out-of-hospital death among patients with cancer, which serves as a proxy measure for HHC deaths. METHODS Using death certification data from the Israel Central Bureau of Statistics, we analyzed 209,158 cancer deaths between 1998 and 2018 in Israel including demographic information, cause of death, and place of death (POD). A multiple logistic regression model was constructed to identify factors associated with out-of-hospital cancer deaths. RESULTS Between 1998 and 2018, 69.1% of cancer deaths occurred in-hospital, and 30.8% out-of-hospital. Out-of-hospital deaths increased by 1% annually during the study period. Older patients and those dying of solid malignancies were more likely to die out-of-hospital (OR = 2.65, OR = 1.93, respectively). Likelihood of dying out-of-hospital varied with area of residency; patients living in the Southern district were more likely than those in the Jerusalem district to die out-of-hospital (OR = 2.37). CONCLUSION The proportion of cancer deaths occurring out-of-hospital increased during the study period. We identified clinical and demographic factors associated with POD. Differences between geographical areas probably stem from disparity in the distribution of PC services and highlight the need for increasing access to primary EOL care. However, differences in age and tumor type probably reflect cultural changes and suggest focusing on educating patients, families, and physicians on the benefits of PC.
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Affiliation(s)
| | - Pesach Shvartzman
- Pain and Palliative Care Unit, Department of Family Medicine, Ben Gurion University, Beer Sheva, Israel
| | - Ido Wolf
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Oncology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Barbara G Silverman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Israel National Cancer Registry, Israel Ministry of Health, Ramat Gan, Israel
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Chaput G, Bhanabhai H. Deprescribing: A Prime Opportunity to Optimize Care of Cancer Patients. Curr Oncol 2023; 30:9701-9709. [PMID: 37999124 PMCID: PMC10670366 DOI: 10.3390/curroncol30110704] [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: 08/18/2023] [Revised: 10/21/2023] [Accepted: 10/30/2023] [Indexed: 11/25/2023] Open
Abstract
Patients with incurable cancers have an increasing number of comorbidities, which can lead to polypharmacy and its associated adverse events (drug-to-drug interaction, prescription of a potentially inappropriate medication, adverse drug event). Deprescribing is a patient-centered process aimed at optimizing patient outcomes by discontinuing medication(s) deemed no longer necessary or potentially inappropriate. Improved patient quality of life, risk reduction of side effects or worse clinical outcomes, and a decrease in healthcare costs are well-documented benefits of deprescribing. Deprescribing and advance care planning both require consideration of patients' values, preferences, and care goals. Here, we provide an overview of comorbidities and associated polypharmacy risks in cancer patients, as well as useful tools and resources for deprescribing in daily practice, and we shed light on how deprescribing can facilitate advance care planning discussions with patients who have advanced cancer or a limited life expectancy.
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Affiliation(s)
- Genevieve Chaput
- Division of Supportive and Palliative Care, McGill University Health Centre, Department of Family Medicine, McGill University, Montreal, QC H4A 3J1, Canada
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10
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Shen MJ, Cho S, De Los Santos C, Yarborough S, Maciejewski PK, Prigerson HG. Planning for Your Advance Care Needs (PLAN): A Communication Intervention to Improve Advance Care Planning among Latino Patients with Advanced Cancer. Cancers (Basel) 2023; 15:3623. [PMID: 37509284 PMCID: PMC10377387 DOI: 10.3390/cancers15143623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/02/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The goal of this study was to develop and optimize an intervention designed to address barriers to engagement in advance care planning (ACP) among Latino patients with advanced cancer. The resulting intervention, titled Planning Your Advance Care Needs (PLAN), is grounded in theoretical models of communication competence and sociocultural theory. MATERIALS AND METHODS An initial version of the PLAN manual was developed based on a prior intervention, Ca-HELP, that was designed to improve communication around pain among cancer patients. PLAN uses this framework to coach patients on how to plan for and communicate their end-of-life care needs through ACP. In the present study, feedback was obtained from key stakeholders (n = 11 patients, n = 11 caregivers, n = 10 experts) on this preliminary version of the PLAN manual. Participants provided ratings of acceptability and feedback around the intervention content, format, design, modality, and delivery through quantitative survey questions and semi-structured qualitative interviews. RESULTS Results indicated that the PLAN manual was perceived to be helpful and easy to understand. All stakeholder groups liked the inclusion of explicit communication scripts and guidance for having conversations about ACP with loved ones and doctors. Specific feedback was given to modify PLAN to ensure it was optimized and tailored for Latino patients. Some patients noted reviewing the manual motivated engagement in ACP. CONCLUSIONS Feedback from stakeholders resulted in an optimized, user-centered version of PLAN tailored to Latino patients. Future research will examine the acceptability, feasibility, and potential efficacy of this intervention to improve engagement in ACP.
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Affiliation(s)
- Megan J. Shen
- Division of Clinical Research, Fred Hutchinson Cancer Center, 1100 Fairview Ave. N., Mail Stop D5-290, Seattle, WA 98109, USA; (C.D.L.S.); (S.Y.)
| | - Susie Cho
- School of Nursing, University of Washington, Seattle, WA 98195, USA;
| | - Claudia De Los Santos
- Division of Clinical Research, Fred Hutchinson Cancer Center, 1100 Fairview Ave. N., Mail Stop D5-290, Seattle, WA 98109, USA; (C.D.L.S.); (S.Y.)
| | - Sarah Yarborough
- Division of Clinical Research, Fred Hutchinson Cancer Center, 1100 Fairview Ave. N., Mail Stop D5-290, Seattle, WA 98109, USA; (C.D.L.S.); (S.Y.)
| | - Paul K. Maciejewski
- Department of Radiology, Weill Cornell Medical College, New York, NY 10065, USA;
| | - Holly G. Prigerson
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA;
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11
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Yu TH, Lu FL, Wei CJ, Wu WW. The impacts of the scope of benefits expansion on hospice care among adult decedents: a nationwide longitudinal observational study. BMC Palliat Care 2023; 22:29. [PMID: 36978057 PMCID: PMC10053103 DOI: 10.1186/s12904-023-01146-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/09/2023] [Indexed: 03/30/2023] Open
Abstract
OBJECTIVES Compared to aggressive treatment for patients at the end stage of life, hospice care might be more likely to satisfy such patients' need and benefits and improve their dignity and quality of life. Whether the reimbursement policy expansion affect the use of hospice care among various demographics characteristics and health status was unknown. Therefore, the purpose of this study was to explore the impacts of reimbursement policy expansion on hospice care use, and to investigate the effects on people with various demographics characteristics and health status. METHODS We used the 2001-2017 Taiwan NHI claims data, Death Registry, and Cancer Registry in this study, and we included people who died between 2002 and 2017. The study period was divided into 4 sub-periods. hospice care use and the initiation time of 1st hospice care use were used as dependent variables; demographic characteristics and health status were also collected. RESULTS There were 2,445,781 people who died in Taiwan during the study period. The results show that the trend of hospice care use increased over time, going steeply upward after the scope of benefits expansion, but the initiation time of 1st hospice care use did not increase after the scope of benefits expansion. The results also show that the effects of expansion varied among patients by demographic characteristics. CONCLUSION The scope of benefits expansion might induce people's needs in hospice care, but the effects varied by demographic characteristics. Understanding the reasons for the variations in all populations would be the next step for Taiwan's health authorities.
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Affiliation(s)
- Tsung-Hsien Yu
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Frank Leigh Lu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
- School of Medicine, National Taiwan University, No.1 Jen-Ai Road section 1 Taipei 100, Taipei, Taiwan
| | - Chung-Jen Wei
- Department of Public Health, Fu-Jen Catholic University, New Taipei, Taiwan
| | - Wei-Wen Wu
- School of Medicine, National Taiwan University, No.1 Jen-Ai Road section 1 Taipei 100, Taipei, Taiwan.
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan.
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
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Jewitt N, Rapoport A, Gupta A, Srikanthan A, Sutradhar R, Luo J, Widger K, Wolfe J, Earle CC, Gupta S, Kassam A. The Effect of Specialized Palliative Care on End-of-Life Care Intensity in AYAs with Cancer. J Pain Symptom Manage 2023; 65:222-232. [PMID: 36423804 DOI: 10.1016/j.jpainsymman.2022.11.013] [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: 09/08/2022] [Revised: 11/01/2022] [Accepted: 11/11/2022] [Indexed: 11/23/2022]
Abstract
CONTEXT Many adolescents and young adults (AYAs; 15-39 years) with cancer receive high intensity (HI) care at the end of life (EOL). Palliative care (PC) involvement in this population is associated with lower risk of HI-EOL care. Whether this association differs by specialized vs. generalist PC (SPC, GPC) is unknown. OBJECTIVES (1) To evaluate whether SPC had an impact on the intensity of EOL care received by AYAs with cancer; (2) to determine which subpopulations are at highest risk for reduced access to SPC. METHODS A decedent cohort of AYAs with cancer who died between 2000-2017 in Ontario, Canada was identified using registry and population-based data. The primary composite measure of HI-EOL care included any of: intravenous chemotherapy <14 days from death; more than one ED visit, more than one hospitalization or any ICU admission <30 days from death. Physician's billing codes were used to define SPC and GPC involvement. RESULTS Of 7122 AYA decedents, 2140 (30%) received SPC and 943 (13%) received GPC. AYAs who died in earlier years, those with hematologic malignancies, males and rural AYAs were least likely to receive SPC. No PC involvement was associated with higher odds of receiving HI-EOL care (odds ratio (OR) 1.5; P < 0.0001). SPC involvement was associated with the lowest risk of HI-EOL care (OR SPC vs. GPC 0.8; P = 0.007) and decreased odds of ICU admission (OR 0.7; P = 0.006). CONCLUSION SPC involvement was associated with the lowest risk of HI-EOL care in AYAs with cancer. However, access to SPC remains a challenge.
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Affiliation(s)
- Natalie Jewitt
- Paediatric Advanced Care Team (PACT) (N.J., A.R., K.W.), The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine (N.J., A.R., A.G., S.G., A.K.), University of Toronto, Toronto, Ontario, Canada; Emily's House Children's Hospice (A.R.), Toronto, Ontario, Canada; Division of Haematology/Oncology (A.G., S.G., A.K.), The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Oncology (A.S.), The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine (A.S.), University of Ottawa, Ottawa, Ontario, Canada; Cancer Research Program (R.S., J.L., C.E., S.G.), Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing (K.W.), University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.W.), Boston, Massachusetts; Department of Pediatrics (J.W.), Boston Children's Hospital, Boston, Massachusetts; Institute for Health Policy (S.G.), Evaluation and Management, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics and Division of Palliative Care (A.K.), Southlake Regional Health Centre, Newmarket, Ontario, Canada.
| | - Adam Rapoport
- Paediatric Advanced Care Team (PACT) (N.J., A.R., K.W.), The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine (N.J., A.R., A.G., S.G., A.K.), University of Toronto, Toronto, Ontario, Canada; Emily's House Children's Hospice (A.R.), Toronto, Ontario, Canada; Division of Haematology/Oncology (A.G., S.G., A.K.), The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Oncology (A.S.), The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine (A.S.), University of Ottawa, Ottawa, Ontario, Canada; Cancer Research Program (R.S., J.L., C.E., S.G.), Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing (K.W.), University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.W.), Boston, Massachusetts; Department of Pediatrics (J.W.), Boston Children's Hospital, Boston, Massachusetts; Institute for Health Policy (S.G.), Evaluation and Management, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics and Division of Palliative Care (A.K.), Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Abha Gupta
- Paediatric Advanced Care Team (PACT) (N.J., A.R., K.W.), The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine (N.J., A.R., A.G., S.G., A.K.), University of Toronto, Toronto, Ontario, Canada; Emily's House Children's Hospice (A.R.), Toronto, Ontario, Canada; Division of Haematology/Oncology (A.G., S.G., A.K.), The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Oncology (A.S.), The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine (A.S.), University of Ottawa, Ottawa, Ontario, Canada; Cancer Research Program (R.S., J.L., C.E., S.G.), Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing (K.W.), University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.W.), Boston, Massachusetts; Department of Pediatrics (J.W.), Boston Children's Hospital, Boston, Massachusetts; Institute for Health Policy (S.G.), Evaluation and Management, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics and Division of Palliative Care (A.K.), Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Amirrtha Srikanthan
- Paediatric Advanced Care Team (PACT) (N.J., A.R., K.W.), The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine (N.J., A.R., A.G., S.G., A.K.), University of Toronto, Toronto, Ontario, Canada; Emily's House Children's Hospice (A.R.), Toronto, Ontario, Canada; Division of Haematology/Oncology (A.G., S.G., A.K.), The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Oncology (A.S.), The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine (A.S.), University of Ottawa, Ottawa, Ontario, Canada; Cancer Research Program (R.S., J.L., C.E., S.G.), Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing (K.W.), University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.W.), Boston, Massachusetts; Department of Pediatrics (J.W.), Boston Children's Hospital, Boston, Massachusetts; Institute for Health Policy (S.G.), Evaluation and Management, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics and Division of Palliative Care (A.K.), Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Rinku Sutradhar
- Paediatric Advanced Care Team (PACT) (N.J., A.R., K.W.), The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine (N.J., A.R., A.G., S.G., A.K.), University of Toronto, Toronto, Ontario, Canada; Emily's House Children's Hospice (A.R.), Toronto, Ontario, Canada; Division of Haematology/Oncology (A.G., S.G., A.K.), The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Oncology (A.S.), The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine (A.S.), University of Ottawa, Ottawa, Ontario, Canada; Cancer Research Program (R.S., J.L., C.E., S.G.), Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing (K.W.), University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.W.), Boston, Massachusetts; Department of Pediatrics (J.W.), Boston Children's Hospital, Boston, Massachusetts; Institute for Health Policy (S.G.), Evaluation and Management, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics and Division of Palliative Care (A.K.), Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Jin Luo
- Paediatric Advanced Care Team (PACT) (N.J., A.R., K.W.), The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine (N.J., A.R., A.G., S.G., A.K.), University of Toronto, Toronto, Ontario, Canada; Emily's House Children's Hospice (A.R.), Toronto, Ontario, Canada; Division of Haematology/Oncology (A.G., S.G., A.K.), The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Oncology (A.S.), The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine (A.S.), University of Ottawa, Ottawa, Ontario, Canada; Cancer Research Program (R.S., J.L., C.E., S.G.), Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing (K.W.), University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.W.), Boston, Massachusetts; Department of Pediatrics (J.W.), Boston Children's Hospital, Boston, Massachusetts; Institute for Health Policy (S.G.), Evaluation and Management, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics and Division of Palliative Care (A.K.), Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Kimberley Widger
- Paediatric Advanced Care Team (PACT) (N.J., A.R., K.W.), The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine (N.J., A.R., A.G., S.G., A.K.), University of Toronto, Toronto, Ontario, Canada; Emily's House Children's Hospice (A.R.), Toronto, Ontario, Canada; Division of Haematology/Oncology (A.G., S.G., A.K.), The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Oncology (A.S.), The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine (A.S.), University of Ottawa, Ottawa, Ontario, Canada; Cancer Research Program (R.S., J.L., C.E., S.G.), Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing (K.W.), University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.W.), Boston, Massachusetts; Department of Pediatrics (J.W.), Boston Children's Hospital, Boston, Massachusetts; Institute for Health Policy (S.G.), Evaluation and Management, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics and Division of Palliative Care (A.K.), Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Joanne Wolfe
- Paediatric Advanced Care Team (PACT) (N.J., A.R., K.W.), The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine (N.J., A.R., A.G., S.G., A.K.), University of Toronto, Toronto, Ontario, Canada; Emily's House Children's Hospice (A.R.), Toronto, Ontario, Canada; Division of Haematology/Oncology (A.G., S.G., A.K.), The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Oncology (A.S.), The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine (A.S.), University of Ottawa, Ottawa, Ontario, Canada; Cancer Research Program (R.S., J.L., C.E., S.G.), Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing (K.W.), University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.W.), Boston, Massachusetts; Department of Pediatrics (J.W.), Boston Children's Hospital, Boston, Massachusetts; Institute for Health Policy (S.G.), Evaluation and Management, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics and Division of Palliative Care (A.K.), Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Craig C Earle
- Paediatric Advanced Care Team (PACT) (N.J., A.R., K.W.), The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine (N.J., A.R., A.G., S.G., A.K.), University of Toronto, Toronto, Ontario, Canada; Emily's House Children's Hospice (A.R.), Toronto, Ontario, Canada; Division of Haematology/Oncology (A.G., S.G., A.K.), The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Oncology (A.S.), The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine (A.S.), University of Ottawa, Ottawa, Ontario, Canada; Cancer Research Program (R.S., J.L., C.E., S.G.), Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing (K.W.), University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.W.), Boston, Massachusetts; Department of Pediatrics (J.W.), Boston Children's Hospital, Boston, Massachusetts; Institute for Health Policy (S.G.), Evaluation and Management, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics and Division of Palliative Care (A.K.), Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Sumit Gupta
- Paediatric Advanced Care Team (PACT) (N.J., A.R., K.W.), The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine (N.J., A.R., A.G., S.G., A.K.), University of Toronto, Toronto, Ontario, Canada; Emily's House Children's Hospice (A.R.), Toronto, Ontario, Canada; Division of Haematology/Oncology (A.G., S.G., A.K.), The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Oncology (A.S.), The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine (A.S.), University of Ottawa, Ottawa, Ontario, Canada; Cancer Research Program (R.S., J.L., C.E., S.G.), Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing (K.W.), University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.W.), Boston, Massachusetts; Department of Pediatrics (J.W.), Boston Children's Hospital, Boston, Massachusetts; Institute for Health Policy (S.G.), Evaluation and Management, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics and Division of Palliative Care (A.K.), Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Alisha Kassam
- Paediatric Advanced Care Team (PACT) (N.J., A.R., K.W.), The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine (N.J., A.R., A.G., S.G., A.K.), University of Toronto, Toronto, Ontario, Canada; Emily's House Children's Hospice (A.R.), Toronto, Ontario, Canada; Division of Haematology/Oncology (A.G., S.G., A.K.), The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Oncology (A.S.), The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine (A.S.), University of Ottawa, Ottawa, Ontario, Canada; Cancer Research Program (R.S., J.L., C.E., S.G.), Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing (K.W.), University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.W.), Boston, Massachusetts; Department of Pediatrics (J.W.), Boston Children's Hospital, Boston, Massachusetts; Institute for Health Policy (S.G.), Evaluation and Management, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics and Division of Palliative Care (A.K.), Southlake Regional Health Centre, Newmarket, Ontario, Canada
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13
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Anaka M, Lee M, Lim E, Ghosh S, Cheung WY, Spratlin J. Changing Rates of Goals of Care Designations in Patients With Advanced Pancreatic Cancer During a Multifactorial Advanced Care Planning Initiative: A Real-World Evidence Study. JCO Oncol Pract 2022; 18:e869-e876. [PMID: 35108030 DOI: 10.1200/op.21.00649] [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: 09/03/2021] [Revised: 11/03/2021] [Accepted: 01/10/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Goals of care (GoC) designations are an important part of advanced care planning (ACP) for patients with incurable cancers. Studies of outpatient oncology records show that most patients do not have GoC documented. We performed a retrospective analysis of changes in GoC designations in patients with advanced pancreatic cancer in Northern Alberta, Canada, during a system-wide ACP quality improvement initiative. METHODS Four hundred seventy-one patients with newly diagnosis of advanced, non-neuroendocrine pancreatic cancer between 2010 and 2015 in Northern Alberta, Canada, were included. The ACP initiation launched April 2014, and included educational materials for patients and families, and a coded system of GoC designations describing care philosophies and preferences for resuscitation and medical interventions. Data sources included the Alberta Cancer Registry and oncology-specific electronic medical records. RESULTS 25.5% of patients had a documented GoC, which increased over the study period (Mantel-Haenszel test-of-trend P < .001; increased from 7.8% in 2010 to 50.0% in 2015). GoC designations occurred later in patients who received palliative chemotherapy versus those who did not (median 130 days from diagnosis [95% CI, 76.019 to 183.981] v 36 days [95% CI, 28.107 to 43.893]; P < .001), and coincided with the end of treatment (median 4.5 days from last treatment). 64.8% of GoC designations were documented by palliative care physicians, but the proportion documented by medical oncologists increased with time (Mantel-Haenszel test-of-trend P = .020; increased from 0% in 2010 to 52.1% in 2015). CONCLUSION GoC documentation increased in the outpatient records of patients with advanced pancreatic cancer during the system-wide, multifactorial ACP initiative. GoC documentation by medical oncologists also increased. These data provide real-world evidence supporting the impact of a specific ACP initiative to improve rates of GoC designation in patients with advanced cancer.
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Affiliation(s)
| | - Minji Lee
- University of Alberta, Edmonton, AB, Canada
| | - Elisa Lim
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Sunita Ghosh
- Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Winson Y Cheung
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
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14
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Driller B, Talseth-Palmer B, Hole T, Strømskag KE, Brenne AT. Cancer patients spend more time at home and more often die at home with advance care planning conversations in primary health care: a retrospective observational cohort study. Palliat Care 2022; 21:61. [PMID: 35501797 PMCID: PMC9063101 DOI: 10.1186/s12904-022-00952-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/19/2022] [Indexed: 12/05/2022] Open
Abstract
Background Spending time at home and dying at home is advocated to be a desirable outcome in palliative care (PC). In Norway, home deaths among cancer patients are rare compared to other European countries. Advance care planning (ACP) conversations enable patients to define goals and preferences, reflecting a person’s wishes and current medical condition. Method The study included 250 cancer patients in the Romsdal region with or without an ACP conversation in primary health care who died between September 2018 and August 2020. The patients were identified through their contact with the local hospital, cancer outpatient clinic or hospital-based PC team. Results During the last 90 days of life, patients who had an ACP conversation in primary health care (N=125) were mean 9.8 more days at home, 4.5 less days in nursing home and 5.3 less days in hospital. Having an ACP conversation in primary health care, being male or having a lower age significantly predicted more days at home at the end of life (p< .001). Patients with an ACP conversation in primary health care where significantly more likely to die at home (p< .001) with a four times higher probability (RR=4.5). Contact with the hospital-based PC team was not associated with more days at home or death at home. Patients with contact with the hospital-based PC team were more likely to have an ACP conversation in primary health care. Conclusion Palliative cancer patients with an ACP conversation in primary health care spent more days at home and more frequently died at home. Data suggest it is important that ACP conversations are conducted in primary health care setting. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00952-1.
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15
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Case AA, Epstein AS, Gustin JL. Advance care planning imperative: High-quality patient-centred goals of care. BMJ Support Palliat Care 2022; 12:407-409. [PMID: 35477675 DOI: 10.1136/bmjspcare-2022-003677] [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: 04/03/2022] [Accepted: 04/12/2022] [Indexed: 11/03/2022]
Abstract
Advance care planning (ACP) discussions aim to ensure goal-concordant care for patients with serious illness, throughout treatment and especially at the end of life. But recent literature has forced the field of palliative care to wrestle with the definition and impact of ACP. Are ACP discussions worthwhile? Is there a difference between ACP discussions early in a patient's illness versus discussions occurring later when a concrete medical care decision must be made? Here, we identify elements needed to answer these questions and describe how a multisite initiative will elucidate the value of discussing and documenting what matters most to patients.
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Affiliation(s)
- Amy Allen Case
- Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | | | - Jillian L Gustin
- Division of Palliative Medicine, Arthur G James Cancer Hospital and Richard J Solove Research Institute, The Ohio State University College of Medicine, Columbus, Ohio, USA
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16
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Allner M, Gostian M, Balk M, Rupp R, Allner C, Mantsopoulos K, Ostgathe C, Iro H, Hecht M, Gostian AO. Advance directives in patients with head and neck cancer - status quo and factors influencing their creation. Palliat Care 2022; 21:47. [PMID: 35395940 PMCID: PMC8991502 DOI: 10.1186/s12904-022-00932-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 03/10/2022] [Indexed: 12/24/2022] Open
Abstract
Background Advance Care Planning including living wills and durable powers of attorney for healthcare is a highly relevant topic aiming to increase patient autonomy and reduce medical overtreatment. Data from patients with head and neck cancer (HNC) are not currently available. The main objective of this study was to survey the frequency of advance directives (AD) in patients with head and neck cancer. Methods In this single center cross-sectional study, we evaluated patients during their regular follow-up consultations at Germany’s largest tertiary referral center for head and neck cancer, regarding the frequency, characteristics, and influencing factors for the creation of advance directives using a questionnaire tailored to our cohort. The advance directives included living wills, durable powers of attorney for healthcare, and combined directives. Results Four hundred and forty-six patients were surveyed from 07/01/2019 to 12/31/2019 (response rate = 68.9%). The mean age was 62.4 years (SD 11.9), 26.9% were women (n = 120). 46.4% of patients (n = 207) reported having authored at least one advance directive. These documents included 16 durable powers of attorney for healthcare (3.6%), 75 living wills (16.8%), and 116 combined directives (26.0%). In multivariate regression analysis, older age (OR ≤ 0.396, 95% CI 0.181–0.868; p = 0.021), regular medication (OR = 1.896, 95% CI 1.029–3.494; p = 0.040), and the marital status (“married”: OR = 2.574, 95% CI 1.142–5.802; p = 0.023; and “permanent partnership”: OR = 6.900, 95% CI 1.312–36.295; p = 0.023) emerged as significant factors increasing the likelihood of having an advance directive. In contrast, the stage of disease, the therapeutic regimen, the ECOG status, and the time from initial diagnosis did not correlate with the presence of any type of advance directive. Ninety-one patients (44%) with advance directives created their documents before the initial diagnoses of head and neck cancer. Most patients who decide to draw up an advance directive make the decision themselves or are motivated to do so by their immediate environment. Only 7% of patients (n = 16) actively made a conscious decision not create an advance directive. Conclusion Less than half of head and neck cancer patients had created an advance directive, and very few patients have made a conscious decision not to do so. Older and comorbid patients who were married or in a permanent partnership had a higher likelihood of having an appropriate document. Advance directives are an essential component in enhancing patient autonomy and allow patients to be treated according to their wishes even when they are unable to consent. Therefore, maximum efforts are advocated to increase the prevalence of advance directives, especially in head and neck cancer patients, whose disease often takes a crisis-like course. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00932-5.
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Affiliation(s)
- Moritz Allner
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany.
| | - Magdalena Gostian
- Department of Anesthesiology, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
| | - Matthias Balk
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
| | - Robin Rupp
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
| | - Clarissa Allner
- Emergency Medical Center, Department of Internal Medicine, Klinikum Fürth, Fürth, Germany
| | - Konstantinos Mantsopoulos
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), Erlangen-Nürnberg, Germany
| | - Heinrich Iro
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
| | - Markus Hecht
- Department of Radiation Oncology, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), Erlangen-Nürnberg, Germany
| | - Antoniu-Oreste Gostian
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
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17
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Lee RY, Kross EK, Downey L, Paul SR, Heywood J, Nielsen EL, Okimoto K, Brumback LC, Merel SE, Engelberg RA, Curtis JR. Efficacy of a Communication-Priming Intervention on Documented Goals-of-Care Discussions in Hospitalized Patients With Serious Illness: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e225088. [PMID: 35363271 PMCID: PMC8976242 DOI: 10.1001/jamanetworkopen.2022.5088] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE High-quality goals-of-care communication is critical to delivering goal-concordant, patient-centered care to hospitalized patients with chronic life-limiting illness. However, implementation and documentation of goals-of-care discussions remain important shortcomings in many health systems. OBJECTIVE To evaluate the efficacy, feasibility, and acceptability of a patient-facing and clinician-facing communication-priming intervention to promote goals-of-care communication for patients hospitalized with serious illness. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial enrolled patients from November 6, 2018, to February 18, 2020. The setting was 2 hospitals in an academic health care system in Seattle, Washington. Participants included hospitalized adults with chronic life-limiting illness, aged 65 years or older and with markers of frailty, or aged 80 years or older. Data analysis was performed from August 2020 to August 2021. INTERVENTION Patients were randomized to usual care with baseline questionnaires (control) vs the Jumpstart communication-priming intervention. Patients or surrogates in the intervention group and their clinicians received patient-specific Jumpstart Guides populated with data from questionnaires and the electronic health records (EHRs) that were designed to prompt and guide a goals-of-care discussion. MAIN OUTCOMES AND MEASURES The primary outcome was EHR documentation of a goals-of-care discussion between randomization and hospital discharge. Additional outcomes included patient-reported or surrogate-reported goals-of-care discussions, patient-reported or surrogate-reported quality of communication, and intervention feasibility and acceptability. RESULTS Of 428 eligible patients, this study enrolled 150 patients (35% enrollment rate; mean [SD] age, 59.2 [13.6] years; 66 women [44%]; 132 [88%] by patient consent and 18 [12%] by surrogate consent). Seventy-five patients each were randomized to the intervention and control groups. Compared with the control group, the cumulative incidence of EHR-documented goals-of-care discussions between randomization and hospital discharge was higher in the intervention group (16 of 75 patients [21%] vs 6 of 75 patients [8%]; risk difference, 13% [95% CI, 2%-24%]; risk ratio, 2.67 [95% CI, 1.10-6.44]; P = .04). Patient-reported or surrogate-reported goals-of-care discussions did not differ significantly between groups (30 of 66 patients [45%] vs 36 of 66 patients [55%]), although the intrarater consistency of patient and surrogate reports was poor. Patient-rated or surrogate-rated quality of communication did not differ significantly between groups. The intervention was feasible and acceptable to patients, surrogates, and clinicians. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, a patient-facing and clinician-facing communication priming intervention for seriously ill, hospitalized patients promoted EHR-documented goals-of-care discussions before discharge with good feasibility and acceptability. Communication-priming interventions should be reexamined in a larger randomized clinical trial to better understand their effectiveness in the inpatient setting. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03746392.
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Affiliation(s)
- Robert Y. Lee
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Lois Downey
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Sudiptho R. Paul
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
- University of Washington School of Medicine, Seattle
| | - Joanna Heywood
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Elizabeth L. Nielsen
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Kelson Okimoto
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
- Department of Family Medicine, University of Washington, Seattle
| | - Lyndia C. Brumback
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
| | - Susan E. Merel
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
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18
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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.
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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
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19
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Lee JS, Khan AD, Dorlac WC, Dunn J, McIntyre RC, Wright FL, Platnick KB, Brockman V, Vega SA, Cofran JM, Duero C, Schroeppel TJ. The patient's voice matters: The impact of advance directives on elderly trauma patients. J Trauma Acute Care Surg 2022; 92:339-346. [PMID: 34538829 DOI: 10.1097/ta.0000000000003400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Geriatric trauma rates are increasing, yet trauma centers often struggle to provide autonomy regarding decision making to these patients. Advance care planning can assist with this process. Currently, there are limited data on the impact of advance directives (ADs) in elderly trauma patients. The purpose of this study was to evaluate the prevalence of preinjury AD in geriatric trauma patients and its impact on outcomes, with the hypothesis that ADs would not be associated with an increase in mortality. METHODS A multicenter retrospective review was conducted on patients older than 65 years with traumatic injury between 2017 and 2019. Three Level I trauma centers and one Level II trauma center were included. Exclusion criteria were readmission, burn injury, transfer to another facility, discharge from emergency department, and mortality prior to being admitted. RESULTS There were 6,135 patients identified; 751 (12.2%) had a preinjury AD. Patients in the AD+ group were older (86 vs. 77 years, p < 0.0001), more likely to be women (67.0% vs. 54.8%, p < 0.0001), and had more comorbidities. Hospital length of stay and ventilator days were similar. In-hospital mortality occurred in 236 patients, and 75.4% of them underwent withdrawal of care (WOC). The mortality rate was higher in AD+ group (10.5% vs. 2.9%, p < 0.0001). No difference was seen in the rate of AD between the WOC+ and WOC- group (31.5% vs. 39.6%, p = 0.251). A preinjury AD was identified as an independent predictor of mortality, but not a predictor of WOC. CONCLUSION Despite a high WOC rate in patients older than 65 years, most patients did not have an AD prior to injury. As the elderly trauma population grows, advance care planning should be better integrated into geriatric care to encourage a patient-centered approach to end-of-life care. LEVEL OF EVIDENCE Prognostic and epidemiological, level IV.
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Affiliation(s)
- Janet S Lee
- From the Department of Trauma and Acute Care Surgery (J.S.L., A.D.K., V.B., T.J.S.), University of Colorado Health Memorial Hospital, Colorado Springs; Department of Surgery (J.S.L., R.C.M., F.L.W., S.A.V.), University of Colorado Anschutz Medical Campus, Aurora; Department of Trauma and Acute Care Surgery (W.C.D., J.D., J.M.C.), University of Colorado Health Medical Center of the Rockies, Loveland; and Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health (B.P., C.D.), Denver, Colorado
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20
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Michael NG, Georgousopoulou E, Hepworth G, Melia A, Tuohy R, Sulistio M, Kissane D. Patient-caregiver dyads advance care plan value discussions: randomised controlled cancer trial of video decision support tool. BMJ Support Palliat Care 2022:bmjspcare-2021-003240. [PMID: 35078875 DOI: 10.1136/bmjspcare-2021-003240] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 01/01/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Uptake of advance care planning (ACP) in cancer remains low. An emphasis on personal value discussions and adoption of novel interventions may serve as the catalyst to increase engagement. This study examined the effectiveness of a video decision support tool (VDST) modelling values conversations in cancer ACP. METHODS This single site, open-label, randomised controlled trial allocated patient-caregiver dyads on a 1:1 ratio to VDST or usual care (UC). Previously used written vignettes were converted to video vignettes using standard methodology. We evaluated ACP document completion rates, understanding and perspectives on ACP, congruence in communication and preparation for decision-making. RESULTS Participants numbered 113 (60.4% response rate). The VDST did not improve overall ACP document completion (37.7% VDST; 36.7% UC). However, the VDST improved ACP document completion in older patients (≥70) compared with younger counterparts (<70) (OR=0.308, 95% CI 0.096 to 0.982, p=0.047), elicited greater distress in patients (p=0.015) and improved patients and caregivers ratings for opportunities to discuss ACP with health professionals. ACP improved concordance in communication (VDST p=0.006; UC p=0.045), more so with the VDST (effect size: VDST 0.7; UC 0.54). Concordance in communication also improved in both arms with age. CONCLUSION The VDST failed to improve ACP document completion rates but highlighted that exploring core patient values may improve concordance in patient-caregiver communication. Striving towards a more rigorous design of the VDST intervention, incorporating clinical outcome scenarios with values conversations may be the catalyst needed to progress ACP towards a more fulfilling process for those who partake in it. TRIAL REGISTRATION NUMBER ACTRN12620001035910.
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Affiliation(s)
- Natasha G Michael
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, Malvern, Victoria, Australia
- School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Ekavi Georgousopoulou
- School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Graham Hepworth
- Statistical Consulting Centre, The University of Melbourne, Carlton, Victoria, Australia
| | - Adelaide Melia
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, Malvern, Victoria, Australia
| | - Roisin Tuohy
- Faulty of Business and Economics, Monash University, Clayton, Victoria, Australia
| | - Merlina Sulistio
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, Malvern, Victoria, Australia
- School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - David Kissane
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, Malvern, Victoria, Australia
- School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
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21
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Sherry D, Dodge LE, Buss M. Is Primary Care Physician Involvement Associated with Earlier Advance Care Planning?: A Study of Patients in an Academic Primary Care Setting. J Palliat Med 2022; 25:75-80. [PMID: 34978906 PMCID: PMC9022131 DOI: 10.1089/jpm.2021.0069] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Advance care planning (ACP) is important to improving end-of-life care. Few studies have examined the impact of primary care physician (PCP) involvement in ACP. Objectives: To determine whether complete ACP, defined as health care proxy (HCP), provider orders for life-sustaining treatment (POLST), and documented goals-of-care (GOC) conversations, would occur earlier when the PCP was involved in POLST and/or GOC conversations. Design: Charts of deceased patients from 2015 to 2017 in a U.S. academic primary care practice were reviewed. Demographic factors, mortality risk scores, palliative care involvement, and visits within the last year of life to PCPs and specialists were collected. Poisson models with robust variance estimators were used to estimate the likelihood of PCP involvement being associated with earlier complete ACP after adjusting for confounders and accounting for clustering by PCP. Due to high rates of HCP documentation at the institution, 10 patients without HCP were excluded from the review. Results: Of 403 decreased patients, 71 (18%) met criteria for complete ACP and 214 (53%) had HCP only; the remaining 118 patients had partial (2/3 components) ACP. Of the 71 patients with complete ACP, 40.1% had ACP earlier than three months of death (early) and 59.2% had ACP within three months of death (late). PCP involvement was associated with early ACP compared with late ACP and HCP only for both PCP completion of the POLST (risk ratio [RR]: 4.7; 95% confidence interval [CI]: 1.3-17.1) and for PCP documentation of GOC conversation (RR: 4.6; 95% CI: 1.2-17.1) after adjustment for clustering by PCP and other relevant variables. Conclusion: This retrospective cohort study suggests that PCP involvement in ACP correlates with earlier completion. This finding highlights the importance of educating and encouraging PCPs on completing ACP with their patients.
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Affiliation(s)
- Dylan Sherry
- Fox Chase Cancer Center, Temple University Health System, Philadelphia, Pennsylvania, USA.,Address correspondence to: Dylan Sherry, MD, Fox Chase Cancer Center, Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Laura E. Dodge
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary Buss
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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22
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Forner D, Lee DJ, Grewal R, MacDonald J, Noel CW, Taylor SM, Goldstein DP. Advance care planning in adults with oral cancer: Multi-institutional cross-sectional study. Laryngoscope Investig Otolaryngol 2021; 6:1020-1023. [PMID: 34667844 PMCID: PMC8513442 DOI: 10.1002/lio2.647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/16/2021] [Accepted: 08/17/2021] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Patients undergoing head and neck surgery are often elderly and frail with significant comorbidities. Discussion and documentation of what patients would desire for end-of-life care and decision-making is, therefore, essential for delivering patient-centered care. MATERIALS AND METHODS This was a retrospective, cross-sectional study of patients undergoing surgery for head and neck cancer at two large, academic, tertiary care centers in Canada. Advance care planning was defined as any documentation of advance directives, resuscitation orders, or end-of-life care preferences. RESULTS Among 301 patients, advance care planning was documented for 31 (10.3%). Patients with locally advanced disease (T3+) were twice as likely to have advance care planning documentation compared to those with early disease (RR 1.97, 95%CI [0.98, 3.97]). CONCLUSIONS In this multi-institutional cross-sectional study of two large academic centers, we have demonstrated that advance care planning and documentation is overall poor in patients undergoing surgery for oral cancer. These findings may have health policy implications, as advance care planning is associated with increased patient and provider satisfaction and improved alignment of patient goals and care delivered. Future work will investigate barriers and facilitators to advance care-planning documentation in this setting.
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Affiliation(s)
- David Forner
- Division of Otolaryngology—Head & Neck Surgery, Queen Elizabeth II Health Sciences CentreDalhousie UniversityHalifaxNova ScotiaCanada
| | - Daniel J. Lee
- Department of Otolaryngology—Head & Neck SurgeryUniversity Health Network, University of TorontoTorontoOntarioCanada
| | - Rajan Grewal
- Department of Otolaryngology—Head & Neck SurgeryUniversity Health Network, University of TorontoTorontoOntarioCanada
| | - Jenna MacDonald
- Division of Otolaryngology—Head & Neck Surgery, Queen Elizabeth II Health Sciences CentreDalhousie UniversityHalifaxNova ScotiaCanada
| | - Christopher W. Noel
- Department of Otolaryngology—Head & Neck SurgeryUniversity Health Network, University of TorontoTorontoOntarioCanada
| | - S. Mark Taylor
- Division of Otolaryngology—Head & Neck Surgery, Queen Elizabeth II Health Sciences CentreDalhousie UniversityHalifaxNova ScotiaCanada
| | - David P. Goldstein
- Department of Otolaryngology—Head & Neck SurgeryUniversity Health Network, University of TorontoTorontoOntarioCanada
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23
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Michael N, O'Callaghan C, Georgousopoulou E, Melia A, Sulistio M, Kissane D. Video decision support tool promoting values conversations in advanced care planning in cancer: protocol of a randomised controlled trial. BMC Palliat Care 2021; 20:95. [PMID: 34167538 PMCID: PMC8229383 DOI: 10.1186/s12904-021-00794-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 06/10/2021] [Indexed: 11/18/2022] Open
Abstract
Background Views on advance care planning (ACP) has shifted from a focus solely on treatment decisions at the end-of-life and medically orientated advanced directives to encouraging conversations on personal values and life goals, patient-caregiver communication and decision making, and family preparation. This study will evaluate the potential utility of a video decision support tool (VDST) that models values-based ACP discussions between cancer patients and their nominated caregivers to enable patients and families to achieve shared-decisions when completing ACP’s. Methods This open-label, parallel-arm, phase II randomised control trial will recruit cancer patient-caregiver dyads across a large health network. Previously used written vignettes will be converted to video vignettes using the recommended methodology. Participants will be ≥18 years and be able to complete questionnaires. Dyads will be randomised in a 1:1 ratio to a usual care (UC) or VDST group. The VDST group will watch a video of several patient-caregiver dyads communicating personal values across different cancer trajectory stages and will receive verbal and written ACP information. The UC group will receive verbal and written ACP information. Patient and caregiver data will be collected individually via an anonymous questionnaire developed for the study, pre and post the UC and VDST intervention. Our primary outcome will be ACP completion rates. Secondarily, we will compare patient-caregiver (i) attitudes towards ACP, (ii) congruence in communication, and (iii) preparation for decision-making. Conclusion We need to continue to explore innovative ways to engage cancer patients in ACP. This study will be the first VDST study to attempt to integrate values-based conversations into an ACP intervention. This pilot study’s findings will assist with further refinement of the VDST and planning for a future multisite study. Trial registration Australian New Zealand Clinical Trials Registry No: ACTRN12620001035910. Registered 12 October 2020. Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00794-3.
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Affiliation(s)
- Natasha Michael
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, Melbourne, VIC, Australia. .,School of Medicine, Sydney Campus, University of Notre Dame Australia Darlinghurst, Darlinghurst, NSW, Australia. .,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
| | - Clare O'Callaghan
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, Melbourne, VIC, Australia.,Departments of Psychosocial Cancer Care, St Vincent's Hospital, Sydney, NSW, Australia
| | - Ekavi Georgousopoulou
- School of Medicine, Sydney Campus, University of Notre Dame Australia Darlinghurst, Darlinghurst, NSW, Australia
| | - Adelaide Melia
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, Melbourne, VIC, Australia
| | - Merlina Sulistio
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, Melbourne, VIC, Australia.,School of Medicine, Sydney Campus, University of Notre Dame Australia Darlinghurst, Darlinghurst, NSW, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - David Kissane
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, Melbourne, VIC, Australia.,School of Medicine, Sydney Campus, University of Notre Dame Australia Darlinghurst, Darlinghurst, NSW, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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24
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Lightfoot N, Kirkova Y, Fox S, Alan S. Overcoming Challenges to Surrogate Decision Making for Young Adults at the End of Life. Am J Hosp Palliat Care 2021; 38:596-600. [PMID: 33715423 DOI: 10.1177/10499091211001007] [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: 11/17/2022] Open
Abstract
Surrogate decision makers (SDMs) are challenged by difficult decisions at the end of life. This becomes more complex in young adult patients when parents are frequently the SDMs. This age group (18 to 39 years old) commonly lacks advanced directives to provide guidance which results in increased moral distress during end of life decisions. Multiple factors help guide medical decision making throughout a patient's disease course and at the end of life. These include personal patient factors and SDM factors. It has been identified that spiritual and community group support is a powerful, but inadequately used resource for these discussions. It can improve patient-SDM-provider communications, decrease psycho-social distress, and avoid unnecessary interventions at the end of life.
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Affiliation(s)
- Nathan Lightfoot
- Department of Neurology, 12231Georgetown University Hospital, Washington, DC, USA
| | - Yordanka Kirkova
- Department of Palliative Care, 12231Georgetown University Hospital, Washington, DC, USA
| | - Stephen Fox
- Department of Medicine, 12231Georgetown University Hospital, Washington, DC, USA
| | - Sheinei Alan
- Department of Medicine, 12231Georgetown University Hospital, Washington, DC, USA
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25
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Berkowitz CM, Wolf SP, Troy J, Kamal AH. Characteristics of Advance Care Planning in Patients With Cancer Referred to Palliative Care. JCO Oncol Pract 2021; 17:e94-e100. [PMID: 33439744 DOI: 10.1200/op.20.00657] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Advance care planning (ACP) is a process in which patients share their values, goals, and preferences regarding future medical care. ACP can improve care quality, yet may be challenging to address for patients with cancer. We sought to characterize key components of ACP in patients with cancer as compared with patients with noncancer serious illness referred to palliative care (PC). METHODS We performed a retrospective cross-sectional analysis of initial outpatient PC visits from the Quality Data Collection Tool for PC database from 2015 to 2019. Quality Data Collection Tool is a web-based point-of-care specialty PC registry to track quality metrics. RESULTS We analyzed 1,604 patients with cancer and 1,094 patients without cancer: 44% of patients were female, 87% were White, and 98% were non-Hispanic. The average age was 72.2 years (standard deviation [SD] 15.4). Patients with cancer were on average younger than patients without cancer (66.5 [SD: 13.9] v 80.5 [SD: 13.8]) and had a higher Palliative Performance Scale (PPS) (59.5 [SD: 22.4] v 33.4 [SD: 25.1]). In our unadjusted comparison, patients with cancer were less likely to be DNR/DNI (37% v 53%; P < .0001) and less likely to have an advance directive (53% v 73%; < .0001); rates of healthcare proxy identification were similar (92.8% v 94.5%; P = .10). These differences did not persist when we accounted for age, race, sex, and PPS, with age being the primary explanatory factor. CONCLUSION Despite having serious illness meriting PC referral, many patients with cancer in our study lacked advance directives. This highlights both the important role of oncologists in facilitating ACP and the utility of PC playing a complementary role.
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Affiliation(s)
| | - Steven P Wolf
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Jesse Troy
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Arif H Kamal
- Department of Medicine, Duke University School of Medicine, Durham, NC.,Duke Cancer Institute, Duke University Medical Center, Durham, NC
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26
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Ma JD, Dullea A, Hagmann C, Friedman S, Russell M, Cramer A, Benn M, Roeland EJ. Exploring the Expanded Role of Pharmacists in Advance Care Planning. JCO Oncol Pract 2021; 17:102-106. [PMID: 33417492 DOI: 10.1200/op.20.00684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Advance care planning (ACP) is a clinical skill that can be taught. An opportunity exists to teach how to conduct ACP to clinicians not typically engaged in these conversations to increase the likelihood that patients and caregivers engage in ACP. We conducted a prospective study exploring the feasibility of a pharmacist-led ACP intervention. METHODS We completed a prospective, single-center study from July 2015 to July 2017. We included patients of age ≥ 18 years with incurable cancer referred to the palliative care clinic. A trained pharmacist led an ACP discussion with the patient and selected proxy. We defined feasibility as completion of ≥ 30 pharmacist-led ACP discussions over the study period. Additionally, we defined an informed healthcare proxy as someone who understood three key end-of-life (EOL) treatment preferences: the patient's personal definition of quality of life, desired resuscitation status, and preferred location of death (in or out of the hospital). Patients were followed until the end of the study or death. For those patients who died, the pharmacist contacted the proxy for follow-up and explored satisfaction with the ACP intervention. RESULTS Thirty-four patients completed the study. All selected proxies completed the intervention and were able to understand the three EOL preferences. At the time of the patient's death (n = 20), proxies reported that 66.6% received their preferred resuscitation status and 72.2% died in their preferred location. Proxy satisfaction with the ACP process was 7.6 ± 2.5 (mean ± SD) on a 11-point Likert scale. CONCLUSION These findings indicate the potential for pharmacists to lead and engage in ACP in the outpatient setting.
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Affiliation(s)
- Joseph D Ma
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California (UC) San Diego, La Jolla, CA
| | | | | | | | | | | | - Melanie Benn
- UC San Diego, Moores Cancer Center, La Jolla, CA
| | - Eric J Roeland
- Massachusetts General Hospital Cancer Center, Boston, MA
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27
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Affiliation(s)
- Ambereen K. Mehta
- Palliative Care Program, Department of Medicine, University of California, Los Angeles, Santa Monica
| | - Thomas J. Smith
- Johns Hopkins Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
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28
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Toguri JT, Grant-Nunn L, Urquhart R. Views of advanced cancer patients, families, and oncologists on initiating and engaging in advance care planning: a qualitative study. BMC Palliat Care 2020; 19:150. [PMID: 33004023 PMCID: PMC7531150 DOI: 10.1186/s12904-020-00655-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/15/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Advance care planning (ACP) is a process by which patients reflect upon their goals, values and beliefs to allow them to make decisions about their future medical treatment that align with their goals and values, improving patient-centered care. Despite this, ACP is underutilized and is reported as one of the most difficult processes of oncology. We sought to: 1) explore patients' and families' understanding, experience and reflections on ACP, as well as what they need from their physicians during the process; 2) explore physicians' views of ACP, including their experiences with initiating ACP and views on ACP training. METHODS This was a qualitative descriptive study in Nova Scotia, Canada with oncologists, advanced cancer out-patients and their family members. Semi-structured interviews with advanced cancer out-patients and their family members (n = 4 patients, 4 family members) and oncologists (n = 10) were conducted; each participant was recruited separately. Data were analyzed using constant comparative analysis, which entailed coding, categorizing, and identifying themes recurrent across the datasets. RESULTS Themes were identified from the patient / family and oncologist groups, four and five respectively. Themes from patients / families included: 1) positive attitudes towards ACP; 2) healthcare professionals (HCPs) lack an understanding of patients' and families' informational needs during the ACP process; 3) limited access to services and supports; and 4) poor communication between HCPs. Themes from oncologists included: 1) initiation of ACP discussions; 2) navigating patient-family dynamics; 3) limited formal training in ACP; 4) ACP requires a team approach; and 5) lack of coordinated systems hinders ACP. CONCLUSIONS Stakeholders believe ACP for advanced cancer patients is important. Patients and families desire earlier and more in-depth discussion of ACP, additional services and supports, and improved communication between their HCPs. In the absence of formal training or guidance, oncologists have used clinical acumen to initiate ACP and a collaborative healthcare team approach.
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Affiliation(s)
- J T Toguri
- Dalhousie Medical School, Dalhousie University, Halifax, NS, Canada
| | - L Grant-Nunn
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - R Urquhart
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.
- Department of Community Health and Epidemiology, Dalhousie University, Room 8-032, Centennial Building, 1276 South Park Street, Halifax, Nova Scotia, B3H 2Y9, Canada.
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McMahan RD, Tellez I, Sudore RL. Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review. J Am Geriatr Soc 2020; 69:234-244. [PMID: 32894787 DOI: 10.1111/jgs.16801] [Citation(s) in RCA: 223] [Impact Index Per Article: 55.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/30/2020] [Accepted: 08/02/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND/OBJECTIVES Advance care planning (ACP) has shown benefit in some, but not all, studies. It is important to understand the utility of ACP. We conducted a scoping review to identify promising interventions and outcomes. DESIGN Scoping review. MEASUREMENTS We searched MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science for ACP randomized controlled trials from January 1, 2010, to March 3, 2020. We used standardized Preferred Reporting Items for Systematic Review and Meta-Analyses methods to chart study characteristics, including a standardized ACP Outcome Framework: Process (e.g., readiness), Action (e.g., communication), Quality of Care (e.g., satisfaction), Health Status (e.g., anxiety), and Healthcare Utilization. Differences between arms of P < .05 were deemed positive. RESULTS Of 1,464 articles, 69 met eligibility; 94% were rated high quality. There were variable definitions, age criteria (≥18 to ≥80 years), diseases (e.g., dementia and cancer), and settings (e.g., outpatient and inpatient). Interventions included facilitated discussions (42%), video only (20%), interactive, multimedia (17%), written only (12%), and clinician training (9%). For written only, 75% of primary outcomes were positive, as were 69% for multimedia programs; 67% for facilitated discussions, 59% for video only, and 57% for clinician training. Overall, 72% of Process and 86% of Action outcomes were positive. For Quality of Care, 88% of outcomes were positive for patient-surrogate/clinician congruence, 100% for patients/surrogate/clinician satisfaction with communication, and 75% for surrogate satisfaction with patients' care, but not for goal concordance. For Health Status outcomes, 100% were positive for reducing surrogate/clinician distress, but not for patient quality of life. Healthcare Utilization data were mixed. CONCLUSION ACP is complex, and trial characteristics were heterogeneous. Outcomes for all ACP interventions were predominantly positive, as were Process and Action outcomes. Although some Quality of Care and Health Status outcomes were mixed, increased patient/surrogate satisfaction with communication and care and decreased surrogate/clinician distress were positive. Further research is needed to appropriately tailor interventions and outcomes for local contexts, set appropriate expectations of ACP outcomes, and standardize across studies.
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Affiliation(s)
- Ryan D McMahan
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Ismael Tellez
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
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Levoy K, Buck H, Behar-Zusman V. The Impact of Varying Levels of Advance Care Planning Engagement on Perceptions of the End-of-Life Experience Among Caregivers of Deceased Patients With Cancer. Am J Hosp Palliat Care 2020; 37:1045-1052. [PMID: 32281390 DOI: 10.1177/1049909120917899] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CONTEXT Advance care planning (ACP) is used to prepare patients and caregivers for future "in the moment" decisions at the end-of-life. Patients with cancer generally do not engage in all 3 components of ACP (documented living will, health-care surrogate, end-of-life discussions); however, little is known about the impact of these varying levels of ACP engagement on caregivers postdeath. OBJECTIVE To examine the relationship between varying levels of ACP engagement and caregivers' perceptions of cancer decedents' end-of-life experiences. METHODS A secondary analysis of the 2002 to 2014 waves of the Health and Retirement Study data using structural equation modeling was conducted. Five levels of ACP engagement were defined: full (discussions/documents), augmented discussions, documents only, discussions only, and no engagement. RESULTS Among the 2172 cancer death cases, the analyzed sample included 983 cases where end-of-life decisions occurred. Compared to no ACP, all levels of ACP were significantly associated with caregivers' positive perceptions of cancer decedents' end-of-life experiences (P ≤ .001), controlling for sex, race, and Hispanic ethnicity (R 2 = .21). However, the relative impact of each level of ACP engagement was not equal; full engagement (β = .61) was associated with a greater impact compared to each of the partial levels of engagement (augmented discussions [β = .33], documents only [β = .17], discussions only [β = .17]). CONCLUSION Partial ACP engagement, not just nonengagement, serves as an important clinically modifiable target to improve the end-of-life care experience among patients with cancer and the perceptions of those experiences among bereaved caregivers.
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Affiliation(s)
- Kristin Levoy
- NewCourtland Center for Transitions and Health, 6572University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Harleah Buck
- 7831University of South Florida College of Nursing, Tampa, FL, USA
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Huang HL, Tsai JS, Yao CA, Cheng SY, Hu WY, Chiu TY. Shared decision making with oncologists and palliative care specialists effectively increases the documentation of the preferences for do not resuscitate and artificial nutrition and hydration in patients with advanced cancer: a model testing study. BMC Palliat Care 2020; 19:17. [PMID: 32019540 PMCID: PMC7001377 DOI: 10.1186/s12904-020-0521-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Communication in do not resuscitate (DNR) and artificial nutrition and hydration (ANH) at the end of life is a key component of advance care planning (ACP) which is essential for patients with advanced cancer to have cares concordant with their wishes. The SOP model (Shared decision making with Oncologists and Palliative care specialists) aimed to increase the rate of documentation on the preferences for DNR and ANH in patients with advanced cancer. METHODS The SOP model was implemented in a national cancer treatment center in Taiwan from September 2016 to August 2018 for patients with advanced cancer visiting the oncology outpatient clinic. The framework was based on the model of shared decision making as "choice talk" initiated by oncologists with "option talk" and "decision talk" conducted by palliative care specialists. RESULTS Among 375 eligible patients, 255 patients (68%) participated in the model testing with the mean age of 68.5 ± 14.7 years (mean ± SD). Comparing to 52.3% of DNR documentation among patients with advanced cancer who died in our hospital, the rate increased to 80.9% (206/255) after the decision talk in our model. Only 6.67% (n = 17) of the participants documented their preferences on ANH after the model. A worse Eastern Cooperative Oncology Group Performance Status was the only statistically significant associating factor with a higher rate of DNR documentation in the multiple logistic regression model. CONCLUSIONS The SOP model significantly increased the rate of DNR documentation in patients with advanced cancer in this pilot study. Dissemination of the model could help the patients to receive care that is concordant with their wishes and be useful for the countries having laws on ACP.
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Affiliation(s)
- Hsien-Liang Huang
- Department of Family Medicine, College of Medicine and Hospital, National 7 Chung-Shan South Road, Taipei, 100, Taiwan
| | - Jaw-Shiun Tsai
- Department of Family Medicine, College of Medicine and Hospital, National 7 Chung-Shan South Road, Taipei, 100, Taiwan
| | - Chien-An Yao
- Department of Family Medicine, College of Medicine and Hospital, National 7 Chung-Shan South Road, Taipei, 100, Taiwan
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National 7 Chung-Shan South Road, Taipei, 100, Taiwan
| | - Wen-Yu Hu
- School of Nursing, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Tai-Yuan Chiu
- Department of Family Medicine, College of Medicine and Hospital, National 7 Chung-Shan South Road, Taipei, 100, Taiwan.
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Shaw M, Bouchal SR, Hutchison L, Booker R, Holroyd-Leduc J, White D, Grant A, Simon J. Influence of clinical context on interpretation and use of an advance care planning policy: a qualitative study. CMAJ Open 2020; 8:E9-E15. [PMID: 31911442 PMCID: PMC6951450 DOI: 10.9778/cmajo.20190100] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Advance care planning is a process through which people share their values, goals and preferences regarding future medical treatments with the purpose of aligning care received with patient wishes. The objective of this study was to explore perspectives from patients and clinicians in 4 clinical settings to understand how context influences interpretation and application of advance care planning processes. METHODS This study used a qualitative interpretive descriptive design. Patient and clinician participants were recruited across 4 clinical outpatient settings (cancer, heart failure, renal failure and supportive living) in Calgary and Edmonton. Data were collected between 2014 and 2015 by means of recorded one-on-one semistructured interviews. We analyzed the data using thematic analysis in 2016-2017. RESULTS Thirty-four patients and 34 clinicians participated in interviews. Themes common to all 4 contexts were lack of shared understanding between patients and clinicians, and a lack of consistent clinical process related to advance care planning. Advance care planning understanding and process varied substantially between contexts. This variation seemed to be driven by differences in perceptions around disease burden and the nature of the physician-patient relationship. INTERPRETATION Provision of a system-wide policy and procedural framework alone was not found to be sufficient to form a standardized approach to advance care planning, as considerable variability existed in advance care planning process between and within clinical settings. Quality-improvement methods that consider local processes, gaps and barriers can help in developing a consistent, comprehensive process.
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Affiliation(s)
- Marta Shaw
- Cumming School of Medicine (Shaw, Grant), University of Calgary; Community Health Sciences (Holroyd-Leduc, Simon), University of Calgary; Faculty of Nursing (Raffin Bouchal, Hutchison, Booker, White), University of Calgary, Calgary, Alta.
| | - Shelley Raffin Bouchal
- Cumming School of Medicine (Shaw, Grant), University of Calgary; Community Health Sciences (Holroyd-Leduc, Simon), University of Calgary; Faculty of Nursing (Raffin Bouchal, Hutchison, Booker, White), University of Calgary, Calgary, Alta
| | - Lauren Hutchison
- Cumming School of Medicine (Shaw, Grant), University of Calgary; Community Health Sciences (Holroyd-Leduc, Simon), University of Calgary; Faculty of Nursing (Raffin Bouchal, Hutchison, Booker, White), University of Calgary, Calgary, Alta
| | - Reanne Booker
- Cumming School of Medicine (Shaw, Grant), University of Calgary; Community Health Sciences (Holroyd-Leduc, Simon), University of Calgary; Faculty of Nursing (Raffin Bouchal, Hutchison, Booker, White), University of Calgary, Calgary, Alta
| | - Jayna Holroyd-Leduc
- Cumming School of Medicine (Shaw, Grant), University of Calgary; Community Health Sciences (Holroyd-Leduc, Simon), University of Calgary; Faculty of Nursing (Raffin Bouchal, Hutchison, Booker, White), University of Calgary, Calgary, Alta
| | - Deborah White
- Cumming School of Medicine (Shaw, Grant), University of Calgary; Community Health Sciences (Holroyd-Leduc, Simon), University of Calgary; Faculty of Nursing (Raffin Bouchal, Hutchison, Booker, White), University of Calgary, Calgary, Alta
| | - Andrew Grant
- Cumming School of Medicine (Shaw, Grant), University of Calgary; Community Health Sciences (Holroyd-Leduc, Simon), University of Calgary; Faculty of Nursing (Raffin Bouchal, Hutchison, Booker, White), University of Calgary, Calgary, Alta
| | - Jessica Simon
- Cumming School of Medicine (Shaw, Grant), University of Calgary; Community Health Sciences (Holroyd-Leduc, Simon), University of Calgary; Faculty of Nursing (Raffin Bouchal, Hutchison, Booker, White), University of Calgary, Calgary, Alta
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Feng C, Wu J, Li J, Deng HY, Liu J, Zhao S. Advance directives of lung cancer patients and caregivers in China: A cross sectional survey. Thorac Cancer 2019; 11:253-263. [PMID: 31851775 PMCID: PMC6996976 DOI: 10.1111/1759-7714.13237] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 10/18/2019] [Indexed: 02/05/2023] Open
Abstract
Background This study aimed to investigate lung cancer patients and attitudes of their caregivers toward advance directives (ADs) in China. Methods A cross sectional study was conducted in the Department of Oncology outpatient clinic in West China Hospital, Sichuan University. A questionnaire was used to survey the attitudes of lung cancer patients and caregivers toward ADs. Results A total of 148 lung cancer patients and 149 caregivers were enrolled into the study. Of these, 94.6% and 89.9% of patients and caregivers had not heard of AD and none of those in the study had ever signed an AD. A total of 79.7% patients and 75.2% caregivers were willing to sign ADs after they were provided with information. Patients who preferred the end of life period to sign ADs were 5.4 times more likely to have ADs than patients who chose to sign ADs when their disease was diagnosed (P < 0.05, 95%CI [1.27–22.93]). Caregivers who were reluctant to undergo chemotherapy when diagnosed with cancer were 2.16 times more likely to sign ADs than those willing to receive chemotherapy (P < 0.05, 95%CI [1.20–3.90]). Conclusions In China, lung cancer patients and their caregivers showed lack of knowledge about ADs, and the completion rate of ADs was extremely low. However, participants were positive about ADs and public education on ADs may help to increase the completion rate of ADs in China.
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Affiliation(s)
- Chenchen Feng
- Department of Outpatient, West China Hospital, Sichuan University, Chengdu, China
| | - Juan Wu
- Department of Outpatient, West China Hospital, Sichuan University, Chengdu, China
| | - Junying Li
- Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Han Yu Deng
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jiewei Liu
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Shuzhen Zhao
- Department of Outpatient, West China Hospital, Sichuan University, Chengdu, China
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Ermers DJM, van Bussel KJH, Perry M, Engels Y, Schers HJ. Advance care planning for patients with cancer in the palliative phase in Dutch general practices. Fam Pract 2019; 36:587-593. [PMID: 30535044 DOI: 10.1093/fampra/cmy124] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is a crucial element of palliative care. It improves the quality of end-of-life care and reduces aggressive and needless life-prolonging medical interventions. However, little is known about its application in daily practice. This study aims to examine the application of ACP for patients with cancer in general practice. METHODS We performed a retrospective cohort study in 11 general practices in the Netherlands. Electronic patient records (EPRs) of deceased patients with colorectal or lung cancer were analysed. Data on ACP documentation, correspondence between medical specialist and GP, and health care use in the last year of life were extracted. RESULTS Records of 163 deceased patients were analysed. In 74% of the records, one or more ACP items were registered. GPs especially documented patients' preferences for euthanasia (58%), palliative sedation (46%) and preferred place of death (26%). Per patient, GPs received on average six letters from medical specialists. These letters mainly contained information regarding medical treatment and rarely ACP items. In the last year of life, patients contacted the GP over 30 times, and 51% visited the emergency department at least once, of whom 54% in the last month. CONCLUSIONS Registration of ACP items in GPs' EPRs appeared to be limited. ACP elements were rarely subject of communication between primary and secondary care, which may impact the continuity of patient care during the last year of life. More emphasis on registration of ACP items and better exchange of information regarding patients' preferences are needed.
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Affiliation(s)
- Daisy J M Ermers
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Karin J H van Bussel
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marieke Perry
- Department of Geriatrics, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Yvonne Engels
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Henk J Schers
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands
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Khandelwal N, Long AC, Lee RY, McDermott CL, Engelberg RA, Curtis JR. Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals. THE LANCET RESPIRATORY MEDICINE 2019; 7:613-625. [PMID: 31122895 DOI: 10.1016/s2213-2600(19)30170-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.
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Affiliation(s)
- Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA.
| | - Ann C Long
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Cara L McDermott
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
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Hamada S, Haruta J, Hamano J, Maeno T, Maeno T. Associated factors for discussing advance directives with family physicians by noncancer outpatients in Japan. J Gen Fam Med 2019; 20:82-92. [PMID: 31065472 PMCID: PMC6498101 DOI: 10.1002/jgf2.238] [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: 08/31/2018] [Revised: 01/20/2019] [Accepted: 01/24/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Advance directives (ADs) are seldom discussed between primary care physicians (PCPs) and their patients, especially those with noncancer diseases. The aim was to identify the factors associated with discussing AD by noncancer patients with their physicians. METHODS This cross-sectional study was conducted in a hospital or clinic from October to December 2017. Physicians chose eligible noncancer patients aged 20 years or older to respond to an anonymous self-completed questionnaire inquiring about the objective variable "I want to discuss AD with my doctor," as well as basic characteristics, and facilitators and barriers to discussing AD identified in previous studies. The physicians responded to a survey comprising the Palliative Performance Scale (PPS) and inquiring about the disease category for each patient. Data were analyzed using binomial logistic regression analysis. RESULTS A total of 270 patients (valid response rate, 79.6%) were included. Multivariate analysis identified a period of visit to the study site ≥ 3 years (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.05-4.10), physicians who are very good at taking care of patients' disease (OR, 12.68; 95% CI, 1.12-143.22), and patients' worry about their quality of life (QOL) in the future (OR, 2.69; 95% CI, 1.30-5.57) as facilitators for discussing AD with physicians, and PPS ≤ 90 (OR, 0.51; 95% CI, 0.26-0.98) as a barrier. CONCLUSIONS Our study indicates that patients' future QOL concerns, a long period of visit to a hospital, and the presence of physical symptoms were associated with the willingness of noncancer patients to discuss AD with PCPs.
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Affiliation(s)
- Shuhei Hamada
- Graduate School of Comprehensive Human SciencesUniversity of TsukubaTsukubaJapan
| | - Junji Haruta
- Faculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Jun Hamano
- Faculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Takami Maeno
- Faculty of MedicineUniversity of TsukubaTsukubaJapan
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AlFayyad IN, Al-Tannir MA, AlEssa WA, Heena HM, Abu-Shaheen AK. Physicians and nurses' knowledge and attitudes towards advance directives for cancer patients in Saudi Arabia. PLoS One 2019; 14:e0213938. [PMID: 30978182 PMCID: PMC6461283 DOI: 10.1371/journal.pone.0213938] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 03/04/2019] [Indexed: 11/26/2022] Open
Abstract
This study aimed to investigate physicians' and nurses' knowledge and attitudes toward advance directives (ADs) for cancer patients, which empower patients to take decisions on end-of-life needs if they lose their capacity to make medical decisions. A cross-sectional study was conducted using convenience sampling. The outcomes were responses to the knowledge and attitude questions, and the main outcome variables were the total scores for knowledge and attitudes toward ADs. This study included 281 physicians and nurses (60.5%). Most physicians were men (95, 80.5%), whereas most nurses were women (147, 86.5%). The mean (standard deviation; SD) total knowledge score was 6.8 (4.0) for physicians and 9.1 (3.0) for nurses (p < 0.001). There was a significant difference in the total knowledge score between nurses and physicians, with an adjusted mean difference of 1.54 (95% confidence interval [CI]; 0.08-2.97). Other significant independent predictors of knowledge of ADs were female sex (1.60, 95% CI; 0.27-3.13) and education level (master's versus bachelor's: 1.26, 95% CI; 0.30-2.33 and Ph.D. versus bachelor's: 2.22, 95% CI; 0.16-4.52). Nurses' attitudes appeared to be significantly more positive than those of physicians, and the mean total attitude score (SD) was 19.5 for nurses (6.2) and 15.1 (8.1) for physicians (p < 0.001). The adjusted mean difference (95% CI) for nurses versus physicians was 3.71 (0.57-6.98). All participants showed a high level of knowledge of ADs; however, nurses showed considerably more positive attitudes than physicians.
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Affiliation(s)
| | | | - Waleed A. AlEssa
- Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
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Aslakson RA, Isenberg SR, Crossnohere NL, Conca-Cheng AM, Moore M, Bhamidipati A, Mora S, Miller J, Singh S, Swoboda SM, Pawlik TM, Weiss M, Volandes A, Smith TJ, Bridges JFP, Roter DL. Integrating Advance Care Planning Videos into Surgical Oncologic Care: A Randomized Clinical Trial. J Palliat Med 2019; 22:764-772. [PMID: 30964385 DOI: 10.1089/jpm.2018.0209] [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: 01/11/2023] Open
Abstract
Background: Preoperative advance care planning (ACP) may benefit patients undergoing major surgery. Objective: To evaluate feasibility, safety, and early effectiveness of video-based ACP in a surgical population. Design: Randomized controlled trial with two study arms. Setting: Single, academic, inner-city tertiary care hospital. Subjects: Patients undergoing major cancer surgery were recruited from nine surgical clinics. Of 106 consecutive potential participants, 103 were eligible and 92 enrolled. Interventions: In the intervention arm, patients viewed an ACP video developed by patients, surgeons, palliative care clinicians, and other stakeholders. In the control arm, patients viewed an informational video about the hospital's surgical program. Measurements: Primary Outcomes-ACP content and patient-centeredness in patient-surgeon preoperative conversation. Secondary outcomes-patient Hospital Anxiety and Depression Scale (HADS) score; patient goals of care; patient and surgeon satisfaction; video helpfulness; and medical decision maker designation. Results: Ninety-two patients (target enrollment: 90) were enrolled. The ACP video was successfully integrated with no harm noted. Patient-centeredness was unchanged (incidence rate ratio [IRR] = 1.06, confidence interval [0.87-1.3], p = 0.545), although there were more ACP discussions in the intervention arm (23% intervention vs. 10% control, p = 0.18). While slightly underpowered, study results did not signal that further enrollment would have yielded statistical significance. There were no differences in secondary outcomes other than the intervention video was more helpful (p = 0.007). Conclusions: The ACP video was successfully integrated into surgical care without harm and was thought to be helpful, although video content did not significantly change the ACP content or patient-surgeon communication. Future studies could increase the ACP dose through modifying video content and/or who presents ACP. Trial Registration: clinicaltrials.gov Identifier NCT02489799.
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Affiliation(s)
- Rebecca A Aslakson
- 1 Palliative Care Section, Department of Medicine, Stanford University School of Medicine, Stanford, California.,2 Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.,3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarina R Isenberg
- 3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,4 Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Norah L Crossnohere
- 3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Alison M Conca-Cheng
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Madeleine Moore
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Akshay Bhamidipati
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Silvia Mora
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Judith Miller
- 6 Patient/Family Member Co-Investigator, Ellicott City, Maryland
| | - Sarabdeep Singh
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sandra M Swoboda
- 7 Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Timothy M Pawlik
- 8 Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Matthew Weiss
- 7 Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Angelo Volandes
- 9 Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas J Smith
- 10 Department of Oncology and Palliative Care Program, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland
| | - John F P Bridges
- 8 Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Debra L Roter
- 3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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ParK EJ, Lim YJ, Kim JJ, Oh SB, Oh SY, Park K. Feasibility of Early Application of an Advance Directive at the Time of First-Line Palliative Chemotherapy in Patients With Incurable Cancer: A Prospective Study. Am J Hosp Palliat Care 2019; 36:893-899. [PMID: 30913904 DOI: 10.1177/1049909119839355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
CONTEXT This study aimed to evaluate the feasibility of an advance directive (AD) at the time of starting first-line palliative chemotherapy. We investigated changes in emotional distress, quality of life (QoL), and attitudes toward anticancer treatments between before and after AD. METHODS Patients with advanced cancer who had just started palliative chemotherapy were prospectively enrolled. We assessed attitudes toward chemotherapy, Hospital Anxiety and Depression Scale (HADS), and European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ) before conducting the AD and subsequently performed the AD after the first cycle of chemotherapy. Follow-up evaluations using same parameters were performed in the next cycle visit. RESULTS During the study period, 104 patients started palliative chemotherapy. Among them, 41 patients (11 with cognitive impairment at baseline, 14 with clinical deteriorations after the first cycle of chemotherapy, 6 with follow-up loss, 7 without proxy, 3 with protocol violations) were excluded, and the AD were recommended in the remaining 64 patients (proportion of AD recommendation: 62%). Among the 64 patients, 44 agreed to conduct the AD (proportion of AD consent: 69%). There were no significant changes before and after AD in terms of HADS and EORTC-QLQ. Attitudes regarding chemotherapy were also unchanged (P = .773). A total of 36 (82%) patients followed physician's recommendations, with the exception of 8 patients who terminated chemotherapy due to refusal or loss to follow-up. CONCLUSIONS Considering our results showing no significant changes in depression and anxiety scores, QoL, and attitudes toward anticancer treatments after the AD, early integration of the AD at initiation of first-line palliative chemotherapy might be feasible.
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Affiliation(s)
- Eun-Ju ParK
- 1 Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yeon Jae Lim
- 2 Department of Medical Oncology and Hematology, Hanil General Hospital, Seoul, Korea
| | - Jae-Joon Kim
- 3 Department of Internal medicine, Medical Oncology and Hematology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang-Bo Oh
- 3 Department of Internal medicine, Medical Oncology and Hematology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - So Yeon Oh
- 3 Department of Internal medicine, Medical Oncology and Hematology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Kwonoh Park
- 2 Department of Medical Oncology and Hematology, Hanil General Hospital, Seoul, Korea.,3 Department of Internal medicine, Medical Oncology and Hematology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Martinez-Tapia C, Canoui-Poitrine F, Caillet P, Bastuji-Garin S, Tournigand C, Assaf E, Varnier G, Pamoukdjian F, Brain E, Rollot-Trad F, Laurent M, Paillaud E. Preferences for surrogate designation and decision-making process in older versus younger adults with cancer: A comparative cross-sectional study. PATIENT EDUCATION AND COUNSELING 2019; 102:429-435. [PMID: 30293935 DOI: 10.1016/j.pec.2018.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To compare the preferences of older (≥70 years old) versus younger (<70 years old) cancer patients regarding surrogate designation and decision making. METHODS A cross-sectional survey. Patient characteristics and information about surrogacy and involvement in decision making were collected. Associations between patient characteristics and preferences were examined. RESULTS The study included 130 patients aged ≥70 years (mean age 80 years) and 102 patients aged <70 years (mean age 55) and. Factors independently associated with surrogate knowledge (66%): younger age, more children living nearby, high income; factors associated with having already designated a surrogate (62%): younger age, decreased number of daily medications; factors associated with designating a surrogate after questionnaire administration (40%): low education, metastasis. Patients requiring an informed consent for any intervention was associated with older age (adjusted OR [aOR]per year = 1.04[95% confidence interval 1.00-1.08]), not living alone (aOR = 2.52[1.00-6.36]), and having children (aOR = 4.49[1.13-17.81]). CONCLUSION All cancer patients, wanted to be fully informed and 72% wanted to be involved in medical decisions. Preferences for decision control vary between age groups, depending on family members' presence and living alone. PRACTICE IMPLICATIONS Sharing complete and clear information should be an important key in the process of cancer patients' care, regardless of patient age.
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Affiliation(s)
- Claudia Martinez-Tapia
- Paris-Est University, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology and Ageing Unit), Créteil, France.
| | - Florence Canoui-Poitrine
- Paris-Est University, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology and Ageing Unit), Créteil, France; Assistance Publique Hôpitaux de Paris (AP-HP), Henri-Mondor Hospital, Public Health Department, Créteil, France
| | - Philippe Caillet
- Paris-Est University, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology and Ageing Unit), Créteil, France; AP-HP, Henri-Mondor Hospital, Internal Medicine and Geriatric Department, Paris- Sud-Val-de-Marne Geriatric Oncology Clinic, Créteil, France; AP-HP, Georges-Pompidou European Hospital (HEGP), Geriatric Department, Paris, France
| | - Sylvie Bastuji-Garin
- Paris-Est University, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology and Ageing Unit), Créteil, France; Assistance Publique Hôpitaux de Paris (AP-HP), Henri-Mondor Hospital, Public Health Department, Créteil, France; AP-HP, Henri-Mondor Hospital, Clinical Research Unit (URC Mondor), Créteil, France
| | - Christophe Tournigand
- AP-HP, Henri-Mondor Hospital, Department of Medical Oncology, Créteil, France; Paris-Est University, UPEC, EC2M3 Unit, VIC DHU, Créteil, France
| | - Elias Assaf
- AP-HP, Henri-Mondor Hospital, Department of Medical Oncology, Créteil, France
| | - Gwénaëlle Varnier
- AP-HP, Henri-Mondor Hospital, Internal Medicine and Geriatric Department, Paris- Sud-Val-de-Marne Geriatric Oncology Clinic, Créteil, France
| | - Frederic Pamoukdjian
- APHP, Avicenne Hospital, Geriatric department, Coordination Unit in Geriatric Oncology, Bobigny, France; Paris 13 University, Sorbonne Paris Cité, Health Education and Practices Laboratory, (LEPS EA3412), Bobigny, France
| | - Etienne Brain
- Institut Curie (Hôpital René Huguenin), Department of Medical Oncology, St Cloud, France
| | - Florence Rollot-Trad
- Institut Curie Hospital, Geriatric oncology and supportive care department, Paris, France
| | - Marie Laurent
- Paris-Est University, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology and Ageing Unit), Créteil, France; AP-HP, Henri-Mondor Hospital, Internal Medicine and Geriatric Department, Paris- Sud-Val-de-Marne Geriatric Oncology Clinic, Créteil, France
| | - Elena Paillaud
- Paris-Est University, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology and Ageing Unit), Créteil, France; AP-HP, Henri-Mondor Hospital, Internal Medicine and Geriatric Department, Paris- Sud-Val-de-Marne Geriatric Oncology Clinic, Créteil, France; AP-HP, Georges-Pompidou European Hospital (HEGP), Geriatric Department, Paris, France
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Wichmann AB, van Dam H, Thoonsen B, Boer TA, Engels Y, Groenewoud AS. Advance care planning conversations with palliative patients: looking through the GP's eyes. BMC FAMILY PRACTICE 2018; 19:184. [PMID: 30486774 PMCID: PMC6263059 DOI: 10.1186/s12875-018-0868-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/13/2018] [Indexed: 11/23/2022]
Abstract
Background Although it is often recommended that general practitioners (GPs) initiate advance care planning (ACP), little is known about their experiences with ACP. This study aimed to identify GP experiences when conducting ACP conversations with palliative patients, and what factors influence these experiences. Methods Dutch GPs (N = 17) who had participated in a training on timely ACP were interviewed. Data from these interviews were analysed using direct content analysis. Results Four themes were identified: ACP and society, the GP’s perceived role in ACP, initiating ACP and tailor-made ACP. ACP was regarded as a ‘hot topic’. At the same time, a tendency towards a society in which death is not a natural part of life was recognized, making it difficult to start ACP discussions. Interviewees perceived having ACP discussions as a typical GP task. They found initiating and timing ACP easier with proactive patients, e.g. who are anxious of losing capacity, and much more challenging when it concerned patients with COPD or heart failure. Patients still being treated in hospital posed another difficulty, because they often times are not open to discussion. Furthermore, interviewees emphasized that taking into account changing wishes and the fact that not everything can be anticipated, is of the utmost importance. Moreover, when patients are not open to ACP, at a certain point it should be granted that choosing not to know, for example about where things are going or what possible ways of care planning might be, is also a form of autonomy. Conclusions ACP currently is a hot topic, which has favourable as well as unfavourable effects. As GPs experience difficulties in initiating ACP if patients are being treated in the hospital, future research could focus on a multidisciplinary ACP approach and the role of medical specialists in ACP. Furthermore, when starting ACP with palliative patients, we recommend starting with current issues. In doing so, a start can be made with future issues kept in view. Although the tension between ACP’s focus on the patient’s direction and the right not to know can be difficult, ACP has to be tailored to each individual patient. Electronic supplementary material The online version of this article (10.1186/s12875-018-0868-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anne B Wichmann
- Radboud Institute for Health Sciences, IQ healthcare, Radboud university medical center, Nijmegen, The Netherlands.
| | - Hanna van Dam
- Radboud Institute for Health Sciences, IQ healthcare, Radboud university medical center, Nijmegen, The Netherlands
| | - Bregje Thoonsen
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Theo A Boer
- Section Ethics, University Kampen, Kampen, The Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - A Stef Groenewoud
- Radboud Institute for Health Sciences, IQ healthcare, Radboud university medical center, Nijmegen, The Netherlands
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Supporting Supportive Care in Cancer: The ethical importance of promoting a holistic conception of quality of life. Crit Rev Oncol Hematol 2018; 131:90-95. [DOI: 10.1016/j.critrevonc.2018.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/03/2018] [Indexed: 01/01/2023] Open
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Goldberg SL, Paramanathan D, Khoury R, Patel S, Jagun D, Arunajadai S, DeVincenzo V, Benito RP, Gruman B, Kaur S, Paddock S, Norden AD, Schultz EV, Hervey J, Jordan T, Goy A, Pecora AL. A Patient-Reported Outcome Instrument to Assess Symptom Burden and Predict Survival in Patients with Advanced Cancer: Flipping the Paradigm to Improve Timing of Palliative and End-of-Life Discussions and Reduce Unwanted Health Care Costs. Oncologist 2018; 24:76-85. [PMID: 30266893 DOI: 10.1634/theoncologist.2018-0238] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 08/08/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Discussions regarding palliative care and end-of-life care issues are frequently delayed past the time of usefulness, resulting in unwanted medical care. We sought to develop a patient-reported outcome (PRO) instrument that allows patients to voice their symptom burdens and facilitate timing of discussions. SUBJECTS, MATERIALS, AND METHODS A seven-item PRO instrument (Cota Patient Assessed Symptom Score-7 item [CPASS-7]) covering physical performance status, pain, burden, and depression was administered (September 2015 through October 2016) with correlation to overall survival, correcting for time to complete survey since diagnosis. RESULTS A total of 1,191 patients completed CPASS-7 at a median of 560 days following the diagnosis of advanced cancer. Of these patients, 49% were concerned that they could not do the things they wanted; 35% reported decreased performance status. Financial toxicity was reported by 39% of patients, with family burdens noted in 25%. Although depression was reported by 15%, 43% reported lack of pleasure. Pain was reported by 33%. The median CPASS-7 total symptom burden score was 16 (possible 0-112). With a median follow-up of 15 months from initial survey, 46% had died. Patients with symptom burden scores <29 and ≥29 had a 6-month overall survival rate of 87% and 67%, respectively, and 12-month survival rates of 72% and 50%. A one-point score increase resulted in a 1.8% increase in expected hazard. CONCLUSION Patients with advanced cancer with higher levels of symptom burden, as self-reported on the CPASS-7, had inferior survival. The PRO facilitates identification of patients appropriate for reassessment of treatment goals and potentially palliative and end-of-life care in response to symptom burden concerns. IMPLICATIONS FOR PRACTICE A seven-item patient-reported outcome (PRO) instrument was administered to 1,191 patients with advanced cancers. Patients self-reporting higher levels of physical and psychological symptom burden had inferior overall survival rates. High individual item symptom PRO responses should serve as a useful trigger to initiate supportive interventions, but when scores indicate global problems, discussions regarding end-of-life care might be appropriate.
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Affiliation(s)
- Stuart L Goldberg
- Cota Inc, New York, New York, USA
- John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, New Jersey, USA
| | | | - Raya Khoury
- Genentech, South San Francisco, California, USA
| | | | - Dayo Jagun
- Genentech, South San Francisco, California, USA
| | | | | | | | | | | | | | | | | | | | - Terrill Jordan
- Regional Cancer Care Associates, Hackensack, New Jersey, USA
| | - Andre Goy
- John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Andrew L Pecora
- Cota Inc, New York, New York, USA
- Hackensack Meridian Healthcare, Edison, New Jersey, USA
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Nakazato K, Wakui T, Hirayama R, Shimada C. [Factors related to parent-child communication about end-of-life care -A survey of adult children with an elderly parent]. Nihon Ronen Igakkai Zasshi 2018; 55:378-385. [PMID: 30122704 DOI: 10.3143/geriatrics.55.378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM In Japan, because adult children are expected to perform a key role in decision-making on end-of-life care for older adults, conversing with parents on their wished-for end-of-life care can help these children to become prepared for this filial responsibility. Our aim in this study was to explore how likely Japanese adult children were to discuss end-of-life care with their parents as well as correlates of such discussions. METHODS We conducted an online survey using a sample of 1,590 adult children with at least one living parent aged 65 or older. We analyzed data from 1,010 children who responded during three consecutive days in October, 2015. RESULTS A small portion of our participants (22.8%) had discussed end-of-life care with their parents. Logistic regression analysis revealed that such discussions were likely in son-mother (Odds Ratio 〈OR〉 = 3.01) and daughter-mother (OR = 3.15) dyads compared with son-father ones as the reference. Occurrence of such discussions was also associated with having older parents (OR = 1.03), parental experience of severe diseases (OR = 1.47), parent-child coresiding (OR = 2.08), a higher level of perceived necessity for (OR = 1.36) and a lower level of emotional avoidance of (OR = 0.68) end-of-life communication. CONCLUSION Generally, adult children rarely discuss end-of-life care with their aging parents, suggesting the need to promote such familial communication while considering both children's and parents' circumstances.
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Curtis JR, Downey L, Back AL, Nielsen EL, Paul S, Lahdya AZ, Treece PD, Armstrong P, Peck R, Engelberg RA. Effect of a Patient and Clinician Communication-Priming Intervention on Patient-Reported Goals-of-Care Discussions Between Patients With Serious Illness and Clinicians: A Randomized Clinical Trial. JAMA Intern Med 2018; 178:930-940. [PMID: 29802770 PMCID: PMC6145723 DOI: 10.1001/jamainternmed.2018.2317] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 04/07/2018] [Indexed: 12/20/2022]
Abstract
Importance Clinician communication about goals of care is associated with improved patient outcomes and reduced intensity of end-of-life care, but it is unclear whether interventions can improve this communication. Objective To evaluate the efficacy of a patient-specific preconversation communication-priming intervention (Jumpstart-Tips) targeting both patients and clinicians and designed to increase goals-of-care conversations compared with usual care. Design, Setting, and Participants Multicenter cluster-randomized trial in outpatient clinics with physicians or nurse practitioners and patients with serious illness. The study was conducted between 2012 and 2016. Interventions Clinicians were randomized to the bilateral, preconversation, communication-priming intervention (n = 65) or usual care (n = 67), with 249 patients assigned to the intervention and 288 to usual care. Main Outcomes and Measures The primary outcome was patient-reported occurrence of a goals-of-care conversation during a target outpatient visit. Secondary outcomes included clinician documentation of a goals-of-care conversation in the medical record and patient-reported quality of communication (Quality of Communication questionnaire [QOC]; 4-indicator latent construct) at 2 weeks, as well as patient assessments of goal-concordant care at 3 months and patient-reported symptoms of depression (8-item Patient Health Questionnaire; PHQ-8) and anxiety (7-item Generalized Anxiety Disorder survey; GAD-7) at 3 and 6 months. Analyses were clustered by clinician and adjusted for confounders. Results We enrolled 132 of 485 potentially eligible clinicians (27% participation; 71 women [53.8%]; mean [SD] age, 47.1 [9.6] years) and 537 of 917 eligible patients (59% participation; 256 women [47.7%]; mean [SD] age, 73.4 [12.7] years). The intervention was associated with a significant increase in a goals-of-care discussion at the target visit (74% vs 31%; P < .001) and increased medical record documentation (62% vs 17%; P < .001), as well as increased patient-rated quality of communication (4.6 vs 2.1; P = .01). Patient-assessed goal-concordant care did not increase significantly overall (70% vs 57%; P = .08) but did increase for patients with stable goals between 3-month follow-up and last prior assessment (73% vs 57%; P = .03). Symptoms of depression or anxiety were not different between groups at 3 or 6 months. Conclusions and Relevance This intervention increased the occurrence, documentation, and quality of goals-of-care communication during routine outpatient visits and increased goal-concordant care at 3 months among patients with stable goals, with no change in symptoms of anxiety or depression. Understanding the effect on subsequent health care delivery will require additional study. Trial Registration ClinicalTrials.gov identifier: NCT01933789.
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Affiliation(s)
- J. Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Anthony L. Back
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
| | - Elizabeth L. Nielsen
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Sudiptho Paul
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Alexandria Z. Lahdya
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Patsy D. Treece
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Priscilla Armstrong
- Community Advisory Board, Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ronald Peck
- Community Advisory Board, Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
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Bestvina CM, Wroblewski KE, Daly B, Beach B, Chow S, Hantel A, Malec M, Huber MT, Polite BN. A Rules-Based Algorithm to Prioritize Poor Prognosis Cancer Patients in Need of Advance Care Planning. J Palliat Med 2018; 21:846-849. [DOI: 10.1089/jpm.2017.0408] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Bobby Daly
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brittany Beach
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Selina Chow
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Andrew Hantel
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Monica Malec
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Michael T. Huber
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Blase N. Polite
- Department of Medicine, University of Chicago, Chicago, Illinois
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Singh S, Rodriguez A, Lee D, Min SJ, Fischer S. Usefulness of the Surprise Question on an Inpatient Oncology Service. Am J Hosp Palliat Care 2018; 35:1421-1425. [PMID: 29783852 DOI: 10.1177/1049909118777990] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Prognostication of survival in patients with advanced cancer has been challenging and contributes to poor illness understanding. Prognostic disagreement occurs even among providers and is a less studied phenomenon. OBJECTIVE We introduced the surprise question (SQ), "Would I be surprised if this patient died in the next 1 year, 6 months, and 1 month?," at multidisciplinary rounds to increase palliative care referrals through the introduction of this prognostic prompt. DESIGN, SETTING, PATIENTS This quality improvement project took place from March 2016 to May 2016 on the medical oncology service at a tertiary academic medical center. The question was asked 3 times a week at multidisciplinary rounds which are attended by the hospital medicine provider, palliative care provider, and consulting oncologist. Primary oncologists and bedside nurses were also asked the SQ. MEASUREMENTS Referral rates to outpatient palliative care clinic, community-based palliative care clinic, inpatient palliative care consults, and hospice 3 months prior to, during, and 5 months postintervention. RESULTS Regular discussion of prognosis of patients with cancer in an inpatient medical setting did not increase referrals to inpatient or outpatient palliative care or hospice. Increased clinical experience impacted hospital medicine providers and bedside nurses' estimation of prognosis differently than oncology providers. Medical oncologists were significantly more optimistic than hospital medicine providers.
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Affiliation(s)
- Sarguni Singh
- 1 Division of Hospital Medicine, University of Colorado Denver, Aurora, CO, USA
| | - Adrian Rodriguez
- 2 College of Nursing, University of Colorado Denver, Aurora, CO, USA
| | - Darrell Lee
- 2 College of Nursing, University of Colorado Denver, Aurora, CO, USA
| | - Sung-Joon Min
- 3 Division of Health Care Policy and Research, University of Colorado Denver, Aurora, CO, USA
| | - Stacy Fischer
- 4 Division of General Internal Medicine, University of Colorado Denver, Aurora, CO, USA
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Bond WF, Kim M, Franciskovich CM, Weinberg JE, Svendsen JD, Fehr LS, Funk A, Sawicki R, Asche CV. Advance Care Planning in an Accountable Care Organization Is Associated with Increased Advanced Directive Documentation and Decreased Costs. J Palliat Med 2018; 21:489-502. [PMID: 29206564 PMCID: PMC5867515 DOI: 10.1089/jpm.2017.0566] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) documents patient wishes and increases awareness of palliative care options. OBJECTIVE To study the association of outpatient ACP with advanced directive documentation, utilization, and costs of care. DESIGN This was a case-control study of cases with ACP who died matched 1:1 with controls. We used 12 months of data pre-ACP/prematch and predeath. We compared rates of documentation with logit model regression and conducted a difference-in-difference analysis using generalized linear models for utilization and costs. SETTING/SUBJECTS Medicare beneficiaries attributed to a large rural-suburban-small metro multisite accountable care organization from January 2013 to April 2016, with cross reference to ACP facilitator logs to find cases. MEASUREMENTS The presence of advance directive forms was verified by chart review. Cost analysis included all utilization and costs billed to Medicare. RESULTS We matched 325 cases and 325 controls (51.1% female and 48.9% male, mean age 81). 320/325 (98.5%) ACP versus 243/325 (74.8%) of controls had a Healthcare Power of Attorney (odds ratio [OR] 21.6, 95% CI 8.6-54.1) and 172/325(52.9%) ACP versus 145/325 (44.6%) controls had Practitioner Orders for Life Sustaining Treatment (OR 1.40, 95% CI 1.02-1.90) post-ACP/postmatch. Adjusted results showed ACP cases had fewer inpatient admissions (-0.37 admissions, 95% CI -0.66 to -0.08), and inpatient days (-3.66 days, 95% CI -6.23 to -1.09), with no differences in hospice, hospice days, skilled nursing facility use, home health use, 30-day readmissions, or emergency department visits. Adjusted costs were $9,500 lower in the ACP group (95% CI -$16,207 to -$2,793). CONCLUSIONS ACP increases documentation and was associated with a reduction in overall costs driven primarily by a reduction in inpatient utilization. Our data set was limited by small numbers of minorities and cancer patients.
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Affiliation(s)
- William F. Bond
- Jump Simulation, OSF HealthCare, Peoria, Illinois
- Department of Emergency Medicine, OSF HealthCare, Peoria, Illinois
- Department of Emergency Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | - Minchul Kim
- Center for Outcomes Research, University of Illinois College of Medicine at Peoria, Peoria, Illinois
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | | | | | | | - Linda S. Fehr
- Division of Supportive Care, OSF HealthCare, Peoria, Illinois
| | - Amy Funk
- College of Nursing, Illinois Wesleyan University, Bloomington, Illinois
| | - Robert Sawicki
- Division of Supportive Care, OSF HealthCare, Peoria, Illinois
| | - Carl V. Asche
- Center for Outcomes Research, University of Illinois College of Medicine at Peoria, Peoria, Illinois
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois
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49
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Massa I, Balzi W, Altini M, Bertè R, Bosco M, Cassinelli D, Vignola V, Cavanna L, Foca F, Dall'Agata M, Nanni O, Rossi R, Maltoni M. The challenge of sustainability in healthcare systems: frequency and cost of diagnostic procedures in end-of-life cancer patients. Support Care Cancer 2018; 26:2201-2208. [PMID: 29387995 PMCID: PMC5982433 DOI: 10.1007/s00520-018-4067-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 01/22/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Literature data on the overuse and misuse of diagnostic procedures leading to end-of-life aggressiveness are scarce due to the limited amount of estimated economic waste. This study investigated the potential overuse of diagnostic procedures in a population of end-of-life patients. METHODS This is a retrospective study on consecutive advanced patients admitted into two Italian hospices. Frequency and relative costs of X-ray imaging, CT scans, MRI, and interventional procedures prescribed in the 3 months before admission were collected in patient electronic charts and/or in administrative databases. We conducted a deeper analysis of 83 cancer patients with a diagnosis of at least 1 year before admission to compare the number of examinations performed at two distant time periods. RESULTS Out of 541 patients, 463 (85.6%) had at least one radiological exam in the 3 months before last admission. The mean radiological exam number was 3.9 ± 3.2 with a relative mean cost of 278.60 ± 270.20 € per patient with a statistically significant (p < 0.001) rise near death. In the 86-patient group, a higher number of procedures was performed in the last 3 months of life than in the first quarter of the year preceding last admission (38.43 ± 28.62 vs. 27.95 ± 23.21, p < 0.001) with a consequent increase in cost. CONCLUSIONS Patients nearing death are subjected to a high level of "diagnostic aggressiveness." Further studies on the integration of palliative care into the healthcare pathway could impact the appropriateness of interventions, quality of care, and, ultimately, estimated costs.
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Affiliation(s)
- Ilaria Massa
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy.
| | - William Balzi
- Healthcare Administration, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy
| | - Mattia Altini
- Healthcare Administration, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy
| | - Raffaella Bertè
- Palliative Care Unit, Department of Oncology and Hematology, Guglielmo da Saliceto Hospital, Via Taverna 49, 29100, Piacenza, Italy
| | - Monica Bosco
- Palliative Care Unit, Department of Oncology and Hematology, Guglielmo da Saliceto Hospital, Via Taverna 49, 29100, Piacenza, Italy
| | - Davide Cassinelli
- Palliative Care Unit, Department of Oncology and Hematology, Guglielmo da Saliceto Hospital, Via Taverna 49, 29100, Piacenza, Italy
| | - Valentina Vignola
- Palliative Care Unit, Department of Oncology and Hematology, Guglielmo da Saliceto Hospital, Via Taverna 49, 29100, Piacenza, Italy
| | - Luigi Cavanna
- Department of Oncology and Hematology, Guglielmo da Saliceto Hospital, Via Taverna 49, 29100, Piacenza, Italy
| | - Flavia Foca
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy
| | - Monia Dall'Agata
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy
| | - Oriana Nanni
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy
| | - Romina Rossi
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy.,Palliative Care Unit, Valerio Grassi Hospice, Forlimpopoli Hospital, Via Duca D'Aosta 33, 47034, Forlimpopoli, Italy
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50
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Pfirstinger J, Bleyer B, Blum C, Rechenmacher M, Wiese CH, Gruber H. Determinants of completion of advance directives: a cross-sectional comparison of 649 outpatients from private practices versus 2158 outpatients from a university clinic. BMJ Open 2017; 7:e015708. [PMID: 29273648 PMCID: PMC5778305 DOI: 10.1136/bmjopen-2016-015708] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To compare outpatients from private practices and outpatients from a university clinic regarding the determinants of completion of advance directives (AD) in order to generalise results of studies from one setting to the other. Five determinants of completion of AD were studied: familiarity with AD, source of information about AD, prior experiences with own life-threatening diseases or family members in need of care and motives in favour and against completion of AD. DESIGN Observational cross-sectional study. SETTING Private practices and a university clinic in Germany in 2012. PARTICIPANTS 649 outpatients from private practices and 2158 outpatients from 10 departments of a university clinic. OUTCOME MEASURES Completion of AD, familiarity with AD, sources of information about AD (consultation), prior experiences (with own life-threatening disease and family members in need of care), motives in favour of or against completion of AD, sociodemographic data. RESULTS Determinants of completion of AD did not differ between outpatients from private practices versus university clinic outpatients. Prior experience with severe disease led to a significantly higher rate of completion of AD (33%/36% with vs 24%/24% without prior experience). Participants with completion of AD had more often received legal than medical consultation before completion, but participants without completion of AD are rather aiming for medical consultation. The motives in favour of or against completion of AD indicated inconsistent patterns. CONCLUSIONS Determinants of completion of AD are comparable in outpatients from private practices and outpatients from a university clinic. Generalisations from university clinic samples towards a broader context thus seem to be legitimate. Only one-third of patients with prior experience with own life-threatening diseases or family members in need of care had completed an AD as expression of their autonomous volition. The participants' motives for or against completion of AD indicate that ADs are considered a kind of 'negative autonomy' as instruments to prevent particular forms of therapy. Interactive, repeated and situation-based AD discussions might reach a higher percentage of patients and concurrently enable personal volitions and thereby strengthen individual 'positive autonomy'.
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Affiliation(s)
- Jochen Pfirstinger
- Department of Internal Medicine II, St. Marien Hospital Amberg, Amberg, Germany
- Department of Hematology, Regensburg University Hospital, Regensburg, Germany
| | - Bernhard Bleyer
- Institute of Sustainability, Ostbayerische Technische Hochschule Amberg-Weiden, Amberg, Germany
- Faculty of Catholic Theology, University of Regensburg, Regensburg, Germany
| | - Christian Blum
- Department of Educational Science, University of Regensburg, Regensburg, Germany
| | | | - Christoph H Wiese
- Department of Anaesthesiology, Regensburg University Hospital, Regensburg, Germany
- Department of Anaesthesiology, Herzogin Elisabeth Hospital, Braunschweig, Germany
| | - Hans Gruber
- Department of Educational Science, University of Regensburg, Regensburg, Germany
- Faculty of Education, University of Turku, Turku, Finland
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