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Hochrath MS, Dhollander DN, Deliens PL, Schots PR, Daenen DF, Kerre PT, Beernaert PK, Pardon PK. Palliative Care in Hematology: A Systematic Review of the Components, Effectiveness, and Implementation. J Pain Symptom Manage 2024:S0885-3924(24)00960-6. [PMID: 39173896 DOI: 10.1016/j.jpainsymman.2024.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 08/09/2024] [Accepted: 08/12/2024] [Indexed: 08/24/2024]
Abstract
CONTEXT While the evidence supporting the benefits of integration of palliative care into cancer care for patients and informal caregivers is growing, it poses challenges for hematological cancer patients due to rapidly changing disease trajectories, uncertain prognosis, and diverse care needs. OBJECTIVES This systematic review aims to provide an overview of the intervention components, the targeted outcomes, the effectiveness in improving patient and informal caregiver outcomes, and the implementation into clinical practice. METHODS We systematically searched PubMed (MEDLINE), EMBASE, CENTRAL, PsycINFO, and CINAHL in March 2023. The studies included described interventions in palliative care, with multiple components, targeting patients with hematological cancer and/or their informal caregivers, and producing primary data on effectiveness or implementation. Quality was assessed using the QualSyst tool. RESULTS We identified 19 reports on 16 different palliative care interventions, including 4 quasi-randomized controlled trials. These interventions were provided by secondary and tertiary palliative care providers in a hospital setting. Tertiary interventions significantly improved the most common patient outcomes, including pain, quality of life, symptom burden, depression, and anxiety. Meanwhile, secondary interventions were feasible and well-accepted by healthcare professionals and patients. Despite limited inclusion of informal caregivers, the results indicated significant improvements in quality of life and depression. CONCLUSION While palliative care interventions are found to improve patient outcomes, future research is needed on the effectiveness of secondary palliative care interventions, integrating primary palliative care, and more reliable and frequent implementation measurements. More focus on informal caregivers and resource allocation based on patient needs is warranted.
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Affiliation(s)
- Ms Sophie Hochrath
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels; Belgium & Ghent University, Ghent, Belgium..
| | - Dr Naomi Dhollander
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels; Belgium & Ghent University, Ghent, Belgium
| | - Professor Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels; Belgium & Ghent University, Ghent, Belgium.; Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Professor Rik Schots
- Department of Hematology, University Hospital Brussels, Brussels, Belgium; Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Dr Frederick Daenen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels; Belgium & Ghent University, Ghent, Belgium
| | - Professor Tessa Kerre
- Department of Hematology (University Hospital Ghent), Ghent; Belgium & Ghent University, Ghent, Belgium
| | - Professor Kim Beernaert
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels; Belgium & Ghent University, Ghent, Belgium
| | - Professor Koen Pardon
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels; Belgium & Ghent University, Ghent, Belgium
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Letica-Kriegel AS, Rosen R, McNeil N, Thompson E, James M, Broach V, Roche KL, Riportella M, Ng S, Bernal C, Vaynrub M, Downey R, Voigt L, Epstein AS, Nelson J, Goldfrank D, Nash GM. Development and perception of surgery-specific goals of care discussions in the preoperative setting: A learning pilot. J Surg Oncol 2024; 129:1384-1389. [PMID: 38549286 DOI: 10.1002/jso.27632] [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: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Goals of care discussions are infrequently documented in the preoperative period. Furthermore, documentation does not consistently address what matters most to patients, although patient values (PV) are central to person-centered care. METHODS A multidisciplinary working group was formed. An electronic note comprised of (1) topics of discussion, (2) PV, and (3) advance care planning (ACP), was created and embedded into existing note templates for Gynecologic Surgical Oncology. Surgeons and advanced practice providers (APPs) were educated to conduct and document these conversations in preoperative clinic for patients undergoing cancer surgery for a pilot period. Data were collected regarding usage of the template. Focus groups with surgeons, APPs, and patients were conducted. Qualitative analysis was performed on transcripts. RESULTS During the pilot, 7 surgeon/APP teams utilized the template on a total of 55 notes. Average number of notes completed per surgeon was 7.8 (SD 8.5). Forty-six notes (84%) included topics of discussion, 15 (27%) included PV, 4 (7%) included ACP. Qualitative analysis of focus group transcripts revealed that clinicians and patients perceived the initiative to be useful and important, although implementation barriers were identified. CONCLUSION Creating a surgery-specific GOC template is feasible. Iterative revisions are needed to increase utility in clinic workflows.
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Affiliation(s)
| | - Roni Rosen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nita McNeil
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Errika Thompson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Monique James
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vance Broach
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kara Long Roche
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michaela Riportella
- Clinical Informatics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Susan Ng
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Camila Bernal
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Max Vaynrub
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Robert Downey
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Louis Voigt
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrew S Epstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Judith Nelson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Deborah Goldfrank
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Garrett M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Nelson JE, Gonzalez CJ, Alvarado A, Costas-Muniz R, Epstein AS, Hoque A, Gany FM. Beyond translation: Transcreation of a clinicians' guide to structure discussions about health-related values with Latinx patients throughout cancer. PATIENT EDUCATION AND COUNSELING 2024; 120:108100. [PMID: 38104422 PMCID: PMC11019714 DOI: 10.1016/j.pec.2023.108100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE This study aimed to ensure accurate translation and cultural appropriateness of a guide designed to help oncology clinicians provide person-centered care to Spanish-speaking Latinx patients with cancer. METHODS Initial translation of a clinician-patient values discussion guide in open-ended question format ("Guide") was pretested in interviews with 27 Spanish-speaking individuals, followed by national expert panel review. At three sites, semi-structured, in-depth, audio-recorded interviews in the participant's preferred language (Spanish/English) were then conducted with Latinx patients receiving systemic treatment for a solid tumor malignancy and family joining them at clinic. RESULTS Interviews of 43 patient/family participants representing diverse Latinx communities addressed the Guide's understandability, acceptability, relevance and responsiveness. Rapid analysis of interviews contributed to cultural adaptation/transcreation of the Guide for a pilot interventional trial. CONCLUSION Moving beyond translation to transcreation can help promote inclusion, equity, and cultural sensitivity in oncologic care/communication. PRACTICE IMPLICATIONS Clinicians now have a linguistically- and culturally-adapted guide including questions and prompts to help structure discussions in Spanish or English of health-related values with Latinx patients receiving oncologic care.
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Affiliation(s)
- Judith E Nelson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, USA; Weill Cornell Medical College, USA.
| | - Carlos J Gonzalez
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, USA
| | - Angelica Alvarado
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, USA
| | - Rosario Costas-Muniz
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, USA; Weill Cornell Medical College, USA
| | - Andrew S Epstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, USA; Weill Cornell Medical College, USA
| | - Afshana Hoque
- Department of Medicine, Memorial Sloan Kettering Cancer Center, USA
| | - Francesca M Gany
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, USA; Weill Cornell Medical College, USA
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Aller A, Shirazi A, Pedell L, Altschuler A, Hauser K, Cheslock M, Wei J, Duffens A, Whitehead H, Lim P, Katzel J, Martinez F, Lin A, Aller S, Aller C, Jones T, Yen SM, Liu R. What Matters Most: The Documented Goals, Values and Motivators of Advanced Cancer Patients. Am J Hosp Palliat Care 2023:10499091231223144. [PMID: 38112439 DOI: 10.1177/10499091231223144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Goals of care conversations are essential to delivery of goal concordant care. Infrequent and inconsistent goals of care documentation potentially limit delivery of goal concordant care. METHODS At Kaiser Permanente San Francisco Cancer Center, a standardized documentation template was designed and implemented to increase goals of care documentation by oncologists. The centralized, prompt-based template included value clarification of the goals and values of advanced cancer patients beyond treatment preferences. Documented conversations using the template during the initial pilot period were reviewed to characterization the clinical context in which conversations were recorded. Common goals and motivators were also identified. RESULTS A total of 178 advanced cancer patients had at least 1 documented conversation by a medical oncologist using the goals of care template. Oncologists consistently documented within the template goals of therapy and motivating factors in decision making. The most frequently documented goals of care were "Avoiding Pain and Suffering," "Physical Independence," and "Living as Long as Possible." The least recorded goal was "Comfort Focused Treatment Only." CONCLUSIONS Review of oncologist documented goals of care conversations using a prompt-based template allowed for characterization of the clinical context, therapy goals and motivators of advanced cancer patients. Communication of goals of care conversations by oncologists using a standardized prompt-based template within a centralized location has the potential to improve delivery of goal concordant care.
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Affiliation(s)
- Ashley Aller
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Aida Shirazi
- Department of Graduate Medical Education, Kaiser Permanente Northern California, San Francisco, CA, USA
| | | | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Karen Hauser
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Megan Cheslock
- Department of Geriatrics Medicine, Edith Nourse Rogers Memorial Veterans' Hospital, Bedford, MA, USA
| | - Jenny Wei
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Ali Duffens
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Hannah Whitehead
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Peggy Lim
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Jed Katzel
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Francisco Martinez
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Amy Lin
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Steve Aller
- Department of Hematology-Oncology, Seattle Children's Hospital, Seattle, WA, USA
| | - Cynthia Aller
- Department of Hematology, Providence Regional Cancer System Lacey Cancer Clinic, Lacey, WA, USA
| | - Tyler Jones
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Sue May Yen
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Raymond Liu
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Rosa WE, Gilliland J, McDarby M, Nelson JE, Desai AV, Epstein AS. Patient and Clinician Stakeholder Perspectives on a Patient Portal Questionnaire Eliciting Illness and Treatment Understanding and Core Health-Related Values. Palliat Med Rep 2023; 4:316-325. [PMID: 38089435 PMCID: PMC10712361 DOI: 10.1089/pmr.2023.0057] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 12/29/2023] Open
Abstract
Introduction Person-centered communication is foundational to cancer care. In pilot research, a questionnaire eliciting patients' illness and treatment understanding (ITU) and core health-related values (HRV) through the electronic patient portal demonstrated feasibility, acceptability, and efficacy. The aim of this study was to elicit stakeholder feedback to refine the design of the portal-based intervention, remain end-user centered, and optimize future system-wide integration. Methods Between April and June 2023, we purposively sampled patients and clinicians from a previous pilot study to participate in a 20-30-minute semistructured interview about their opinions of and experiences with the portal questionnaire on ITU and HRV. An interdisciplinary coding team used a two-phase rapid analysis to identify themes, subthemes, and illustrative participant quotations. Results Fourteen patients (mean age = 68 years) and 12 clinicians participated (total n = 26). Colorectal cancer was the commonest malignancy (64%) among patients. Clinicians were mostly physicians (50%), nurse practitioners (33%), and registered nurses (17%), with two-thirds having >15 years of experience in their specialty. Analysis generated four themes: (1) clinical utility of questionnaire, (2) barriers to questionnaire implementation, (3) considerations and strategies for modifying the questionnaire, and (4) considerations and strategies for questionnaire implementation. Themes captured key information about incorporating this questionnaire into clinical practice. Conclusion Patients with cancer and their clinicians found a portal-based ITU and HRV questionnaire clinically useful to improve multiple aspects of person-centered communication. Participant recommendations about questionnaire timing and sharing of questionnaire responses with the clinical team will inform future questionnaire implementation and scaling in clinical settings.
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Affiliation(s)
- William E. Rosa
- Department of Psychiatry, Behavioral Sciences and Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jaime Gilliland
- Department of Psychiatry, Behavioral Sciences and Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Meghan McDarby
- Department of Psychiatry, Behavioral Sciences and Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Judith E. Nelson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Anjali V. Desai
- Oncology Palliative Care Services, Atlantic Health System, Morristown, New Jersey, USA
| | - Andrew S. Epstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Han HJ, Pilgrim CR, Buss MK. Integrating palliative care into the evolving landscape of oncology. Curr Probl Cancer 2023; 47:101013. [PMID: 37714795 DOI: 10.1016/j.currproblcancer.2023.101013] [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: 06/16/2023] [Accepted: 08/10/2023] [Indexed: 09/17/2023]
Abstract
Patients with cancer have many palliative care needs. Robust evidence supports the early integration of palliative care into the care of patients with advanced cancer. International organizations, such as the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO), have recommended early, longitudinal integration of palliative care into oncology care throughout the cancer trajectory. In this review, we pose a series of clinical questions related to the current state of early palliative care integration into oncology. We review the evidence to address each of these questions and highlight areas for further investigation. As cancer care continues to evolve, incorporating new treatment modalities and improving patient outcomes, we reflect on how to apply the existing evidence supporting early palliative care-oncology integration into this ever-changing therapeutic landscape and how specialty palliative care might adapt to meet the evolving needs of patients, caregivers, and the multidisciplinary oncology team.
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Affiliation(s)
- Harry J Han
- Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA.
| | - Carol R Pilgrim
- Division of Palliative Care, Tufts Medical Center, Boston, MA
| | - Mary K Buss
- Division of Palliative Care, Tufts Medical Center, Boston, MA
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7
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Epstein AS, Knezevic A, Romano DR, Hoque A, Raj N, Reidy D, Rosa WE, Cruz E, Calderon C, O'Shaughnessy S, Sansone A, Okpako M, Nelson JE. Patient Portals to Elicit Essential Patient-Reported Elements of Communication Supporting Person-Centered Oncologic Care: A Pilot Study of the PERSON Approach. JCO Clin Cancer Inform 2023; 7:e2300125. [PMID: 37890120 PMCID: PMC10642868 DOI: 10.1200/cci.23.00125] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/14/2023] [Accepted: 09/06/2023] [Indexed: 10/29/2023] Open
Abstract
PURPOSE Patient portal technology offers important new opportunities to support person-centered clinician-patient communication. METHODS Questionnaires relating to understanding of illness and treatment intent were sent quarterly via portal to all patients scheduled for follow-up in GI medical oncology clinics. For patients in selected clinics, items eliciting health-related values were added. Patient responses were available to all oncology team members in the electronic health record. Workflow and content of clinician-patient discussions about illness, treatment, and care goals stayed within clinicians' discretion. Feasibility (patient response rate), patient understanding, acceptability (three-item patient questionnaire), and efficacy (quality of clinician communication) were evaluated. RESULTS From May 2021 through December 2022, a total of 12,233 questionnaires about illness/treatment understanding were sent to 6,325 patients (one to six per patient), with 97% response, including 9,358 with both open- and closed-ended responses. Fewer than 0.1% of patients indicated distress related to the questionnaire/process. Open-ended responses complemented closed-ended answers by revealing prognostic awareness and illness concerns. Of 48 patients approached to complete the full questionnaire including values items via portal, 15 first received and completed them in clinic (5 on iPad, 10 on paper), while 33 received and 27 (82%) completed the portal questionnaire. Patients found the portal process acceptable, and ratings of clinician communication were higher after clinic visits informed by patients' questionnaire responses (average prescore 6.8 v 5.9 post; P = .03). CONCLUSION Almost all patients in this large GI cancer cohort responded via the portal about their understanding of illness and treatment goals. Eliciting their personal values by portal was also feasible, accepted by patients, and improved patient ratings of clinicians' communication. Portals represent a promising tool for scaling assessment of essential patient-reported elements of person-centered communication.
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Affiliation(s)
- Andrew S. Epstein
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | | | | | - Afshana Hoque
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nitya Raj
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Diane Reidy
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | - Molly Okpako
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Judith E. Nelson
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
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8
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Govindarajan A. Chasing Milestones. J Clin Oncol 2023; 41:1626-1628. [PMID: 36512737 DOI: 10.1200/jco.22.01379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/27/2022] [Accepted: 10/07/2022] [Indexed: 12/15/2022] Open
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Cooley ME, Biedrzycki B, Brant JM, Hammer MJ, Lally RM, Tucker S, Ginex PK. Translation of Evidence-Based Interventions Into Oncology Care Settings: An Integrative Review. Cancer Nurs 2023; 46:E110-E121. [PMID: 36480276 DOI: 10.1097/ncc.0000000000001109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Adoption of evidence remains slow, leading to variations in practices and quality of care. Examining evidence-based interventions implemented within oncology settings can guide knowledge translation efforts. OBJECTIVE This integrative review aimed to (1) identify topics implemented for oncology-related evidence-based practice (EBP) change; (2) describe frameworks, guidelines, and implementation strategies used to guide change; and (3) evaluate project quality. METHODS PubMed and CINAHL were searched to identify published practice change projects. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. Fifty articles met the inclusion criteria. Data were extracted; content analysis was conducted. The Quality Improvement Minimum Quality Criteria Set guided quality assessment. RESULTS Topics included infection control/prevention (n = 18), pain/palliative care (n = 13), psychosocial assessment (n = 11), and medication adherence (n = 8). Among the projects, Plan, Do, Study, Act (n = 8) and Lean Six Sigma (n = 6) frameworks were used most. Thirty-six projects identified guidelines that directed interventions. Multiple implementation strategies were reported in all articles with planning, education, and restructuring the most common. Reach, sustainability, and ability to be replicated were identified as quality gaps across projects. CONCLUSION The EBP topics that emerged are consistent with the oncology nursing priorities, including facilitating integration of EBP into practice. The studies identified used national guidelines and implementation strategies to move evidence into practice. Heterogeneity in measurement made synthesis of findings difficult across studies, although individual studies showed improvement in patient outcomes. IMPLICATIONS FOR PRACTICE Development of an interprofessional oncology consortium could facilitate a standardized approach to implementation of high-priority topics that target improved patient outcomes, harmonize measures, and accelerate translation of evidence into practice.
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Affiliation(s)
- Mary E Cooley
- Author Affiliations: Dana-Farber Cancer Institute, Boston, Massachusetts (Drs Cooley and Hammer); Formerly of the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (Dr Biedrzycki); Billings Clinic, Montana (Dr Brant); University of Nebraska Medical Center, Omaha (Dr Lally); The Ohio State University, Columbus (Dr Tucker); and Oncology Nursing Society, Pittsburgh, Pennsylvania (Dr Ginex)
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10
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The Acknowledge-Normalize-Partner (ANP) Framework: A novel empathic communication tool for oncology nurses. Palliat Support Care 2023; 21:12-19. [PMID: 35236541 DOI: 10.1017/s1478951522000086] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To describe the development and implementation of a novel tool designed to enhance nurse-patient communication in a major academic cancer center, which nurses can learn quickly, incorporate into their primary palliative care practice, and broadly disseminate in order to improve the patient experience. METHOD An evidence-based empathic communication tool and educational program were designed to provide essential skills to oncology nurses in having discussions with patients about their personal values. Evaluation included nurse focus groups, pre- and post-course evaluations and interviews, and patient questionnaires. RESULTS Nurses were satisfied with the educational program and found the communication tool effective in a variety of clinical situations including discussions about personal values. Patients reported increased occurrences of these discussions when nurses utilized the framework (97% vs. 58%, p < 0.0001) and a higher quality of clinician communication (mean [SD] from 0 = very worst to 10 = very best: 7.18 [2.3] vs. 5.04 [2.9], p = 0.001). SIGNIFICANCE OF RESULTS Skilled, empathic communication is an essential component of high-quality primary palliative care. Oncology nurses are well suited to lead communication and provide this care as part of an interprofessional team. The training and tool described here are targeted and efficient, and prepare nurses to respond skillfully to emotion while facilitating important discussions about patient values.
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11
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Strachna O, Asan O, Stetson PD. Managing Critical Patient-Reported Outcome Measures in Oncology Settings: System Development and Retrospective Study. JMIR Med Inform 2022; 10:e38483. [PMID: 36326801 PMCID: PMC9672998 DOI: 10.2196/38483] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/27/2022] [Accepted: 09/25/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Remote monitoring programs based on the collection of patient-reported outcome (PRO) data are being increasingly adopted in oncology practices. Although PROs are a great source of patient data, the management of critical PRO data is not discussed in detail in the literature. OBJECTIVE This first-of-its-kind study aimed to design, describe, and evaluate a closed-loop alerting and communication system focused on managing PRO-related alerts in cancer care. METHODS We designed and developed a novel solution using an agile software development methodology by incrementally building new capabilities. We evaluated these new features using participatory design and the Fit between Individuals, Task, and Technology framework. RESULTS A total of 8 questionnaires were implemented using alerting features, resulting in an alert rate of 7.82% (36,838/470,841) with 13.28% (10,965/82,544) of the patients triggering at least one alert. Alerts were reviewed by 501 staff members spanning across 191 care teams. All the alerts were reviewed with a median response time of 1 hour (SD 185 hours) during standard business hours. The most severe (red) alerts were documented 56.83% (2592/4561) of the time, whereas unlabeled alerts were documented 27.68% (1298/4689) of the time, signaling clinician concordance with the alert thresholds. CONCLUSIONS A PRO-based alert and communication system has some initial benefits in reviewing clinically meaningful PRO data in a reasonable amount of time. We have discussed key system design considerations, workflow integration, and the mitigation of potential impact on the burden of care teams. The introduction of a PRO-based alert and communication system provides a reliable mechanism for care teams to review and respond to patient symptoms quickly. The system was standardized across many different oncology settings, demonstrating system flexibility. Future studies should focus on formally evaluating system usability through qualitative methods.
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Affiliation(s)
- Olga Strachna
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, United States
- Division of Digital Products and Informatics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Onur Asan
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, United States
| | - Peter D Stetson
- Division of Digital Products and Informatics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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12
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Epstein AS, Riley M, Nelson JE, Bernal C, Martin S, Xiao H. Goals of care documentation by medical oncologists and oncology patient end-of-life care outcomes. Cancer 2022; 128:3400-3407. [PMID: 35866716 PMCID: PMC9420787 DOI: 10.1002/cncr.34400] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/06/2022] [Accepted: 06/15/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Goals of care (GOC) documentation is important but underused. We aimed to improve oncologist GOC documentation and end-of-life (EOL) care. METHODS In April 2020, our cancer center launched a GOC note template, including optional fields for documenting discussion with the patient about: cancer natural history, goals, and/or EOL (resuscitation preferences, hospice receptivity). Associations between GOC notes and EOL care were evaluated. RESULTS Among 1721 patients dying between June 1, 2020 and June 30, 2021, median days from first GOC note (± with documentation of EOL discussion) to death was 92, whereas a GOC note including EOL discussion ("GOC EOL note"), specifically, was 31. Patients with a first GOC note >60 days before death spent fewer days inpatient (6.7 vs 10.6 days, p < .001). Among patients with GOC EOL notes, those with such documentation >30 days before death had fewer inpatient (5 vs 11, p < .001) and intensive care unit days (0.5 vs 1.5, p < .001), more hospice referrals (57% vs 44%, p = .003), and less chemotherapy ≤14 days before death (6% vs 11%, p = .010). Of 925 admissions of patients dying within ≤30 days, those with GOC EOL notes were shorter (7 vs 9 days, p = .013) but not associated with more hospice discharge (30% vs 25%, p = .163). Oncologist (vs nononcologist) GOC documentation and earlier documentation of EOL discussion were associated in subset analyses with less inpatient care and more hospice referrals. CONCLUSIONS Documentation of GOC, including EOL discussions, is associated with favorable performance on accepted indicators of quality EOL care.
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Affiliation(s)
- Andrew S. Epstein
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Michael Riley
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Judith E. Nelson
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Camila Bernal
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Steven Martin
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Han Xiao
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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13
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Agarwal R, Shin P, Knezevic A, Nelson JE, Romano DR, Bernal C, Desai AV, Epstein AS. Accuracy of curability expectations in patients with gastrointestinal cancers. Cancer Med 2022; 12:20-29. [PMID: 35959986 PMCID: PMC9844646 DOI: 10.1002/cam4.4947] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/03/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Assessment of illness and treatment understanding among cancer patients has largely focused on those with advanced disease. Less is known about patient expectations at earlier stages of cancer and potential modifiers of accurate understanding. METHODS We assessed accuracy of cure expectations in patients across all stages with gastrointestinal (GI) cancers. Accuracy was determined by independent reviews of patient health records by oncologists on the investigative team. Impact on cure accuracy of selected clinical variables and health-information preferences was analyzed. RESULTS Hundred and thirty five patients were included for analysis, with 100% interrater agreement for accuracy between oncologist reviewers. Sixety five patients (48%) had accurate cure expectations from their cancer treatment. Accuracy was lower in Stage IV versus Stage I-III disease (35% vs. 63%, p < 0.01), lower in unresectable versus resectable disease (35% vs. 67%, p < 0.01), and higher in patients with early-stage disease who received adjuvant chemotherapy versus those who did not (78% vs. 53%, p = 0.04). Accuracy did not differ by health-information preferences and remained stable over time. Of 63 patients who died, baseline accuracy differed by location of death (p = 0.03), with greater accuracy in those who died with home hospice (56%). Accuracy was lower in those who were hospitalized in the last 30 days of life versus those who were not (25% vs. 59%, p = 0.01). CONCLUSIONS Inaccurate cure expectations are prevalent across all stages of GI cancers, but particularly among those with metastatic or unresectable disease. High-quality, iterative communication strategies may facilitate patient illness and treatment understanding throughout the disease course.
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Affiliation(s)
- Rajiv Agarwal
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Paul Shin
- Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | | | - Judith E. Nelson
- Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
- Weill Cornell Medical CollegeNew YorkNew YorkUSA
| | | | - Camila Bernal
- Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Anjali V. Desai
- Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
- Weill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Andrew S. Epstein
- Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
- Weill Cornell Medical CollegeNew YorkNew YorkUSA
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14
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Sigler LE, Althouse AD, Thomas TH, Arnold RM, White D, Smith TJ, Chu E, Rosenzweig M, Smith KJ, Schenker Y. Effects of an Oncology Nurse-Led, Primary Palliative Care Intervention (CONNECT) on Illness Expectations Among Patients With Advanced Cancer. JCO Oncol Pract 2022; 18:e504-e515. [PMID: 34767474 PMCID: PMC9014423 DOI: 10.1200/op.21.00573] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Patients with advanced cancer often have unrealistic expectations about prognosis and treatment. This study assessed the effect of an oncology nurse-led primary palliative care intervention on illness expectations among patients with advanced cancer. METHODS This study is a secondary analysis of a cluster-randomized trial of primary palliative care conducted at 17 oncology clinics. Adult patients with advanced solid tumors for whom the oncologist would not be surprised if died within 1 year were enrolled. Monthly visits were designed to foster realistic illness expectations by eliciting patient concerns and goals for their medical care and empowering patients and families to engage in discussions with oncologists about treatment options and preferences. Baseline and 3-month questionnaires included questions about life expectancy, treatment intent, and terminal illness acknowledgment. Odds of realistic illness expectations at 3 months were adjusted for baseline responses, patient demographic and clinical characteristics, and intervention dose. RESULTS Among 457 primarily White patients, there was little difference in realistic illness expectations at 3 months between intervention and standard care groups: 12.8% v 11.4% for life expectancy (adjusted odds ratio [aOR] = 1.15; 95% CI, 0.59 to 2.22; P = .684); 24.6% v 33.3% for treatment intent (aOR = 0.76; 95% CI, 0.44 to 1.27; P = .290); 53.6% v 44.7% for terminal illness acknowledgment (aOR = 1.28; 95% CI, 0.81 to 2.00; P = .288). Results did not differ when accounting for variation in clinic sites or intervention dose. CONCLUSION Illness expectations are difficult to change among patients with advanced cancer. Additional work is needed to identify approaches within oncology practices that foster realistic illness expectations to improve patient decision making.
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Affiliation(s)
- Lauren E. Sigler
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA,Emory Palliative Care Center, Emory University School of Medicine, Atlanta, GA,Lauren E. Sigler, MD, Emory Palliative Care Center, Emory University School of Medicine, 1821 Clifton Road NE, Suite 1017 Atlanta, GA 30329; e-mail:
| | - Andrew D. Althouse
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
| | - Teresa H. Thomas
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA,University of Pittsburgh School of Nursing, Pittsburgh, PA
| | - Robert M. Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA,Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
| | - Douglas White
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Thomas J. Smith
- Division of General Internal Medicine, Section of Palliative Medicine, Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Edward Chu
- Albert Einstein Cancer Center, Albert Einstein College of Medicine, New York, NY
| | - Margaret Rosenzweig
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA,University of Pittsburgh School of Nursing, Pittsburgh, PA
| | - Kenneth J. Smith
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Yael Schenker
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA,Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
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15
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Chen J, de la Rosa A, Lai D, De La Cruz M, Zhukovsky D, Revere L, Lairson D, Wermuth P, Hui D. A National Survey of Palliative Care Team Compositions. J Palliat Care 2022; 37:142-151. [PMID: 34939878 DOI: 10.1177/08258597211058963] [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] [Indexed: 11/16/2022]
Abstract
Objective: It is unclear how well palliative care teams are staffed at US cancer centers. Our primary objective was to compare the composition of palliative care teams between National Cancer Institute (NCI)-designated cancer centers and non-NCI-designated cancer centers in 2018. We also assessed changes in team composition between 2009 and 2018. Methods: This national survey examined the team composition in palliative care programs at all 61 NCI-designated cancer centers and in a random sample of 60 of 1252 non-NCI-designated cancer centers in 2018. Responses were compared to those from our 2009 survey. The primary outcome was the presence of an interprofessional team defined as a palliative care physician, nurse, and psychosocial member. Secondary outcomes were the size and number of individual disciplines. Results: In 2018, 52/61 (85%) of NCI-designated and 27/38 (71%) non-NCI-designated cancer centers in the primary outcome comparison responded to the survey. NCI-designated cancer centers were more likely to have interprofessional teams than non-NCI-designated cancer centers (92% vs 67%; P = .009). Non-NCI-designated cancer centers were more likely to have nurse-led teams (14.8% vs 0.0%; P = .01). The median number of disciplines did not differ between groups (NCI, 6.0; non-NCI, 5.0; P = .08). Between 2009 and 2018, NCI-designated and non-NCI-designated cancer centers saw increased proportions of centers with interprofessional teams (NCI, 64.9% vs 92.0%, P < .001; non-NCI, 40.0% vs 66.7%; P = .047). Conclusion: NCI-designated cancer centers were more likely to report having an interprofessional palliative care team than non-NCI-designated cancer centers. Growth has been limited over the past decade, particularly at non-NCI-designated cancer centers.
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Affiliation(s)
- Joseph Chen
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Allison de la Rosa
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dejian Lai
- Department of Biostatistics and Data Science, The UTHealth School of Public Health, Houston, TX, USA
| | - Maxine De La Cruz
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Donna Zhukovsky
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lee Revere
- Department of Management, Policy, and Community Health, The UTHealth School of Public Health, Houston, TX, USA
| | - David Lairson
- Department of Management, Policy, and Community Health, The UTHealth School of Public Health, Houston, TX, USA
| | - Paige Wermuth
- Department of Management, Policy, and Community Health, The UTHealth School of Public Health, Houston, TX, USA
| | - David Hui
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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16
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Lynch KA, Bernal C, Romano DR, Shin P, Nelson JE, Okpako M, Anderson K, Cruz E, Desai AV, Klimek VM, Epstein AS. Navigating a newly diagnosed cancer through clinician-facilitated discussions of health-related patient values: a qualitative analysis. BMC Palliat Care 2022; 21:29. [PMID: 35249532 PMCID: PMC8898465 DOI: 10.1186/s12904-022-00914-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 02/04/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Advance care planning, the process through which patient values and goals are explored and documented, is a core quality indicator in cancer care. However, patient values are predominantly elicited at the end of life; patient values earlier in serious illness are not clearly delineated. The objective of this analysis is to assess the content of patient-verified summaries of health-related values among newly diagnosed cancer outpatients in order to develop a theoretical framework to guide future values discussions and optimize person-centered oncologic care. METHODS Values summaries among patients with gastrointestinal (GI) cancers or myelodysplastic syndrome (MDS) were extracted from the medical record. Modified grounded theory analysis included interdisciplinary team coding of values summaries to identify key domains; code categorization; and identification of thematic constructs during successive consensus meetings. A final round of coding stratified themes by disease type. RESULTS Analysis of 128 patient values summary documents from 67 patients (gastrointestinal [GI] cancers, n = 49; myelodysplastic syndrome [MDS], n = 18) generated 115 codes across 12 categories. Resultant themes demonstrated patients' focus on retaining agency, personhood and interpersonal connection amidst practical and existential disruption caused by cancer. Themes coalesced into a theoretical framework with 5 sequenced constructs beginning with the cancer diagnosis, leading to 3 nesting constructs of individual identity (character), interpersonal (communication) preferences and needs, and social identity (connection), signifying sources of meaning and fulfillment. Values differences between GI cancer and MDS patients-including greater focus on normalcy, prognosis, and maintaining professional life among GI patients-reflected the distinct therapeutic options and prognoses across these disease groups. CONCLUSIONS Patient values reflect goals of meaning-making and fulfillment through individual agency and interpersonal supports in the setting of a newly diagnosed cancer. Early, nurse-led values discussions provide important and patient-specific data that are informative and likely actionable by clinicians in the delivery of person-centered care. Values can also facilitate discussions between patients and families and clarify patient preferences.
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Affiliation(s)
- Kathleen A Lynch
- Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY, 10022, USA.
| | - Camila Bernal
- Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY, 10022, USA
| | - Danielle R Romano
- Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY, 10022, USA
| | - Paul Shin
- Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY, 10022, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Judith E Nelson
- Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY, 10022, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Molly Okpako
- Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY, 10022, USA
| | - Kelley Anderson
- Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY, 10022, USA
| | - Elizabeth Cruz
- Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY, 10022, USA
| | - Anjali V Desai
- Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY, 10022, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Virginia M Klimek
- Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY, 10022, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Andrew S Epstein
- Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY, 10022, USA
- Weill Cornell Medical College, New York, NY, USA
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17
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Desai AV, Agarwal R, Epstein AS, Kuperman GJ, Michael CL, Mittelstaedt H, Connor M, Bernal C, Lynch KA, Ostroff JS, Katz B, Corrigan KL, Kramer D, Davis ME, Nelson JE. Needs and Perspectives of Cancer Center Stakeholders for Access to Patient Values in the Electronic Health Record. JCO Oncol Pract 2021; 17:e1524-e1536. [PMID: 33555928 PMCID: PMC9810135 DOI: 10.1200/op.20.00644] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE High-quality cancer care must incorporate patients' personal values in decision making throughout illness. Unfortunately, patient values are neither consistently elicited nor easily accessible in the electronic health record (EHR). Memorial Sloan Kettering Cancer Center is deploying a major EHR innovation, called the Patient Values Tab, which provides ready access to patients' values and personhood. To inform the Tab's design, we interviewed a large, diverse group of institutional stakeholders to understand their user needs for this Tab. METHODS Qualitative data were collected through semistructured, audio-recorded, in-person, individual interviews. An interdisciplinary team of four coders conducted a process of thematic content analysis. Thematic saturation was achieved, and member checking was performed. RESULTS A total of 110 stakeholders were approached and interviewed. Participants comprised a wide range of disciplines or professions and others involved in hospital and/or clinic administration. Analysis revealed the following themes related to important Tab content: personhood, support system or resources, social history, communication preferences, future planning, end of life, and illness and treatment understanding. Participants also discussed implementation considerations, the Tab's potential to improve communication, and privacy implications. CONCLUSION This study focused on a major EHR innovation to centralize information about values and personhood of patients with cancer. We elicited views of over 100 institutional stakeholders through in-depth interviews that were rigorously analyzed, yielding themes related to content and format that helped guide the Tab's design. The interviews generated a sense of ownership and enthusiasm for the Tab among future users. The Tab's introduction advances the use of the EHR as a driver of the delivery of patient-centered care.
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Affiliation(s)
- Anjali V. Desai
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Weill Cornell Medical College, New York, NY,Anjali V. Desai, MD, MSCE, 1275 York Avenue, New York, NY 10065; e-mail:
| | - Rajiv Agarwal
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Andrew S. Epstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Weill Cornell Medical College, New York, NY
| | - Gilad J. Kuperman
- Department of Health Informatics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chelsea L. Michael
- Department of Health Informatics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Haley Mittelstaedt
- Department of Health Informatics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - MaryAnn Connor
- Department of Nursing Informatics, Memorial Sloan Kettering Cancer Center, New York, NY,New York University, New York, NY
| | - Camila Bernal
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kathleen A. Lynch
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jamie S. Ostroff
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brittany Katz
- Weill Cornell Medical College, New York, NY,Department of Medicine, New York-Presbyterian Hospital, New York, NY
| | - Kelsey L. Corrigan
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Dana Kramer
- Department of Advanced Practice Providers, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Judith E. Nelson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Weill Cornell Medical College, New York, NY
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18
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Frasca M, Orazio S, Amadeo B, Sabathe C, Berteaud E, Galvin A, Burucoa B, Coureau G, Baldi I, Monnereau A, Mathoulin-Pelissier S. Palliative care referral in cancer patients with regard to initial cancer prognosis: a population-based study. Public Health 2021; 195:24-31. [PMID: 34034002 DOI: 10.1016/j.puhe.2021.03.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 02/23/2021] [Accepted: 03/18/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES More than half of cancer patients require palliative care; however, inequality in access and late referral in the illness trajectory are major issues. This study assessed the cumulative incidence of first hospital-based palliative care (HPC) referral, as well as the influence of patient-, tumor-, and care-related factors. STUDY DESIGN This is a retrospective population-based study. METHODS The study included patients from the 2014 population-based cancer registry of Gironde, France. International Classification of Diseases, Tenth Revision, coding for palliative care identified HPC referrals from 2014 to 2018. The study included 8424 patients. Analyses considered the competing risk of death and were stratified by initial cancer prognosis (favorable vs unfavorable [if metastatic or progressive cancer]). RESULTS The 4-year incidence of HPC was 16.7% (95% confidence interval, 16.6-16.8). Lung cancer led to more referrals, whereas breast, colorectal, and prostatic locations were associated to less frequent HPC compared with other solid tumors. Favorable prognosis central nervous system tumors and unfavorable prognosis hematological malignancies also showed less HPC. The incidence of HPC was higher in tertiary centers, particularly for older patients. In the favorable prognosis subgroup, older and non-deprived patients received more HPC. In the unfavorable prognosis subgroup, the incidence of HPC was lower in patients who lived in rural areas than those who lived in urban areas. CONCLUSIONS One-sixth of cancer patients require HPC. Some factors influencing referral depend on the initial cancer prognosis. Our findings support actions to improve accessibility, especially for deprived patients, people living in rural areas, those with hematological malignancies, and those treated outside tertiary centers. In addition, consideration of age as factor of HPC may allow for improved design of the referral system.
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Affiliation(s)
- Matthieu Frasca
- Epicene team, University of Bordeaux, Inserm, Bordeaux Population Health Research Centre, Epicene Team, UMR 1219, 33000, Bordeaux, France; Department of Palliative Medicine, CHU Bordeaux, 33000, Bordeaux, France.
| | - Sébastien Orazio
- Epicene team, University of Bordeaux, Inserm, Bordeaux Population Health Research Centre, Epicene Team, UMR 1219, 33000, Bordeaux, France
| | - Brice Amadeo
- Epicene team, University of Bordeaux, Inserm, Bordeaux Population Health Research Centre, Epicene Team, UMR 1219, 33000, Bordeaux, France
| | - Camille Sabathe
- Biostatistic team, University of Bordeaux, Inserm, Bordeaux Population Health Research Centre, Biostatistic Team, UMR 1219, 33000, Bordeaux, France
| | - Emilie Berteaud
- Epicene team, University of Bordeaux, Inserm, Bordeaux Population Health Research Centre, Epicene Team, UMR 1219, 33000, Bordeaux, France
| | - Angeline Galvin
- Epicene team, University of Bordeaux, Inserm, Bordeaux Population Health Research Centre, Epicene Team, UMR 1219, 33000, Bordeaux, France
| | - Benoît Burucoa
- Department of Palliative Medicine, CHU Bordeaux, 33000, Bordeaux, France
| | - Gaelle Coureau
- Epicene team, University of Bordeaux, Inserm, Bordeaux Population Health Research Centre, Epicene Team, UMR 1219, 33000, Bordeaux, France
| | - Isabelle Baldi
- Epicene team, University of Bordeaux, Inserm, Bordeaux Population Health Research Centre, Epicene Team, UMR 1219, 33000, Bordeaux, France
| | - Alain Monnereau
- Epicene team, University of Bordeaux, Inserm, Bordeaux Population Health Research Centre, Epicene Team, UMR 1219, 33000, Bordeaux, France
| | - Simone Mathoulin-Pelissier
- Epicene team, University of Bordeaux, Inserm, Bordeaux Population Health Research Centre, Epicene Team, UMR 1219, 33000, Bordeaux, France; Unité d'épidémiologie et de recherche cliniques, Institut Bergonié, 33000, Bordeaux, France
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19
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Desai AV, Klimek VM, Wan PJ, Heinberg A, Anderson KL, Bernal C, Nelson JE. Palliative Medicine in Myelodysplastic Syndromes: Patients and Caregivers - A Qualitative Study. BMJ Support Palliat Care 2021:bmjspcare-2020-002865. [PMID: 33903261 PMCID: PMC8546005 DOI: 10.1136/bmjspcare-2020-002865] [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: 12/21/2020] [Revised: 03/20/2021] [Accepted: 03/30/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Evidence-based guidelines call for integration of palliative care within oncology from diagnosis. Misperceptions about palliative care have impeded implementation. Prior research has not examined perceptions about 'palliative care' versus 'supportive care' among patients and caregivers to whom this care is introduced routinely as part of comprehensive cancer care. We conducted a qualitative study of patients with myelodysplastic syndromes (MDS) and their informal caregivers to elicit perceptions of 'palliative care' and 'supportive care' before and after they received integrated primary/specialist palliative care from diagnosis. METHODS Patients with newly diagnosed MDS and caregivers were interviewed about their understanding of 'palliative care' and 'supportive care' at diagnosis and follow-up. Interviews were audio-recorded, transcribed, and analysed by an interdisciplinary team. RESULTS Forty-eight interviews were conducted in total, including with 21 patients and 13 caregivers at diagnosis, and 10 patients and 4 caregivers at follow-up. Initially, 28/34 participants (82%) associated 'palliative care' with death or fear/alarm. At follow-up, 11/14 participants (79%) recognised that 'palliative care' is not only for terminally ill patients, yet 13/14 participants (93%) still felt apprehensive about the term. Initially, 24/34 participants (71%) felt 'supportive care' sounded 'positive' and 12/14 participants (86%) reported this at follow-up. No participant associated 'supportive care' with death or fear/alarm at either time point. Among participants who had a preference, 'supportive care' was the preferred term initially and at follow-up. CONCLUSIONS Patients with MDS and caregivers receiving integrated primary/specialist palliative care from diagnosis responded more favourably to and felt less apprehensive about 'supportive care', initially and at follow-up.
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Affiliation(s)
- Anjali V Desai
- Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Virginia M Klimek
- Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Peter J Wan
- Touro College of Osteopathic Medicine, New York, New York, USA
| | | | | | - Camila Bernal
- Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Judith E Nelson
- Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Medicine, Weill Cornell Medical College, New York, New York, USA
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20
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Desai AV, Michael CL, Kuperman GJ, Jordan G, Mittelstaedt H, Epstein AS, Connor M, B Villar RP, Bernal C, Kramer D, Davis ME, Chen Y, Malisse C, Markose G, Nelson JE. A Novel Patient Values Tab for the Electronic Health Record: A User-Centered Design Approach. J Med Internet Res 2021; 23:e21615. [PMID: 33595448 PMCID: PMC7929751 DOI: 10.2196/21615] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/21/2020] [Accepted: 10/21/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has shined a harsh light on a critical deficiency in our health care system: our inability to access important information about patients' values, goals, and preferences in the electronic health record (EHR). At Memorial Sloan Kettering Cancer Center (MSK), we have integrated and systematized health-related values discussions led by oncology nurses for newly diagnosed cancer patients as part of routine comprehensive cancer care. Such conversations include not only the patient's wishes for care at the end of life but also more holistic personal values, including sources of strength, concerns, hopes, and their definition of an acceptable quality of life. In addition, health care providers use a structured template to document their discussions of patient goals of care. OBJECTIVE To provide ready access to key information about the patient as a person with individual values, goals, and preferences, we undertook the creation of the Patient Values Tab in our center's EHR to display this information in a single, central location. Here, we describe the interprofessional, interdisciplinary, iterative process and user-centered design methodology that we applied to build this novel functionality as well as our initial implementation experience and plans for evaluation. METHODS We first convened a working group of experts from multiple departments, including medical oncology, health informatics, information systems, nursing informatics, nursing education, and supportive care, and a user experience designer. We conducted in-depth, semistructured, audiorecorded interviews of over 100 key stakeholders. The working group sought consensus on the tab's main content, homing in on high-priority areas identified by the stakeholders. The core content was mapped to various EHR data sources. We established a set of high-level design principles to guide our process. Our user experience designer then created wireframes of the tab design. The designer conducted usability testing with physicians, nurses, and other health professionals. Data validation testing was conducted. RESULTS We have already deployed the Patient Values Tab to a pilot sample of users in the MSK Gastrointestinal Medical Oncology Service, including physicians, advanced practice providers, nurses, and administrative staff. We have early evidence of the positive impact of this EHR innovation. Audit logs show increasing use. Many of the initial user comments have been enthusiastically positive, while others have provided constructive suggestions for additional tab refinements with respect to format and content. CONCLUSIONS It is our challenge and obligation to enrich the EHR with information about the patient as a person. Realization of this capability is a pressing public health need requiring the collaboration of technological experts with a broad range of clinical leaders, users, patients, and families to achieve solutions that are both principled and practical. Our new Patient Values Tab represents a step forward in this important direction.
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Affiliation(s)
- Anjali Varma Desai
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Weill Cornell Medical College, New York, NY, United States
| | | | - Gilad J Kuperman
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Gregory Jordan
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | - Andrew S Epstein
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Weill Cornell Medical College, New York, NY, United States
| | - MaryAnn Connor
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | - Camila Bernal
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Dana Kramer
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | - Yuxiao Chen
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | - Gigi Markose
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Judith E Nelson
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Weill Cornell Medical College, New York, NY, United States
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21
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Michael CL, Mittelstaedt H, Chen Y, Desai AV, Kuperman GJ. Applying User-Centered Design in the Electronic Health Record (EHR) to Facilitate Patient-Centered Care in Oncology. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2021; 2020:833-839. [PMID: 33936458 PMCID: PMC8075506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Patient-centered care is an essential component of quality health care. To support patient-centered care initiatives at our institution, we created a feature in our EHR to centrally view information about the patient's values, goals and preferences. We applied user-centered design methods to ensure that the aggregate view was easy to use and would meet user needs. We created a six-week plan to iterate through increasingly detailed design mock-ups. We defined 7 user stories that later served as a basis for user testing scripts. We conducted user testing on our third design iteration; we reached theme saturation with 8 testing sessions. We incorporated findings into the fourth design (week 6) but continued to refine the design in parallel to development (through week 20+). The advance directives section required the most attention. We will use a pilot and additional user testing to validate the design and to inform future versions.
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Affiliation(s)
| | | | - Yuxiao Chen
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anjali V Desai
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Graduate School of Medical Sciences, New York, NY
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Rosa WE, Ferrell BR, Wiencek C. Increasing Critical Care Nurse Engagement of Palliative Care During the COVID-19 Pandemic. Crit Care Nurse 2020; 40:e28-e36. [PMID: 32699889 PMCID: PMC8034497 DOI: 10.4037/ccn2020946] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The coronavirus disease 2019 pandemic has led to escalating infection rates and associated deaths worldwide. Amid this public health emergency, the urgent need for palliative care integration throughout critical care settings has never been more crucial. OBJECTIVE To promote palliative care engagement in critical care; share palliative care resources to support critical care nurses in alleviating suffering during the coronavirus disease 2019 pandemic; and make recommendations to strengthen nursing capacity to deliver high-quality, person-centered critical care. METHODS Palliative and critical care literature and practice guidelines were reviewed, synthesized, and translated into recommendations for critical care nursing practice. RESULTS Nurses are ideally positioned to drive full integration of palliative care into the critical care delivery for all patients, including those with coronavirus disease 2019, given their relationship-based approach to care, as well as their leadership and advocacy roles. Recommendations include the promotion of healthy work environments and prioritizing nurse self-care in alignment with critical care nursing standards. CONCLUSIONS Nurses should focus on a strategic integration of palliative care, critical care, and ethically based care during times of normalcy and of crisis. Primary palliative care should be provided for each patient and family, and specialist services sought, as appropriate. Nurse educators are encouraged to use these recommendations and resources in their curricula and training. Palliative care is critical care. Critical care nurses are the frontline responders capable of translating this holistic, person-centered approach into pragmatic services and relationships throughout the critical care continuum.
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Affiliation(s)
- William E Rosa
- William E. Rosa is a Robert Wood Johnson Foundation Future of Nursing Scholar, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Betty R Ferrell
- Betty R. Ferrell is a professor and the Director of Nursing Research, City of Hope National Medical Center, Duarte, California
| | - Clareen Wiencek
- Clareen Wiencek is an associate professor of nursing and the Advanced Practice Program Director for MSN and DNP programs, University of Virginia School of Nursing, Charlottesville, Virginia
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24
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Vlckova K, Tuckova A, Polakova K, Loucka M. Factors associated with prognostic awareness in patients with cancer: A systematic review. Psychooncology 2020; 29:990-1003. [DOI: 10.1002/pon.5385] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Karolina Vlckova
- Center for Palliative Care Prague Czech Republic
- First Faculty of MedicineCharles University Prague Czech Republic
| | - Anna Tuckova
- Center for Palliative Care Prague Czech Republic
- Faculty of Social SciencesCharles University Prague Czech Republic
| | | | - Martin Loucka
- Center for Palliative Care Prague Czech Republic
- Third Faculty of MedicineCharles University Prague Czech Republic
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25
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Agarwal R, Shuk E, Romano D, Genoff M, Li Y, O’Reilly EM, Breitbart W, Volandes AE, Epstein AS. A mixed methods analysis of patients' advance care planning values in outpatient oncology: Person-Centered Oncologic Care and Choices (P-COCC). Support Care Cancer 2020; 28:1109-1119. [PMID: 31197540 PMCID: PMC6908761 DOI: 10.1007/s00520-019-04910-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/31/2019] [Indexed: 01/02/2023]
Abstract
PURPOSE Person-Centered Oncologic Care and Choices (P-COCC) combines an advance care planning (ACP) value-focused patient interview with a care goal video decision aid. Our randomized study showed that P-COCC was acceptable but increased participant distress, compared with video-alone and usual care study arms. This mixed methods approach explores the ACP values in the P-COCC arm and their relationship to the distress phenomenon. METHODS Qualitative thematic analysis of the 46 audio-recorded P-COCC interview transcripts with advanced gastrointestinal cancer patients was performed by multiple reviewers. Quantitative (Likert scale) changes in ACP values were compared across study arms. ACP themes and value change were analyzed in participants with increased distress. RESULTS Transcript analysis resulted in thematic saturation and identified eight distinct themes on ACP values relating to end-of-life wishes, communication needs, and psychosocial supports. Of 98 participants (33 P-COCC, 43 videos, 22 usual care) who completed the change in value measure, there was no difference detected with P-COCC compared with either video (p = 0.052) or usual care (p = 0.105) arms alone, but P-COCC led to a frequency distribution of more change in personal values compared with the other study arms combined (p = 0.043). Among the subset of P-COCC participants with increased distress, there was no statistical relationship with change in values. CONCLUSIONS The ACP paradigm P-COCC both informs and supports patients in individualized, value-based decision-making. Distress is not associated with changes in ACP values and may be a necessary, at least transient, byproduct of discussing sensitive but pertinent topics about end-of-life medical care.
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Affiliation(s)
- Rajiv Agarwal
- Memorial Sloan Kettering Cancer Center, 300 E. 66th Street, Room 1013, New York, NY 10065, USA
| | - Elyse Shuk
- Memorial Sloan Kettering Cancer Center, 300 E. 66th Street, Room 1013, New York, NY 10065, USA
| | - Danielle Romano
- Memorial Sloan Kettering Cancer Center, 300 E. 66th Street, Room 1013, New York, NY 10065, USA
| | - Margaux Genoff
- Memorial Sloan Kettering Cancer Center, 300 E. 66th Street, Room 1013, New York, NY 10065, USA
| | - Yuelin Li
- Memorial Sloan Kettering Cancer Center, 300 E. 66th Street, Room 1013, New York, NY 10065, USA
| | - Eileen M. O’Reilly
- Memorial Sloan Kettering Cancer Center, 300 E. 66th Street, Room 1013, New York, NY 10065, USA,Weill Cornell Medical College, New York, NY, USA
| | - William Breitbart
- Memorial Sloan Kettering Cancer Center, 300 E. 66th Street, Room 1013, New York, NY 10065, USA,Weill Cornell Medical College, New York, NY, USA
| | | | - Andrew S. Epstein
- Memorial Sloan Kettering Cancer Center, 300 E. 66th Street, Room 1013, New York, NY 10065, USA,Weill Cornell Medical College, New York, NY, USA
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Moffat GT, Epstein AS, O’Reilly EM. Pancreatic cancer-A disease in need: Optimizing and integrating supportive care. Cancer 2019; 125:3927-3935. [PMID: 31381149 PMCID: PMC6819216 DOI: 10.1002/cncr.32423] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/05/2019] [Accepted: 07/08/2019] [Indexed: 12/24/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy that continues to be challenging to treat. PDAC has the lowest 5-year relative survival rate compared with all other solid tumor malignancies and is expected to become the second-leading cause of cancer-related death in the United States by 2030. Given the high mortality, there is an increasing role for concurrent anticancer and supportive care in the management of patients with PDAC with the aims of maximizing length of life, quality of life, and symptom control. Emerging trends in supportive care that can be integrated into the clinical management of patients with PDAC include standardized supportive care screening, early integration of supportive care into routine cancer care, early implementation of outpatient-based advance care planning, and utilization of electronic patient-reported outcomes for improved symptom management and quality of life. The most common symptoms experienced are nausea, constipation, weight loss, diarrhea, anorexia, and abdominal and back pain. This review article includes current supportive management strategies for these and others. Common disease-related complications include biliary and duodenal obstruction requiring endoscopic procedures and venous thromboembolic events. Patients with PDAC continue to have a poor prognosis. Systemic therapy options are able to palliate the high symptom burden but have a modest impact on overall survival. Early integration of supportive care can lead to improved outcomes.
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Affiliation(s)
- Gordon T. Moffat
- Memorial Sloan Kettering Cancer Center (MSK), New York, New York, USA
| | - Andrew S. Epstein
- Memorial Sloan Kettering Cancer Center (MSK), New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Eileen M. O’Reilly
- Memorial Sloan Kettering Cancer Center (MSK), New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
- David M. Rubenstein Center for Pancreatic Cancer Research, MSK
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Derry HM, Epstein AS, Lichtenthal WG, Prigerson HG. Emotions in the room: common emotional reactions to discussions of poor prognosis and tools to address them. Expert Rev Anticancer Ther 2019; 19:689-696. [PMID: 31382794 PMCID: PMC6709526 DOI: 10.1080/14737140.2019.1651648] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/30/2019] [Indexed: 12/15/2022]
Abstract
Introduction: Advanced cancer patients often want prognostic information, and discussions of prognosis have been shown to enhance patient understanding of their illness. Such discussions can lead to high-quality, value-consistent care at the end of life, yet they are also often emotionally challenging. Despite how common and normal it is for patients to experience transient emotional distress when receiving 'bad news' about prognosis, emotional responses have been under-addressed in existing literature on prognostic discussions. Areas covered: Drawing upon psychology research, principles of skilled clinical communication, and published approaches to discussions of serious illness, we summarize patients' common emotional reactions and coping strategies. We then provide suggestions for how to respond to them in clinic. Expert opinion: Ultimately, effective management of emotional reactions to bad news may lead to earlier, more frequent, and more transparent discussions of prognosis, thus promoting cancer patients' understanding of, and adjustment to, their illness and improving the quality of their end-of-life care.
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Epstein AS, Desai AV, Bernal C, Romano D, Wan PJ, Okpako M, Anderson K, Chow K, Kramer D, Calderon C, Klimek VV, Rawlins-Duell R, Reidy DL, Goldberg JI, Cruz E, Nelson JE. Giving Voice to Patient Values Throughout Cancer: A Novel Nurse-Led Intervention. J Pain Symptom Manage 2019; 58:72-79.e2. [PMID: 31034869 PMCID: PMC6849206 DOI: 10.1016/j.jpainsymman.2019.04.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/18/2019] [Accepted: 04/19/2019] [Indexed: 12/22/2022]
Abstract
CONTEXT Optimal advance care planning allows patients to articulate their values as a touchstone for medical decision making. Ideally, this occurs when patients are clinically stable, and with opportunities for iteration as the clinical situation unfolds. OBJECTIVES Testing feasibility and acceptability in busy outpatient oncology clinics of a novel program of systematic, oncology nurse-led values discussions with all new cancer patients. METHODS Within an institutional initiative integrating primary and specialist palliative care from diagnosis for all cancer patients, oncology nurses were trained to use specific questions and an empathic communication framework to discuss health-related values during outpatient clinic visits. Nurses summarized discussions on a template for patient verification, oncologist review, and electronic medical record documentation. Summaries were reviewed with the patient at least quarterly. Feasibility and acceptability were evaluated in three clinics for patients with hematologic or gastrointestinal malignancies. RESULTS Oncology nurses conducted 177 total discussions with 67 newly diagnosed cancer patients (17 with hematologic and 50 with gastrointestinal malignancies) over two years. No patient declined participation. Discussions averaged eight minutes, and all patients verified values summaries. Clinic patient volume was maintained. Of 31 patients surveyed, 30 (97%) reported feeling comfortable with the process, considered it helpful, and would recommend it to others. Clinicians strongly endorsed the values discussion process. CONCLUSION Nurse-led discussions of patient values soon after diagnosis are feasible and acceptable in busy oncology clinics. Further research will evaluate the impact of this novel approach on additional patient-oriented outcomes after broader dissemination of this initiative throughout our institution.
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Affiliation(s)
- Andrew S Epstein
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA.
| | - Anjali V Desai
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | - Camila Bernal
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Danielle Romano
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Peter J Wan
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Molly Okpako
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kelly Anderson
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kimberly Chow
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Dana Kramer
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Virginia V Klimek
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | | | - Diane L Reidy
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | | | - Elizabeth Cruz
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Judith E Nelson
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
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