Meaning-centered pain coping skills training for patients with metastatic cancer: Protocol for a randomized controlled efficacy trial

BACKGROUND

Many patients with advanced cancer describe pain as a debilitating symptom that greatly interferes with daily activities and enjoyment of life. Psychosocial interventions can improve cancer-related pain but rarely address spiritual concerns (e.g., loss of meaning, peace), which can influence the pain experience for those facing life-threatening illness. To address these needs, we systematically developed and pilot tested a novel psychosocial intervention called Meaning-Centered Pain Coping Skills Training (MCPC). In this randomized controlled trial, we aim to determine MCPC's efficacy for reducing pain interference (primary outcome) and improving secondary outcomes. We will also estimate MCPC's cost-effectiveness.

METHOD/DESIGN

Patients (target N = 210) with advanced solid tumor malignancies (Stage IV) and clinically-elevated pain interference will be enrolled and block randomized with equal allocation to MCPC + enhanced usual care or enhanced usual care alone. MCPC's four, videoconferenced, 45-60 min weekly sessions will be individually delivered by trained study therapists. Primary (pain interference) and secondary (pain severity, anxiety and depressive symptoms, pain self-efficacy, social support, spiritual well-being) patient-reported outcomes will be assessed at baseline, and 8-weeks (primary endpoint) and 12-weeks after baseline.

CONCLUSION

Our MCPC intervention is the first to systematically address the biopsychosocial-spiritual aspects of pain in patients with advanced cancer. If MCPC demonstrates efficacy, next steps will involve hybrid efficacy-effectiveness and implementation work to broaden access to this brief, manualized, remotely-delivered intervention, with the goal of reducing suffering in patients with life-threatening illness.

Meaning-centered pain coping skills training for patients with metastatic cancer: Results of a randomized controlled pilot trial

OBJECTIVE

For patients with advanced cancer, pain is a common and debilitating symptom that can negatively impact physical, emotional, and spiritual well-being. This trial examined the feasibility and initial effects of Meaning-Centered Pain Coping Skills Training (MCPC), a cognitive-behavioral pain management intervention with an emphasis on enhancing meaning (i.e., a personal sense of purpose, worth, and significance) and peace.

METHODS

We enrolled 60 adults with stage IV solid tumor cancers and moderate-severe pain between February 2021 and February 2022. Participants were randomized 1:1 to MCPC + usual care or usual care alone. Meaning-Centered Pain Coping Skills Training consisted of four weekly 60-min individual sessions via videoconference or telephone, delivered by a trained therapist using a manualized protocol. Participants completed validated measures of pain severity, pain interference, pain self-efficacy, spiritual well-being (i.e., meaning, peace, and faith), and psychological distress at baseline and 5-week and 10-week follow-ups.

RESULTS

All feasibility metrics exceeded prespecified benchmarks. Fifty-eight percent of screened patients were eligible, and 69% of eligible patients consented. Of those assigned to MCPC, 93% completed all sessions and 100% of those who completed follow-ups reported using coping skills weekly. Retention was strong at 5-week (85%) and 10-week (78%) follow-ups. Meaning-Centered Pain Coping Skills Training participants reported better scores than control participants across outcome measures, including moderate-to-large sized differences at 10-week follow-up in pain severity (Cohen's d = -0.75 [95% confidence interval: -1.36, -0.14]), pain interference (d = -0.82 [-1.45, -0.20]), and pain self-efficacy (d = 0.74 [0.13, 1.35]).

CONCLUSIONS

MCPC is a highly feasible, engaging, and promising approach for improving pain management in advanced cancer. Future efficacy testing is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04431830, registered 16 June 2020.

"Between Wings of Hope and Fear": Muslim Parents' Experiences with the American Health Care System

Background and Objectives: Historically marginalized religious and cultural groups are at risk for lower quality of care than majority groups. No study to date specifically queries Muslim experiences with the American health care system (AHCS). We performed a thematic analysis of Muslim parents' interactions with the AHCS and how their background informs their approach to care. Methods: This was a qualitative study of Muslim parents of children with life-limiting conditions in the Research Triangle Area from December 2019 to March 2019. We conducted semistructured interviews with parents to assess their experiences with the AHCS. We probed interview transcripts using descriptive content analysis with NVivo10. Results: We interviewed 10 parents in the Research Triangle Area. All patients were female, most were married, most spoke at least one other language in addition to English, and most were not born in the United States. Several themes emerged highlighting open communication with care teams, willingness to share religious affiliations, and the importance of leaning into faith and accepting God's will. Conclusions: A thematic analysis of Muslim parents' interactions with the AHCS describes value in honest communication, mixed concerns about how providers will react to their religious affiliation, and emphasizes the importance of leaning heavily into faith and accepting God's plan. Future studies evaluating needs of Muslim patients, especially those with different diagnoses, language barriers, and a larger sample size will further delineate needs to minimize inequalities in care.

How Does Spiritual Well-Being Change Over Time Among US Patients with Heart Failure and What Predicts Change?

Few studies have examined how spiritual well-being changes over time in patients with heart failure. We conducted a secondary analysis of data from the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) trial (N = 314). Spiritual well-being was measured using the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp) at baseline and 12-month follow-up. Of the 165 patients with spiritual well-being data at follow-up, 65 (39%) experienced probable clinically meaningful changes (> 0.5 SD) in spiritual well-being (35 improved, 30 declined). Increased pain (p = 0.04), decreased dyspnea (p < 0.01), and increased life completion (p = 0.02) were associated with improvement in overall spiritual well-being. Exploratory analyses found different predictors for FACIT-Sp subscales.

Spirituality in Serious Illness and Health

IMPORTANCE

Despite growing evidence, the role of spirituality in serious illness and health has not been systematically assessed.

OBJECTIVE

To review evidence concerning spirituality in serious illness and health and to identify implications for patient care and health outcomes.

EVIDENCE REVIEW

Searches of PubMed, PsycINFO, and Web of Science identified articles with evidence addressing spirituality in serious illness or health, published January 2000 to April 2022. Independent reviewers screened, summarized, and graded articles that met eligibility criteria. Eligible serious illness studies included 100 or more participants; were prospective cohort studies, cross-sectional descriptive studies, meta-analyses, or randomized clinical trials; and included validated spirituality measures. Eligible health outcome studies prospectively examined associations with spirituality as cohort studies, case-control studies, or meta-analyses with samples of at least 1000 or were randomized trials with samples of at least 100 and used validated spirituality measures. Applying Cochrane criteria, studies were graded as having low, moderate, serious, or critical risk of bias, and studies with serious and critical risk of bias were excluded. Multidisciplinary Delphi panels consisting of clinicians, public health personnel, researchers, health systems leaders, and medical ethicists qualitatively synthesized and assessed the evidence and offered implications for health care. Evidence-synthesis statements and implications were derived from panelists' qualitative input; panelists rated the former on a 9-point scale (from "inconclusive" to "strongest evidence") and ranked the latter by order of priority.

FINDINGS

Of 8946 articles identified, 371 articles met inclusion criteria for serious illness; of these, 76.9% had low to moderate risk of bias. The Delphi panel review yielded 8 evidence statements supported by evidence categorized as strong and proposed 3 top-ranked implications of this evidence for serious illness: (1) incorporate spiritual care into care for patients with serious illness; (2) incorporate spiritual care education into training of interdisciplinary teams caring for persons with serious illness; and (3) include specialty practitioners of spiritual care in care of patients with serious illness. Of 6485 health outcomes articles, 215 met inclusion criteria; of these, 66.0% had low to moderate risk of bias. The Delphi panel review yielded 8 evidence statements supported by evidence categorized as strong and proposed 3 top-ranked implications of this evidence for health outcomes: (1) incorporate patient-centered and evidence-based approaches regarding associations of spiritual community with improved patient and population health outcomes; (2) increase awareness among health professionals of evidence for protective health associations of spiritual community; and (3) recognize spirituality as a social factor associated with health in research, community assessments, and program implementation.

CONCLUSIONS AND RELEVANCE

This systematic review, analysis, and process, based on highest-quality evidence available and expert consensus, provided suggested implications for addressing spirituality in serious illness and health outcomes as part of person-centered, value-sensitive care.

Clinician End-of-Life Experiences With Pediatric Muslim Patients at a US Quaternary Care Center

CONTEXT

A small, growing body of data exist discussing the experiences of Muslim patients with the palliative care system, both in the United States and abroad, as well as providers' experiences with Muslim patients. However, no studies evaluate clinician experiences with Muslim patients in the United States, and none address the unique dynamics of pediatric clinician experiences with Muslim patients and their families in the EOL setting.

OBJECTIVES

The purpose of this study is to perform a thematic analysis of clinician experiences with pediatric Muslim patients and families at the end of life.

METHODS

This was a qualitative study of pediatric clinicians at Duke University Medical Center in the Pediatric Intensive Care Unit, Pediatric Cardiac Intensive Care Unit, and Pediatric Bone Marrow Unit from August 2018 to February 2019. We conducted semistructured interviews with nurses, attending physicians, and social workers to assess participants' experiences caring for Muslim patients and families. We analyzed interview transcripts using descriptive content analysis with NVivo10.

RESULTS

We interviewed 16 clinicians at Duke University Medical Center Pediatric Intensive Care Unit, Pediatric Cardiac Intensive Care Unit, and Pediatric Bone Marrow Unit. Five physicians, five social workers, and six nurses were interviewed. The majority of providers were female, Caucasian, and Christian in an institution where Muslim patients are a significant minority. Several themes emerged highlighting language barriers, difficulty engaging with Muslim families, variations in approach to care and communication, discomfort with gender roles, moral distress with unrelatable decision-making, and external pressures on patient decision-making.

CONCLUSION

A thematic analysis of pediatric clinicians at a quaternary care center in the Southern United States yielded several prominent themes. Many clinicians recognize they likely provide disparate care to minority patients for a variety of reasons encompassing the above barriers. As we work to care for an increasingly diverse patient population, more research into barriers to care and effective educational methods is needed.

Triadic agreement about advanced cancer treatment decisions: Perceptions among patients, families, and oncologists

OBJECTIVES

When patients make cancer treatment decisions, they consider the needs and preferences of family caregivers and clinicians. We examined how much all three triad members agreed about goals of treatment and caregivers' influence on decision-making.

METHODS

We surveyed 70 triads of patients, caregivers, and oncologists who had recently made an advanced cancer treatment decision. We assessed each triad member's perception of the goal of treatment and the caregiver's influence on the decision. Participants also completed scales related to decisional conflict, satisfaction, and regret.

RESULTS

In only 28/70 triads (40%), all three agreed on the goal of treatment with the most common goal being to live longer (n = 22). Whereas patients and caregivers tended to think the goal was to cure or live longer, oncologists were less optimistic. In only 22 triads (31%), all three agreed on how much influence the caregiver had on decision-making. Oncologists tended to underestimate caregiver influence. Patients and caregivers had low decisional conflict (M=15.40, SD=4.51; M=17.09, SD=6.34, respectively).

CONCLUSIONS

Advanced cancer treatment decision-making occurs amid incomplete understanding among patients, caregivers, and oncologists.

PRACTICE IMPLICATIONS

Confirming agreement about goals of care and influence on treatment decision-making may increase the likelihood of goal-concordant care throughout the illness trajectory.

Spirituality in Patients With Heart Failure

With advances in heart failure (HF) treatment, patients are living longer, putting further emphasis on quality of life (QOL) and the role of palliative care principles in their care. Spirituality is a core domain of palliative care, best defined as a dynamic, multidimensional aspect of oneself for which 1 dimension is that of finding meaning and purpose. There are substantial data describing the role of spirituality in patients with cancer but a relative paucity of studies in HF. In this review article, we explore the current knowledge of spirituality in patients with HF; describe associations among spirituality, QOL, and HF outcomes; and propose clinical applications and future directions regarding spiritual care in this population. Studies suggest that spirituality serves as a potential target for palliative care interventions to improve QOL, caregiver support, and patient outcomes including rehospitalization and mortality. We suggest the development of a spirituality-screening tool, similar to the Patient Health Questionnaire-2 used to screen for depression, to identify patients with HF at risk for spiritual distress. Novel tools are soon to be validated by members of our group. Given spirituality in HF remains less well studied compared with other patient populations, further controlled trials and uniform measures of spirituality are needed to understand its impact better.

Meaning-Centered Pain Coping Skills Training: A Pilot Feasibility Trial of a Psychosocial Pain Management Intervention for Patients with Advanced Cancer

Background: Pain from advanced cancer can greatly reduce patients' physical, emotional, and spiritual well-being. Objective: To examine the feasibility and acceptability of a behavioral pain management intervention, Meaning-Centered Pain Coping Skills Training (MCPC). Design: This trial used a single-arm feasibility design. Setting/Subjects: Thirty participants with stage IV solid tumor cancer, moderate-to-severe pain, and clinically elevated distress were enrolled from a tertiary cancer center in the United States. The manualized protocol was delivered across four 45- to 60-minute videoconference sessions. Measurements: Feasibility and acceptability were assessed through accrual, session/assessment completion, intervention satisfaction, and coping skills usage. Participants completed validated measures of primary outcomes (i.e., pain severity, pain interference, and spiritual well-being) and secondary outcomes at baseline, post-intervention, and four-week follow-up. Results: Eighty-eight percent (38/43) of patients who completed screening met inclusion criteria, and 79% (30/38) consented and completed baseline assessment. Sixty-seven percent (20/30) of participants were female (mean age = 57). Most participants were White/Caucasian (77%; 23/30) or Black/African American (17%; 5/30) with at least some college education (90%; 27/30). Completion rates for intervention sessions and both post-intervention assessments were 90% (27/30), 87% (26/30), and 77% (23/30), respectively. At the post-intervention assessment, participants reported a high degree of intervention satisfaction (mean = 3.53/4.00; SD = 0.46), and 81% (21/26) reported weekly use of coping skills that they learned. Participants also showed improvement from baseline on all primary outcomes and nearly all secondary outcomes at both post-intervention assessments. Conclusions: MCPC demonstrated strong feasibility and acceptability. Findings warrant further evaluation of MCPC in a randomized controlled trial. ClinicalTrials.gov Identifier: NCT03207360.

Meaning-Centered Pain Coping Skills Training: A Pilot Feasibility Trial of a Psychosocial Pain Management Intervention for Patients with Advanced Cancer

Background: Pain from advanced cancer can greatly reduce patients' physical, emotional, and spiritual well-being. Objective: To examine the feasibility and acceptability of a behavioral pain management intervention, Meaning-Centered Pain Coping Skills Training (MCPC). Design: This trial used a single-arm feasibility design. Setting/Subjects: Thirty participants with stage IV solid tumor cancer, moderate-to-severe pain, and clinically elevated distress were enrolled from a tertiary cancer center in the United States. The manualized protocol was delivered across four 45- to 60-minute videoconference sessions. Measurements: Feasibility and acceptability were assessed through accrual, session/assessment completion, intervention satisfaction, and coping skills usage. Participants completed validated measures of primary outcomes (i.e., pain severity, pain interference, and spiritual well-being) and secondary outcomes at baseline, post-intervention, and four-week follow-up. Results: Eighty-eight percent (38/43) of patients who completed screening met inclusion criteria, and 79% (30/38) consented and completed baseline assessment. Sixty-seven percent (20/30) of participants were female (mean age = 57). Most participants were White/Caucasian (77%; 23/30) or Black/African American (17%; 5/30) with at least some college education (90%; 27/30). Completion rates for intervention sessions and both post-intervention assessments were 90% (27/30), 87% (26/30), and 77% (23/30), respectively. At the post-intervention assessment, participants reported a high degree of intervention satisfaction (mean = 3.53/4.00; SD = 0.46), and 81% (21/26) reported weekly use of coping skills that they learned. Participants also showed improvement from baseline on all primary outcomes and nearly all secondary outcomes at both post-intervention assessments. Conclusions: MCPC demonstrated strong feasibility and acceptability. Findings warrant further evaluation of MCPC in a randomized controlled trial. ClinicalTrials.gov Identifier: NCT03207360.

Coordinating assessment of spiritual needs: a cross-walk of narrative and psychometric assessment tools used in palliative care

Addressing spiritual needs of patients in healthcare settings improves patient experiences and clinical outcomes; however, non-chaplain providers typically assess spiritual needs differently (quantitative psychometric) than healthcare chaplains (long form narrative) and thus there is little shared language or cross-disciplinary evaluation frameworks across disciplines. This discrepancy impedes the provision of both team-based and patient-centered care. This paper used scoping review methodology to illustrate the overlap between narrative and psychometric assessment tools, comparing four narrative tools against eight psychometric tools. The SpNQ-120 and Brief RCOPE demonstrated consistent domain coverage across the four chaplain narrative tools. This work provides preliminary resources to aid clinicians and researchers in choosing an appropriate tool. Additionally, for those who do not work closely with chaplains, it provides a sense of what domains chaplains prioritize, from their professional and lived experience, in assessing the spiritual life of the patient. This improves interdisciplinary communication, and therefore, patient care.

Comparing internal and external validation in the discovery of qualitative treatment-subgroup effects using two small clinical trials

In a two-arm randomized trial where both arms receive active treatment (i.e., treatments A and B), often the primary goal is to determine which of the treatments, on average, is more effective. A supplementary objective is to understand possible heterogeneity in the treatment effect by identifying multivariable subgroups of patients for whom A is more effective than B and, conversely, patients for whom B is more effective than A, known as a qualitative interaction. This is the objective of the qualitative interaction trees (QUINT) algorithm developed by Dusseldorp et al (Statistics in Medicine, 2014). We apply QUINT to a small randomized trial comparing facilitated relaxation meditation to facilitated life completion and preparation among patients with life-limiting illness (n = 135). We then conduct an internal validation of the QUINT solution using bootstrap resampling and compare it to an external validation with another, similarly conducted small randomized trial. Internal and external validation showed the apparent range in effect sizes was over-estimated, and subgroups identified were not consistent between the two trials. While the qualitative interaction trees algorithm is a promising area of data-driven multivariable subgroup discovery, our analyses illustrate the importance of validating the solution, particularly for trials with smaller numbers of participants.

A video decision aid to improve acute myeloid leukemia patients’ illness understanding: Results of a pilot trial

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Background: Many acute myeloid leukemia (AML) patients harbor misunderstandings about their illness, overestimating both their likelihood of cure and risks of intensive therapies. Decision aids (DA) can improve illness understanding and reduce decisional conflict, but are not routinely used in AML. Methods: We developed an AML DA with input from patients, caregivers, clinicians, and laypersons, via the International Patient Decision Aids Standards (IPDAS) process. It includes 10 short animated videos with voiceovers, covering AML basics, etiology, outcomes, treatment paradigms, and risks/benefits of various treatment approaches. We enrolled 20 patients in a pilot feasibility and efficacy trial, with pre/post survey assessments of AML knowledge via an 18-item questionnaire, decisional conflict (Decisional Conflict Scale; DCS), anxiety (State Trait Anxiety Inventory, Short Form; STAI-6), and measures of DA usability and satisfaction. Results: Participants were a mean of 62.4 years old, 12 (60%) were male, 17 (85%) white, and 15 (75%) had newly-diagnosed disease. Mean time since AML diagnosis was 145 days (median 31; range 2-1092). 16 (80%) exhibited high-school-level understanding of medical terms per the REALM-SF, and participants on average exhibited moderate numeracy (mean score of 4.1 on the Subjective Numeracy Scale). All participants completed the study, exceeding our pre-determined feasibility threshold. AML knowledge scores generally improved, from a mean of 11.8 correct items on pre-test, to 15.2 on post-test assessment (p < 0.0001), with 80% of participants achieving improved scores. Struggles remained regarding patients’ understanding of the role that genetic tests play in AML care. There was no increase in anxiety after watching the videos, but decisional conflict was significantly reduced, from a mean of 28.5 at baseline to 22 in the post-test (p = .019). Participants reported high satisfaction and usability scores for the DA. Conclusions: Our AML decision aid exhibits favorable performance characteristics, with high satisfaction and usability, a marked increase in patient knowledge, and reduced decisional conflict. Further testing is warranted in a randomized trial. Clinical trial information: NCT03442452.

Identifying core curricular components for behavioral health training in internal medicine residency: Qualitative interviews with residents, faculty, and behavioral health clinicians

OBJECTIVE

Behavioral health services frequently delivered by primary care providers include care for mental health and substance abuse disorders and assistance with behavioral risk factor reduction. Internal medicine residencies in the United States lack formal expectations regarding training in behavioral health for residents. This qualitative study aimed to determine learners' and teachers' perceptions about appropriate behavioral health curricular components for internal medicine residents.

METHOD

Focus groups and interviews were conducted with the following individuals from the Duke Outpatient Clinic: residents with continuity practice (n = 27), advanced practice providers (n = 2), internal medicine attending physicians (n = 4), internal medicine/psychiatry attending physicians (n = 2), and behavioral health clinicians (n = 4). A focus group leader asked regarding residents' successes and challenges in managing behavioral health issues and about specific learning components considered necessary to understand and manage these behavioral health conditions. Transcripts were coded using an editing analysis style to identify central themes and concordance/discordance between groups.

RESULTS

Regarding mental health management (Theme 1), residents emphasized a need for better care coordination with specialty mental health, while attendings and behavioral health clinicians gave priority to residents' skills in primary management of mental health. Residents, attendings, and behavioral health clinicians all emphasized advanced interviewing skills (Theme 2) with subthemes: eliciting the patient's perspective, managing time in encounters, improving patients' understanding, and patient counseling.

CONCLUSIONS

Internal medicine residents, attendings, and behavioral health clinicians may differ significantly in their perceptions of primary care's role in mental health care. Future internal medicine behavioral health curricula should specifically address these attitudinal differences. Curricula should also emphasize interview skills training as an essential component of behavioral health learning.

Older, Seriously Ill Veterans’ Views on the Role of Religion and Spirituality in Health-Care Delivery

Objectives:

To describe older Veteran’s perspectives on the current delivery of religious or spiritual (R/S) care.

Methods:

Semi-structured interviews with older veterans with advanced stage cancer, heart failure, or pulmonary disease to elicit views on when, how, and by whom religious and spiritual care is preferred.

Results:

The sample (n = 17) was largely male (94%), non-Hispanic white (52.9%), Christian (82.3%), and most had at least some college education (64.7%). Participants shared diagnoses of cancer (47%), heart failure (35.2%), or chronic obstructive pulmonary disease (17.6%). As a group, participants had moderate religiosity. Themes relevant to the study goal of improving VA care delivery are as follows: (1) process of R/S engagement, (2) timing of R/S engagement, and (3) awareness of services. Veterans discussed the need for VA providers to accommodate diverse spiritual beliefs, importance of screening for spiritual needs, inclusion of family spiritual support, need for higher visibility of services, use of nonchaplains for R/S support, and times when R/S is important.

Discussion:

Veterans recognize the diversity of their fellow veterans and note the opportunities and challenges in providing R/S support in the VA care setting. The findings have implications for quality improvement in VA care including efforts focused on enhanced outreach to veterans, bolstered education for staff, and more nuanced approaches to R/S support.

Addressing Patient Emotional and Existential Needs During Serious Illness: Results of the Outlook Randomized Controlled Trial

CONTEXT

Few interventions exist to address patients' existential needs.

OBJECTIVES

Determine whether an intervention to address seriously ill patients' existential concerns improves preparation, completion (elements of quality of life [QOL] at end of life), and reduces anxiety and depression.

METHODS

A randomized controlled trial comparing outlook intervention, relaxation meditation (RM), and usual care (UC). Measures included primary-a validated measure of QOL at the end of life and secondary-Functional Assessment of Cancer Therapy-General, anxiety (Profile of Mood States), depression (Center for Epidemiological Studies-Depression Scale), and spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being). Qualitative interviews assessed outlook intervention acceptability. Enrolled patients were nonhospice eligible veterans with advanced cancer, congestive heart failure, chronic obstructive pulmonary disease, end-stage renal disease, or end-stage liver disease.

RESULTS

Patients (n = 221) were randomly assigned 1:1:1 to outlook, RM, and UC. Patients were 96% males, 46% with cancer, 58.4% married, and 43.9% of African American origin. Compared with UC, outlook participants had higher preparation (a validated measure of QOL at the end of life) (mean difference 1.1; 95% CI 0.2, 2.0; P = 0.02) and mean completion (1.6; 95% CI 0.05, 3.1; P = 0.04) at the first but not second postassessment. Compared with RM, outlook participants did not show significant differences over time. Exploratory analyses indicated that in subgroups with cancer and low sense of peace, outlook participants had improved preparation at first and not second postassessment, as compared with UC (mean difference 1.4; 95% CI 0.03, 2.7; P = 0.04) (mean difference = 1.8; 95% CI 0.3, 3.3; P = 0.02), respectively.

CONCLUSION

Outlook had an impact on social well-being and preparation compared with UC. The lack of impact on anxiety and depression differs from previous results among hospice patients. Results suggest that outlook is not demonstratively effective in populations not experiencing existential or emotional distress.

The role of a palliative care intervention in moderating the relationship between depression and survival among individuals with advanced cancer

OBJECTIVE

Randomized controlled trials (RCTs) of early palliative care interventions in advanced cancer have positively impacted patient survival, yet the mechanisms remain unknown. This secondary analysis of 2 RCTs assessed whether an early palliative care intervention moderates the relationship between depressive symptoms and survival.

METHOD

The relationships among mood, survival, and early palliative care intervention were studied among 529 advanced cancer patients who participated in 2 RCTs. The first (N = 322) compared intervention versus usual care. The second (N = 207) compared early versus delayed intervention (12 weeks after enrollment). The interventions included an in-person consultation, weekly nurse coach-facilitated phone sessions, and monthly follow-up. Mood was measured using the Center for Epidemiologic Studies-Depression (CES-D) scale. Cox proportional hazard analyses were used to examine the effects of baseline CES-D scores, the intervention, and their interaction on mortality risk while controlling for demographic variables, cancer site, and illness severity.

RESULTS

The combined sample was 56% male (M = 64.7 years). Higher baseline CES-D scores were significantly associated with greater mortality risk (hazard ratio [HR] = 1.042, 95% confidence interval [CI] [1.017, 1.067], p = .001). However, participants with higher CES-D scores who received the intervention had a lower mortality risk (HR = .963, CI [0.933, 0.993], p = .018) even when controlling for demographics, cancer site, and illness-related variables.

CONCLUSION

This study is the first to demonstrate that patients with advanced cancer who also have depressive symptoms benefit the most from early palliative care. Future research should be devoted to exploring the mechanisms responsible for these relationships. (PsycINFO Database Record

State of the Science of Spirituality and Palliative Care Research Part II: Screening, Assessment, and Interventions

The State of the Science in Spirituality and Palliative Care was convened to address the current landscape of research at the intersection of spirituality and palliative care and to identify critical next steps to advance this field of inquiry. Part II of the SOS-SPC report addresses the state of extant research and identifies critical research priorities pertaining to the following questions: 1) How do we assess spirituality? 2) How do we intervene on spirituality in palliative care? And 3) How do we train health professionals to address spirituality in palliative care? Findings from this report point to the need for screening and assessment tools that are rigorously developed, clinically relevant, and adapted to a diversity of clinical and cultural settings. Chaplaincy research is needed to form professional spiritual care provision in a variety of settings, and outcomes assessed to ascertain impact on key patient, family, and clinical staff outcomes. Intervention research requires rigorous conceptualization and assessments. Intervention development must be attentive to clinical feasibility, incorporate perspectives and needs of patients, families, and clinicians, and be targeted to diverse populations with spiritual needs. Finally, spiritual care competencies for various clinical care team members should be refined. Reflecting those competencies, training curricula and evaluation tools should be developed, and the impact of education on patient, family, and clinician outcomes should be systematically assessed.

State of the Science of Spirituality and Palliative Care Research Part I: Definitions, Measurement, and Outcomes

The State of the Science in Spirituality and Palliative Care was convened to address the current landscape of research at the intersection of spirituality and palliative care and to identify critical next steps to advance this field of inquiry. Part I of the SOS-SPC two-part series focuses on questions of 1) What is spirituality? 2) What methodological and measurement issues are most salient for research in palliative care? And 3) What is the evidence relating spirituality and health outcomes? After describing current evidence we make recommendations for future research in each of the three areas of focus. Results show wide variance in the ways spirituality is operationalized and the need for definition and conceptual clarity in research in spirituality. Furthermore, the field would benefit from hypothesis-driven outcomes research based on a priori specification of the spiritual dimensions under investigation and their longitudinal relationship with key palliative outcomes, the use of validated measures of predictors and outcomes, and rigorous assessment of potential confounding variables. Finally, results highlight the need for research in more diverse populations.

"It Is Like Heart Failure. It Is Chronic … and It Will Kill You": A Qualitative Analysis of Burnout Among Hospice and Palliative Care Clinicians

CONTEXT

Although prior surveys have identified rates of self-reported burnout among palliative care clinicians as high as 62%, limited data exist to elucidate the causes, ameliorators, and effects of this phenomenon.

OBJECTIVES

We explored burnout among palliative care clinicians, specifically their experiences with burnout, their perceived sources of burnout, and potential individual, interpersonal, organizational, and policy-level solutions to address burnout.

METHODS

During the 2014 American Academy of Hospice and Palliative Medicine/Hospice and Palliative Nurses Association Annual Assembly, we conducted three focus groups to examine personal narratives of burnout, how burnout differs within hospice and palliative care, and strategies to mitigate burnout. Two investigators independently analyzed data using template analysis, an inductive/deductive qualitative analytic technique.

RESULTS

We interviewed 20 palliative care clinicians (14 physicians, four advanced practice providers, and two social workers). Common sources of burnout included increasing workload, tensions between nonspecialists and palliative care specialists, and regulatory issues. We heard grave concerns about the stability of the palliative care workforce and concerns about providing high-quality palliative care in light of a distressed and overburdened discipline. Participants proposed antiburnout solutions, including promoting the provision of generalist palliative care, frequent rotations on-and-off service, and organizational support for self-care. We observed variability in sources of burnout between clinician type and by practice setting, such as role monotony among full-time clinicians.

CONCLUSION

Our results reinforce and expand on the severity and potential ramifications of burnout on the palliative care workforce. Future research is needed to confirm our findings and investigate interventions to address or prevent burnout.

Randomized trial of an uncertainty self-management telephone intervention for patients awaiting liver transplant

OBJECTIVE

We tested an uncertainty self-management telephone intervention (SMI) with patients awaiting liver transplant and their caregivers.

METHODS

Participants were recruited from four transplant centers and completed questionnaires at baseline, 10, and 12 weeks from baseline (generally two and four weeks after intervention delivery, respectively). Dyads were randomized to either SMI (n=56) or liver disease education (LDE; n=59), both of which involved six weekly telephone sessions. SMI participants were taught coping skills and uncertainty management strategies while LDE participants learned about liver function and how to stay healthy. Outcomes included illness uncertainty, uncertainty management, depression, anxiety, self-efficacy, and quality of life. General linear models were used to test for group differences.

RESULTS

No differences were found between the SMI and LDE groups for study outcomes.

CONCLUSION

This trial offers insight regarding design for future interventions that may allow greater flexibility in length of delivery beyond our study's 12-week timeframe.

PRACTICE IMPLICATIONS

Our study was designed for the time constraints of today's clinical practice setting. This trial is a beginning point to address the unmet needs of these patients and their caregivers as they wait for transplants that could save their lives.

The elephant in the room: Facilitating conversations about advanced cancer between patients and their spouses

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Background: Interventions to enhance couples’ communication about cancer-related issues can lead to benefits for patients, spouses, and their relationships. We recently conducted a pilot study testing a couples communication skills training (CCST) intervention targeted to couples in which one partner had advanced GI cancer, a population who may need particular help addressing difficult and emotionally-laden topics related to life-limiting illness. Results of quantitative analyses suggested that the intervention was effective in improving relationship satisfaction for these couples. The objective of the current study was to analyze intervention session conversation content to identify themes that couples addressed spontaneously, with the ultimate goal of determining whether an intervention that more specifically guides couples to discuss issues related to end of life and the life-limiting nature of the patient’s illness would be acceptable. Methods: 12 couples (10 male and 2 female patients and their spouses) completed the 6 session CCST intervention which provided training in communication skills for sharing thoughts and feelings and making decisions, and gave couples the opportunity to use these skills to discuss cancer-related issues of their choosing. We conducted qualitative content analysis of the 72 audio-recorded sessions, and coded common and recurrent topics raised by patients and spouses. In addition to identifying breadth of topics, we used theme frequency as an initial gauge of theme importance and acceptability. Results: The most common themes identified were prognosis, treatment, emotional intimacy, completion, spouse’s life after the death of the patient, roles, communication, sublimating needs, emotional support, and family. These represent themes previously identified as important to patients at end of life, as well as themes unique to dyads in intimate relationships. Conclusions: These findings support the feasibility of conducting an intervention that combines training in communication skills with guidance for using these skills to discuss topics that are potentially most meaningful to couples facing advanced illness.

Building Resilience for Palliative Care Clinicians: An Approach to Burnout Prevention Based on Individual Skills and Workplace Factors

For palliative care (PC) clinicians, the work of caring for patients with serious illness can put their own well-being at risk. What they often do not learn in training, because of the relative paucity of evidence-based programs, are practical ways to mitigate this risk. Because a new study indicates that burnout in PC clinicians is increasing, we sought to design an acceptable, scalable, and testable intervention tailored to the needs of PC clinicians. In this article, we describe our paradigm for approaching clinician resilience, our conceptual model, and curriculum for a workplace resilience intervention for hospital-based PC teams. Our paradigm for approaching resilience is based on upstream, early intervention. Our conceptual model posits that clinician well-being is influenced by personal resources and work demands. Our curriculum for increasing clinician resilience is based on training in eight resilience skills that are useful for common challenges faced by clinicians. To address workplace issues, our intervention also includes material for the team leader and a clinician perception survey of work demands and workplace engagement factors. The intervention will focus on individual skill building and will be evaluated with measures of resilience, coping, and affect. For PC clinicians, resilience skills are likely as important as communication skills and symptom management as foundations of expertise. Future work to strengthen clinician resilience will likely need to address system issues more directly.

Effects of enhanced caregiver training program on cancer caregiver's self-efficacy, preparedness, and psychological well-being

PURPOSE

We examined the effects of an enhanced informal caregiver training (Enhanced-CT) protocol in cancer symptom and caregiver stress management to caregivers of hospitalized cancer patients.

METHODS

We recruited adult patients in oncology units and their informal caregivers. We utilized a two-armed, randomized controlled trial design with data collected at baseline, post-training, and at 2 and 4 weeks after hospital discharge. Primary outcomes were self-efficacy for managing patients' cancer symptoms and caregiver stress and preparedness for caregiving. Secondary outcomes were caregiver depression, anxiety, and burden. The education comparison (EDUC) group received information about community resources. We used general linear models to test for differences in the Enhanced-CT relative to the EDUC group.

RESULTS

We consented and randomized 138 dyads: Enhanced-CT = 68 and EDUC = 70. The Enhanced-CT group had a greater increase in caregiver self-efficacy for cancer symptom management and stress management and preparation for caregiving at the post-training assessment compared to the EDUC group but not at 2- and 4-week post-discharge assessments. There were no intervention group differences in depression, anxiety, and burden.

CONCLUSION

An Enhanced-CT protocol resulted in short-term improvements in self-efficacy for managing patients' cancer symptoms and caregiver stress and preparedness for caregiving but not in caregivers' psychological well-being. The lack of sustained effects may be related to the single-dose nature of our intervention and the changing needs of informal caregivers after hospital discharge.

Validation of a measure of family experience of patients with serious illness: the QUAL-E (Fam)

CONTEXT

Family members of seriously ill patients experience significant burden as they advocate with providers and participate in key decisions for loved ones. Most assessments focus on patient experience, yet family members' own quality of experience is central to comprehensive care.

OBJECTIVES

This study validated a measure of the quality of family experience, the QUAL-E (Fam), in palliative care.

METHODS

We enrolled family members of terminally ill patients admitted to general medicine services at two hospitals. Items were based on foundational work originally done for the patient instrument, QUAL-E, and interviews of family members of terminally ill patients. Cognitive interviewing was used to refine items, which then underwent formal testing factor analysis. In the first sample, we assessed factor structure. A subsequent sample established predictive validity and test-retest reliability.

RESULTS

The initial item pool was reduced to a four-domain, 35-item scale and administered to the validation sample. Further analyses produced a final brief scale comprising 17 items, demonstrating appropriate convergent and divergent validity. Test-retest reliability demonstrated expected levels of stability in a highly changeable population. The scale provides an assessment of family experience and includes subscales assessing relationship with health care provider and completion. Additional scale items assess symptom experience and issues of preparation.

CONCLUSION

The QUAL-E (Fam) is a companion instrument to the patient QUAL-E measure of quality of life at the end of life and is part of a package of assessment tools that can help evaluate the entire patient experience and contribute to quality care.

The palliative care in heart failure trial: rationale and design

BACKGROUND

The progressive nature of heart failure (HF) coupled with high mortality and poor quality of life mandates greater attention to palliative care as a routine component of advanced HF management. Limited evidence exists from randomized, controlled trials supporting the use of interdisciplinary palliative care in HF.

METHODS

PAL-HF is a prospective, controlled, unblinded, single-center study of an interdisciplinary palliative care intervention in 200 patients with advanced HF estimated to have a high likelihood of mortality or rehospitalization in the ensuing 6 months. The 6-month PAL-HF intervention focuses on physical and psychosocial symptom relief, attention to spiritual concerns, and advanced care planning. The primary end point is health-related quality of life measured by the Kansas City Cardiomyopathy Questionnaire and the Functional Assessment of Chronic Illness Therapy with Palliative Care Subscale score at 6 months. Secondary end points include changes in anxiety/depression, spiritual well-being, caregiver satisfaction, cost and resource utilization, and a composite of death, HF hospitalization, and quality of life.

CONCLUSIONS

PAL-HF is a randomized, controlled clinical trial that will help evaluate the efficacy and cost effectiveness of palliative care in advanced HF using a patient-centered outcome as well as clinical and economic end points.

Acute myeloid leukemia (AML) patients' understanding of prognosis and treatment goals: A mixed-methods study

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Background: Patients with AML face complex information about the risks and rewards of pursuing treatments of varying intensity. Little is known about what patients understand or value in the decision-making process. Methods: AML inpatients receiving induction chemotherapy completed weekly electronic surveys about their prognosis and treatment goals, along with a baseline semi-structured, qualitative interview exploring their understanding of illness. Their oncologists (MDs) completed baseline surveys about prognosis and treatment goals. We followed a mixed-methods approach to analysis, applying standard statistical methods to survey data, and a constant-comparative qualitative approach to the interview data to enrich our understanding of survey results. Results: We enrolled 13 dyads (a patient and MD pair). Mean patient age was 65.5, and all had high-risk disease due to either age >60, complex cytogenetics, secondary AML, or relapsed disease. At baseline, mean MD-rated chance of cure was 27% (SD 17.6), while patients’ rating was 54% (SD 34.7; p=0.02). Only 2 patients’ estimates of cure matched their MD’s rating, yet MDs rated their patients’ prognostic understanding as high (mean 7.2 on an 11-point scale). MDs reported an average of 3.1 available treatment options, but patients recalled just 1.5. Most MDs gave a specific treatment recommendation (11 of 13), and most patients received the recommended treatment (10 of 11). Agreement about treatment goal was markedly worse than expected by chance (kappa -0.41; 95% CI -0.88-0.07). Qualitative analysis suggests that patients often viewed treatment decisions as binary “life-or-death” propositions, rather than choices between options with differing goals and intensities. Patients also significantly underestimated the risks of induction chemotherapy. Conclusions: AML patients receiving induction chemotherapy have a poor understanding of their prognosis, treatment goals, and risks of induction chemotherapy, but their oncologists are not aware of this. These findings suggest the need for an intervention to improve patient understanding of their illness and treatment options.

Symptom burden, quality of life, and distress in acute myeloid leukemia patients receiving induction chemotherapy: A prospective electronic patient-reported outcomes study

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Background: Induction chemotherapy for acute myeloid leukemia (AML) is more intensive than many solid tumor treatments, and may be associated with a different symptom burden. Little is known about the most prevalent symptoms during AML induction, nor how they change over time. Methods: We enrolled AML inpatients at initiation of induction chemotherapy, and assessed their symptoms, quality of life (QoL), and distress weekly during their month-long hospitalization for treatment, using 3 validated instruments: Patient Care Monitor v2.0 (PCM); Functional Assessment of Cancer Therapy–Leukemia (FACT-Leu); and NCCN distress thermometer (DT). Here we report results from the first 16 enrolled patients, using standard descriptive statistics. Results: Mean age of study participants was 59.6 (SD 12.2), and most were newly diagnosed with AML (SD 87.5%, n=14). Patients were mostly high-risk for recurrence, with 50% (8) being >60 years old and 71% (10) having high-risk cytogenetics. Fatigue was the most prevalent symptom, with an average of 59% of patients reporting moderate to severe fatigue at each assessment. The other most prevalent moderate/severe non-functional symptoms were dysgeusia (50%), dry mouth (42%), diarrhea (41%), decreased appetite (37.5%), insomnia (37.5%), daytime sleepiness (36%), nausea (36%), hair loss (36%), and mouth sores (34%). Median QoL by FACT-Leu total score decreased substantially between weeks 1 and 2 (118.5 to 104.5); the most substantial decrements were in subscales for personal well-being and functional well-being (20.5 to 14.5, and 13.5 to 8.5, respectively). QoL did not return to baseline by week 4. Median DT score at baseline was 6.5, with a trend towards weekly improvements in distress (DT = 3 at week 4). Depressive symptoms like hopelessness and sadness were reported by an average of 25% and 31.3% of patients, respectively. Conclusions: AML patients receiving induction chemotherapy have significant symptom burden, impaired QoL, and psychological distress. The prevalence of these issues suggests sizeable unmet palliative care and psychosocial needs in AML patients receiving induction chemotherapy.

Caregiver experience during advanced chronic illness and last year of life

OBJECTIVES

To compare the prevalence and predictors of caregiver esteem and burden during two different stages of care recipients' illnesses-advanced chronic illness and the last year of life.

DESIGN

Longitudinal, observational cohort study.

SETTING

Community sample recruited from outpatient clinics at Duke University and Durham Veterans Affairs Medical Centers.

PARTICIPANTS

Individuals with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease and their primary caregiver, retrospectively coded as chronic-illness (n = 62) or end-of-life (EOL; n = 62) care recipient-caregiver dyads.

MEASUREMENTS

Caregiver experience was measured monthly using the Caregiver Reaction Assessment, which includes caregiver esteem and four domains of burden: schedule, health, family, and finances.

RESULTS

During chronic illness and at the end of life, high caregiver esteem was almost universal (95%); more than 25% of the sample reported health, family, and financial burden. Schedule burden was the most prevalent form of burden; EOL caregivers (58%) experienced it more frequently than chronic-illness caregivers (32%). Caregiver esteem and all dimensions of burden were relatively stable over 1 year. Few factors were associated with burden.

CONCLUSION

Caregiver experience is relatively stable over 1 year and similar in caregivers of individuals in the last year of life and those earlier in the course of chronic illness. Schedule burden stands out as most prevalent and variable among dimensions of experience. Because prevalence of burden is not specific to stage of illness and is relatively stable over time, multidisciplinary healthcare teams should assess caregiver burden and refer burdened caregivers to supportive resources early in the course of chronic illness.

Nursing strategies to support family members of ICU patients at high risk of dying

OBJECTIVES

To explore how family members of ICU patients at high risk of dying respond to nursing communication strategies.

BACKGROUND

Family members of ICU patients may face difficult decisions. Nurses are in a position to provide support. Evidence of specific strategies that nurses use to support decision-making and how family members respond to these strategies is lacking.

METHODS

This is a prospective, qualitative descriptive study involving the family members of ICU patients identified as being at high risk of dying.

RESULTS

Family members described five nursing approaches: Demonstrating concern, building rapport, demonstrating professionalism, providing factual information, and supporting decision-making. This study provides evidence that when using these approaches, nurses helped family members to cope; to have hope, confidence, and trust; to prepare for and accept impending death; and to make decisions.

CONCLUSION

Knowledge lays a foundation for interventions targeting the areas important to family members and most likely to improve their ability to make decisions and their well-being.

Admission to the intensive care unit and well-being in patients with advanced chronic illness

PURPOSE

To describe the association of intensive care with trajectories of functional, emotional, social, and physical well-being in patients with 3 common advanced illnesses.

METHODS

Cross-sectional cohort study of 42 patients admitted to the intensive care unit selected from 210 patients with stage IV breast, prostate, or colon cancer or stage IIIb or IV lung cancer; New York Heart Association class III or IV congestive heart failure; and chronic obstructive pulmonary disease with hypercapnea (Pco2 > 46 mm Hg). Scores on subscales of the Functional Assessment of Chronic Illness Therapy-General survey were measured monthly for 6 months before and after admission to the intensive care unit and were analyzed by using the unit admission date as a point of discontinuous change to illustrate trajectories before and after the admission.

RESULTS

Overall, trajectories of well-being declined sharply after admission to the intensive care unit. Declines in physical, functional, and emotional well-being were statistically significant. During the 6 months after admission, physical, functional, and emotional well-being scores trended back up to baseline while social well-being scores continued to decline.

CONCLUSIONS

Well-being trajectories declined sharply after admission to the intensive care unit, with recovery in the subsequent 6 months, and may be characterized by common patterns. These results help to better describe intensive care as a marker for advancing illness in patients with advanced chronic illness.

What is your understanding of your illness? A communication tool to explore patients' perspectives of living with advanced illness

BACKGROUND

Provider communication courses and guidelines stress the use of open-ended questions, such as "what is your understanding of your illness?," to explore patients' perceptions of their illness severity, yet descriptions of patients' responses are largely absent from the current literature. These questions are most often used by clinicians as they deliver bad news to cancer patients or address code status at the end of life, but have not been well studied in other diseases or earlier in the disease course.

OBJECTIVES

To explore the responses of patients living with serious illness to the question "what is your understanding of your illness?" and to identify similarities and differences in themes and language used by cancer and non-cancer patients to discuss their illness.

DESIGN

We conducted a qualitative analysis of patients' responses to "what is your understanding of your illness?"

PARTICIPANTS

Two hundred nine subjects, 69 with cancer, 70 CHF, and 70 COPD, who had an estimated 50 % 2-year survival. Mean age was 66 years.

APPROACH

Responses were recorded at the baseline interview of a larger, longitudinal study of patients with advanced life-limiting illness (cancer, CHF, or COPD). After thematic content analysis using open coding, investigators conducted pattern analysis to examine variation associated with diagnosis.

RESULTS

We identified five major themes: naming the diagnosis or describing the pathophysiology, illness history, prognosis, symptoms, and causality. Responses varied by diagnosis. Cancer patients' responses more often included specific diagnostic details and prognosis, while non-cancer patients referenced symptoms and causality.

CONCLUSIONS

Patients' responses to the open-ended question "what is your understanding of your illness?" can provide the clinician with important information and insight on how they view their illness in a non-acute setting. The identified themes can serve as a foundation for patient-centered communication strategies as we strive to build a mutual understanding of illness with patients.

Burden and well-being among a diverse sample of cancer, congestive heart failure, and chronic obstructive pulmonary disease caregivers

CONTEXT

Three important causes of death in the U.S. (cancer, congestive heart failure, and chronic obstructive pulmonary disease) are preceded by long periods of declining health; often, family members provide most care for individuals who are living with serious illnesses and are at risk for impaired well-being.

OBJECTIVES

To expand understanding of caregiver burden and psychosocial-spiritual outcomes among understudied groups of caregivers-cancer, congestive heart failure, and chronic obstructive pulmonary disease caregivers-by including differences by disease in a diverse population.

METHODS

The present study included 139 caregiver/patient dyads. Independent variables included patient diagnosis and function; and caregiver demographics, and social and coping resources. Cross-sectional analyses examined distributions of these independent variables between diagnoses, and logistic regression examined correlates of caregiver burden, anxiety, depressive symptoms, and spiritual well-being.

RESULTS

There were significant differences in patient functioning and caregiver demographics and socioeconomic status between diagnosis groups but few differences in caregiver burden or psychosocial-spiritual outcomes by diagnosis. The most robust social resources indicator of caregiver burden was desire for more help from friends and family. Anxious preoccupation coping style was robustly associated with caregiver psychosocial-spiritual outcomes.

CONCLUSION

Caregiver resources, not patient diagnosis or illness severity, are the primary correlates associated with caregiver burden. Additionally, caregiver burden is not disease specific to those examined here, but it is rather a relatively universal experience that may be buffered by social resources and successful coping styles.

Discussions of the kidney disease trajectory by elderly patients and nephrologists: a qualitative study

BACKGROUND

Elderly patients with advanced kidney disease experience considerable disability, morbidity, and mortality. Little is known about the impact of physician-patient interactions on patient preparation for the illness trajectory. We sought to describe how nephrologists and older patients discuss and understand the prognosis and course of kidney disease leading to renal replacement therapy.

METHODS

We conducted focus groups and interviews with 11 nephrologists and 29 patients older than 65 years with advanced chronic kidney disease or receiving hemodialysis. Interviews were audiorecorded and transcribed. We used qualitative analytic methods to identify common and recurrent themes related to the primary research question.

RESULTS

We identified 6 themes that describe how the kidney disease trajectory is discussed and understood: (1) patients are shocked by their diagnosis, (2) patients are uncertain how their disease will progress, (3) patients lack preparation for living with dialysis, (4) nephrologists struggle to explain illness complexity, (5) nephrologists manage a disease over which they have little control, and (6) nephrologists tend to avoid discussions of the future. Patients and nephrologists acknowledged that prognosis discussions are rare. Patients tended to cope with thoughts of the future through avoidance by focusing on their present clinical status. Nephrologists reported uncertainty and concern for evoking negative reactions as barriers to these conversations.

CONCLUSIONS

Patients and nephrologists face challenges in understanding and preparing for the kidney disease trajectory. Communication interventions that acknowledge the role of patient emotion and address uncertainty may improve how nephrologists discuss disease trajectory with patients and thereby enhance their understanding and preparation for the future.

Discussing life story, forgiveness, heritage, and legacy with patients with life-limiting illnesses

AIM

To explore the perceptions that individuals with life-limiting illnesses have about their lives, both positive and negative, and their messages to future generations.

METHODS

A preparation and life completion intervention (Outlook) was assessed for acceptability and feasibility in an Australian palliative care setting. This paper reports a qualitative analysis of the participants' responses to the intervention. The intervention sessions were audiotaped, transcribed, and analysed using interpretative phenomenological analysis.

RESULTS

Eleven participants were recruited from inpatient and outpatient hospital and hospice settings. Three overarching themes were identified: life review, current situation, and legacy/principles.

CONCLUSIONS

The intervention provided insights into individual palliative care patients' sense of self, views of their current situation, hopes, and how they would like to be remembered.

Comparing three life-limiting diseases: does diagnosis matter or is sick, sick?

CONTEXT

At advanced stages, cancer, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD) produce high rates of hospitalization, disability, and annual mortality. Despite similar prognoses, patients with cancer often are treated differently than those with other illnesses, the former being seen as terminal vs. chronic.

OBJECTIVES

The purpose of this study was to compare the functional capacity, emotional well-being, and quality of life of patients in three disease groups to assess whether diagnosis distinguishes differences in patient experience, and compare patients with cancer and noncancer diagnoses.

METHODS

Baseline data from a cohort study of 210 patients who had an estimated 50% two-year mortality were analyzed. The patients had Stage IV breast, prostate, or colon cancer; Stage IIIb or IV lung cancer; New York Heart Association Stage III or IV CHF with a left ventricular ejection fraction of <40%; or COPD with hypercapnea (pC02>46) and at least one hospitalization or Emergency Department visit during the past year. Measures included the Rosow-Breslau Activities of Daily Living/Instrumental Activities of Daily Living tool, Profile of Mood States anxiety subscale, brief Centers for Epidemiologic Studies Depression Scale, and the Functional Assessment of Cancer Therapy-General quality-of-life instrument. Analyses included descriptive statistics, analysis of variance, and adjusted linear regression models.

RESULTS

A majority of illness outcomes did not differ by diagnostic category. Functional status was associated with diagnosis, with CHF and COPD patients faring worse than those with cancer. Overall, illness experience was most significantly related to disease severity, demographics, and emotional and social well-being.

CONCLUSION

Comparing patients with advanced cancer, CHF, and COPD, illness experience was more similar than different. Patients living with life-limiting illnesses other than cancer may benefit from whole-person services often extended to cancer patients.

Which domains of spirituality are associated with anxiety and depression in patients with advanced illness?

BACKGROUND

Anxiety and depression are common in seriously ill patients and may be associated with spiritual concerns. Little research has examined how concerns in different domains of spirituality are related to anxiety and depression.

OBJECTIVE

To examine the association of spiritual history and current spiritual well-being with symptoms of anxiety and depression in patients with advanced illness.

DESIGN

Cross-sectional cohort study

PARTICIPANTS

Two hundred and ten patients with advanced illness, of whom 1/3 were diagnosed with cancer, 1/3 COPD, and 1/3 CHF. The mean age of the sample was 66 years, and 91% were Christian.

MEASUREMENTS

Outcome measures were the Profile of Mood States' Anxiety Subscale (POMS) and 10-item Center for Epidemiologic Studies Depression Scale (CESD). Predictors were three subscales of the Spiritual History Scale measuring past religious help-seeking and support, past religious participation, and past negative religious experiences and two subscales of the Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale measuring the role of faith in illness and meaning, peace, and purpose in life. We conducted multiple regression analyses, controlling for demographics, disease type and severity, self-rated religiousness/spirituality, and frequency of religious attendance and devotion.

RESULTS

In adjusted analyses, greater spiritual well-being, including both beliefs about the role of faith in illness and meaning, peace, and purpose in life were associated with fewer symptoms of anxiety (P ≤ 0.001) and depression (P < 0.001). Greater past negative religious experiences were associated with more symptoms of anxiety (P = 0.04) and depression (P = 0.004). No other measures of spiritual history were associated with the outcomes.

CONCLUSIONS

In this diverse sample of seriously ill patients, current spiritual well-being and past negative religious experiences were associated with symptoms of anxiety and depression. Healthcare providers should consider asking about current spiritual well-being and past negative religious experiences in their assessment of seriously ill patients with symptoms of anxiety and depression.

End-of-life care at an academic medical center: are attending physicians, house staff, nurses, and bereaved family members equally satisfied? Implications for palliative care

BACKGROUND

End-of-life care is deemed to be poor in the United States - particularly in large teaching hospitals. Via a brief survey, we examined satisfaction with end-of-life care for those patients who died in our academic medical center from provider and family perspectives.

METHODS

To assess the correlation between overall satisfaction between providers (attending, housestaff, and nurses) as well as family members for decedents who died in our hospital, we conducted a satisfaction survey regarding care in the last three days of life. The nine item survey was administered within 1 week of the patient s death to care providers and approximately 8 to 12 weeks to next of kin.

RESULTS

There were 166 deaths examined over the four month study period. Overall satisfaction with care was 3.02 out of 4.0, and differed by respondent group (p= 0.035). Correlation between respondents was very low (range 0.02 to 0.51). The least discordance was between residents and interns (0.5), who had the lowest level of satisfaction (2.72). Housestaff and attendings had the lowest overall correlation in mean satisfaction scores (0.05). Most providers knew their patients for 24 hours or less.

CONCLUSIONS

Overall satisfaction was high, but there was discordance among different providers. Continuity of care was limited. Age and location of death alone did not significantly affect satisfaction with end-of-life care. Implications of this type of research for improving end of life care at academic centers are discussed.

Do preparation and life completion discussions improve functioning and quality of life in seriously ill patients? Pilot randomized control trial

BACKGROUND

Significant palliative care intervention has focused on physical pain and symptom control; yet less empirical evidence supports efforts to address the psychosocial and spiritual dimensions of experience.

OBJECTIVE

To evaluate the impact of an intervention (Outlook) that promotes discussions of end-of-life preparation and completion on health outcomes in dying persons, including pain and symptoms, physical function, emotional function (anxiety and depression), spiritual well-being, and quality of life at the end of life.

DESIGN

A three-arm pilot randomized control trial. Subjects were recruited from inpatient and outpatient hospital, palliative care, and hospice settings. Intervention subjects met with a facilitator three times and discussed issues related to life review, forgiveness, and heritage and legacy. Attention control subjects met with a facilitator three times and listened to a nonguided relaxation CD. True control subjects received no intervention.

MEASUREMENTS

Preoutcomes and postoutcomes included the Memorial Symptom Assessment Scale, QUAL-E, Rosow-Breslau ADL Scale, Profile of Mood States anxiety sub-scale, the CESD short version, and the Daily Spiritual Experience Scale.

RESULTS

Eighty-two hospice eligible patients enrolled in the study; 38 were women, 35 were African American. Participants' primary diagnoses included cancer (48), heart disease (5) lung disease (10), and other (19) Ages ranged from 28-96. Participants in the active discussion intervention showed improvements in functional status, anxiety, depression, and preparation for end of life.

CONCLUSIONS

The Outlook intervention was acceptable to patients from a variety of educational and ethnic backgrounds and offers a brief, manualized, intervention for emotional and spiritual concerns.

Selective adherence to antihypertensive medications as a patient-driven means to preserving sexual potency

OBJECTIVE

To describe hypertensive patients' experiences with sexual side effects and their consequences for antihypertensive medication adherence.

METHODS

Data were from a study conducted to identify facilitators of and barriers to adherence to blood pressure-lowering regimens. Participants were 38 married and unmarried veterans with a diagnosis of hypertension and 13 female spouses. Eight patient and four spouse focus groups were conducted. A directed approach to content analysis was used to determine the facilitators of and barriers to adherence. For this report, all discussion concerning the topic of sexual relations was extracted.

RESULTS

Male patients viewed sexual intercourse as a high priority and felt that a lack of sexual intercourse was unnatural. They pursued strategies to preserve their potency, including discontinuing or selectively adhering to their medications and obtaining treatments for impotence. In contrast, spouses felt that sexual intercourse was a low priority and that a lack of sexual intercourse was natural. They discouraged their husbands from seeking treatments for impotence.

CONCLUSION

Although the primary study was not designed to explore issues of sexual function, the issue emerged spontaneously in the majority of discussions, indicating that sexuality is important in this context for both male patients and their spouses. Physicians should address sexual side effects of antihypertensive medications with patients, ideally involving spouses.

Measuring the quality of dying in long-term care

OBJECTIVES

To describe two versions of a new measure, The Quality of Dying in Long-Term Care, for postdeath administration to surrogate respondents (staff and family caregivers) of all decedents (QOD-LTC) and of cognitively intact decedents (QOD-LTC-C) who die in nursing homes (NHs) and residential care or assisted living (RC/AL) facilities.

DESIGN

Using two levels of exploratory factor analysis, 15 candidate items for the QOD-LTC and 36 candidate items for the QOD-LTC-C were tested using multiple criteria to determine factor structure and interpretability of the quality of dying in long-term care (LTC).

SETTING

One hundred seventeen RC/AL facilities and 31 NHs in FL, MD, NC, and NJ.

PARTICIPANTS

Family (n=439) and staff (n=332) caregivers of 633 decedents from a stratified random sample from RC/AL facilities and NHs in four states.

MEASUREMENTS

Trained interviewers asked respondents to rate statements describing potentially important aspects of the quality of dying using a 5-point Likert scale. The scale items were analyzed using exploratory factor analysis with communalities set to unity using a Promax rotation.

RESULTS

The 11-item QOD-LTC (alpha=0.66), appropriate for surrogate respondents for all decedents, consists of three domains (personhood, closure, preparatory tasks). The 23-item instrument for surrogate respondents of cognitively intact decedents, the QOD-LTC-C (alpha=0.85), consists of five domains (sense of purpose, closure, control, social connection, preparatory tasks).

CONCLUSION

The QOD-LTC and QOD-LTC-C are psychometrically acceptable measures of the quality of the dying experience, developed for and tested in LTC settings. Use of these measures can increase understanding of the dying experience in LTC.