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Mohammed S, Savage P, Kevork N, Swami N, Rodin G, Zimmermann C. "I'm going to push this door open. You can close it": A qualitative study of the brokering work of oncology clinic nurses in introducing early palliative care. Palliat Med 2020; 34:209-218. [PMID: 31659940 DOI: 10.1177/0269216319883980] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early palliative care improves quality of life during life-prolonging treatment for patients with cancer, but the role of nurses in facilitating the early involvement of palliative care is unclear. AIM To conceptualize the psychosocial processes involved in the introduction and provision of palliative care by oncology nurses. DESIGN A constructivist qualitative grounded theory study was conducted. SETTING/PARTICIPANTS A total of 20 nurses (6 staff nurses, 10 nurse practitioners, and 4 advanced practice nurses) completed semi-structured interviews. Participants were from multiple ambulatory care oncology clinics (i.e. breast, pancreatic, hematology) in a comprehensive cancer center. RESULTS The core category, brokering palliative care, represented the overarching concept of the study that linked other subcategories. The other subcategories were as follows: opening the door-creating the possibility of discussing early palliative care at a time when patients show signs of being receptive to this discussion; building trust-establishing relationships with patients as a starting point for open discussions about palliative care; tackling misconceptions-addressing patients' assumptions about palliative care as signifying death; and advocating with oncologists-seeding the process of referral by bringing patients' concerns forward. CONCLUSION Oncology nurses play a central role in "brokering" the introduction of early palliative care; this process is supported by their relational proximity to patients and their location "in between" the patient and the oncologist. Training all nurses in palliative care and empowering them to have proactive discussions in a collaborative practice context would allow greater access to early palliative care.
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Affiliation(s)
- Shan Mohammed
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Pamela Savage
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Nanor Kevork
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Nadia Swami
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Divisions of Palliative Medicine and Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Malik S, Goldman R, Kevork N, Wentlandt K, Husain A, Merrow N, Le LW, Zimmermann C. Engagement of Primary Care Physicians in Home Palliative Care. J Palliat Care 2018; 32:3-10. [PMID: 28662623 DOI: 10.1177/0825859717706791] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To describe prevalence and characteristics associated with family physician and general practitioner (FP/GP) provision of home palliative care (HPC). METHODS We surveyed FP/GPs in an urban health region of Ontario, Canada, to determine their current involvement in HPC, the nature of services provided, and perceived barriers and enablers. RESULTS A total of 1439 surveys were mailed. Of the 302 FP/GP respondents, 295 provided replies regarding engagement in HPC: 101 of 295 (33%) provided HPC, 76 (26%) were engageable with further support, and 118 (40%) were not engageable regardless of support. The most substantial barrier was time to provide home visits (81%). Engaged FP/GPs were most likely to be working with another physician providing HPC ( P < .0001). Engageable FP/GPs were younger ( P = .007) and placed greater value on improved remuneration ( P < .001) than the other groups. Nonengageable physicians were most likely to view time as a barrier ( P < .0001) and to lack interest in PC ( P = .03). CONCLUSION One-third of FP/GPs provide HPC. A cohort of younger physicians could be engageable with adequate support. Integrated practices including collaboration with specialist PC colleagues should be encouraged and supported.
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Affiliation(s)
- Shiraz Malik
- 1 Department of Family Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Russell Goldman
- 2 Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.,3 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nanor Kevork
- 4 Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Kirsten Wentlandt
- 3 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,4 Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Amna Husain
- 2 Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.,3 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nancy Merrow
- 5 Orillia Soldiers Memorial Hospital, Orillia, Ontario, Canada
| | - Lisa W Le
- 6 Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- 4 Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,7 Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,8 Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Hausner D, Pope A, Kevork N, Le L, Zimmermann C. Factors associated with length of stay in an acute palliative care unit: A retrospective analysis. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy295.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Makarem M, Mohammed S, Swami N, Pope A, Kevork N, Krzyzanowska M, Rodin G, Hannon B, Zimmermann C. Experiences and Expectations of Bereavement Contact among Caregivers of Patients with Advanced Cancer. J Palliat Med 2018; 21:1137-1144. [DOI: 10.1089/jpm.2017.0530] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Maisam Makarem
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Shan Mohammed
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Nadia Swami
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Ashley Pope
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Nanor Kevork
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Monika Krzyzanowska
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Breffni Hannon
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Hausner D, Kevork N, Pope A, Hannon B, Bryson J, Lau J, Rodin G, Le LW, Zimmermann C. Factors associated with discharge disposition on an acute palliative care unit. Support Care Cancer 2018; 26:3951-3958. [PMID: 29850945 DOI: 10.1007/s00520-018-4274-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/15/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Acute palliative care units (APCUs) admit patients with cancer for symptom control, transition to community palliative care units or hospice (CPCU/H), or end-of-life care. Prognostication early in the course of admission is crucial for decision-making. We retrospectively evaluated factors associated with patients' discharge disposition on an APCU in a cancer center. METHODS We evaluated demographic, administrative, and clinical data for all patients admitted to the APCU in 2015. Clinical data included cancer diagnosis, delirium screening, and Edmonton Symptom Assessment System (ESAS) symptoms. An ESAS sub-score composed of fatigue, drowsiness, shortness of breath, and appetite (FDSA) was also investigated. Factors associated with patients' discharge disposition (home, CPCU/H, died on APCU) were identified using three-level multinomial logistic regression. RESULTS Among 280 patients, the median age was 65.5 and median length of stay was 10 days; 155 (55.4%) were admitted for symptom control, 65 (23.2%) for transition to CPCU/H, and 60 (21.4%) for terminal care. Discharge dispositions were as follows: 156 (55.7%) died, 63 (22.5%) returned home, and 61 (21.8%) were transferred to CPCU/H. On multivariable analysis, patients who died were less likely to be older (OR 0.97, p = 0.01), or to be admitted for symptom control (OR 0.06, p < 0.0001), and more likely to have a higher FDSA score 21-40 (OR 3.02, p = 0.004). Patients discharged to CPCU/H were less likely to have been admitted for symptom control (OR 0.06, p < 0.0001). CONCLUSION Age, reason for admission, and the FDSA symptom cluster on admission are variables that can inform clinicians about probable discharge disposition on an APCU.
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Affiliation(s)
- David Hausner
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada
| | - Nanor Kevork
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada
| | - Ashley Pope
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada
| | - Breffni Hannon
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada
| | - John Bryson
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada
| | - Jenny Lau
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada.,Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Princess Margaret Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Lisa W Le
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Camilla Zimmermann
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada. .,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada. .,Department of Psychiatry, University of Toronto, Toronto, Canada. .,Princess Margaret Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.
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McDonald JC, du Manoir JM, Kevork N, Le LW, Zimmermann C. Advance directives in patients with advanced cancer receiving active treatment: attitudes, prevalence, and barriers. Support Care Cancer 2016; 25:523-531. [DOI: 10.1007/s00520-016-3433-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 09/26/2016] [Indexed: 11/25/2022]
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Wentlandt K, Seccareccia D, Kevork N, Workentin K, Blacker S, Grossman D, Zimmermann C. Quality of Care and Satisfaction With Care on Palliative Care Units. J Pain Symptom Manage 2016; 51:184-92. [PMID: 26598036 DOI: 10.1016/j.jpainsymman.2015.10.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 10/08/2015] [Accepted: 10/13/2015] [Indexed: 01/22/2023]
Abstract
CONTEXT There is little research on quality of care specific to palliative care units (PCUs). OBJECTIVES To delineate important aspects of satisfaction with care and quality of care on a PCU, as described by inpatients, family caregivers, and health care professionals. METHODS Qualitative interviews and focus groups were conducted across four Toronto PCUs, with a total of 46 patient/caregiver interviews and eight staff focus groups. Interviews and focus groups were semistructured to elicit comments about satisfaction with care and quality of care for inpatients and families on a PCU. Data were analyzed using a grounded theory method, with an inductive, constant comparison approach to identify themes, and were coded to saturation. RESULTS Key elements of quality care and patient satisfaction on a PCU were grouped into six domains: 1) interprofessional team: a team of experts comprising multiple disciplines functioning as a unit; 2) communication: developing rapport, addressing expectations, providing information, listening actively, and facilitating end-of-life discussions; 3) attentive, personalized care: anticipatory and responsive compassionate care with tailored management of physical and nonphysical symptoms; 4) family-centered: support of patients and caregivers within a family; 5) accessible and consistent: appropriate resources and adequate staff to provide consistent care; and 6) supportive setting: a bright noninstitutionalized setting allowing both privacy and socialization. CONCLUSION The elements identified support the delivery of quality care. They may act as a guide for those planning to develop PCUs and form the basis for measures of satisfaction with care.
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Affiliation(s)
- Kirsten Wentlandt
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dori Seccareccia
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nanor Kevork
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Kevin Workentin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto East General Hospital, Toronto, Ontario, Canada
| | - Susan Blacker
- Department of Cancer Services Planning and Performance, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Daphna Grossman
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Baycrest, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Division of Medical Oncology & Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Campbell Family Cancer Research Institute, Ontario Cancer Institute, Toronto, Ontario, Canada.
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Seccareccia D, Wentlandt K, Kevork N, Workentin K, Blacker S, Gagliese L, Grossman D, Zimmermann C. Communication and Quality of Care on Palliative Care Units: A Qualitative Study. J Palliat Med 2015; 18:758-64. [PMID: 26069934 DOI: 10.1089/jpm.2014.0408] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Clinician-patient communication is central in palliative care, but it has not been described qualitatively which specific elements of communication are important for high-quality palliative care, particularly in the inpatient setting. OBJECTIVE Our aim was to identify elements of communication that are central to quality of care and satisfaction with care on palliative care units (PCUs), as described by inpatients, family caregivers, and health care providers. METHODS Qualitative interviews with patients/caregivers and focus groups with staff were conducted on four PCUs. Semi-structured interviews and focus groups elicited thoughts about the characteristics of satisfaction with care and quality of care for PCU inpatients and their family caregivers. Data were analyzed using a grounded theory method with an inductive, constant comparison approach; themes were coded to saturation. RESULTS There were 46 interviews and eight focus groups. Communication was the most prevalent theme regarding satisfaction and quality of care, with five subthemes describing elements important to patients, caregivers, and staff. These included: 1) building rapport with patients and families to build trust and kinship; 2) addressing expectations and explaining goals of care; 3) keeping patients and families informed about the patient's condition; 4) listening actively to validate patients' concerns and individual needs; and 5) providing a safe space for conversations about death and dying. CONCLUSIONS Patients, family caregivers, and health care providers affirmed that communication is a central element of quality of care and family satisfaction on PCUs. The five subthemes identified may serve as a structure for education and for quality improvement tools in palliative care inpatient settings.
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Affiliation(s)
- Dori Seccareccia
- 1 Department of Psychosocial Oncology, Sunnybrook Health Sciences Centre , Toronto, Ontario, Canada .,2 Department of Family and Community Medicine, University of Toronto , Toronto, Ontario, Canada
| | - Kirsten Wentlandt
- 1 Department of Psychosocial Oncology, Sunnybrook Health Sciences Centre , Toronto, Ontario, Canada
| | - Nanor Kevork
- 3 Department of Supportive Care, University Health Network , Toronto, Ontario, Canada
| | - Kevin Workentin
- 2 Department of Family and Community Medicine, University of Toronto , Toronto, Ontario, Canada .,4 Department of Family Medicine, Toronto East General Hospital , Toronto, Ontario, Canada
| | - Susan Blacker
- 5 Department of Cancer Services Planning and Performance, St. Michael's Hospital , Toronto, Ontario, Canada
| | - Lucia Gagliese
- 3 Department of Supportive Care, University Health Network , Toronto, Ontario, Canada .,6 Department of Anesthesia and Psychiatry, Faculty of Medicine, University of Toronto , Toronto, Ontario, Canada .,7 School of Kinesiology and Health Sciences, York University , Toronto, Ontario, Canada .,8 Department of Anesthesia, University Health Network , Toronto, Ontario, Canada .,11 Campbell Family Cancer Research Institute, Ontario Cancer Institute , Toronto, Ontario, Canada
| | - Daphna Grossman
- 2 Department of Family and Community Medicine, University of Toronto , Toronto, Ontario, Canada .,9 Department of Family and Community Medicine , Baycrest Health Sciences, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- 3 Department of Supportive Care, University Health Network , Toronto, Ontario, Canada .,10 Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto , Toronto, Ontario, Canada .,11 Campbell Family Cancer Research Institute, Ontario Cancer Institute , Toronto, Ontario, Canada
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Towns K, Dougherty E, Kevork N, Wiljer D, Seccareccia D, Rodin G, Le LW, Zimmermann C. Availability of Services in Ontario Hospices and Hospitals Providing Inpatient Palliative Care. J Palliat Med 2012; 15:527-34. [DOI: 10.1089/jpm.2011.0453] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kathryn Towns
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Elizabeth Dougherty
- Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, Ontario, Canada
| | - Nanor Kevork
- Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, Ontario, Canada
| | - David Wiljer
- Oncology Education/Radiation Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Dori Seccareccia
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Ontario, Canada
- Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Psychiatry, University of Toronto, Ontario, Canada
- Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, Ontario, Canada
- Ontario Cancer Institute, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Lisa W. Le
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Ontario, Canada
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Ontario, Canada
- Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, Ontario, Canada
- Ontario Cancer Institute, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
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