Enhancing Oncologists' Comfort with Serious Illness Conversations: The Impact of Serious Illness Conversation Guide (SICG) Training

Providers oftentimes need to have difficult conversations with patients facing a poor prognosis. Research indicates that providers generally feel ill prepared for these conversations and that bad conversations may lead to more anxiety for patients. Communication skills development training programs have shown improvement in providers' skills. Our cancer center embarked on skills development training to help providers improve their skills and comfort in having serious illness conversations. During our phased approach, about 500 physicians and advanced practice providers in the Division of Oncology were trained for over a year. Their level of comfort with serious illness conversations was measured before and after the training by using both quantitative and qualitative methods. We found that mean and median comfort scores increased from pre-training to post-training. The findings suggest that the improved comfort and confidence observed among providers who undergo communications skills training can lead to better provider-patient communication, more patient-centered care, and improved patient satisfaction.

Incorporating Cost Measures Into the Merit-Based Incentive Payment System: Implications for Oncologists

PURPOSE

The Merit-Based Incentive Payment System (MIPS) is currently the only federally mandated value-based payment model for oncologists. The weight of cost measures in MIPS has increased from 0% in 2017 to 30% in 2022. Given that cost measures are specialty-agnostic, specialties with greater costs of care such as oncology may be unfairly affected. We investigated the implications of incorporating cost measures into MIPS on physician reimbursements for oncologists and other physicians.

METHODS

We evaluated physicians scored on cost and quality in the 2018 MIPS using the Doctors and Clinicians database. We used multivariable Tobit regression to identify physician-level factors associated with cost and quality scores. We simulated composite MIPS scores and payment adjustments by applying the 2022 cost-quality weights to the 2018 category scores and compared changes across specialties.

RESULTS

Of 168,098 identified MIPS-participating physicians, 5,942 (3.5%) were oncologists. Oncologists had the lowest cost scores compared with other specialties (adjusted mean score, 58.4 for oncologists v 71.0 for nononcologists; difference, -12.66 [95% CI, -13.34 to -11.99]), while quality scores were similar (82.9 v 84.2; difference, -1.31 [95% CI, -2.65 to 0.03]). After the 2022 cost-quality reweighting, oncologists would receive a 4.3-point (95% CI, 4.58 to 4.04) reduction in composite MIPS scores, corresponding to a four-fold increase in magnitude of physician penalties ($4,233.41 US dollars [USD] in 2018 v $18,531.06 USD in 2022) and greater reduction in exceptional payment bonuses compared with physicians in other specialties (-42.8% [95% CI, -44.1 to -41.5] for oncologists v -23.6% [95% CI, -23.8 to -23.4] for others).

CONCLUSION

Oncologists will likely be disproportionally penalized after the incorporation of cost measures into MIPS. Specialty-specific recalibration of cost measures is needed to ensure that policy efforts to promote value-based care do not compromise health care quality and outcomes.

Oncologist Participation and Performance in the Merit-Based Incentive Payment System

The merit-based incentive payment system (MIPS) is a value-based payment model created by the Centers for Medicare & Medicaid Services (CMS) to promote high-value care through performance-based adjustments of Medicare reimbursements. In this cross-sectional study, we examined the participation and performance of oncologists in the 2019 MIPS. Oncologist participation was low (86%) compared to all-specialty participation (97%). After adjusting for practice characteristics, higher MIPS scores were observed among oncologists with alternative payment models (APMs) as their filing source (mean score, 91 for APMs vs. 77.6 for individuals; difference, 13.41 [95% CI, 12.21, 14.6]), indicating the importance of greater organizational resources for participants. Lower scores were associated with greater patient complexity (mean score, 83.4 for highest quintile vs. 84.9 for lowest quintile, difference, -1.43 [95% CI, -2.48, -0.37]), suggesting the need for better risk-adjustment by CMS. Our findings may guide future efforts to improve oncologist engagement in MIPS.

To have done everything

When a patient loses decisional capacity, the responsibility to make treatment decisions often falls on a family member who becomes the surrogate decision-maker. This case study provides an example of a situation where the medical team and the surrogate decision-maker initially disagreed on the best course of action for the patient. The ethicist was called in to lead a guided conversation to help the team and the surrogate decision-maker reach a consensus. This case illustrates the importance of allowing the surrogate decision-maker to ask clarifying questions and process their emotions before making a decision.

Perceptions of Life Support and Advance Care Planning During the COVID-19 Pandemic

Background

Research Question

Study Design and Methods

Results

Interpretation

Continue with ICU care - she is a spiritual being

This case study discusses a dispute between the healthcare team and the patient's surrogate decision maker at a cancer centre. While the healthcare team deemed further care to be futile, the patient's husband argued that they should continue to try to reverse his wife's acute decline. This case study illustrates the inertia and moral distress that can result when there are differences between patients/surrogates and the healthcare team in their goals for intensive care. The issues of moral distress and an inability to make decisions were addressed by involving an ethics consultant, and by creating institutional mechanisms to address end-of-life issues at an earlier stage.

#ColonCancer: Social Media Discussions About Colorectal Cancer During the COVID-19 Pandemic

PURPOSE

Colorectal cancer (CRC) is the second leading cause of cancer-related mortality worldwide. Social media platforms such as Twitter are extensively used to communicate about cancer care, yet little is known about the role of these online platforms in promoting early detection or sharing the lived experiences of patients with CRC. This study tracked Twitter discussions about CRC and characterized participating users to better understand public communication and perceptions of CRC during the COVID-19 pandemic.

METHODS

Tweets containing references to CRC were collected from January 2020 to April 2021 using Twitter's Application Programming Interface. Account metadata was used to predict user demographic information and classify users as either organizations, individuals, clinicians, or influencers. We compared the number of impressions across users and analyzed the content of tweets using natural language processing models to identify prominent topics of discussion.

RESULTS

There were 72,229 unique CRC-related tweets by 31,170 users. Most users were male (66%) and older than 40 years (57%). Individuals accounted for most users (44%); organizations (35%); clinicians (19%); and influencers (2%). Influencers made the most median impressions (35,853). Organizations made the most overall impressions (1,067,189,613). Tweets contained the following topics: bereavement (20%), appeals for early detection (20%), research (17%), National Colorectal Cancer Awareness Month (15%), screening access (14%), and risk factors (14%).

CONCLUSION

Discussions about CRC largely focused on bereavement and early detection. Online coverage of National Colorectal Cancer Awareness Month and personal experiences with CRC effectively stimulated goal-oriented tweets about early detection. Our findings suggest that although Twitter is commonly used for communicating about CRC, partnering with influencers may be an effective strategy for improving communication of future public health recommendations related to CRC.

Appreciating the Dynamicity of Values at the End of Life: A Psychological and Ethical Analysis

It can be difficult for families to accept when loved ones experience a change in saliency of values due to serious illness and inevitable death. When patients lose decision-making capacity, family members often refuse to withdraw care and insist on the continuation of non-beneficial treatment. Through a joint ethical and psychological analysis, this case study examines the narrative of a husband and wife, wed for over 50 years, and how the patient's values, his life's story, and the wife's interpretation of his preferences were reconciled to achieve a resolution that respected the patient's autonomy and previously expressed wishes.

A Practical Approach to Hospital Visitation During a Pandemic: Responding With Compassion to Unjustified Restrictions

During the COVID-19 pandemic, evidence-based resources have been sought to support decision-making and strategically inform hospitals' policies, procedures, and practices. While greatly emphasizing protection, most guiding documents have neglected to support and protect the psychosocial needs of frontline health care workers and patients and their families during provision of palliative and end-of-life care. Consequently, the stage has been set for increased anxiety, moral distress, and moral injury and extreme moral hazard. A family-centered approach to care has been unilaterally relinquished to a secondary and nonessential role during the current crisis. This phenomenon violates a foundational public health principle, namely, to apply the least restrictive means to achieve good for the many. Instead, there has been widespread adoption of utilitarian and paternalistic approaches. In many cases the foundational principles of palliative care have also been neglected. No circumstance, even a global public health emergency, should ever cause health care providers to deny their ethical obligations and human commitment to compassion. The lack of responsive protocols for family visitation, particularly at the end of life, is an important gap in the current recommendations for pandemic triage and contingency planning. A stepwise approach to hospital visitation using a tiered, standardized process for responding to emerging clinical circumstances and individual patients' needs should be considered, following the principle of proportionality. A contingency plan, based on epidemiological data, is the best strategy to refocus health care ethics in practice now and for the future.

When Hanging on at All Costs is the Only Option

Having hope that a terminally ill patient may recover is not an unfamiliar sight in intensive care units across the globe. However, cultural heritage may make it even tougher. This fictional case study, which is a collection of years of experience, addresses decision-making within the Chinese Immigrant culture and focusses on how this may influence the care team. A new initiative, the Goals of Care (GOC) team, is also described.

Advance Care Planning Conversations in the Oncology Setting: Tips from the Experts

Advance care planning (ACP) has been identified as a fundamental part of every patient's total health care plan and is actively supported by a number of health care organizations. Despite these endorsements, however, having advance care planning conversations has not come easily for physicians. Training future physicians should include practical ways to address this issue. Fifty physicians at an oncology hospital, who were identified as having the most ACP conversations, were approached. Twenty-six percent participated in a survey which was sent out electronically via Qualitrics. All answers were recorded online and responses were collected and analyzed according to thematic analysis methodology. Major themes were noted and summarized for each of the survey's 10 questions, resulting in how the physicians can successfully plan for and initiate advance care planning conversations with their patients and families. Themes touched upon self-awareness, one's outlook on the value of life, and the importance of death as part of the care continuum. A physician's own perception of the value of ACP conversations greatly influences them having those conversations. Furthermore, it is key that the physician understands and be aware of the patient's perspective regarding their cancer and how it impacts them. This dynamic will then allow the physician to better align their plan of care with the treatment goals and expectations of the patient. Future training programs should incorporate these suggestions.

Exploring values among three cultures from a global bioethics perspective

The United Nations Educational, Scientific and Cultural Organisation's (UNESCO) Declaration on Bioethics and Human Rights refers to the importance of cultural diversity and pluralism in ethical discourse and care of humanity. The aim of this meta-narrative review is to identify indigenous ethical values pertaining to the Ojibway (Canada), Xhosa (South Africa), and Mayan (Mexico and Central American) cultures from peer-reviewed sources and cultural review, and to ascertain if there are shared commonalities. Three main themes were identified, namely illness, healing, and health care choices. Illness was described with a more complex and dynamic picture than from the western view, as illness is not considered to be one dimensional. Healing needs to take place on various levels in order to restore a state of equilibrium between the different spheres. Health care choices were also considered from a multi-level perspective. In all three of the indigenous cultures explored, good decision-making is seen to have occurred when choices are informed by commitments to one's moral and ethical responsibilities towards the community, nature, and the spirit world.

It Takes Time to Let Go

Futile or nonbeneficial treatment is often a source of contention between care teams and family members of ICU patients. This narrative describes such a case at a cancer center. In the midst of the COVID-19 crisis, the psychosocial team had to act as a bridge between a patient's surrogate decision maker and the care team. In light of COVID-19 visitor restrictions, the psychosocial team, the surrogate/family, and the care team had to respectfully work towards what was best for the patient.

The Hidden Curriculum and Integrating Cure- and Care-Based Approaches to Medicine

Although current literature about the “cure versus care” issue tends to promote a patient-centered approach, the disease-centered approach remains the prevailing model in practice. The perceived dichotomy between the two approaches has created a barrier that could make it difficult for medical students and physicians to integrate psychosocial aspects of patient care into the prevailing disease-based model. This article examines the influence of the formal and hidden curricula on the perception of these two approaches and finds that the hidden curriculum perpetuates the notion that “cure” and “care” based approaches are dichotomous despite significant changes in formal curricula that promote a more integrated approach. The authors argue that it is detrimental for clinicians to view the two approaches as oppositional rather than complementary and attempt to give recommendations on how the influence of the hidden curriculum can be reduced to get a both-cure-and-care-approach, rather than an either-cure-or-care-approach.

A policy and decision-making framework for South African doctors during the COVID-19 pandemic

Faced with a pandemic, doctors around the world are forced to make difficult ethical decisions about clinical, economic and politically charged issues in medicine and healthcare, with little time or resources for support. A decision-making framework is suggested to guide policy and clinical practice to support the needs of healthcare workers, help to allocate scarce resources equitably and promote communication among stakeholders, while drawing on South African doctors' knowledge, culture and experience.

Speaking for Our Father

A living will is a document in which an individual can communicate his or her health care choices to loved ones in the event that he or she is unable to do so directly. Many surrogate decision-makers use living wills as guides; however, the existence of such documents does not entirely relieve them of their burden. Surrogate decision-makers often need to consider the impact of the personal and family burdens entailed by their decisions, and the stress accompanying these burdens regularly creates high levels of anxiety and depression. This stress can be exacerbated when two surrogate decision-makers are at loggerheads as to the best way forward. This case study illustrates the effects of stress accompanying disagreement among surrogate decision-makers-here, the patient's adult sons-and demonstrates that a process of listening can help the bioethicist identify the values that are important to the patient and, consequently, to the surrogate as well, and use these values to help address the issue.

Building an Infrastructure and Standard Methodology for Actively Engaging Patients in Advance Care Planning

PURPOSE

With little to no infrastructure or standardized methodology in place to actively engage patients in advance care planning (ACP), The University of Texas MD Anderson Cancer Center set out to identify needed resources, develop an intervention to improve ACP, and evaluate the intervention's effects.

METHODS

With the support of executive leadership, a multidisciplinary workgroup enlisted the support of ACP champions, performed a root-cause analysis, developed a detailed ACP process flow by provider role, developed patient and family education resources, and developed faculty and staff training materials. The workgroup also implemented two Plan-Do-Study-Act intervention cycles, which identified difficulty using the ACP note function in our electronic health record (EHR) as a barrier to ACP adoption. By educating patients, families, and providers and improving the EHR's functionality, the workgroup aimed to increase the percentage of ambulatory patients with a diagnosis of advanced or metastatic cancer who had a documented ACP conversation with a provider by their third office visit. Our goal was to improve this percentage from 20% at baseline to 50% after the intervention. Data were obtained from our institution's EHRs.

RESULTS

The percentage of patients who had documented ACP conversations increased from 20% at baseline to 34% at the end of fiscal year 2017 and 54% at the end of fiscal year 2018.

CONCLUSION

Owing to the dedicated efforts of many individuals across the institution, the postintervention goal was surpassed. Additional efforts to facilitate ACP conversations are ongoing.

Helping Surrogate Decision-Makers Through Difficult Conversations

Difficult conversations in the ICU are often seen as ones of getting a surrogate decision-maker to make an end-of-life decision. However, allowing the surrogate decision-maker to become a narrator can alleviate the daunting task lying ahead.

Respecting Cultural Differences in Goals of Care Conversations

Goals of care conversations are often tough when patients face a poor prognosis, yet when patients are from a different culture it may be even more difficult. However, seeing cultural values as complementing rather than opposing could be beneficial to the care of the patient.

Review of: Magnussen H. (2017) The Moral Work of Nursing – Asking and Living with the Questions

A narrative description of personal moral challenges of a nurse serving diverse communities.

Comprehensive Quality Assessment in Clinical Ethics

Scholars and professional organizations in bioethics describe various approaches to "quality assessment" in clinical ethics. Although much of this work represents significant contributions to the literature, it is not clear that there is a robust and shared understanding of what constitutes "quality" in clinical ethics, what activities should be measured when tracking clinical ethics work, and what metrics should be used when measuring those activities. Further, even the most robust quality assessment efforts to date are idiosyncratic, in that they represent evaluation of single activities or domains of clinical ethics activities, or a range of activities at a single hospital or healthcare system. Countering this trend, iin this article we propose a framework for moving beyond our current ways of understanding clinical ethics quality, toward comprehensive quality assessment. We first describe a way to conceptualize quality assessment as a process of measuring disparate, isolated work activities; then, we describe quality assessment in terms of tracking interconnected work activities holistically, across different levels of assessment. We conclude by inviting future efforts in quality improvement to adopt a comprehensive approach to quality assessment into their improvement practices, and offer recommendations for how the field might move in this direction.

Patterns of unprofessional conduct by medical practitioners in South Africa (2007–2013)

A role of ethics in the medical context is to protect the interests, freedoms and well-being of patients. A critical analysis of unprofessional conduct by medical practitioners registered with the Health Professions Council of South Africa (HPCSA) requires a better understanding of the specific ethics misconduct trends.To investigate the objectives the case content and sanctions of all guilty decisions related to unprofessional conduct against HPCSA-registered medical practitioners in the period 2007 to 2013 were analysed. A mixed methods approach was followed. The quantitative component focused on annual frequency data regarding the number of decisions taken against practitioners, number of practitioners, number of specific sanctions and categories. Relatively few medical practitioners (between 0.11% and 0.24%) are annually found guilty of unprofessional conduct. The annual average number of guilty decisions per guilty medical practitioner ranged between 1.29 and 2.58. The three most frequent sanctions imposed were fines between ZAR10 000 and ZAR15 000 (28.29%), fines between ZAR1 000 and ZAR8 000 (23.47%) and suspended suspensions between 1 month and 1 year (17.37%). The majority of the unprofessional conduct involved fraudulent behaviour (48.4%), followed by negligence or incompetence in evaluating, treating or caring for patients (29%).Unethical behaviour by medical practitioners in South Africa occurs relatively infrequently.

Ethical misconduct by registered physiotherapists in South Africa (2007-2013): A mixed methods approach

BACKGROUND

The role of ethics in a medical context is to protect the interests of patients. Thus, it is critically important to understand the guilty verdicts related to professional standard breaches and ethics misconduct of physiotherapists.

AIM

To analyse the case content and penalties of all guilty verdicts related to ethics misconduct against registered physiotherapists in South Africa.

METHODS

A mixed methods approach was followed consisting of epidemiological data analysis and qualitative content analysis. The data documents were formal annual lists (2007-2013) of guilty verdicts related to ethical misconduct. Quantitative data analysis focused on annual frequencies of guilty verdicts, transgression categories and the imposed penalties. Qualitative data analysis focused on content analysis of the case content for each guilty verdict.

RESULTS

Relatively few physiotherapists (0.05%) are annually found guilty of ethical misconduct. The two most frequent penalties were fines of R5000.00 and fines of R8000.00 - R10 000.00. The majority of transgressions involved fraudulent conduct (70.3%), followed by performance of procedures without patient consent (10.8%). Fraudulent conduct involved issuing misleading, inaccurate or false medical statements, and false or inaccurate medical aid scheme claims.

CONCLUSION

Unethical conduct by physiotherapists in South Africa occurs rarely. The majority of penalties imposed on sanctioned physiotherapists were monetary penalties.

Professional consequence for dentists involved in unethical decision-making in South Africa

The previously gullible and apathetic South African public, generally speaking, is lately becoming increasingly rights-based sophisticated. Patients are no longer accepting inferior quality work and have become more knowledgeable especially regarding the expected skills and professional conduct of dentists. The present study examined archival material as published between 2007 and 2013 of penalties against ethical misconduct. It was found that the majority of ethical transgressions took place in urban settings and the most predominant transgression was charging for services not performed and submitting these claims to medical aids as well as performing sub-optimal interventions. Legally a practitioner who performs such acts may be held liable for the damage or injury suffered by the patient as a consequence of these acts, on the basis of negligence. Penalties imposed by the Health Professions Council of South Africa vary between 5,000 Rand and 15,000 Rand, as well as suspensions of between 9 to 12 months. It is doubtful that transgressors would change their behaviour in the light of the present Continuous Professional Development programmes where attendance is really the only prerequisite and not moral reflection. This study recommends that the Health Professions Council of South Africa need to re-evaluate the effectiveness of their ethical training programmes and adapt the model to incorporate more inclusive learning.