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Mossman B, Perry LM, Voss HM, Maciejewski PK, Gramling R, Duberstein P, Prigerson HG, Epstein RM, Hoerger M. Patient-Caregiver Dyads & End-of-Life Care: Caregiver Personality Disrupts Gender-Based Norms. J Pain Symptom Manage 2024; 67:e393-e398. [PMID: 38278189 PMCID: PMC11032258 DOI: 10.1016/j.jpainsymman.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 01/28/2024]
Abstract
CONTEXT Gender and personality may individually impact end-of-life care. Men often receive more aggressive treatments than women near death, and personality - particularly openness - may be associated with increased care utilization when it diverges from traditional treatment norms. However, research has not examined the interaction of these variables in a dyadic context. OBJECTIVES This study examined the dyadic effects of patient gender and caregiver personality on end-of-life care. METHODS Using data from the VOICE randomized clinical trial, the present sample consisted of patient-caregiver dyads receiving outpatient care for advanced cancer in Sacramento and Western New York. Analyses assessed whether caregiver personality was associated with gender-based differences in patient chemotherapy or emergency department/inpatient visits in the 30 days before death. Logistic regression examined the interaction between caregivers' Big Five personality dimensions and patient gender while accounting for patient and caregiver demographic and health characteristics. RESULTS Of a total of 134 patient-caregiver dyads, 19.4% (n = 26) of patients received chemotherapy and 47.8% (n = 64) had an emergency department/inpatient visit in the 30 days before death. Results demonstrated a significant interaction between caregiver openness and patient gender on receipt of chemotherapy (odds ratio = 0.07, p = 0.006). When caregivers were less open, men were more likely to receive chemotherapy near death, whereas when caregivers were more open, women were more likely to receive chemotherapy near death. CONCLUSION Results suggest caregiver personality characteristics, particularly openness, might disrupt gender-based treatment norms at end-of-life. Findings demonstrate that patient and caregiver factors can interact to explain patient healthcare utilization.
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Affiliation(s)
- Brenna Mossman
- Department of Psychology (B.M., H.M.V., M.H.), Tulane University, New Orleans, LA, USA
| | - Laura M Perry
- Department of Medical Social Sciences (L.M.P.), Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Medicine (L.M.P.), Tulane University School of Medicine, New Orleans, LA, USA
| | - Hallie M Voss
- Department of Psychology (B.M., H.M.V., M.H.), Tulane University, New Orleans, LA, USA
| | - Paul K Maciejewski
- Cornell Center for Research on End-of-Life Care (P.K.M., H.G.P.), Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Robert Gramling
- Department of Family Medicine (R.G.), University of Vermont, Burlington, VT, USA
| | - Paul Duberstein
- Department of Health Behavior (P.D.), Society, and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Holly G Prigerson
- Cornell Center for Research on End-of-Life Care (P.K.M., H.G.P.), Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Ronald M Epstein
- Departments of Family Medicine (R.M.E.), Medicine and Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Michael Hoerger
- Department of Psychology (B.M., H.M.V., M.H.), Tulane University, New Orleans, LA, USA; Departments of Psychiatry and Medicine (M.H.), Tulane Cancer Center, and Freeman School of Business, Tulane University, New Orleans, LA, USA.
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Ventres WB, Stone LA, Akhtar R, Ring JM, Candib LM, Messias E, Epstein RM, Tunzi M, Lee AL, Morley CP, Brown CM, Slawson D, Konkin J, Campbell DG, Couper I, Williams S, Brooks R, Walters L. Storylines of family medicine IV: perspectives on practice-lenses of appreciation. Fam Med Community Health 2024; 12:e002791. [PMID: 38609092 PMCID: PMC11029283 DOI: 10.1136/fmch-2024-002791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Abstract
Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'IV: perspectives on practice-lenses of appreciation', authors address the following themes: 'Relational connections in the doctor-patient partnership', 'Feminism and family medicine', 'Positive family medicine', 'Mindful practice', 'The new, old ethics of family medicine', 'Public health, prevention and populations', 'Information mastery in family medicine' and 'Clinical courage.' May readers nurture their curiosity through these essays.
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Affiliation(s)
- William B Ventres
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Leslie A Stone
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Radeeb Akhtar
- Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jeffrey M Ring
- Independent Health Psychologist, Los Angeles, California, USA
| | - Lucy M Candib
- Family Medicine and Community Health, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Erick Messias
- Psychiatry and Behavioral Neurosciences, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Ronald M Epstein
- Family Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Marc Tunzi
- Family Medicine Residency Program, Natividad Medical Center, Salinas, California, USA
| | - Amy L Lee
- Family Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Christopher P Morley
- Public Health and Preventive Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Carina M Brown
- Cone Health Family Medicine Residency, The University of North Carolina School of Medicine, Greensboro, North Carolina, USA
| | - David Slawson
- Family Medicine, Atrium Health, Charlotte, North Carolina, USA
| | - Jill Konkin
- Family Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - David G Campbell
- Cunninghame Arm Medical Centre, Australian College of Rural and Remote Medicine, Lakes Entrance, Queensland, Australia
| | - Ian Couper
- Ukwanda Centre for Rural Health, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Susan Williams
- Adelaide Rural Clinical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Robert Brooks
- Department of Rural Health, Broken Hill University, Broken Hill, New South Wales, Australia
| | - Lucie Walters
- Adelaide Rural Clinical School, The University of Adelaide Faculty of Health and Medical Sciences, Mount Gambier, South Australia, Australia
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Epstein RM, Beach MC. "I don't need your pills, I need your attention:" Steps toward deep listening in medical encounters. Curr Opin Psychol 2023; 53:101685. [PMID: 37659284 DOI: 10.1016/j.copsyc.2023.101685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/07/2023] [Accepted: 08/07/2023] [Indexed: 09/04/2023]
Abstract
Patients highly value being listened to, taken seriously, heard, and understood; indeed, listening to patients is essential to alleviate suffering. Yet listening as a clinical skill has been virtually ignored in the training of physicians. In this paper, we synthesize literature related to listening in medicine and explore the internal and external challenges and complexity of listening - including the need to listen with a diagnostic as well as a relational ear to take in physical symptoms, emotions, and contexts - often in chaotic and time-pressured environments. We suggest physicians focus on the development of "deep listening" skills, involving cultivating curiosity, openness, reflective self-questioning, and epistemic reciprocity; we also suggest how to ensure patients know they are being listened to.
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Affiliation(s)
- Ronald M Epstein
- Center for Communication and Disparities Research, Departments of Family Medicine and Medicine (Palliative Care), Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, 1381 South Avenue, Rochester, NY 14620, USA.
| | - Mary Catherine Beach
- Department of Medicine (General Internal Medicine), School of Medicine, Berman Institute of Bioethics, Johns Hopkins University, 2024 East Monument Street, Baltimore, MD 21287, USA
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4
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Saeed F, Dahl S, Horowitz RK, Duberstein PR, Epstein RM, Fiscella KA, Allen RJ. Development and Acceptability of a Kidney Therapy Decision Aid for Patients Aged 75 Years and Older: A Design-Based Research Involving Patients, Caregivers, and a Multidisciplinary Team. Kidney Med 2023; 5:100671. [PMID: 37492114 PMCID: PMC10363565 DOI: 10.1016/j.xkme.2023.100671] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
Rationale & Objective Many older adults prefer quality of life over longevity, and some prefer conservative kidney management (CKM) over dialysis. There is a lack of patient-decision aids for adults aged 75 years or older facing kidney therapy decisions, which not only include information on dialysis and CKM but also encourage end-of-life planning. We iteratively developed a paper-based patient-decision aid for older people with low literacy and conducted surveys to assess its acceptability. Study Design Design-based research. Setting and Participants Informed by design-based research principles and theory of behavioral activation, a multidisciplinary team of experts created a first version of the patient-decision aid containing 2 components: (1) educational material about kidney therapy options such as CKM, and (2) a question prompt list relevant to kidney therapy and end-of-life decision making. On the basis of the acceptability input of patients and caregivers, separate qualitative interviews of 35 people receiving maintenance dialysis, and with the independent feedback of educated layperson, we further modified the patient-decision aid to create a second version. Analytical Approach We used descriptive statistics to present the results of acceptability surveys and thematic content analyses for patients' qualitative interviews. Results The mean age of patients (n=21) who tested the patient-decision aid was 80 years and the mean age of caregivers (n=9) was 70 years. All respondents held positive views about the educational component and would recommend the educational component to others (100% patients and caregivers). Most of the patients reported that the question prompt list helped them put concerns into words (80% patients and 88% caregivers) and would recommend the question prompt list to others (95% patients and 100% caregivers). Limitations Single-center study. Conclusions Both components of the patient-decision aid received high acceptability ratings. We plan to launch a larger effectiveness study to test the outcomes of a decision-supporting intervention combining the patient-decision aid with palliative care-based decision coaching.
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Affiliation(s)
- Fahad Saeed
- Department of Medicine, Division of Nephrology, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Department of Medicine, Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Spencer Dahl
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Robert K. Horowitz
- Department of Medicine, Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Paul R. Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ
| | - Ronald M. Epstein
- Department of Medicine, Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Kevin A. Fiscella
- Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Rebecca J. Allen
- Mount St. Joseph University, School of Behavioral and Natural Sciences, Cincinnati, OH
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5
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Kazi BS, Duberstein PR, Kluger BM, Epstein RM, Fiscella KA, Kazi ZS, Dahl SK, Allen RJ, Saeed F. Prevalence and Correlates of Preference-Concordant Care Among Hospitalized People Receiving Maintenance Dialysis. Kidney360 2023; 4:e751-e758. [PMID: 37143194 PMCID: PMC10371368 DOI: 10.34067/kid.0000000000000131] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/30/2023] [Indexed: 05/06/2023]
Abstract
Key Points A large proportion of hospitalized patients receiving dialysis report not receiving preference-concordant care. Hospitalized patients on dialysis desiring a comfort-oriented medical plan were likely to report receiving preference-concordant care. Background Preference-concordant care is a cornerstone of high-quality medical decision-making, yet the prevalence and correlates of preference-concordant care have not been well-studied in patients receiving dialysis. We surveyed hospitalized people receiving maintenance dialysis to estimate the prevalence and correlates of preference-concordant care among this population. Methods We assessed preference concordance by asking participants (223/380, 59% response rate), “How strongly do you agree or disagree that your current treatment plan meets your preference?” We assessed treatment plan preference by asking whether patients preferred a plan that focused on (1 ) extending life or (2 ) relieving pain and discomfort. We assessed shared dialysis decision-making using the 9-item Shared Decision-Making Questionnaire. We examined the differences between those reporting lack of preference-concordant care and those reporting receipt of preference-concordant care using chi-squared analyses. We also studied whether patients' treatment plan preferences or shared dialysis decision-making scores were correlated with their likelihood of receiving preference-concordant care. Results Of the 213 respondents who provided data on preference concordance, 90 (42.3%) reported that they were not receiving preference-concordant care. Patients who preferred pain and discomfort relief over life extension were less likely (odds ratio, 0.15 [95% confidence interval, 0.08 to 0.28] P = <0.0001) to report receiving preference-concordant care; patients with higher shared decision-making scores were more likely (odds ratio, 1.02 [95% confidence interval, 1.01 to 1.03], P = 0.02) to report preference-concordant care. Conclusions A substantial proportion of this sample of hospitalized people receiving maintenance dialysis reported not receiving preference-concordant care. Efforts to improve symptom management and enhance patient engagement in dialysis decision-making may improve the patients' perceptions of receiving preference-concordant care.
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Affiliation(s)
- Basil S Kazi
- Department of Internal Medicine, University of Illinois at Chicago, Chicago, Illinois
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Paul R Duberstein
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey
| | - Benzi M Kluger
- Department of Palliative Care, University of Rochester Medical Center, Rochester, New York
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Ronald M Epstein
- Department of Palliative Care, University of Rochester Medical Center, Rochester, New York
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Zain S Kazi
- Institute of Advanced Analytics, North Carolina State University, Raleigh, North Carolina
| | - Spencer K Dahl
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Rebecca J Allen
- School of Behavioral and Natural Sciences, Mount St. Joseph University, Cincinnati, Ohio
| | - Fahad Saeed
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
- Department of Nephrology, University of Rochester Medical Center, Rochester, New York
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6
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George LS, Epstein RM, Akincigil A, Saraiya B, Trevino KM, Kuziemski A, Pushparaj L, Policano E, Prigerson HG, Godwin K, Duberstein P. Psychological Determinants of Physician Variation in End-of-Life Treatment Intensity: A Systematic Review and Meta-Synthesis. J Gen Intern Med 2023; 38:1516-1525. [PMID: 36732436 PMCID: PMC10160244 DOI: 10.1007/s11606-022-08011-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/23/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Physicians treating similar patients in similar care-delivery contexts vary in the intensity of life-extending care provided to their patients at the end-of-life. Physician psychological propensities are an important potential determinant of this variability, but the pertinent literature has yet to be synthesized. OBJECTIVE Conduct a review of qualitative studies to explicate whether and how psychological propensities could result in some physicians providing more intensive treatment than others. METHODS Systematic searches were conducted in five major electronic databases-MEDLINE ALL (Ovid), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), and Cochrane CENTRAL (Wiley)-to identify eligible studies (earliest available date to August 2021). Eligibility criteria included examination of a physician psychological factor as relating to end-of-life care intensity in advanced life-limiting illness. Findings from individual studies were pooled and synthesized using thematic analysis, which identified common, prevalent themes across findings. RESULTS The search identified 5623 references, of which 28 were included in the final synthesis. Seven psychological propensities were identified as influencing physician judgments regarding whether and when to withhold or de-escalate life-extending treatments resulting in higher treatment intensity: (1) professional identity as someone who extends lifespan, (2) mortality aversion, (3) communication avoidance, (4) conflict avoidance, (5) personal values favoring life extension, (6) decisional avoidance, and (7) over-optimism. CONCLUSIONS Psychological propensities could influence physician judgments regarding whether and when to de-escalate life-extending treatments. Future work should examine how individual and environmental factors combine to create such propensities, and how addressing these propensities could reduce physician-attributed variation in end-of-life care intensity.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Kendra Godwin
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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7
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Duberstein PR, Hoerger M, Norton SA, Mohile S, Dahlberg B, Hyatt EG, Epstein RM, Wittink MN. The TRIBE model: How socioemotional processes fuel end-of-life treatment in the United States. Soc Sci Med 2023; 317:115546. [PMID: 36509614 DOI: 10.1016/j.socscimed.2022.115546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/18/2021] [Revised: 03/21/2022] [Accepted: 11/13/2022] [Indexed: 11/25/2022]
Abstract
Prior interventions have repeatedly failed to decrease the prescription and receipt of treatments and procedures that confer more harm than benefit at the End-of-Life (EoL); new approaches to intervention are needed. Ideally, future interventions would be informed by a social-ecological conceptual model that explains EoL healthcare utilization patterns, but current models ignore two facts: (1) healthcare is an inherently social activity, involving clinical teams and patients' social networks, and (2) emotions influence social activity. To address these omissions, we scaffolded Terror Management Theory and Socioemotional Selectivity Theory to create the Transtheoretical Model of Irrational Biomedical Exuberance (TRIBE). Based on Terror Management Theory, TRIBE suggests that the prospect of patient death motivates healthcare teams to conform to a biomedical norm of care, even when clinicians believe that biomedical interventions will likely be unhelpful. Based on Socioemotional Selectivity Theory, TRIBE suggests that the prospect of dwindling time motivates families to prioritize emotional goals, and leads patients to consent to disease-directed treatments they know will likely be unhelpful, as moral emotions motivate deference to the perceived emotional needs of their loved ones. TRIBE is unique among models of healthcare utilization in its acknowledgement that moral emotions and processes (e.g., shame, compassion, regret-avoidance) influence healthcare delivery, patients' interactions with family members, and patients' outcomes. TRIBE is especially relevant to potentially harmful EoL care in the United States, and it also offers insights into the epidemics of overtreatment in healthcare settings worldwide. By outlining the role of socioemotional processes in the care of persons with serious conditions, TRIBE underscores the critical need for psychological innovation in interventions, health policy and research on healthcare utilization.
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Affiliation(s)
- Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers University School of Public Heath, 683 Hoes Lane West, Piscataway, NJ, 08854, United States.
| | - Michael Hoerger
- Department of Psychology, Psychiatry, and Medicine, Tulane University, 131 S. Robertson Building, 131 S Robertson St, New Orleans, LA, 70112, United States; Tulane Cancer Center, Tulane University, 1415 Tulane Ave, New Orleans, LA, 70112, United States.
| | - Sally A Norton
- School of Nursing, University of Rochester, 255 Crittenden Blvd, Rochester, NY, 14642, United States; Department of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States.
| | - Supriya Mohile
- Department of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States; James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, 90 Crittenden Blvd, Rochester, NY, 14642, United States.
| | - Britt Dahlberg
- Center for Humanism, Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States.
| | - Erica Goldblatt Hyatt
- Rutgers School of Social Work, 536 George St, New Brunswick, NJ, 08901, United States.
| | - Ronald M Epstein
- Department of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States; James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, 90 Crittenden Blvd, Rochester, NY, 14642, United States; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States.
| | - Marsha N Wittink
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States.
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8
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Yu V, Yilmaz S, Freitag J, Loh KP, Kehoe L, Digiovanni G, Bauer J, Sanapala C, Epstein RM, Yousefi-Nooraie R, Mohile S. The role of social networks in prognostic understanding of older adults with advanced cancer. Patient Educ Couns 2023; 106:135-141. [PMID: 36270857 PMCID: PMC10069282 DOI: 10.1016/j.pec.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 10/05/2022] [Accepted: 10/13/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Explore how older patients utilize their social networks to inform prognostic understanding. METHODS In a pilot study of adults (≥65 years old) with advanced cancer, 16 patients completed surveys, social network maps, and semi-structured interviews exploring with whom they preferred to communicate about their illness. Interviews were analyzed using open-coding, and codes were categorized into emergent themes. Social network maps and themes were analyzed via mixed-methods social network analysis (MMSNA). Three case examples with diverse network characteristics and communication patterns were selected for further analysis. RESULTS Three overarching themes (i.e., prognostic understanding, social support, and therapeutic alliance) revealed that patients' prognostic understanding was strongly influenced by the quality of the social support patients perceived from members of their social networks. Patients demonstrated prognostic understanding when they reported close relationships and open communication with their network members. Case examples revealed some ways that patients sought information and had better sense of their prognosis when they had supportive social networks. CONCLUSION Findings illustrate how understanding social networks may provide information on how older adults with cancer seek, share, and process prognostic information.
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Affiliation(s)
- Veronica Yu
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Sule Yilmaz
- Department of Surgery, Division of Supportive Care in Cancer, University of Rochester Medical Center, Rochester, NY, USA.
| | - Jorie Freitag
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Kah Poh Loh
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center School of Medicine and Dentistry, Rochester, NY, USA
| | - Lee Kehoe
- Department of Surgery, Division of Supportive Care in Cancer, University of Rochester Medical Center, Rochester, NY, USA
| | - Grace Digiovanni
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Jessica Bauer
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Chandrika Sanapala
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Ronald M Epstein
- Department of Family Medicine Research, University of Rochester Medical Center School of Medicine and Dentistry, Rochester, NY, USA
| | - Reza Yousefi-Nooraie
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Supriya Mohile
- Geriatric Oncology Research, James P Wilmot Cancer Institute, University of Rochester Medical Center School of Medicine and Dentistry, Rochester, NY, USA
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9
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Dwyer LA, Epstein RM, Feeney BC, Blair IV, Bolger N, Ferrer RA. Responsive social support serves important functions in clinical communication: Translating perspectives from relationship science to improve cancer clinical interactions. Soc Sci Med 2022; 315:115521. [PMID: 36384086 PMCID: PMC9722606 DOI: 10.1016/j.socscimed.2022.115521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/26/2022] [Accepted: 11/06/2022] [Indexed: 11/09/2022]
Abstract
Patient-clinician interactions are critical to patient-centered care, including in cancer care contexts which are often defined by multiple patient-clinician interactions over an extended period. Research on these dyadic interactions has been guided by perspectives in clinical communication science, but the study of clinical communication has not been fully integrated with perspectives on interpersonal interactions from relationship science research. An overlapping concept in both fields is the concept of responsive socialsupport. In this article, we discuss responsiveness as a concept that offers opportunities for connections between these two disciplines. Next, we focus on how relationship science can be applied to research in clinical settings. We discuss how three areas of relationship science define responsiveness and have potential for extension to clinical communication: (1) (in)visibility of social support, (2) attachment orientations, and (3) shared meaning systems. We also discuss how social biases can impede responsiveness and suggest research avenues to develop ideas and understand potential challenges in connecting these two fields. Many opportunities exist for interdisciplinary theory development that can generate momentum in understanding interpersonal processes in cancer care.
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Affiliation(s)
| | - Ronald M Epstein
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Brooke C Feeney
- Department of Psychology, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Irene V Blair
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, USA
| | - Niall Bolger
- Department of Psychology, Columbia University, New York, NY, USA
| | - Rebecca A Ferrer
- Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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10
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Kehoe L, Sanapala C, DiGiovanni G, Yousefi-Nooraie R, Yilmaz S, Bauer J, Loh KP, Norton S, Duberstein P, Kamen C, Gilmore N, Gudina A, Kleckner A, Mohile S, Epstein RM. Older adults with advanced cancer are selective in sharing and seeking information with social networks. Patient Educ Couns 2022; 105:3116-3122. [PMID: 35717349 PMCID: PMC9724683 DOI: 10.1016/j.pec.2022.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 05/31/2022] [Accepted: 06/07/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Little is known about how older adults (OA) with advanced cancer interact with social network members (NM), and the nature of communication. This qualitative study aimed to characterize the processes by which OAs with cancer engage with NMs regarding their illness. METHODS OAs 65 + with advanced cancer and considering treatment (n = 29) and NMs (n = 18) underwent semi-structured interviews asking 1) about their illness understanding; 2) to identify NMs with whom OAs discuss health-related matters; and 3) to describe the content, process, and impact of those illness-related conversations. Three coders analyzed transcribed interviews. Codes were categorized and emergent themes were identified to generate hypotheses. RESULTS OAs seek NMs with medical backgrounds for cancer-related information and NMs with personal experience of a serious illness for emotional support. Patients characterize geographical location, frequency of communication, and length of NM relationship as factors that influence the nature of support the NM provides. Additionally, differences emerged between OA and NM perspectives on the depth of conversations and decision-making. CONCLUSIONS A better characterization of how OAs' seek and share information and support may improve medical communication, disease understanding, and support goals-concordant care.
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Affiliation(s)
- Lee Kehoe
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA; Division of Supportive Care in Cancer, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Chandrika Sanapala
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Grace DiGiovanni
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Reza Yousefi-Nooraie
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Sule Yilmaz
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Jessica Bauer
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Kah Poh Loh
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Sally Norton
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA; School of Nursing, University of Rochester, Rochester, NY, USA.
| | - Paul Duberstein
- Department of Health Behavior, Society and Policy, Rutgers University School of Public Health, Piscataway, NJ, USA.
| | - Charles Kamen
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA; Division of Supportive Care in Cancer, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Nikesha Gilmore
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA; Division of Supportive Care in Cancer, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Abdi Gudina
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Amber Kleckner
- School of Nursing, University of Maryland, Baltimore, MD, USA.
| | - Supriya Mohile
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Ronald M Epstein
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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11
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Epstein RM. Mechanics and gardeners: The role of mindfulness in medical education. The Clinical Teacher 2022. [DOI: 10.1111/tct.13495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Ronald M. Epstein
- Family Medicine, Oncology and Medicine
- American Cancer Society Clinical Research
- Center for Communication and Disparities Research
- Mindful Practice in Medicine
- School of Medicine and Dentistry University of Rochester Rochester NY USA
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12
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Loh KP, Seplaki CL, Sanapala C, Yousefi-Nooraie R, Lund JL, Epstein RM, Duberstein PR, Flannery M, Culakova E, Xu H, McHugh C, Klepin HD, Lin PJ, Watson E, Grossman VA, Liu JJ, Geer J, O’Rourke MA, Mustian K, Mohile SG. Association of Prognostic Understanding With Health Care Use Among Older Adults With Advanced Cancer: A Secondary Analysis of a Cluster Randomized Clinical Trial. JAMA Netw Open 2022; 5:e220018. [PMID: 35179585 PMCID: PMC8857680 DOI: 10.1001/jamanetworkopen.2022.0018] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE A poor prognostic understanding regarding curability is associated with lower odds of hospice use among patients with cancer. However, the association between poor prognostic understanding or prognostic discordance and health care use among older adults with advanced incurable cancers is not well characterized. OBJECTIVE To evaluate the association of poor prognostic understanding and patient-oncologist prognostic discordance with hospitalization and hospice use among older adults with advanced cancers. DESIGN, SETTING, AND PARTICIPANTS This was a post hoc secondary analysis of a cluster randomized clinical trial that recruited patients from October 29, 2014, to April 28, 2017. Data were collected from community oncology practices affiliated with the University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program. The parent trial enrolled 541 patients who were aged 70 years or older and were receiving or considering any line of cancer treatment for incurable solid tumors or lymphomas; the patients' oncologists and caregivers (if available) were also enrolled. Patients were followed up for at least 1 year. Data were analyzed from January 3 to 16, 2021. MAIN OUTCOMES AND MEASURES At enrollment, patients and oncologists were asked about their beliefs regarding cancer curability (100%, >50%, 50%, <50%, and 0%; answers other than 0% reflected poor prognostic understanding) and life expectancy (≤6 months, 7-12 months, 1-2 years, 2-5 years, and >5 years; answers of >5 years reflected poor prognostic understanding). Any difference between oncologist and patient in response options was considered discordant. Outcomes were any hospitalization and hospice use at 6 months captured by the clinical research associates. RESULTS Among the 541 patients, the mean (SD) age was 76.6 (5.2) years, 264 of 540 (49%) were female, and 486 of 540 (90%) were White. Poor prognostic understanding regarding curability was reported for 59% (206 of 348) of patients, and poor prognostic understanding regarding life expectancy estimates was reported for 41% (205 of 496) of patients. Approximately 60% (202 of 336) of patient-oncologist dyads were discordant regarding curability, and 72% (356 of 492) of patient-oncologist dyads were discordant regarding life expectancy estimates. Poor prognostic understanding regarding life expectancy estimates was associated with lower odds of hospice use (adjusted odds ratio, 0.30; 95% CI, 0.16-0.59). Discordance regarding life expectancy estimates was associated with greater odds of hospitalization (adjusted odds ratio, 1.64; 95% CI, 1.01-2.66). CONCLUSIONS AND RELEVANCE This study highlights different constructs of prognostic understanding and the need to better understand the association between prognostic understanding and health care use among older adult patients with advanced cancer. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02107443.
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Affiliation(s)
- Kah Poh Loh
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Christopher L. Seplaki
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Chandrika Sanapala
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Reza Yousefi-Nooraie
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Jennifer L. Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Ronald M. Epstein
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
- Department of Medicine, Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Paul R. Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey
| | - Marie Flannery
- School of Nursing, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Eva Culakova
- Department of Surgery, Cancer Control, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Huiwen Xu
- Department of Preventive Medicine and Population Health, School of Medicine, Sealy Center on Aging, University of Texas Medical Branch, Galveston
| | - Colin McHugh
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Heidi D Klepin
- Section on Hematology and Oncology, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, North Carolina
| | - Po-Ju Lin
- Department of Surgery, Cancer Control, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | | | - Jane Jijun Liu
- Heartland National Cancer Institute Community Oncology Research Program (NCORP), Decatur, Illinois
| | - Jodi Geer
- Metro Minnesota Community Oncology Research Program, St Louis Park
| | - Mark A. O’Rourke
- NCORP of the Carolinas (Greenville Health System NCORP), Greenville, South Carolina
| | - Karen Mustian
- Department of Surgery, Cancer Control, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Supriya G. Mohile
- James P. Wilmot Cancer Center, Department of Medicine, University of Rochester, Rochester, New York
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Epstein RM, Marshall F, Sanders M, Krasner MS. Effect of an Intensive Mindful Practice Workshop on Patient-Centered Compassionate Care, Clinician Well-Being, Work Engagement, and Teamwork. J Contin Educ Health Prof 2022; 42:19-27. [PMID: 34459443 DOI: 10.1097/ceh.0000000000000379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Mindfulness-based interventions for health professionals have been linked to improvements in burnout, well-being, empathy, communication, patient-centered care, and patient safety, but the optimal formats and intensity of training have been difficult to determine because of the paucity of studies and the heterogeneity of programs. A 4-days residential "Mindful Practice" workshop for physicians and medical educators featuring contemplative practices, personal narratives, and appreciative dialogs about challenging experiences may hold promise in improving participants' well-being while also improving compassionate care, job satisfaction, work engagement, and teamwork. METHODS We collected baseline and 2-month follow-up data during four workshops conducted in 2018 to 2019 at conference centers in the United States and Europe. Primary outcomes were burnout, work-related distress, job satisfaction, work engagement, patient-centered compassionate care, and teamwork. RESULTS Eighty-five of 120 participants (71%) completed both surveys (mean age was 49.3 and 68.2% female). There were improvements (P < .01) in two of three burnout components (emotional exhaustion and depersonalization), work-related distress, job satisfaction, patient-centered compassionate care, work engagement and meaning, teamwork, well-being, positive emotion, mindfulness, somatic symptoms, and spirituality. Effect sizes (standardized mean difference of change) ranged from 0.25 to 0.61. With Bonferroni adjustments (P < .0031), teamwork, general well-being, and mindfulness became nonsignificant. DISCUSSION An intensive, multiday, mindfulness-based workshop for physicians had clinically significant positive effects on clinician well-being, quality of interpersonal care and work satisfaction, and meaning and engagement, all important indicators of improved health and sustainability of the health care workforce. Future iterations of the program should increase the focus on teamwork.
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Affiliation(s)
- Ronald M Epstein
- Mr. Epstein: Professor of Family Medicine, Oncology and Medicine (Palliative Care), and American Cancer Society's Clinical Research Professor, Codirector, Center for Communication and Disparities Research, Departments of Family Medicine and Medicine and the Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY. Mr. Marshall: Professor, Department of Neurology, Division of Geriatric Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY. Mr. Sanders: Senior Instructor, Department of Family Medicine, Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY. Mr. Krasner: Professor of Clinical Medicine and Clinical Family Medicine, Departments Medicine and Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
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14
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Epstein RM. Facing epistemic and complex uncertainty in serious illness: The role of mindfulness and shared mind. Patient Educ Couns 2021; 104:2635-2642. [PMID: 34334265 DOI: 10.1016/j.pec.2021.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Epistemic uncertainty refers to situations in which available evidence is insufficient or unreliable, often accompanied by complexity due to novel contexts, multifactorial causation, and emerging options (the "unknowable unknown"). It stands in contrast to aleatory uncertainty where probabilities are known, and potential benefits and harms can be calculated and presented graphically (the "knowable unknown"). DISCUSSION Epistemic uncertainty is common, and encompasses uncertainty about the nature of the illness, whom to entrust with one's care, and one's ability to adapt and cope. Communication about the "unknowable unknown" occurs infrequently and ineffectively, and there is little research on improving communication in the face of epistemic and complex uncertainty. Terror Management Theory (TMT) predicts that in encountering serious illness, people engage in "worldview defense" - suppressing death-related thoughts, affiliating with like-minded others, and developing cognitive rigidity and intolerance of information that challenges their worldview. Mindfulness is associated with diminished defensive worldview reactions and cognitive rigidity, and greater tolerance of ambiguity. Shared mind encompasses shared understanding and affective attunement. CONCLUSION For clinicians and seriously ill patients facing epistemic uncertainty, psychologically-informed interventions that promote mindfulness and shared mind offer promise in promoting open discussions regarding prognostic uncertainty, advance care planning, and treatment decision-making.
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Affiliation(s)
- Ronald M Epstein
- Center for Communication and Disparities Research, Department of Family Medicine, and Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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15
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Harvey SB, Epstein RM, Glozier N, Petrie K, Strudwick J, Gayed A, Dean K, Henderson M. Mental illness and suicide among physicians. Lancet 2021; 398:920-930. [PMID: 34481571 PMCID: PMC9618683 DOI: 10.1016/s0140-6736(21)01596-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 04/09/2021] [Accepted: 07/01/2021] [Indexed: 12/11/2022]
Abstract
The COVID-19 pandemic has heightened interest in how physician mental health can be protected and optimised, but uncertainty and misinformation remain about some key issues. In this Review, we discuss the current literature, which shows that despite what might be inferred during training, physicians are not immune to mental illness, with between a quarter and a third reporting increased symptoms of mental ill health. Physicians, particularly female physicians, are at an increased risk of suicide. An emerging consensus exists that some aspects of physician training, working conditions, and organisational support are unacceptable. Changes in medical training and health systems, and the additional strain of working through a pandemic, might have amplified these problems. A new evidence-informed framework for how individual and organisational interventions can be used in an integrated manner in medical schools, in health-care settings, and by professional colleagues is proposed. New initiatives are required at each of these levels, with an urgent need for organisational-level interventions, to better protect the mental health and wellbeing of physicians.
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Affiliation(s)
- Samuel B Harvey
- Black Dog Institute, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia.
| | - Ronald M Epstein
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Nicholas Glozier
- Sydney School of Medicine (Central Clinical School), Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Katherine Petrie
- Black Dog Institute, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia; School of Psychiatry, UNSW Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Jessica Strudwick
- Black Dog Institute, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia
| | - Aimee Gayed
- Black Dog Institute, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia
| | - Kimberlie Dean
- School of Psychiatry, UNSW Medicine, University of New South Wales, Kensington, NSW, Australia; Justice Health and Forensic Mental Health Network, Matraville, NSW, Australia
| | - Max Henderson
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Saeed F, Shah AY, Allen RJ, Epstein RM, Fiscella KA. Communication principles and practices for making shared decisions about renal replacement therapy: a review of the literature. Curr Opin Nephrol Hypertens 2021; 30:507-515. [PMID: 34148978 PMCID: PMC8373782 DOI: 10.1097/mnh.0000000000000731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of the skill set required for communication and person-centered decision making for renal replacement therapy (RRT) choices, especially conservative kidney management (CKM). RECENT FINDINGS Research on communication and decision-making skills for shared RRT decision making is still in infancy. We adapt literature from other fields such as primary care and oncology for effective RRT decision making. SUMMARY We review seven key skills: (1) Announcing the need for decision making (2) Agenda Setting (3) Educating patients about RRT options (4) Discussing prognoses (5) Eliciting patient preferences (6) Responding to emotions and showing empathy, and (7) Investing in the end. We also provide example sentences to frame the conversations around RRT choices including CKM.
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Affiliation(s)
- Fahad Saeed
- Departments of Medicine and Public Health, Division of Nephrology
- Division of Palliative Care
- University of Rochester School of Medicine, National University of Medical Sciences
| | - Amna Yousaf Shah
- Rawalpindi, Pakistan; CITE Center, Department of Behavioral and Natural Sciences
| | | | - Ronald M Epstein
- Division of Palliative Care
- Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Kevin A Fiscella
- Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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17
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Tuch G, Sanapala C, Mohile SG, Duberstein PR, Soto-Perez-de-Celis E, Xu H, Culakova E, Flannery M, Yousefi-Nooraie R, Epstein RM, McHugh C, Aarne V, Kim H, Geer J, O'Rourke MA, Vogelzang NJ, Loh KP. Association Between Caregiver-Oncologist Discordance in Patient's Life Expectancy Estimates and Caregiver Perceived Autonomy Support by the Oncologist. Oncologist 2021; 26:e1992-e2001. [PMID: 34309111 DOI: 10.1002/onco.13913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 03/04/2021] [Accepted: 07/12/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Caregiver perceived autonomy support by the oncologist is important for caregiver well-being and may be affected by the patient's survival. We determined the association of caregiver-oncologist discordance in patient's life expectancy estimates with perceived autonomy support over time and whether the association differed by patient survival status. MATERIALS AND METHODS We used data from a geriatric assessment cluster-randomized trial (URCC 13070) that recruited patients aged at least 70 years with incurable cancer considering or receiving treatment, their caregivers, and their oncologists. At baseline, caregivers and oncologists were asked to estimate patient's life expectancy (0-6 months, 7-12 months, 1-2 years, 2-5 years, and >5 years; any difference in response was considered discordant). At 4-6 weeks, 3 months, and 6 months, caregivers completed the Health Care Climate Questionnaire (HCCQ), which measured perceived autonomy support by the oncologist. Generalized estimating equation modeling was conducted to assess the association of baseline caregiver-oncologist discordance with longitudinal HCCQ scores, stratified by patient 6-month survival status. RESULTS Discordant life expectancy estimates were present in 72.0% of dyads. In multivariate analyses, caregiver-oncologist discordance in patient's life expectancy estimates was associated with higher caregiver HCCQ scores. In stratified analysis, caregiver-oncologist discordance was associated with lower caregiver HCCQ scores (β = -3.46; 95% CI, -4.64 to -2.29) among patients who died within 6 months but with higher caregiver HCCQ scores (β = 1.33; 95% CI, 0.63-2.04) among patients who survived beyond 6 months. CONCLUSION Interventions aimed at mitigating discordance need to consider its association with caregiver perceived autonomy support and patient's survival in order to better inform caregiver expectations. IMPLICATIONS FOR PRACTICE Among patients who died within the first 6 months, caregivers who estimated a different length of life for the patient compared with oncologists were more likely to report lower support from the oncologist, whereas the opposite relationship was seen within patients who survived beyond the first 6 months. When designing interventions to improve caregiver understanding of the patient's prognosis, its relationship with caregiver-perceived support and patient's survival needs to be considered.
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Affiliation(s)
- Gina Tuch
- Department of Aged Care, Alfred Health, Melbourne, Australia
| | - Chandrika Sanapala
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York, USA
| | - Supriya G Mohile
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York, USA
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Huiwen Xu
- Department of Surgery, Cancer Control, University of Rochester Medical Center, Rochester, New York, USA
| | - Eva Culakova
- Department of Surgery, Cancer Control, University of Rochester Medical Center, Rochester, New York, USA
| | - Marie Flannery
- School of Nursing, University of Rochester Medical Center, Rochester, New York, USA
| | - Reza Yousefi-Nooraie
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Ronald M Epstein
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA.,Department of Medicine, Palliative Care, University of Rochester Medical Center, Rochester, New York, USA
| | - Colin McHugh
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York, USA
| | - Valerie Aarne
- SCOREboard Advisory Group, University of Rochester Medical Center, Rochester, New York, USA
| | - Hannah Kim
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York, USA
| | - Jodi Geer
- Metro Minnesota Community Oncology Research Program, St. Louis Park, Minnesota, USA
| | - Mark A O'Rourke
- National Cancer Institute Community Oncology Research Program (NCORP) of the Carolinas (Greenville Health System NCORP), Greenville, South Carolina, USA
| | | | - Kah Poh Loh
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York, USA
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Saeed F, Duberstein PR, Epstein RM, Lang VJ, Liebman SE. Frequency and Severity of Moral Distress in Nephrology Fellows: A National Survey. Am J Nephrol 2021; 52:487-495. [PMID: 34153971 PMCID: PMC10073901 DOI: 10.1159/000516575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/16/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Moral distress is a negative affective response to a situation in which one is compelled to act in a way that conflicts with one's values. Little is known about the workplace scenarios that elicit moral distress in nephrology fellows. METHODS We sent a moral distress survey to 148 nephrology fellowship directors with a request to forward it to their fellows. Using a 5-point (0-4) scale, fellows rated both the frequency (never to very frequently) and severity (not at all disturbing to very disturbing) of commonly encountered workplace scenarios. Ratings of ≥3 were used to define "frequent" and "moderate-to-severe" moral distress. RESULTS The survey was forwarded by 64 fellowship directors to 386 fellows, 142 of whom (37%) responded. Their mean age was 33 ± 3.6 years and 43% were female. The scenarios that most commonly elicited moderate to severe moral distress were initiating dialysis in situations that the fellow considered futile (77%), continuing dialysis in a hopelessly ill patient (81%) and carrying a high patient census (75%), and observing other providers giving overly optimistic descriptions of the benefits of dialysis (64%). Approximately 27% had considered quitting fellowship during training, including 9% at the time of survey completion. CONCLUSION A substantial majority of nephrology trainees experienced moral distress of moderate to severe intensity, mainly related to the futile treatment of hopelessly ill patients. Efforts to reduce moral distress in trainees are required.
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Affiliation(s)
- Fahad Saeed
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Department of Public Health, University of Rochester Medical Center, Rochester, NY, USA
| | - Paul R. Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Ronald M. Epstein
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- James P Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Valerie J Lang
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Division of Hospital Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Scott E. Liebman
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Epstein RM, Privitera MR. Finding Our Way Out of Burnout. JCO Oncol Pract 2021; 17:375-377. [PMID: 34152836 DOI: 10.1200/op.21.00233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ronald M Epstein
- Center for Communication and Disparities Research, University of Rochester Medical Center, Rochester, NY
| | - Michael R Privitera
- Medical Faculty and Clinician Wellness Program, University of Rochester Medical Center, Rochester, NY
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Loh KP, Seplaki C, Yousefi Nooraie R, Lund JL, Epstein RM, Duberstein P, Flannery MA, Culakova E, Xu H, Klepin HD, Lin PJ, Sanapala C, Watson E, Targia V, Vogelzang NJ, Dib EG, Onitilo AA, Mustian KM, Mohile SG. Prognostic understanding, hospitalization, and hospice use among older patients with advanced cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.12037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12037 Background: Poor prognostic understanding of curability is associated with lower hospice use in patients with advanced cancer. Little is known if this holds true for older adults specifically. In addition, prognostic understanding are variably assessed and defined in prior studies. We evaluated the associations of poor prognostic understanding and patient-oncologist discordance in both curability and survival estimates with hospitalization and hospice use in older patients with advanced cancer. Methods: We utilized data from a national geriatric assessment cluster-randomized trial (URCC 13070: PI Mohile) that recruited 541 patients aged ≥70 with incurable solid tumor or lymphoma considering any line of cancer treatment and their oncologists. At enrollment, patients and oncologists were asked about their beliefs about cancer curability (options: 100%, > 50%, 50/50, < 50%, 0%, and uncertain) and estimates of patient’s survival (options: 0-6 months, 7-12 months, 1-2 years, 2-5 years, and > 5 years). Non-0% options were considered poor understanding of curability (uncertain was removed from the analysis) and > 5 years was considered poor understanding of survival estimates. Any difference in response options was considered discordant. We used generalized estimating equations to estimate adjusted odds ratios (AOR) assessing associations of poor prognostic understanding and discordance with hospitalization and hospice use at 6 months, adjusting for covariates and practice clusters. Results: Poor prognostic understanding of curability and survival estimates occurred in 59% (206/348) and 41% (205/496) of patients, respectively. Approximately 60% (202/336) and 72% (356/492) of patient-oncologist dyads were discordant in curability and survival estimates, respectively. In the first 6 months after enrollment, 24% were hospitalized and 15% utilized hospice. Poor prognostic understanding of survival estimates was associated with lower odds of hospice use (AOR 0.30, 95% CI 0.16-0.59) (Table). Discordance in survival estimates was associated with greater odds of hospitalization (AOR 1.64, 95% CI 1.01-2.66). Conclusions: Prognostic understanding may be associated with hospitalization or hospice use depending on how patients were queried about their prognosis and whether oncologists’ estimates were considered.[Table: see text]
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Affiliation(s)
- Kah Poh Loh
- University of Rochester Medical Center, Rochester, NY
| | | | | | | | | | | | | | - Eva Culakova
- University of Rochester Medical Center, Rochester, NY
| | - Huiwen Xu
- University of Rochester Medical Center, Rochester, NY
| | - Heidi D. Klepin
- Comprehensive Cancer Center, Wake Forest Baptist Health, Winston Salem, NC
| | - Po-Ju Lin
- University of Rochester Medical Center, Rochester, NY
| | | | - Erin Watson
- University of Rochester Medical Center, Rochester, NY
| | - Valerie Targia
- Stakeholders for the Care and Research of Oncology Elders (SCOREBoard) Advisory Committee, Rochester, NY
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Loh KP, Mohamed MR, Kadambi S, Culakova E, Xu H, Magnuson A, Flannery M, Duberstein PR, Epstein RM, McHugh C, Nipp RD, Trevino KM, Sanapala C, Hall BA, Canin B, Gayle AA, Conlin A, Bearden J, Mohile SG. Caregiver-Oncologist Prognostic Concordance, Caregiver Mastery, and Caregiver Psychological Health and Quality of Life. Oncologist 2021; 26:310-317. [PMID: 33523583 PMCID: PMC8018313 DOI: 10.1002/onco.13699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 10/03/2020] [Accepted: 01/22/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Caregivers of adults with cancer often report a different understanding of the patient's prognosis than the oncologist. We examine the associations of caregiver-oncologist prognostic concordance with caregiver depressive symptoms, distress, and quality of life (QoL). We also explore whether these relationships differed by caregiver environment mastery, an individual's sense of control, and effectiveness in managing life situations. MATERIALS AND METHODS We used data from a national geriatric assessment cluster-randomized trial (URCC 13070) that recruited patients aged 70 years and older with incurable cancer considering any line of cancer treatment at community oncology practices, their caregivers, and their oncologists. At enrollment, caregivers and oncologists estimated the patient's prognosis (0-6 months, 7-12 months, 1-2 years, 2-5 years, and >5 years; identical responses were concordant). Caregivers completed the Ryff's environmental mastery at enrollment. At 4-6 weeks, caregivers completed the Patient Health Questionnaire-2 (depressive symptoms), distress thermometer, and 12-Item Short-Form Health Survey (quality of life [QoL]). We used generalized estimating equations in models adjusted for covariates. We then assessed the moderation effect of caregiver mastery. RESULTS Of 411 caregiver-oncologist dyads (mean age = 66.5 years), 369 provided responses and 28% were concordant. Prognostic concordance was associated with greater caregiver depressive symptoms (β = 0.30; p = .04) but not distress or QoL. A significant moderation effect for caregiver depressive symptoms was found between concordance and mastery (p = .01). Specifically, among caregivers with low mastery (below median), concordance was associated with greater depressive symptoms (β = 0.68; p = .003). CONCLUSIONS Caregiver-oncologist prognostic concordance was associated with caregiver depressive symptoms. We found a novel moderating effect of caregiver mastery on the relationship between concordance and caregiver depressive symptoms. IMPLICATIONS FOR PRACTICE Caregiver-oncologist prognostic concordance is associated with greater caregiver depressive symptoms, particularly in those with low caregiver mastery. When discussing prognosis with caregivers, physicians should be aware that prognostic understanding may affect caregiver psychological health and should assess their depressive symptoms. In addition, while promoting accurate prognostic understanding, physicians should also identify strengths and build resilience among caregivers.
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Affiliation(s)
- Kah Poh Loh
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Mostafa R Mohamed
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sindhuja Kadambi
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Eva Culakova
- Department of Surgery, Cancer Control, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Huiwen Xu
- Department of Surgery, Cancer Control, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Allison Magnuson
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Marie Flannery
- School of Nursing, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Ronald M Epstein
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Department of Medicine, Palliative Care, University of Rochester Medical Center, Rochester, New York, USA
| | - Colin McHugh
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Ryan D Nipp
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kelly M Trevino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Chandrika Sanapala
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Bianca A Hall
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Beverly Canin
- SCOREboard Advisory Group, University of Rochester Medical Center, Rochester, New York, USA
| | - Arlene A Gayle
- Wisconsin National Cancer Institute (NCI) Community Oncology Research Program, Wisconsin, USA
| | - Alison Conlin
- Pacific Cancer Research Consortium NCI Community Oncology Research Program, Washington, USA
| | - James Bearden
- Southeast Clinical Oncology Research Consortium, Winston-Salem, North Carolina, USA
| | - Supriya G Mohile
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Verduzco-Aguirre HC, Babu D, Mohile SG, Bautista J, Xu H, Culakova E, Canin B, Zhang Y, Wells M, Epstein RM, Duberstein P, McHugh C, Dale W, Conlin A, Bearden J, Berenberg J, Tejani M, Loh KP. Associations of Uncertainty With Psychological Health and Quality of Life in Older Adults With Advanced Cancer. J Pain Symptom Manage 2021; 61:369-376.e1. [PMID: 32822750 PMCID: PMC7854861 DOI: 10.1016/j.jpainsymman.2020.08.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/06/2020] [Accepted: 08/08/2020] [Indexed: 02/08/2023]
Abstract
CONTEXT Older adults with advanced cancer face uncertainty related to their disease and treatment. OBJECTIVES To evaluate the associations of uncertainty with psychological health and quality of life (QoL) in older adults with advanced cancer. METHODS Secondary cross-sectional analysis of baseline data from a national clustered geriatric assessment trial. Patients 70 years and older with advanced cancer considering a new line of chemotherapy were recruited. We measured uncertainty using the modified nine-item Mishel Uncertainty in Illness Scale. Dependent variables included anxiety (Generalized Anxiety Disorder-7), depression (Generalized Depression Scale-15), distress (distress thermometer), QoL (Functional Assessment of Cancer Therapy-General), and emotional well-being (Functional Assessment of Cancer Therapy-General subscale). We used multivariate linear regression analyses to evaluate the association of uncertainty with each dependent variable. We conducted a partial least squares analysis with a variable importance in projection (VIP) plot to assess the contribution of individual variables to the model. Variables with a VIP <0.8 were considered less influential. RESULTS We included 527 patients (median age 76 years; range 70-96). In multivariate analyses, higher levels of uncertainty were significantly associated with greater anxiety (β = 0.11; SE = 0.04), depression (β = 0.09; SE = 0.02), distress (β = 0.12; SE = 0.02), as well as lower QoL (β = -1.08; SE = 0.11) and emotional well-being (β = -0.29; SE = 0.03); the effect sizes were considered small. Uncertainty items related to disease and treatment were most strongly associated with psychological health and QoL scores (all VIP >0.8). CONCLUSION Uncertainty among older patients with advanced cancer is associated with worse psychological health and QoL. Tailored uncertainty management strategies are warranted.
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Affiliation(s)
- Haydee C Verduzco-Aguirre
- Department of Hemato-Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Dilip Babu
- Kaiser Permanente, Portland, Oregon, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Javier Bautista
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Huiwen Xu
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Eva Culakova
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Beverly Canin
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Yingzi Zhang
- University of Rochester School of Nursing, Rochester, New York, USA
| | - Megan Wells
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Ronald M Epstein
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Paul Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Colin McHugh
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - William Dale
- Department of Supportive Care Medicine, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Alison Conlin
- Pacific Cancer Research Consortium National Cancer Institute Community Oncology Research Program (NCORP), Seattle, Washington, USA
| | - James Bearden
- Southeast Clinical Oncology Research Consortium NCORP, Winston-Salem, North Carolina, USA
| | - Jeffrey Berenberg
- Hawaii Minority Underserved National Cancer Institute Community Oncology Research Program (MU-NCORP), Honolulu, Hawaii, USA
| | | | - Kah Poh Loh
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA.
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23
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Loh KP, Culakova E, Xu H, Kadambi SM, Magnuson A, Flannery MA, Duberstein P, Epstein RM, McHugh C, Nipp RD, Trevino KM, Sanapala C, Canin B, Gayle AA, Conlin AK, Bearden J, Mohile SG. Caregiver-oncologist concordance in patient prognosis, caregiver depression, and caregiver mastery. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
143 Background: Caregivers of older adults with advanced cancer often have a different understanding of the patient’s prognosis compared with their oncologist. Among patients, accurate prognostic awareness is associated with greater depressive symptoms, except when patients utilize more adaptive coping skills. We examined the relationship between caregiver-oncologist prognostic concordance and caregiver depressive symptoms and explored whether this relationship differed by caregiver mastery, the capacity to cope, adjust, and adapt to problems. Methods: We utilized data from a national geriatric assessment cluster-randomized trial (URCC 13070: PI Mohile) that recruited patients aged ≥70 with incurable cancer considering any line of cancer treatment at community oncology practices, their caregivers, and oncologists. At enrollment, caregivers and oncologists estimated the patient’s prognosis (0-6 months, 7-12 months, 1-2 years, 2-5 years, > 5 years); same response was considered concordant. Caregivers completed Ryff’s mastery subscale (range 7-35, higher is better) at enrollment and depression screen (the Patient Health Questionnaire (PHQ)-2 (range 0-6) 4-6 weeks later. To assess the association of prognostic concordance with caregiver depressive symptoms, we used generalized estimating equations in models adjusted for cancer type, study arm, practice sites, and caregiver demographics. We then assessed moderation effect of caregiver mastery on this association. Results: Among 410 caregiver-oncologist dyads, mean caregiver age was 66.5, 75% were female, and 26% were caregivers of patients with lung cancer. Mean mastery score at enrollment was 27.6 (SD 4.7) and 19% screened positive on PHQ-2 at week 4-6. Among dyads who provided response (N = 370), 28% were concordant. Prognostic concordance was associated with higher caregiver depressive symptoms (β = 0.30; p = 0.04). Significant moderation effect was found between concordance and mastery for caregiver depressive symptoms (p = 0.02). Among caregivers with low mastery ( < median), prognostic concordance was associated with higher depressive symptoms (β = 0.68; p = 0.003). Among caregivers with high mastery (≥median), concordance was not associated with depressive symptoms (β = -0.06; p = 0.67). Conclusions: There is a need to study how prognostic understanding might lead to depression in at-risk caregivers. Interventions targeting caregiver prognostic understanding need to consider its relationship with depressive symptoms, while seeking to increase caregiver mastery.
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Affiliation(s)
- Kah Poh Loh
- University of Rochester Medical Center, Rochester, NY
| | - Eva Culakova
- University of Rochester Medical Center, Rochester, NY
| | - Huiwen Xu
- University of Rochester Medical Center, Rochester, NY
| | | | | | | | | | | | - Colin McHugh
- University of Rochester Medical Center, Rochester, NY
| | | | | | | | - Beverly Canin
- University of Rochester Medical Center, Rochester, NY
| | | | | | - James Bearden
- Southeast Clinical Oncology Research Consortium (SCOR), Winston-Salem, NC
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Saeed F, Sardar M, Rasheed K, Naseer R, Epstein RM, Davison SN, Mujtaba M, Fiscella KA. Dialysis Decision Making and Preferences for End-of-Life Care: Perspectives of Pakistani Patients Receiving Maintenance Dialysis. J Pain Symptom Manage 2020; 60:336-345. [PMID: 32201311 PMCID: PMC7375006 DOI: 10.1016/j.jpainsymman.2020.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/11/2020] [Accepted: 03/12/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT Previous studies from the U.S. and Canada report deficiencies in informed decision making and a need to improve end-of-life (EoL) care in patients undergoing dialysis. However, there is a paucity of literature on these issues in Pakistani dialysis patients, who differ from Western patients in culture, religion, and available health care services. OBJECTIVES To study informed dialysis decision-making and EoL attitudes and beliefs in Pakistani patients receiving dialysis. METHODS We used convenience sampling to collect 522 surveys (90% response rate) from patients in seven different dialysis units in Pakistan. We used an existing dialysis survey tool, translated into Urdu, and backtranslated to English. A facilitator distributed the survey, explained questions, and orally administered it to patients unable to read. RESULTS Less than one-fourth of the respondents (23%) felt informed about their medical condition, and 45% were hopeful that their condition would improve in the future. More than half (54%) wished to know their prognosis, and 80% reported having no prognostic discussion. Almost 63% deemed EoL planning important, but only 5% recalled discussing EoL decisions with a doctor during the last 12 months. Nearly 62% of the patients regretted their decision to start dialysis. Patients' self-reported knowledge of hospice (5%) and palliative care (7.9%) services was very limited, yet 46% preferred a treatment plan focused on comfort and symptom management rather than life extension. CONCLUSION Pakistani patients reported a need for better informed dialysis decision making and EoL care and better access to palliative care services. These findings underscore the need for palliative care training of Pakistani physicians and in other developing countries to help address communication and EoL needs of their dialysis patients.
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Affiliation(s)
- Fahad Saeed
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
| | - Muhammad Sardar
- Department of Medicine, University of Arizona, Tuscan, Arizona, USA
| | - Khalid Rasheed
- Department of Medicine, Shifa medical Center, Islamabad, Pakistan
| | - Raza Naseer
- The Wright Center for Community Health, Scranton, Pennsylvania, USA
| | - Ronald M Epstein
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine and Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sara N Davison
- Division of Nephrology & Immunology, University of Alberta, Edmonton, Alberta, Canada
| | - Muhammad Mujtaba
- Division of Nephrology, Department of Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Kevin A Fiscella
- Department of Family Medicine and Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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25
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Affiliation(s)
- Ronald M Epstein
- Family Medicine, University of Rochester Medical Center, Rochester, NY, USA.
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26
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Loh KP, Xu H, Epstein RM, Mohile SG, Prigerson HG, Plumb S, Ladwig S, Kadambi S, Wong ML, McHugh C, An A, Trevino K, Saeed F, Duberstein PR. Associations of Caregiver-Oncologist Discordance in Prognostic Understanding With Caregiver-Reported Therapeutic Alliance and Anxiety. J Pain Symptom Manage 2020; 60:20-27. [PMID: 32061833 PMCID: PMC7311277 DOI: 10.1016/j.jpainsymman.2020.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 01/28/2023]
Abstract
CONTEXT Discordance in prognostic understanding between caregivers of adults with advanced cancer and the oncologist may shape caregivers' views of the oncologist and bereavement outcomes. OBJECTIVES We examined prospective associations of caregiver-oncologist discordance with caregiver-oncologist therapeutic alliance and caregiver anxiety after patient death. METHODS We conducted a secondary analysis of data collected in a cluster randomized controlled trial from August 2012 to June 2014 in Western New York and California. At enrollment, caregivers and oncologists used a seven-point scale to rate their beliefs about the patient's curability and living two years or more: 100%, about 90%, about 75%, about 50 of 50, about 25%, about 10%, and 0%. Discordance was defined as a difference of two points or more. Outcomes at seven months after patient death included caregiver-oncologist therapeutic alliance (The Human Connection scale, modified into five items) and caregiver anxiety (Generalized Anxiety Disorder-7). We conducted multivariable linear regression models to assess the independent associations of discordance with alliance and anxiety. RESULTS We included 97 caregivers (mean age 63) and 38 oncologists; 41% of caregiver-oncologist dyads had discordant beliefs about the patient's curability, and 63% of caregiver-oncologist dyads had discordant beliefs about living two years or more. On multivariate analysis, discordance in beliefs about curability was associated with lower anxiety (β = -2.20; SE 0.77; P = 0.005). Discordance in beliefs about length of life was associated with a weaker alliance (β = -5.87; SE = 2.56; P = 0.02). CONCLUSION A better understanding of how caregivers understand and come to terms with poor prognoses will guide interventions to improve cancer care delivery and outcomes of cancer treatment.
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Affiliation(s)
- Kah Poh Loh
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
| | - Huiwen Xu
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Ronald M Epstein
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Supriya G Mohile
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Holly G Prigerson
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA; Cornell Center for Research on End-of-Life Care, New York, New York, USA
| | - Sandra Plumb
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Susan Ladwig
- Department of Medicine, Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sindhuja Kadambi
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Melisa L Wong
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California, USA
| | - Colin McHugh
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Amy An
- Department of Medicine, Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Kelly Trevino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Fahad Saeed
- Department of Medicine, Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
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Saeed F, Ladwig SA, Epstein RM, Monk RD, Duberstein PR. Dialysis Regret: Prevalence and Correlates. Clin J Am Soc Nephrol 2020; 15:957-963. [PMID: 32499230 PMCID: PMC7341783 DOI: 10.2215/cjn.13781119] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 04/09/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Although some patients regret the decision to start dialysis, modifiable factors associated with regret have rarely been studied. We aimed to identify factors associated with patients' regret to initiate dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A 41-item questionnaire was administered to adult patients receiving maintenance dialysis in seven dialysis units located in Cleveland, Ohio, and its suburbs. Of the 450 patients asked to participate in the study, 423 agreed and 397 provided data on decisional regret. We used multivariable logistic regression to identify predictors of regret, which was assessed using a single item, "Do you regret your decision to start dialysis?" We report adjusted odd ratios (ORs) and 95% confidence intervals (95% CIs) for the following candidate predictors: knowledge of CKD, attitudes toward CKD treatment, and preference for end-of-life care. RESULTS Eighty-two of 397 respondents (21%) reported decisional regret. There were no significant demographic correlates of regret. Regret was more common when patients reported choosing dialysis to please doctors or family members (OR, 2.34; 95% CI, 1.27 to 4.31; P<0.001). Patients who reported having a prognostic discussion about life expectancy with their doctors (OR, 0.42; 95% CI, 0.18 to 0.98; P=0.03) and those who had completed a living will (OR, 0.48; 95% CI, 0.25 to 0.95; P=0.03) were less likely to report regret with dialysis initiation. CONCLUSIONS Dialysis regret was common in this sample. Demographic factors (age, sex, marital status, race, or educational attainment) were not significantly associated with regret, but modifiable care processes were. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_06_09_CJN13781119.mp3.
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Affiliation(s)
- Fahad Saeed
- Department of Medicine, School of Public Health, Division of Nephrology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Susan A. Ladwig
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Ronald M. Epstein
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York
- Departments of Psychiatry and Family Medicine, and Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Rebeca D. Monk
- Department of Medicine, School of Public Health, Division of Nephrology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Paul R. Duberstein
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey
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28
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Loh KP, Mohile SG, Epstein RM, Duberstein PR. Helping patients to understand terrifying news: Addressing the inner lives of physicians and extending beyond what we know. Cancer 2020; 126:2713-2714. [PMID: 32073666 DOI: 10.1002/cncr.32768] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/15/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Kah Poh Loh
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Supriya G Mohile
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Ronald M Epstein
- James P. Wilmot Cancer Institute and Departments of Family Medicine, Psychiatry, and Medicine (Palliative Care Program), University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey
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Duberstein PR, Chen M, Hoerger M, Epstein RM, Perry LM, Yilmaz S, Saeed F, Mohile SG, Norton SA. Conceptualizing and Counting Discretionary Utilization in the Final 100 Days of Life: A Scoping Review. J Pain Symptom Manage 2020; 59:894-915.e14. [PMID: 31639495 PMCID: PMC8928482 DOI: 10.1016/j.jpainsymman.2019.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT There has been surprisingly little attention to conceptual and methodological issues that influence the measurement of discretionary utilization at the end of life (DIAL), an indicator of quality care. OBJECTIVE The objectives of this study were to examine how DIALs have been operationally defined and identify areas where evidence is biased or inadequate to inform practice. METHODS We conducted a scoping review of the English language literature published from 1/1/04 to 6/30/17. Articles were eligible if they reported data on ≥2 DIALs within 100 days of the deaths of adults aged ≥18 years. We explored the influence of research design on how researchers measure DIALs and whether they examine demographic correlates of DIALs. Other potential biases and influences were explored. RESULTS We extracted data from 254 articles published in 79 journals covering research conducted in 29 countries, mostly focused on cancer care (69.1%). More than 100 DIALs have been examined. Relatively crude, simple variables (e.g., intensive care unit admissions [56.9% of studies], chemotherapy [50.8%], palliative care [40.0%]) have been studied more frequently than complex variables (e.g., burdensome transitions; 7.3%). We found considerable variation in the assessment of DIALs, illustrating the role of research design, professional norms and disciplinary habit. Variables are typically chosen with little input from the public (including patients or caregivers) and clinicians. Fewer than half of the studies examined age (44.6%), gender (37.3%), race (26.5%), or socioeconomic (18.5%) correlates of DIALs. CONCLUSION Unwarranted variation in DIAL assessments raises difficult questions concerning how DIALs are defined, by whom, and why. We recommend several strategies for improving DIAL assessments. Improved metrics could be used by the public, patients, caregivers, clinicians, researchers, hospitals, health systems, payers, governments, and others to evaluate and improve end-of-life care.
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Affiliation(s)
- Paul R Duberstein
- Department of Health Behavior, Society and Policy, Rutgers University School of Public Health, Piscataway, New Jersey, USA.
| | - Michael Chen
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Michael Hoerger
- Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana, USA; Tulane Cancer Center, Tulane University, New Orleans, Louisiana, USA
| | - Ronald M Epstein
- James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Laura M Perry
- Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Sule Yilmaz
- Margaret Warner School of Human Development, Rochester, New York, USA
| | - Fahad Saeed
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sally A Norton
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; School of Nursing, University of Rochester, Rochester, New York, USA
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Hlubocky FJ, Taylor LP, Marron JM, Spence RA, McGinnis MM, Brown RF, McFarland DC, Tetzlaff ED, Gallagher CM, Rosenberg AR, Popp B, Dragnev K, Bosserman LD, Dudzinski DM, Smith S, Chatwal M, Patel MI, Markham MJ, Levit K, Bruera E, Epstein RM, Brown M, Back AL, Shanafelt TD, Kamal AH. A Call to Action: Ethics Committee Roundtable Recommendations for Addressing Burnout and Moral Distress in Oncology. JCO Oncol Pract 2020; 16:191-199. [PMID: 32223701 DOI: 10.1200/jop.19.00806] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Oncologist well-being is critical to initiating and maintaining the physician-patient relationship, yet many oncologists suffer from symptoms of burnout. Burnout has been linked to poor physical and mental health, as well as increased medical errors, patient dissatisfaction, and workforce attrition. In this Call to Action article, we discuss causes of and interventions for burnout and moral distress in oncology, highlight existing interventions, and provide recommendations for addressing burnout and improving well-being at the individual and organizational levels to deliver ethical, quality cancer care.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Abby R Rosenberg
- University of Washington School of Medicine, Department of Pediatrics, Seattle, WA
| | - Beth Popp
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | | | | | | | | | | | - Eduardo Bruera
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Marie Brown
- American Medical Association and Rush University, Chicago, IL
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Abstract
Communicating prognosis clearly and empathically can foster accurate prognostic awareness in patients with advanced cancer and their family members. Whereas patients and doctors desire clear prognostic communication, it presents many challenges in oncologic and palliative care settings. Patients with advanced cancer often have poor prognostic awareness as a result of deficiencies in doctor communication and understandable-and potentially adaptive-attempts by patients and families to reduce the threat of death and maintain hope. Interventions to promote prognostic discussion have largely succeeded in increasing the frequency, but not necessarily the quality, of such discussions, yet have failed to improve prognostic awareness. Because clear communication of prognosis is an ethical mandate, more research is needed to provide an evidence base for teaching and practice in this area.
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Affiliation(s)
| | - Josephine M Clayton
- The University of Sydney, Sydney, NSW, Australia.,Greenwich Hospital, Greenwich, Sydney, NSW, Australia
| | - Ronald M Epstein
- University of Rochester School of Medicine and Dentistry, New York, NY
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Scheepers RA, Emke H, Epstein RM, Lombarts KMJMH. The impact of mindfulness-based interventions on doctors' well-being and performance: A systematic review. Med Educ 2020; 54:138-149. [PMID: 31868262 PMCID: PMC7003865 DOI: 10.1111/medu.14020] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 10/04/2019] [Accepted: 10/14/2019] [Indexed: 05/30/2023]
Abstract
OBJECTIVES The well-being of doctors is at risk, as evidenced by high burnout rates amongst doctors around the world. Alarmingly, burned-out doctors are more likely to exhibit low levels of professionalism and provide suboptimal patient care. Research suggests that burnout and the well-being of doctors can be improved by mindfulness-based interventions (MBIs). Furthermore, MBIs may improve doctors' performance (eg in empathy). However, there are no published systematic reviews that clarify the effects of MBIs on doctor well-being or performance to inform future research and professional development programmes. We therefore systematically reviewed and narratively synthesised findings on the impacts of MBIs on doctors' well-being and performance. METHODS We searched PubMed and PsycINFO from inception to 9 May 2018 and independently reviewed studies investigating the effects of MBIs on doctor well-being or performance. We systematically extracted data and assessed study quality according to the Medical Education Research Study Quality Instrument (MERSQI), and narratively reported study findings. RESULTS We retrieved a total of 934 articles, of which 24 studies met our criteria; these included randomised, (un)controlled or qualitative studies of average quality. Effects varied across MBIs with different training contents or formats: MBIs including essential mindfulness training elements, or employing group-based training, mostly showed positive effects on the well-being or performance of doctors across different educational and hospital settings. Doctors perceived both benefits (enhanced self- and other-understanding) and challenges (time limitations and feasibility) associated with MBIs. Findings were subject to the methodological limitations of studies (eg the use of self-selected participants, lack of placebo interventions, use of self-reported outcomes). CONCLUSIONS This review indicates that doctors can perceive positive impacts of MBIs on their well-being and performance. However, the evidence was subject to methodological limitations and does not yet support the standardisation of MBIs in professional development programmes. Rather, health care organisations could consider including group-based MBIs as voluntary modules for doctors with specific well-being needs or ambitions regarding professional development.
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Affiliation(s)
- Renée A. Scheepers
- Research Group in Socio‐Medical SciencesErasmus School of Health Policy and ManagementErasmus University of RotterdamRotterdamthe Netherlands
- Professional Performance and Compassionate Care Research GroupDepartment of Medical PsychologyAmsterdam University Medical CentreUniversity of AmsterdamAmsterdamthe Netherlands
| | - Helga Emke
- Professional Performance and Compassionate Care Research GroupDepartment of Medical PsychologyAmsterdam University Medical CentreUniversity of AmsterdamAmsterdamthe Netherlands
- Department of Health SciencesFaculty of ScienceFree University of AmsterdamAmsterdamthe Netherlands
| | - Ronald M. Epstein
- Department of Family Medicine, Psychiatry and OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Kiki M. J. M. H. Lombarts
- Professional Performance and Compassionate Care Research GroupDepartment of Medical PsychologyAmsterdam University Medical CentreUniversity of AmsterdamAmsterdamthe Netherlands
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Mohile SG, Epstein RM, Hurria A, Heckler CE, Canin B, Culakova E, Duberstein P, Gilmore N, Xu H, Plumb S, Wells M, Lowenstein LM, Flannery MA, Janelsins M, Magnuson A, Loh KP, Kleckner AS, Mustian KM, Hopkins JO, Liu JJ, Geer J, Gorawara-Bhat R, Morrow GR, Dale W. Communication With Older Patients With Cancer Using Geriatric Assessment: A Cluster-Randomized Clinical Trial From the National Cancer Institute Community Oncology Research Program. JAMA Oncol 2020; 6:196-204. [PMID: 31697365 PMCID: PMC6865234 DOI: 10.1001/jamaoncol.2019.4728] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/22/2019] [Indexed: 01/19/2023]
Abstract
Importance Older patients with cancer and their caregivers worry about the effects of cancer treatment on aging-related domains (eg, function and cognition). Quality conversations with oncologists about aging-related concerns could improve patient-centered outcomes. A geriatric assessment (GA) can capture evidence-based aging-related conditions associated with poor clinical outcomes (eg, toxic effects) for older patients with cancer. Objective To determine whether providing a GA summary and GA-guided recommendations to oncologists can improve communication about aging-related concerns. Design, Setting, and Participants This cluster-randomized clinical trial enrolled 541 participants from 31 community oncology practices within the University of Rochester National Cancer Institute Community Oncology Research Program from October 29, 2014, to April 28, 2017. Patients were aged 70 years or older with an advanced solid malignant tumor or lymphoma who had at least 1 impaired GA domain; patients chose 1 caregiver to participate. The primary outcome was assessed on an intent-to-treat basis. Interventions Oncology practices were randomized to receive either a tailored GA summary with recommendations for each enrolled patient (intervention) or alerts only for patients meeting criteria for depression or cognitive impairment (usual care). Main Outcomes and Measures The predetermined primary outcome was patient satisfaction with communication about aging-related concerns (modified Health Care Climate Questionnaire [score range, 0-28; higher scores indicate greater satisfaction]), measured after the first oncology visit after the GA. Secondary outcomes included the number of aging-related concerns discussed during the visit (from content analysis of audiorecordings), quality of life (measured with the Functional Assessment of Cancer Therapy scale for patients and the 12-Item Short Form Health Survey for caregivers), and caregiver satisfaction with communication about aging-related patient concerns. Results A total of 541 eligible patients (264 women, 276 men, and 1 patient did not provide data; mean [SD] age, 76.6 [5.2] years) and 414 caregivers (310 women, 101 men, and 3 caregivers did not provide data; mean age, 66.5 [12.5] years) were enrolled. Patients in the intervention group were more satisfied after the visit with communication about aging-related concerns (difference in mean score, 1.09 points; 95% CI, 0.05-2.13 points; P = .04); satisfaction with communication about aging-related concerns remained higher in the intervention group over 6 months (difference in mean score, 1.10; 95% CI, 0.04-2.16; P = .04). There were more aging-related conversations in the intervention group's visits (difference, 3.59; 95% CI, 2.22-4.95; P < .001). Caregivers in the intervention group were more satisfied with communication after the visit (difference, 1.05; 95% CI, 0.12-1.98; P = .03). Quality of life outcomes did not differ between groups. Conclusions and Relevance Including GA in oncology clinical visits for older adults with advanced cancer improves patient-centered and caregiver-centered communication about aging-related concerns. Trial Registration ClinicalTrials.gov identifier: NCT02107443.
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Affiliation(s)
- Supriya G. Mohile
- Department of Medicine, University of Rochester, Rochester, New York
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
| | - Ronald M. Epstein
- Department of Family Medicine, University of Rochester, Rochester, New York
| | - Arti Hurria
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, California
| | - Charles E. Heckler
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
- Department of Surgery, University of Rochester, Rochester, New York
| | - Beverly Canin
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
- Stakeholders for Care in Oncology and Research for our Elders, Rochester, New York
| | - Eva Culakova
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
- Department of Surgery, University of Rochester, Rochester, New York
| | - Paul Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers University School of Public Health, Piscataway, New Jersey
| | - Nikesha Gilmore
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
- Department of Surgery, University of Rochester, Rochester, New York
| | - Huiwen Xu
- Department of Medicine, University of Rochester, Rochester, New York
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
| | - Sandy Plumb
- Department of Medicine, University of Rochester, Rochester, New York
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
| | - Megan Wells
- Department of Medicine, University of Rochester, Rochester, New York
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
| | - Lisa M. Lowenstein
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
| | - Marie A. Flannery
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
- University of Rochester School of Nursing, Rochester, New York
| | - Michelle Janelsins
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
- Department of Surgery, University of Rochester, Rochester, New York
| | - Allison Magnuson
- Department of Medicine, University of Rochester, Rochester, New York
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
| | - Kah Poh Loh
- Department of Medicine, University of Rochester, Rochester, New York
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
| | - Amber S. Kleckner
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
- Department of Surgery, University of Rochester, Rochester, New York
| | - Karen M. Mustian
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
- Department of Surgery, University of Rochester, Rochester, New York
| | - Judith O. Hopkins
- Novant Health Oncology Specialists, Winston-Salem, North Carolina
- Southeast Clinical Oncology Research Consortium National Cancer Institute Community Oncology Research Program, Winston-Salem, North Carolina
| | - Jane Jijun Liu
- Heartland Cancer Research National Cancer Institute Community Oncology Research Program, Decatur, Illinois
| | - Jodi Geer
- Metro Minnesota Community Oncology Research Program, St Louis Park
| | | | - Gary R. Morrow
- University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program Research Base, Rochester, New York
- Department of Surgery, University of Rochester, Rochester, New York
| | - William Dale
- Department of Supportive Care, City of Hope National Medical Center, Duarte, California
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An AW, Ladwig S, Epstein RM, Prigerson HG, Duberstein PR. The impact of the caregiver-oncologist relationship on caregiver experiences of end-of-life care and bereavement outcomes. Support Care Cancer 2020; 28:4219-4225. [DOI: 10.1007/s00520-019-05185-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 11/07/2019] [Indexed: 11/29/2022]
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Loh KP, Soto Pérez de Celis E, Duberstein PR, Culakova E, Epstein RM, Xu H, Kadambi S, Flannery M, Magnuson A, McHugh C, Trevino KM, Tuch G, Ramsdale E, Yousefi-Nooraie R, Sedenquist M, Liu JJ, Melnyk N, Geer J, Mohile SG. Patient and caregiver agreement on prognosis estimates for older adults with advanced cancer. Cancer 2020; 127:149-159. [PMID: 33036063 PMCID: PMC7736110 DOI: 10.1002/cncr.33259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 11/27/2019] [Revised: 07/06/2020] [Accepted: 08/07/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Disagreements between patients and caregivers about treatment benefits, care decisions, and patients' health are associated with increased patient depression as well as increased caregiver anxiety, distress, depression, and burden. Understanding the factors associated with disagreement may inform interventions to improve the aforementioned outcomes. METHODS For this analysis, baseline data were obtained from a cluster-randomized geriatric assessment trial that recruited patients aged ≥70 years who had incurable cancer from community oncology practices (University of Rochester Cancer Center 13070; Supriya G. Mohile, principal investigator). Patient and caregiver dyads were asked to estimate the patient's prognosis. Response options were 0 to 6 months, 7 to 12 months, 1 to 2 years, 2 to 5 years, and >5 years. The dependent variable was categorized as exact agreement (reference), patient-reported longer estimate, or caregiver-reported longer estimate. The authors used generalized estimating equations with multinomial distribution to examine the factors associated with patient-caregiver prognostic estimates. Independent variables were selected using the purposeful selection method. RESULTS Among 354 dyads (89% of screened patients were enrolled), 26% and 22% of patients and caregivers, respectively, reported a longer estimate. Compared with dyads that were in agreement, patients were more likely to report a longer estimate when they screened positive for polypharmacy (β = 0.81; P = .001), and caregivers reported greater distress (β = 0.12; P = .03). Compared with dyads that were in agreement, caregivers were more likely to report a longer estimate when patients screened positive for polypharmacy (β = 0.82; P = .005) and had lower perceived self-efficacy in interacting with physicians (β = -0.10; P = .008). CONCLUSIONS Several patient and caregiver factors were associated with patient-caregiver disagreement about prognostic estimates. Future studies should examine the effects of prognostic disagreement on patient and caregiver outcomes.
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Affiliation(s)
- Kah Poh Loh
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Enrique Soto Pérez de Celis
- Department of Geriatrics, Salvador Zubiran National Institute of Medical Sciences and Nutrition, Mexico City, Mexico
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey
| | - Eva Culakova
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Ronald M Epstein
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York.,Department of Family Medicine, University of Rochester Medical Center, Rochester, New York.,Department of Psychiatry, University of Rochester Medical Center, Rochester, New York.,Department of Medicine, Palliative Care, University of Rochester Medical Center, Rochester, New York
| | - Huiwen Xu
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York.,Department of Surgery, Cancer Control, University of Rochester Medical Center, Rochester, New York
| | - Sindhuja Kadambi
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Marie Flannery
- School of Nursing, University of Rochester Medical Center, Rochester, New York
| | - Allison Magnuson
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Colin McHugh
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Kelly M Trevino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gina Tuch
- Department of Aged Care, Alfred Health, Melbourne, Victoria, Australia
| | - Erika Ramsdale
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Reza Yousefi-Nooraie
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Margaret Sedenquist
- SCOREboard Advisory Group, University of Rochester Medical Center, Rochester, New York
| | - Jane Jijun Liu
- Heartland National Cancer Institute Community Oncology Research Program (NCORP), Decatur, Illinois
| | | | - Jodi Geer
- Metro-Minnesota NCORP, St Paul, Minnesota
| | - Supriya G Mohile
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
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Trevino KM, Prigerson HG, Epstein RM, Duberstein PR. Reply to Hope, optimism, and the importance of caregivers in end-of-life care. Cancer 2019; 125:4330-4331. [PMID: 31381145 DOI: 10.1002/cncr.32441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kelly M Trevino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Holly G Prigerson
- Department of Medicine, Weill Cornell Medicine, New York, New York.,Department of Medicine, New York Presbyterian Hospital, New York, New York
| | - Ronald M Epstein
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
| | - Paul R Duberstein
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York.,Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, New Brunswick, New Jersey
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Saeed F, Adams H, Epstein RM. Matters of Life and Death: Why Do Older Patients Choose Conservative Management? Am J Nephrol 2019; 51:35-42. [PMID: 31775149 PMCID: PMC10073899 DOI: 10.1159/000504692] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 11/09/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although many older patients with end-stage renal disease and limited prognoses prefer conservative management (CM), it is not widely offered in the United States. Moreover, there is a dearth of US-based literature reporting clinical experience with shared decision making regarding CM of advanced chronic kidney disease (CKD). METHODS We describe the clinical experience of 13 patients who opted for CM at the University of Rochester Medical Center's CKD clinic during 2016-2017. Main outcomes include: (1) reason for choosing CM, (2) completion of advance directives, (3) location of death, and (4) utilization of hospice service. Patients' reasons for choosing CM were categorized into 4 broad categories based on a review of their electronic medical records. A retrospective chart review conducted by 2 reviewers determined the status of advance care planning, hospice referral, and place of death. RESULTS The mean age of these patients was 81.8 years (SD 7.3). Their reasons for choosing CM included: poor prognoses; a wish to maintain their quality of life; their desire for a dignified life closure; and the intention to protect family members from having to see them suffer, based on their own memory of having witnessed a relative on dialysis previously. A total of 8 patients died: all received hospice services, 6 died at home, one at a nursing home, and one at a hospital. Advance care planning was completed in 100% of the cases. Symptoms were managed in collaboration with primary care physicians. CONCLUSION Patients' decisions to choose CM were influenced by their values and previous experience with dialysis, in addition to comorbidities and limited prognoses. Promoting the choice of CM in the United States will require training of clinicians in primary palliative care competencies, including communication and decision-making skills, as well as basic symptom management proficiencies.
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Affiliation(s)
- Fahad Saeed
- Department of Medicine, Division of Nephrology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA,
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA,
- Department of Public Health, University of Rochester, Rochester, New York, USA,
| | - Hugh Adams
- Department of Medicine, Division of Nephrology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Ronald M Epstein
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Department of Psychiatry and Family Medicine and Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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An AW, McHugh C, Nicholls LE, Epstein RM, Tejani MA. Balanced framing in prognostic discussions among patients with advanced cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.31_suppl.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
22 Background: Prognostic awareness, which incorporates understanding of treatment goals, curability, life-expectancy, and anticipated course of illness, is critical to informed decision-making. In this qualitative study, we explored how balanced framing is utilized during prognostic discussions in oncology office visits. Methods: We (2 oncologists, 3 palliative care physicians) performed a secondary analysis of transcripts of audio-recorded visits between oncologists, caregivers, and patients with advanced cancer obtained as part of a large NIH-funded study. Transcripts were from one study site and included a variety of oncologists, cancer sites, and levels of patient prognostic awareness, as defined by concordance with the oncologist. For analysis, we chose transcripts with some discussion relating to prognosis (eg. treatment goals, etc.). We met regularly to identify themes contributing to prognostic awareness. Differences were reconciled via group discussion. This process continued iteratively until saturation was achieved (n = 24). Results: Prognosis content was reviewed during discussion of treatment goals (n = 15), life-expectancy (n = 14), and future planning (n = 18). In 8 examples of balanced framing of treatment options, oncologists acknowledged the uncertain benefit of treatment and considered patient quality of life; in 7 that did not, oncologists presented treatment as default and emphasized positive outcomes. In 8 examples of balanced framing in estimating life-expectancy, oncologists presented patient-specific ranges and acknowledged exceptionally long and short survival possibilities; in 6 that did not, oncologists provided broad ranges or focused on unusually long survival. In 6 examples of balanced framing in future planning, oncologists acknowledged best supportive care as an alternative to treatment; of 12 that did not, only the next line in treatment or clinical trial was discussed. Conclusions: Although prior research suggests that balanced framing is uncommon, we have identified occasions in which it occurs and characterized how it can be accomplished in prognostic discussions. Further study is needed to better understand the effect of balanced framing on patient prognostic awareness.
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Affiliation(s)
- Amy W. An
- University of Rochester Medical Center, Rochester, NY
| | - Colin McHugh
- University of Rochester Medical Center, Rochester, NY
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Loh KP, Xu H, Epstein RM, Mohile SG, Prigerson HG, Plumb S, Ladwig S, Wong ML, Kadambi SM, McHugh C, An AW, Trevino KM, Saeed F, Duberstein P. Associations of caregiver-oncologist discordance in prognostic understanding with caregiver-reported therapeutic alliance and anxiety. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.31_suppl.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
15 Background: Discordance in prognostic understanding between caregivers of adults with cancer and the patient’s oncologist is common. However, the relationship between caregiver-oncologist discordance and caregiver bereavement outcomes is unknown. We evaluated the associations of caregiver-oncologist discordance in beliefs about the patient’s curability and life expectancy with caregiver-reported therapeutic alliance and anxiety. Methods: This is a secondary analysis of a multicenter study that assessed the effect of a communication intervention among patients with advanced cancer and their caregivers. Prior to intervention exposure, caregivers and oncologists were asked about their belief in the patient’s chances for cure and living ≥2 years: 100%, about 90%, about 75%, about 50/50, about 25%, about 10%, and 0%. Discordance was defined as a difference by 2 response levels on each prognostic understanding item. Outcomes at 7 months after patient death included caregiver-reported therapeutic alliance [modified 5-item Human Connection (THC) scale] and anxiety (Generalized Anxiety Disorder-7). We used multivariable linear regression models to assess the independent associations of discordance with therapeutic alliance and anxiety. Results: We included 97 caregivers (mean age 63, range 22-83). Approximately 40% of caregiver-oncologist dyads had discordant beliefs about curability (caregivers were more optimistic in 100% of dyads) and 63% had discordant beliefs about life expectancy (caregivers were more optimistic in 94% of dyads). On multivariate analysis, discordance in beliefs about prognostic estimates was associated with lower THC score (b = -6.94, SE 3.17, p = 0.03). Discordance in beliefs about curability was associated with lower anxiety levels (b = -1.79, SE 0.90, p = 0.05). Conclusions: Caregiver-oncologist discordance may decrease caregiver-reported therapeutic alliance and anxiety, both of which may shape how caregivers interact with the healthcare system. A better understanding the role of caregivers’ prognostic understanding will guide interventions to improve caregiver-oncologist therapeutic alliance and caregiver anxiety. Clinical trial information: NCT01485627.
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Affiliation(s)
- Kah Poh Loh
- University of Rochester Medical Center, Rochester, NY
| | - Huiwen Xu
- University of Rochester Medical Center, Rochester, NY
| | | | | | | | - Sandy Plumb
- University of Rochester Medical Center, Rochester, NY
| | - Susan Ladwig
- University of Rochester Medical Center, Rochester, NY
| | | | | | - Colin McHugh
- University of Rochester Medical Center, Rochester, NY
| | - Amy W. An
- University of Rochester Medical Center, Rochester, NY
| | | | - Fahad Saeed
- University of Rochester Medical Center, Rochester, NY
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40
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Duberstein PR, Kravitz RL, Fenton JJ, Xing G, Tancredi DJ, Hoerger M, Mohile SG, Norton SA, Prigerson HG, Epstein RM. Physician and Patient Characteristics Associated With More Intensive End-of-Life Care. J Pain Symptom Manage 2019; 58:208-215.e1. [PMID: 31004774 PMCID: PMC6679778 DOI: 10.1016/j.jpainsymman.2019.04.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/12/2019] [Accepted: 04/12/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties. OBJECTIVE To test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL. METHODS We report secondary analyses of data collected prospectively from physicians (n = 38) and patients with advanced cancer (n = 265) in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15-31 days before death [scored 1], and >31 days [scored 0]) and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0]) in the last month of life. RESULTS Chemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95% CI = 0.047-0.429) or reported an unfavorable attitude toward palliative care (0.247 points, 95% CI = 0.047-0.450). A two-standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95% CI = 0.03-0.66) for chemotherapy and 0.33 (95% CI = 0.04-0.61) for emergency department visits/inpatient admissions. There was no evidence of effect modification. CONCLUSION Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.
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Affiliation(s)
- Paul R Duberstein
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Health Behavior, Society, and Policy, Rutgers University School of Public Heath, Piscataway, New Jersey, USA.
| | - Richard L Kravitz
- Department of Internal Medicine, University of California, Davis, Sacramento, California, USA; Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA; UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento, California, USA
| | - Joshua J Fenton
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA; UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento, California, USA; Department of Family and Community Medicine, University of California, Davis, Sacramento, California, USA
| | - Guibo Xing
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA
| | - Daniel J Tancredi
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA; Department of Pediatrics, University of California, Davis, Sacramento, California, USA
| | - Michael Hoerger
- Tulane Cancer Center, Tulane University, New Orleans, Louisiana, USA; Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sally A Norton
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; School of Nursing, University of Rochester, Rochester, New York, USA
| | - Holly G Prigerson
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA; Cornell Center for Research on End-of-Life Care, New York, New York, USA
| | - Ronald M Epstein
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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41
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Duberstein PR, Maciejewski PK, Epstein RM, Fenton JJ, Chapman B, Norton SA, Hoerger M, Wittink MN, Tancredi DJ, Xing G, Mohile S, Kravitz RL, Prigerson HG. Effects of the Values and Options in Cancer Care Communication Intervention on Personal Caregiver Experiences of Cancer Care and Bereavement Outcomes. J Palliat Med 2019; 22:1394-1400. [PMID: 31237459 DOI: 10.1089/jpm.2019.0078] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 12/27/2022] Open
Abstract
Background: Care teams are increasingly expected to attend to the needs of patient's personal caregivers (e.g., family members). Improving communication among oncologists, patients with advanced cancer, and their personal caregivers might enhance caregivers' experiences of end-of-life (EoL) cancer care and bereavement outcomes. Objective: To explore the effects of the Values and Options in Cancer Care intervention on caregivers' experiences of EoL care and bereavement outcomes. Design: We developed a brief behavioral intervention to improve communication among oncologists, patients with advanced cancer, and their personal caregivers. The intervention was designed to help patients/caregivers ask questions, express concerns, and help oncologists respond effectively. We randomly assigned oncologists (and their patients/caregivers) to the intervention or usual care. Setting/Subjects: Medical oncologists in NY and CA; patients/personal caregivers with advanced cancer. Measurements: Two months after the patient's death, caregivers completed three instruments assessing their experiences of EoL care. Seven months after the patient's death, caregivers completed the Prolonged Grief Disorder-13 (PG-13; primary prespecified outcome), the Purpose-in-Life scale, and scales assessing mental health function, depression, and anxiety. Results: The intervention did not significantly improve caregivers' scores on the PG-13 (p = 0.21), mental health function, depression, or anxiety, but it did improve purpose-in-life scores (p = 0.018). Cohen's d (95% confidence interval) for all three experiences of EoL care outcomes were promising, ranging from 0.22 (-0.19 to 0.63) to 0.39 (-0.07 to 0.86) although none was statistically significant. Conclusion: Preliminary findings show promise that scalable interventions in cancer care settings may improve caregiver experiences with cancer care and some bereavement outcomes.
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Affiliation(s)
- Paul R Duberstein
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Health Behavior, Society, and Policy, Rutgers University School of Public Heath, Piscataway, New Jersey
| | - Paul K Maciejewski
- Department of Radiology, Department of Medicine, Weill Cornell Medical College, New York, New York.,Cornell Center for Research on End-of-Life Care, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Ronald M Epstein
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.,James P Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Joshua J Fenton
- Department of Family and Community Medicine, University of California, Davis, Sacramento, California.,UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento, California.,Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California
| | - Benjamin Chapman
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Sally A Norton
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.,School of Nursing, University of Rochester, Rochester, New York
| | - Michael Hoerger
- Tulane Cancer Center, Tulane University, New Orleans, Louisiana.,Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana
| | - Marsha N Wittink
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Daniel J Tancredi
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California.,Department of Pediatrics, University of California, Davis, Sacramento, California
| | - Guibo Xing
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California
| | - Supriya Mohile
- James P Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Richard L Kravitz
- UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento, California.,Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California.,Department of Internal Medicine, University of California, Davis, Sacramento, California
| | - Holly G Prigerson
- Cornell Center for Research on End-of-Life Care, Department of Medicine, Weill Cornell Medical College, New York, New York.,Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
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Ingersoll LT, Alexander SC, Priest J, Ladwig S, Anderson W, Fiscella K, Epstein RM, Norton SA, Gramling R. Racial/ethnic differences in prognosis communication during initial inpatient palliative care consultations among people with advanced cancer. Patient Educ Couns 2019; 102:1098-1103. [PMID: 30642715 DOI: 10.1016/j.pec.2019.01.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/12/2018] [Accepted: 01/02/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE We examined whether conversations involving Black or Latino patients with advanced cancer differ in the presence or characteristics of prognosis communication. METHODS We audio-recorded initial consultations between 54 palliative care clinicians and 231 hospitalized people with advanced cancer. We coded for the presence and characteristics of prognosis communication. We examined whether the presence or characteristics of prognosis communication differed by patients' self-reported race/ethnicity. RESULTS In 231 consultations, 75.7% contained prognosis communication. Prognosis communication was less than half as likely to occur during conversations with Black or Latino patients (N = 48) compared to others. Among consultations in which prognosis was addressed, those involving Black or Latino patients were more than 8 times less likely to contain optimistically cued prognoses compared to others. CONCLUSION Prognosis communication occurred less frequently for Black and Latino patients and included fewer optimistic cues than conversations with other patients. More work is needed to better understand these observed patterns of prognosis communication that vary by race and ethnicity. PRACTICE IMPLICATIONS Growing evidence supports prognosis communication being important for end-of-life decision-making and disproportionately rare among non-White populations. Therefore, our findings identify a potentially salient target for clinical interventions that are focused on ameliorating disparities in end-of-life care.
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Affiliation(s)
- Luke T Ingersoll
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America.
| | - Stewart C Alexander
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Jeff Priest
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Susan Ladwig
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Wendy Anderson
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Kevin Fiscella
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Ronald M Epstein
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Sally A Norton
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Robert Gramling
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
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Trevino KM, Prigerson HG, Shen MJ, Tancredi DJ, Xing G, Hoerger M, Epstein RM, Duberstein PR. Association between advanced cancer patient-caregiver agreement regarding prognosis and hospice enrollment. Cancer 2019; 125:3259-3265. [PMID: 31145833 PMCID: PMC6717015 DOI: 10.1002/cncr.32188] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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: 11/10/2018] [Revised: 03/12/2019] [Accepted: 04/23/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with advanced, incurable cancer who understand their illness is incurable are more likely to prefer hospice care at the end of life compared with patients who believe their illness is curable. To the authors' knowledge, it is unclear whether patient-caregiver agreement regarding perceived prognosis is associated with hospice enrollment. METHODS The current study examined the prospective relationship between patient-caregiver agreement concerning perceived prognosis and hospice enrollment in the last 30 days of life. Data were collected during a cluster randomized controlled trial examining a communication intervention for oncologists and patients with advanced cancer and their caregivers. At the time of study entry, patients and caregivers (141 dyads) were categorized as endorsing a "good" prognosis if they: 1) reported a >50% chance of surviving ≥2 years; or if they 2) predicted that the patient's quality of life 3 months into the future would be ≥7 on an 11-point scale. RESULTS Approximately one-fifth of dyads agreed on a poor prognosis whereas approximately one-half disagreed regarding prognosis. In approximately one-third of dyads, patients and caregivers both believed the patient's future quality of life would be good (34%) and that the patient would live for ≥2 years (30%). Patients in these dyads were less likely to enroll in hospice compared with patients in dyads who disagreed and those who agreed on a shorter life expectancy and poor future quality of life. CONCLUSIONS Dyadic understanding of patients' projected life expectancy and future quality of life appears to be predictive of care received at the end of life. Improving rates of hospice enrollment may be best achieved with dyadic interventions.
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Affiliation(s)
- Kelly M Trevino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Holly G Prigerson
- Department of Medicine, Weill Cornell Medicine, New York, New York.,Department of Medicine, New York Presbyterian Hospital, New York, New York
| | - Megan Johnson Shen
- Department of Medicine, Weill Cornell Medicine, New York, New York.,Department of Medicine, New York Presbyterian Hospital, New York, New York
| | - Daniel J Tancredi
- Department of Pediatrics, University of California at Davis, Davis, California
| | - Guibo Xing
- Department of Pediatrics, University of California at Davis, Davis, California
| | - Michael Hoerger
- Department of Psychology, Tulane University, New Orleans, Louisiana
| | - Ronald M Epstein
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
| | - Paul R Duberstein
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York.,Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, New Brunswick, New Jersey
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Flannery MA, Culakova E, Loh KP, Epstein RM, Kamen CS, Obrecht S, Melnyk N, Whitehead MI, Geer J, Giguere JK, Mustian KM, Duberstein P, Dale W, Mohile SG. Improving person-centered communication of goals, proxy, and advance directives in older patients with advanced cancer: Secondary analysis from a University of Rochester NCI Community Oncology Research Program (NCORP) cluster randomized controlled trial (CRCT). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.11523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11523 Background: Quality person-centered care relies on effective communication between the clinical team and the patient/caregiver eliciting goals and discussing wishes. In a PCORI- and NCI-funded CRCT, we found that providing community-based oncologists with geriatric assessment-guided recommendations led to more and higher quality discussions of age-related issues for older patients with advanced cancer. In this secondary analysis, we assessed whether specific recommendations to oncologists to discuss patient goals, proxy and advance directives resulted in increased communication about these topics. Methods: Patients aged 70+ with advanced solid tumors or lymphoma and at least one impaired geriatric domain (e.g., function, cognition) were enrolled (URCC 13070; PI: Mohile). Oncology practices were randomized to the intervention (oncologists received recommendations to elicit goals and discuss wishes) or usual care. The clinic visit after the oncologist received recommendations was recorded and transcribed; two blinded coders evaluated the transcripts for discussion of the specific topic areas recommended in the intervention. Between arm differences were compared using generalized linear models controlling for practice cluster. Results: From 2014-17, 528 patients (284 intervention) provided transcripts from 31 practices (mean age = 77, range 70-96 years; 49% female; mixed cancer diagnoses). Topics related to patient goals, proxy and advance directive wishes were more often discussed in the intervention arm (goals of care preferences: 9 vs 2%, p = .02, treatment goals: 35 vs 20%. p = .04, elicit caregiver input: 28 vs 3%. p < .01, assess values and goals: 25 vs 7%, p = .07, health care proxy: 40 vs 1%, p = .004, advance directive: 25 vs 1%, p = .002). Conclusions: In this community-based study of older adults providing recommendations to oncologists to discuss specific topics resulted in increased person-centered discussions with patients and caregivers about goals, proxy and advance directive wishes. However, the content areas were discussed in less than half of all visits. Clinical trial information: NCT02107443.
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Affiliation(s)
| | - Eva Culakova
- University of Rochester Medical Center, Rochester, NY
| | - Kah Poh Loh
- University of Rochester Medical Center, Rochester, NY
| | | | | | | | - Nataliya Melnyk
- Rutgers Robert Wood Johnson Medcl School, East Brunswick, NJ
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Loh KP, LeBlanc TW, Lee S, Back A, Duberstein P, Mohile SG, Epstein RM, El-Jawahri A. Prognostic understanding in hematologic malignancies: A multicenter longitudinal study. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.11524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11524 Background: Accurate prognostic understanding facilitates the receipt of goal-concordant medical care. Few studies have evaluated prognostic understanding in patients with hematologic malignancies. In this secondary analysis of a multicenter, longitudinal study of patients with hematologic malignancies referred for a second opinion hematology subspecialty consultation, we assessed changes in prognostic understanding after consultation, and predictors of post-consultation patient-oncologist prognostic discordance. Methods: Patients were recruited from 4 academic centers. Before and 1-7 days after consultation, patients were asked about their perceived chance of cure (options < 10%, 10-19%, and up to 90-100% in 10% increments, and “do not wish to answer”). Oncologists were asked the same question after consultation. Discordance was defined as a difference in response by 2 levels in the patient-oncologist dyads. We used multivariate analysis to assess the demographic and clinical predictors of patient-oncologist discordance. Results: We included 216 patients (median age 55 years, range 22-79) and 46 oncologists (47, 30-70). Overall, ≥On multivariate analysis, discordance before consultation [Odds Ratio (OR) 6.05, 95% Confidence Interval (CI) 2.96-12.36) and < college education (vs. post-graduate education; OR 2.34, 95% CI 1.09-5.14) were associated with discordance after consultation. Other patient demographics, comorbidity, cancer type, psychological distress, social support, decision-making preference, and coping strategies were not associated with discordance. Conclusions: Patient-oncologist concordance in prognostic understanding improved after subspecialty consultation, but over half of patients’ views of their prognosis remained discordant with those of their oncologists. Interventions to improve patient-oncologist communication about prognosis are needed, especially in patients with lower education level.
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Affiliation(s)
- Kah Poh Loh
- University of Rochester Medical Center, Rochester, NY
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Babu DS, Loh KP, Bautista J, Xu H, Culakova E, Canin BE, Conlin AK, Bearden J, Berenberg JL, Zhang Y, Wells M, Epstein RM, Dale W, Duberstein P, Mohile SG, Tejani MA. Associations of uncertainty with psychological status and quality of life (QoL) among 527 older patients with advanced cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.11544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11544 Background: Older patients with advanced cancer face considerable uncertainty related to their disease and treatment. The aim of our study was to evaluate the associations of uncertainty with psychological status and QoL. Methods: This is a secondary analysis of baseline data from a national geriatric assessment (GA) cluster randomized trial (URCC 13070; PI: Mohile). Patients aged ≥70 years with ≥1 GA domain impairment (e.g., function, cognition) and advanced cancer who were considering or receiving any line of cancer treatment were enrolled (n=541). Uncertainty was measured using the modified 9-item Mishel Uncertainty in Illness (MUIS), where respondents with higher scores perceive more uncertainty (range 9-45). QoL and psychological measures consisted of Functional Assessment of Cancer Therapy-General (FACT-G), emotional wellbeing (EWB; FACT-G subscale), distress (distress thermometer), anxiety (Generalized Anxiety Disorder-7), and depression (Geriatric Depression Scale-15). Multiple linear regressions were used to evaluate the associations of MUIS scores with each measure, adjusted for demographics, cancer type, and number of impaired GA domains. Results: Mean age was 77 years (SD 5, range 70-96); 26% had gastrointestinal cancer and 26% had lung cancer. Mean number of GA domain impairments was 4 (SD 1, range 1-7). Mean MUIS score was 20 (SD 5, range 9-37). On multivariate analyses, higher MUIS score was associated with lower QoL (β=-1.08, SE=0.11) and EWB (β=-0.29, SE=0.03), as well as higher distress (β=0.12, SE=0.02), anxiety (β=0.11, SE=0.04), and depression (β=0.09, SE=0.03; all P<0.01). Conclusions: Distress associated with uncertainty was common in a vulnerable population of frail older patients with advanced cancer and ≥1 GA domain impairment. A higher degree of uncertainty was associated with poorer psychological health and QoL. Our results underscore the important role that uncertainty plays in older patients' psychological status. Previous tested uncertainty management interventions (mainly including information and coping strategies) could be revised, tailored and tested to meet the unique needs of older patients with cancer. Clinical trial information: NCT02107443.
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Affiliation(s)
| | - Kah Poh Loh
- University of Rochester Medical Center, Rochester, NY
| | | | - Huiwen Xu
- University of Rochester Medical Center, Rochester, NY
| | - Eva Culakova
- University of Rochester Medical Center, Rochester, NY
| | | | | | - James Bearden
- Southeast Clinical Oncology Research Consortium (SCOR), Winston-Salem, NC
| | | | | | - Megan Wells
- University of Rochester Medical Center, Rochester, NY
| | | | - William Dale
- City of Hope National Medical Center, Duarte, CA
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Rodenbach RA, Norton SA, Wittink MN, Mohile S, Prigerson HG, Duberstein PR, Epstein RM. When chemotherapy fails: Emotionally charged experiences faced by family caregivers of patients with advanced cancer. Patient Educ Couns 2019; 102:909-915. [PMID: 30579772 PMCID: PMC6491225 DOI: 10.1016/j.pec.2018.12.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/23/2018] [Accepted: 12/12/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To explore family caregivers' emotional experiences while caring for patients with advanced cancer and navigating distressing information, awareness of dying, and difficult decisions. METHODS Qualitative descriptive study of semi-structured interviews with 92 bereaved caregivers of patients with advanced cancer. Interviews explored caregivers' experiences as patients transitioned out of active cancer treatment and neared the end of life. RESULTS Included in caregivers' characterization of this transition time were three particularly emotionally charged experiences. The first occurred when caregivers felt jolted into awareness that patients were dying.They were startled to realize that patients would die sooner than expected; some expressed frustration that they had not been adequately warned. In the second, caregivers felt conflicted when involved in decisions that pitted patients' preferences against what caregivers felt patients needed, resulting in ambivalence, guilt, and grief. Thirdly, caregivers who felt they did their best for patients expressed fulfillment and gratitude. CONCLUSION Caregivers of patients with advanced cancer face unique, emotionally charged experiences that can lead to distress and affect care at the end of life. PRACTICE IMPLICATIONS Awareness of these situations may help oncology teams to provide sufficient guidance and support, partner with caregivers to clarify patients' needs, and deliver higher quality care.
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Affiliation(s)
- Rachel A Rodenbach
- University of Pittsburgh Medical Center, 3459 5th Ave, Pittsburgh, PA, 15213, USA; Center for Communication and Disparities Research, 1381 South Ave, Rochester, NY, 14620, USA.
| | - Sally A Norton
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Marsha N Wittink
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Supriya Mohile
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Holly G Prigerson
- Weill Cornell Medicine, 413 E 69th St, New York City, NY, 10021, USA
| | - Paul R Duberstein
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA; Center for Communication and Disparities Research, 1381 South Ave, Rochester, NY, 14620, USA; Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ, 08854, USA
| | - Ronald M Epstein
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA; Center for Communication and Disparities Research, 1381 South Ave, Rochester, NY, 14620, USA
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48
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Malhotra K, Fenton JJ, Duberstein PR, Epstein RM, Xing G, Tancredi DJ, Hoerger M, Gramling R, Kravitz RL. Prognostic accuracy of patients, caregivers, and oncologists in advanced cancer. Cancer 2019; 125:2684-2692. [PMID: 31034597 DOI: 10.1002/cncr.32127] [Citation(s) in RCA: 10] [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] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 02/04/2019] [Accepted: 03/08/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND In caring for patients with advanced cancer, accurate estimation of survival is important for clinical decision making. The purpose of this study was to assess the accuracy of 2-year survival probabilities estimated by oncologists, patients, and caregivers and to identify demographic and clinical factors associated with prognostic accuracy. METHODS This was a secondary observational analysis of data obtained from a cluster randomized controlled trial. Participants included 38 oncologists, 263 patients with advanced nonhematologic cancer, and 193 of their caregivers from clinics in Sacramento and Western New York. Discrimination within each group (oncologists, patients, caregivers) was evaluated using the C statistic, whereas calibration was assessed by comparing observed to predicted 2-year mortality using the chi-square statistic. RESULTS The median survival from study entry was 18 months, and 41.8% of patients survived for 2 years. C statistics for oncologists, patients, and caregivers were 0.81 (95% CI, 0.76-0.86), 0.62 (95% CI, 0.55-0.68), and 0.72 (95% CI, 0.65-0.78), respectively; oncologists' predictions were better than the predictions of both patients (P = .001) and caregivers (P = .03). Oncologists also had superior calibration: their predictions of 2-year survival were similar to actual survival (P = .17), whereas patients' (P = .0001) and caregivers' (P = .003) predictions diverged significantly from actual survival. Although most oncologists' predictions were classified as realistic (62.0%), approximately one-half of patients' and caregivers' predictions (50.0% and 46.0%, respectively) were unduly optimistic. Among patients, nonwhite race and higher levels of social well-being predicted undue optimism (P < .05). CONCLUSIONS Compared with oncologists, patients and caregivers displayed inferior prognostic discrimination, and their predictions were poorly calibrated, primarily because of overoptimism.
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Affiliation(s)
- Kirti Malhotra
- Department of Internal Medicine, University of California at Davis, Sacramento, California
| | - Joshua J Fenton
- Department of Family and Community Medicine, University of California at Davis, Sacramento, California
| | - Paul R Duberstein
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
| | - Ronald M Epstein
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
| | - Guibo Xing
- Center for Healthcare Policy and Research, University of California at Davis, Sacramento, California
| | - Daniel J Tancredi
- Center for Healthcare Policy and Research, University of California at Davis, Sacramento, California
| | - Michael Hoerger
- Department of Psychology, Tulane University, New Orleans, Louisiana
| | - Robert Gramling
- Division of Palliative Medicine, University of Vermont, Burlington, Vermont
| | - Richard L Kravitz
- Center for Healthcare Policy and Research, University of California at Davis, Sacramento, California
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49
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Loh KP, Mohile SG, Epstein RM, McHugh C, Flannery M, Culakova E, Lei L, Wells M, Gilmore N, Babu D, Whitehead MI, Dale W, Hurria A, Wittink M, Magnuson A, Conlin A, Thomas M, Berenberg J, Duberstein PR. Willingness to bear adversity and beliefs about the curability of advanced cancer in older adults. Cancer 2019; 125:2506-2513. [PMID: 30920646 DOI: 10.1002/cncr.32074] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [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: 09/13/2018] [Revised: 01/07/2019] [Accepted: 02/28/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Older patients with advanced cancer who are 100% certain they will be cured pose unique challenges for clinical decision making, but to the authors' knowledge, the prevalence and correlates of absolute certainty about curability (ACC) are unknown. METHODS Cross-sectional data were collected in a geriatric assessment trial. ACC was assessed by asking patients, "What do you believe are the chances that your cancer will go away and never come back with treatment?" Response options were 100% (coded as ACC), >50%, 50/50, <50%, 0%, and uncertain. The willingness to bear adversity in exchange for longevity was assessed by asking patients to consider trade-offs between survival and 2 clinical outcomes that varied in abstractness: 1) maintaining quality of life (QOL; an abstract outcome); and 2) specific treatment-related toxicities (eg, nausea/vomiting, worsening memory). Logistic regression was used to assess the independent associations between willingness to bear adversity and ACC. RESULTS Of the 524 patients aged 70 to 96 years, approximately 5.3% reported that there was a 100% chance that their cancer would be cured (ACC). ACC was not found to be significantly associated with willingness to bear treatment-related toxicities, but was more common among patients who were willing to trade QOL for survival (adjusted odds ratio, 4.08; 95% CI, 1.17-14.26). CONCLUSIONS Patients who were more willing to bear adversity in the form of an abstract state, namely decreased QOL, were more likely to demonstrate ACC. Although conversations regarding prognosis should be conducted with all patients, those who are willing to trade QOL for survival may especially benefit from conversations that focus on values and emotions.
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Affiliation(s)
- Kah Poh Loh
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Supriya G Mohile
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Ronald M Epstein
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Division of Palliative Care, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Colin McHugh
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Marie Flannery
- School of Nursing, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Eva Culakova
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Lianlian Lei
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Megan Wells
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Nikesha Gilmore
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Dilip Babu
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Mary I Whitehead
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - William Dale
- Department of Supportive Care Medicine, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Arti Hurria
- Department of Supportive Care Medicine, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Marsha Wittink
- Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Allison Magnuson
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Alison Conlin
- Pacific Cancer Research Consortium National Cancer Institute Community Oncology Research Program (NCORP), Seattle, Washington
| | - Melanie Thomas
- Southeast Clinical Oncology Research Consortium (SCOR), Winston-Salem, North Carolina
| | - Jeffrey Berenberg
- Hawaii Minority Underserved National Cancer Institute Community Oncology Research Program (MU-NCORP), Honolulu, Hawaii
| | - Paul R Duberstein
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Social and Behavioral Health Sciences, Rutgers School of Public Health, New Brunswick, New Jersey
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50
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Shields CG, Griggs JJ, Fiscella K, Elias CM, Christ SL, Colbert J, Henry SG, Hoh BG, Hunte HER, Marshall M, Mohile SG, Plumb S, Tejani MA, Venuti A, Epstein RM. The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment. J Gen Intern Med 2019; 34:435-442. [PMID: 30632104 PMCID: PMC6420510 DOI: 10.1007/s11606-018-4785-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 08/30/2018] [Accepted: 11/19/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pain management racial disparities exist, yet it is unclear whether disparities exist in pain management in advanced cancer. OBJECTIVE To examine the effect of race on physicians' pain assessment and treatment in advanced lung cancer and the moderating effect of patient activation. DESIGN Randomized field experiment. Physicians consented to see two unannounced standardized patients (SPs) over 18 months. SPs portrayed 4 identical roles-a 62-year-old man with advanced lung cancer and uncontrolled pain-differing by race (black or white) and role (activated or typical). Activated SPs asked questions, interrupted when necessary, made requests, and expressed opinions. PARTICIPANTS Ninety-six primary care physicians (PCPs) and oncologists from small cities, and suburban and rural areas of New York, Indiana, and Michigan. Physicians' mean age was 52 years (SD = 27.17), 59% male, and 64% white. MAIN MEASURES Opioids prescribed (or not), total daily opioid doses (in oral morphine equivalents), guideline-concordant pain management, and pain assessment. KEY RESULTS SPs completed 181 covertly audio-recorded visits that had complete data for the model covariates. Physicians detected SPs in 15% of visits. Physicians prescribed opioids in 71% of visits; 38% received guideline-concordant doses. Neither race nor activation was associated with total opioid dose or guideline-concordant pain management, and there were no interaction effects (p > 0.05). Activation, but not race, was associated with improved pain assessment (ẞ, 0.46, 95% CI 0.18, 0.74). In post hoc analyses, oncologists (but not PCPs) were less likely to prescribe opioids to black SPs (OR 0.24, 95% CI 0.07, 0.81). CONCLUSIONS Neither race nor activation was associated with opioid prescribing; activation was associated with better pain assessment. In post hoc analyses, oncologists were less likely to prescribe opioids to black male SPs than white male SPs; PCPs had no racial disparities. In general, physicians may be under-prescribing opioids for cancer pain. TRIAL REGISTRATION NCT01501006.
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Affiliation(s)
- Cleveland G Shields
- Center for Cancer Research, Purdue University, West Lafayette, IN, USA
- Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, USA
- Human Development & Family Studies, Purdue University, West Lafayette, IN, USA
| | - Jennifer J Griggs
- Department of Internal Medicine, Hematology/ Oncology Division, and Health Management and Policy, University of Michigan School of Medicine, Ann Arbor, MI, USA
- Department of Health Management & Policy, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Kevin Fiscella
- Center for Communication and Disparities Research, University of Rochester School of Medicine, Rochester, NY, USA
- Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, NY, USA
| | - Cezanne M Elias
- Human Development & Family Studies, Purdue University, West Lafayette, IN, USA
| | - Sharon L Christ
- Human Development & Family Studies, Purdue University, West Lafayette, IN, USA
- Department of Statistics, Purdue University, West Lafayette, IN, USA
| | - Joseph Colbert
- Department of Biostatistics, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Stephen G Henry
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Beth G Hoh
- Department of Psychiatry, University of Rochester School of Medicine, Rochester, NY, USA
| | - Haslyn E R Hunte
- School of Public Health, Department of Social and Behavioral Sciences, West Virginia University, Morgantown, WV, USA
| | - Mary Marshall
- Human Development & Family Studies, Purdue University, West Lafayette, IN, USA
| | - Supriya Gupta Mohile
- James P Wilmot Cancer Center, University of Rochester School of Medicine, Rochester, NY, USA
| | - Sandy Plumb
- Center for Communication and Disparities Research, University of Rochester School of Medicine, Rochester, NY, USA
- Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA
- James P Wilmot Cancer Center, University of Rochester School of Medicine, Rochester, NY, USA
| | - Mohamedtaki A Tejani
- James P Wilmot Cancer Center, University of Rochester School of Medicine, Rochester, NY, USA
| | - Alison Venuti
- Center for Communication and Disparities Research, University of Rochester School of Medicine, Rochester, NY, USA
| | - Ronald M Epstein
- Center for Communication and Disparities Research, University of Rochester School of Medicine, Rochester, NY, USA.
- Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA.
- Department of Psychiatry, University of Rochester School of Medicine, Rochester, NY, USA.
- James P Wilmot Cancer Center, University of Rochester School of Medicine, Rochester, NY, USA.
- Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA.
- Family Medicine Research Programs, University of Rochester, Rochester, NY, USA.
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