Difficulties of Cancer Patients' Relatives in End-of-Life Discussions: Validation of a Questionnaire

CONTEXT

Despite the potential benefits and the desire for end-of-life communication, it rarely occurs in the familial context. Relatives play a significant role in the communication process; thus, it is crucial to understand the difficulties that they face.

OBJECTIVES

To develop and evaluate the relatives' version of the Difficulties in End-of-Life Discussions - Family Inventory (DEOLD-FI-r) regarding its factor structure, reliability and validity.

METHODS

Relatives of patients with advanced cancer were recruited in a German hospital. The factor structure of the questionnaire was explored. Construct validity was examined through correlations between the DEOLD-FI-r and measures of avoidance of cancer communication, quality of life, distress, and experienced difficulty during end-of-life discussions. Additionally, we examined the group difference between those who had and had not engaged in the conversation.

RESULTS

About 111 relatives completed the survey (mean age 55.5 years, 52% female). The final version of the DEOLD-FI-r contained 23 items (α = .92). The exploratory factor analysis resulted in three factors explaining 74% of the variance. Each factor described another dimension of potential communication barriers in end-of-life discussions: 1) Own emotional burden, 2) Relational and patient-related difficulties, 3) Negative attitudes. Construct validity was supported by correlations consistent with our hypotheses and less reported communication difficulty by those who had already talked about the end-of-life with their relative (t(106) = 5.38, P < .001, d = 0.8).

CONCLUSION

The results indicate that the DEOLD-FI-r is a valid and reliable instrument for the systematic assessment of difficulties in family end-of-life communication. By focusing on relatives, it complements the already validated patient-version.

Questionnaires About the End of Life for Cancer Patients - Is the Response Burden Acceptable?

CONTEXT

Research about the end of life with the help of patient-reported outcomes in vulnerable populations such as cancer patients is needed but is potentially burdensome and can therefore raise concerns.

OBJECTIVES

To assess the response burden due to questionnaires about the end of life in cancer patients and to explore associations with individual variables.

METHODS

In a cross-sectional design response burden was assessed using a six-item instrument after completion of a survey that concerned the end of life. Associations with age, gender, type of care (curative/palliative), years since diagnosis, distress, depression, anxiety, death anxiety, readiness for end-of-life conversations, and readiness for advance care planning were explored via correlational analyses and multiple regressions. Burden due to the topic of end-of-life and completing questionnaires in general was compared.

RESULTS

A total of 269 cancer patients (mean age 61.4 (SD =12.3); 59.5% male; 58.4% in palliative care) completed the survey in a German hospital. The majority did not report response burden; 29.7% reported at least some burden due to study participation. The multiple regression (F [10,26] = 9.97, p < 0.001) indicated that stable predictors of response burden were higher death anxiety (ß = 0.4), lower readiness to talk about one's end of life (ß = -0.34) and higher age (ß = 0.23). No additional subjective burden due to the topic of end-of-life was reported.

CONCLUSION

The reported response burden seems acceptable since it was generally low. However, a subgroup did report some burden. Minimising burden and enhancing participants' benefits without compromising the research quality should further influence study designs in this field.

Cancer patients' expectations of advance care planning: A typological content analysis of qualitative interviews

BACKGROUND

Advance care planning (ACP) can help to elicit cancer patients' preferences in a discussion process to promote person-centred medical decision-making. Expectations are known to be highly relevant determinants of decisional processes. So far, however, little is known about cancer patients' expectations of ACP that lead to acceptance or refusal of the programme. The presented study, therefore, aims to explore cancer patients' expectations of ACP.

METHODS

Semi-structured interviews were conducted with a purposeful sample of 27 cancer patients consenting to or refusing a newly implemented ACP programme in a German university hospital. Data were analysed using typological content analysis.

RESULTS

We identified five different expectation clusters in relation to ACP. Consenting participants held expectations about the impact of ACP that were either 'ego-centred' or 'family-centred'. Refusers had expectations based on ignorance and misinformation, or-if they had already completed an advance directive-expectations to avoid unpleasant redundancy, perceiving no additional benefit but a burden from ACP. Finally, refusers in particular expressed expectations of delegated responsibility at the end of life, including anticipation of proxy decision-making.

CONCLUSION

Our study results suggest that expectation-modifying measures could be taken to positively influence cancer patients' expectations and thus the acceptance of ACP. In this respect, reducing ignorance and misguided expectations plays a decisive role. Especially in family constellations with expected delegation of responsibility and dependence at the end of life, it might be important to promote ACP as a family-intervention to improve family outcomes.

Quality of breaking bad news to patients diagnosed with neoplasia of the uterine cervix

OBJECTIVE

Little is known about the quality of receiving bad news (BN) for women diagnosed with cervical neoplasia. We evaluated adherence to the SPIKES protocol in three cohorts of women with different stages of the disease and treatment modalities.

PATIENTS AND METHODS

We included women with cervical cancer who underwent radical vaginal trachelectomy (RVT group, n = 110), radical hysterectomy or chemo-radiation (HE/RCT group, n = 101), and women with CIN 3 treated by loop excision (CIN group, n = 108). We asked the participants about how they received the bad news delivery in reality and how they would envision an ideal communication process based on the main items of the SPIKES protocol. The participants filled out a questionnaire with 38 items of the Marburg Breaking Bad News (MABBAN) Scale representing the six SPIKES subscales.

RESULTS

Only 72% of all patients reported being satisfied with their BBN experience. The following factors were considered important by 90% of the patients: an undisturbed atmosphere, taking enough time, coherent explanation of the disease, and the possibility to ask questions. However, the reality of their experiences fell significantly short of their expectations. Asking about the patient's knowledge of the disease, addressing their concerns, allowing them to show emotions, providing clarity about the change in quality of life, informing them about alternative therapies, and involving them in further planning were also significantly lacking in the actual BBN encounters compared to the patients' preferences. The experience of RVT patients was more negative compared to the HE/RCT patients (p = 0.036). The CIN patients had an overall satisfactory impression (p < 0.0001).

CONCLUSION

The process of breaking bad news in German women diagnosed with cervical neoplasia requires substantial improvement. The SPIKES protocol can be used as a guideline for enhancement but should be supplemented by incorporating a second consultation as the norm rather than the exception. Continuous monitoring and improvement of the quality of BBN is recommended for all oncologic institutions, utilizing the MABBAN questionnaire as a valuable tool.

Cancer advance care planning: development of a screening tool

OBJECTIVES

Advance care discussions are a useful communication tools for medical preferences and beneficial for shared decision-making processes in hospital settings. The present study developed the first screening tool for need for advance care planning (ACP).

METHODS

In phase 1 (n=92), items were evaluated using feasibility analysis and item reduction. In phase 2 (n=201), reduced screening items were analysed for predictive value of need for ACP. Statistical analysis included receiver-operating characteristics analysis (area under the curve>0.80), optimal cut-off based on sensitivity and specificity, interpretation of OR and construct validity using correlation with death anxiety, communication avoidance within families and trust based on the relationship with the treating physician.

RESULTS

Participants in both phases were approximately 60 years old with non-curative prognosis. After item reduction, predictive values of four possible items with good item difficulty and discrimination were compared for mild, moderate and great levels of death anxiety. A two-item combination of I am burdened by thoughts of an unfavourable course of the disease and I am burdened by the feeling of being ill-prepared for the end of life showed best prediction of death anxiety and communication avoidance. Clinical cut-off at sum-score ≥6 was of high sensitivity (95%) and specificity (81%). Previous use of social support and readiness for ACP was related to higher chance of interest in ACP.

CONCLUSION

Screening for need of ACP is possible with two objective items and one subjective item. Positive screening therefore indicates when to offer ACP discussions and provides routine estimation of ACP need in clinical practice.

Communication with cancer patients: the perspective of caregivers versus non-caregivers in Iran

Objective

This study investigated and compared the attitudes of healthy Iranian individuals (n = 302) in forms of two groups of caregivers and non-caregivers of cancer patients about the communication with cancer patients, and their personal wish to know the diagnosis if they ever had cancer. In addition, this study aimed to identify how many participants in the caregivers' group had spoken with their family member affected by cancer about their illness.

Methods

Caregivers (50.7%) and non-caregivers (49.3%) responded to two questionnaires regarding their general attitudes about communicating with cancer patients, and their willingness to know about their illness if they had cancer.

Results

The majority of participants (92.8%), especially in the caregiver group, agreed with the right of patients to know the diagnosis and prognosis, and also wished to know if they ever had cancer. However, around 64% of caregivers never talked about cancer with the affected patients.

Conclusion

Participants generally believed that patients have the right to know the diagnosis and prognosis, and they also wished to know if they ever had cancer. However, in reality many cancer patients are not included in communication sessions in Iran. Health professionals should focus on how to create a balance between medical bioethics with cultural influences on communication with patients.

Better than expected? Predictors of coping with expectation violations in the communication about death and dying

Background

End-of-life (EOL) communication is often avoided, especially among young adults. Negative expectations concerning EOL conversations with relatives or significant others are one major reason.

Objective

To investigate how best to violate negative expectations concerning EOL conversations by identifying predictors of coping with expectation violations in this context.

Methods

Vignettes describing expectation violations in the context of EOL communication were presented to a sample of 261 university students. In a first experiment, the credibility of the expectation-disconfirming information was manipulated. In a second experiment, the valence of the disconfirming evidence was manipulated. As outcome measures, the subjective likelihood of two different responses to the expectation violation was assessed: (1) ignoring the disconfirming evidence (immunization) and (2) changing expectations (accommodation).

Results

Overall, participants experiencing a worse-than-expected event showed more immunization [F(1, 257) = 12.15, p < 0.001, ηp = 0.05], while participants experiencing a better-than-expected event showed more accommodation [F(1, 257) = 30.98, p < 0.001, ηp = 0.11]. Participants with higher fear of death [F(1, 257) = 12.24, p < 0.001, ηp = 0.05] as well as higher death avoidance tendencies [F(1, 257) = 17.16, p < 0.001, ηp = 0.06] showed less accommodation in response to a better-than-expected event.

Conclusion

In general, young adults appear to update their expectations quickly in response to unexpectedly positive experiences in the context of EOL communication. However, individuals with higher fear of death and higher death avoidance tendencies appear to be at higher risk of maintaining negative expectations despite disconfirming evidence.

Do parents get what they want during bad news delivery in NICU?

OBJECTIVES

Little is known about parents' preferences in breaking bad news (BBN) in neonatology. The study was aimed at comparing parents' experiences with their first BBN discussion with a neonatologist/pediatric surgeon to their personal preferences.

METHODS

We conducted a quantitative survey amongst 54 parents of hospitalized preterm or term infants with severe diseases in two medium-size and one small German neonatal units. Parents answered self-rated questions on how they perceived BBN during their infant's hospital stay, asking for procedure and perception of BBN, their preferences and satisfaction with BBN.

RESULTS

Overall satisfaction with BBN was moderate to high (median (min-max): 8 (1-10) on a 1-10-Likert scale). A compassionate way of disclosure correlated highest with overall satisfaction with BBN. Thorough transmission of information in an easy to understand manner emerged as another crucial point and correlated significantly to satisfaction with BBN, too. The study revealed that it was highly important for parents, that physicians had good knowledge of the infant and the course of his/her disease, which was only met in a minority of cases. Moreover, there was a major discrepancy between expected and observed professional competence of the delivering physicians. Additionally, physicians did not set aside sufficient time for BBN and parents reported a lack of transporting assurance and hope.

CONCLUSIONS

In BBN physicians should draw greatest attention to ensure understanding in parents, with good knowledge of child and disease and sufficient time in a trustworthy manner. Physicians should focus on transporting competence, trust and gentleness.

Does Educational Status Influence Parents' Response to Bad News in the NICU?

Communication in neonatal intensive care units and the relationship between families and staff have been reported to influence parental mental well-being. Research has also shown an impact of parental educational level on their well-being. However, whether different educational levels result in different reactions to breaking bad news (BBN) by physicians remains unanswered so far. We therefore examined the impact of parental level of education on their mental state after a BBN conversation and their relation to physicians. A prospective quantitative survey was conducted amongst 54 parents whose preterm or term infants were hospitalized in three German neonatal units. Parental education was classified as low (lower secondary/less (1), n: 23) or high (higher secondary/more (2), n: 31). Parents answered questions about certain aspects of and their mental state after BBN and their trust in physicians. The two groups did not differ significantly in their mental condition after BBN, with both reporting high levels of exhaustion and worries, each (median (min;max): (1): 16 (6;20) vs. (2): 14 (5;20), (scaling: 5-20)). However, lower-educated parents reported a lower trust in physicians (median (min;max): (1): 2 (0;9) vs. (2): 1 (0;6), p < 0.05 (scaling: 0-10)) and felt less safe during BBN (median (min;max): (1): 15 (9;35) vs. (2): 13 (9;33), p < 0.05). Only among higher-educated parents was trust in physicians significantly correlated with the safety and orientation provided during BBN (r: 0.583, p < 0.05, r: 0.584, p < 0.01). Concurrently, only among less-educated parents was safety correlated with the hope conveyed during BBN (r: 0.763, p < 0.01). Therefore, in BBN discussions with less-educated parents, physicians should focus more on giving them hope to promote safety.

Prolonged Grief in Times of Lockdown During the COVID-19 Pandemic

This study aimed to estimate the prevalence of prolonged grief (PG) during the COVID-19 pandemic and to analyze associated variables. 142 family members of patients who died during the lockdown at a hospital were surveyed 6 months after the death. Prolonged grief, depression and anxiety, grief rumination, and loss-related variables were captured. Logistic regression analyses were conducted to detect the associated variables of PG symptoms. Prolonged grief was present in 44.4% of the bereaved. 76.2% of the relatives reported feeling distressed due to visitor restrictions, and the majority of them were unable to bid farewell to their family member at the time of death. Pastoral or psychological care was also lacking. Low education (p < 0.001), emotional closeness (p = 0.007), loss of a spouse (p < 0.001), inability to bid farewell after death (p = 0.024), feeling of threat due to the pandemic (p < 0.001), depression (p = 0.014), and anxiety (p = 0.028) were significantly associated with prolonged grief.

The Treatment Expectation Questionnaire (TEX-Q): Validation of a generic multidimensional scale measuring patients' treatment expectations

BACKGROUND

Patients' expectations, as a central mechanism behind placebo and nocebo effects, are an important predictor of health outcomes. Yet, theoretically based generic assessment tools allowing for an integrated understanding of expectations across conditions and treatments are lacking. Based on the preliminary 35-item version, this study reports the development and validation of the Treatment Expectation Questionnaire (TEX-Q), a generic, multidimensional self-report scale measuring patients' expectations of medical and psychological treatments.

METHODS

The TEX-Q was developed in a validation sample of n = 251 patients undergoing different treatments using exploratory factor analyses and item analyses, as well as analysis of convergent and divergent validity. Confirmatory factor analysis was conducted in an independent sample of n = 303 patients undergoing cancer treatment. Two-weeks test-retest reliability was assessed in n = 28 psychosomatic outpatients.

RESULTS

Factor analyses revealed six theoretically founded stable subscales. The TEX-Q assesses expectations of treatment benefit, positive impact, adverse events, negative impact, process and behavioural control with a total of 15 items. Results for the subscales and the sum score indicated good internal consistency (α = .71-.92), moderate to high test-retest reliability (r = .39-.76) as well as good convergent validity with regard to other expectation measures (r = .42-.58) and divergent validity with regard to measures of generalized expectations (r < .32) and psychopathology (r < .28).

CONCLUSIONS

While further validation is needed, the results suggest that the TEX-Q is a valid and reliable scale for the generic, multidimensional assessment of patients' treatment expectations. The TEX-Q overcomes constraints of ad-hoc and disease-specific scales, while allowing to compare the impact of different expectation constructs across conditions and treatments.

Validation of the Readiness for End-of-Life Conversations (REOLC) scale in a German hospital setting

Objective

For every health behavior, readiness to engage is a necessary and crucial foundation for following conversations, interventions or behavior changes. The present study aims to support a one-factor structure for the Readiness for End-of-Life Conversations (REOLC) scale (Berlin et al., 2021) in a population of cancer patients (N = 295).

Methods

For validation purposes, data of patients participating in a screening development study at a university clinic was used. Model adequacy was analyzed with structural equation modelling and controlled for with goodness of fit indices: χ²-test, SRMR, rRMSEA. Discriminant and convergent validity were assessed with correlations of REOLC and psychological or health behavior measures.

Results

Factor structure was supported with good fit indices, discriminant validity and convergent validity. Readiness correlated significantly with age and reported death anxiety.

Conclusion

The REOLC scale is a reliable instrument to assess cancer patients' readiness for end-of-life conversations. Future studies may further address moderating and mediating effects of socio-demographic, medical and psychological factors.

Innovation

The assessment of readiness may further indicate anxiety levels of cancer patients and enables practitioners to provide interventions accordingly. However, in a clinical setting and especially for patients with a palliative prognosis, end-of-life care conversations may need to be introduced early.

Developing a care pathway for hospital-based advance care planning for cancer patients: A modified Delphi study

OBJECTIVES

The objective of this study is to develop a care pathway for a hospital-based advance care planning service for cancer patients.

METHODS

A web-based modified Delphi study consulted an expert panel consisting of a convenience sample of stakeholders including professionals with a special interest in advance care planning as well as a 'public and patient involvement group'. After generating ideas for core elements of a care pathway in the first round, numerical ratings and rankings informed the multi-professional research steering group's decision process eventually resulting in a final pathway.

RESULTS

The 41 participants in the Delphi study identified 177 potential core elements of the pathway in the first round. In two further rounds, consensus was reached on a final version of the pathway with 148 elements covering the 10 domains: prerequisites, organisation and coordination, identification and referral, provision of information, information sources, family involvement, advance care planning discussion, documentation, update and quality assurance.

CONCLUSION

We propose a care pathway for advance care planning for hospital patients with cancer based on the results of a Delphi study that reached consensus on an implementation strategy. Our study pioneers the standardisation of the process and provides input for further policy and research with the aim of aligning cancer patients' care with their preferences and values.

Expectations in the Communication About Death and Dying: Development and Initial Validation of the End-of-Life Conversations - Expectations Scale

End-of-life (EOL) conversations with relatives or significant others are often avoided. One reason can be negative expectations regarding these conversations. The present study was conducted to develop and initially validate the End-of-Life Conversations - Expectations Scale (EOLC-E). An exploratory factor analysis (N = 307) resulted in a 20-item version with three distinct dimensions: expected own emotional burden (α = .92), expected other person's emotional burden (α = .94) and communication self-efficacy (α = .89). The EOLC-E total score correlated significantly with communication apprehension about death (r = .62), fear of death (r = .58), death avoidance (r = .52) as well as readiness for end-of-life conversations (r = -.38) and occurrence of previous conversations (r = -.29). Results suggest that the EOLC-E is a reliable and valid instrument to assess death and dying communication expectations. This measure has utility in communication research focusing on optimizing expectations and increasing EOL communication.

Death anxiety as general factor to fear of cancer recurrence

OBJECTIVE

Fear of cancer recurrence or progress is strongly related to death anxiety in cancer patients, but due to lack of conceptualization and measurement methods, the relationship was not analyzed quantitatively before. The aim of the present study was to investigate the conceptual relationship of both constructs, with death anxiety expected to be the general construct.

METHODS

Cancer patients (N=121) participated in an online study. They provided information on socio-demographical, medical and psychological measures including death anxiety (DADDS-G) and fear of cancer recurrence or progression (FoP-Q-SF). Relation of constructs was assessed using a two-step process: Confirming individual construct structure with CFA, including correlation of constructs and modification of measurement model, followed by structural equation modeling and comparison of structure models for best model fit.

RESULTS

The measurement model was modified to include three residual correlations within and between constructs. Comparison of structure models supported a bifactor structure with death anxiety as general factor and fear of recurrence or progression as group factor: SBχ² (173)=207.74 (p<.05), SB=1.538, relative χ² =1.2, rRMSEA=0.05[.01,0.07] (p>.05), SRMR=0.07, CFI=0.94, AIC=7543.60.

CONCLUSIONS

Death anxiety can be interpreted as general factor to fear of cancer recurrence or progression. Psychological interventions to reduce emotional burden of cancer patients need to focus additionally on existential threat and individual fears regarding death anxiety. This article is protected by copyright. All rights reserved.

Expectations, end-of-life fears and end-of-life communication among palliative patients with cancer and caregivers: a cross-sectional study

OBJECTIVES

During serious illness, open communication with caregivers can ensure high-quality care. Without end-of-life communication, caregivers may become surrogates and decision-makers without knowing the patient's preferences. However, expectations and fears may influence the initiation of communication. The present study investigates differences between palliative patients with cancer and caregivers regarding expectations of end-of-life communication, end-of-life fears and experiences with end-of-life communication.

DESIGN

A cross-sectional study using a semi-structured interview and a paper-based questionnaire SETTING: University Hospital in Germany.

PARTICIPANTS

151 participants: 85 palliative cancer patients (mean age: 62.8 years, 65.9% male) and 66 caregivers (mean age: 56.3 years, 28.8% male).

PRIMARY AND SECONDARY OUTCOME MEASURES

Expectations, end-of-life fears and experiences of end-of-life discussions.

RESULTS

Patients and caregivers wish for the patient to be self-determined. In general, participants reported more positive than negative expectations of end-of-life discussions. Importantly, concerns about emotionally burdening other person was rated much higher in an informal context than a professional context (F(1,149)=316 958, p<0.001, η_p²=0.680), even though the emotional relief was expected to be higher (F(1,149)=46.115, p<0.001, η_p²=0.236). Caregivers reported more fears about the last period of life and more fears about end-of-life discussions than palliative patients, whereas palliative patients tended to avoid the topics of death and dying to a greater extent.

CONCLUSIONS

There seems to exist a 'self-other' asymmetry: palliative patients and their caregivers expect substantial personal relief when openly talking about end-of-life issues, but also expect the other person to be burdened by such communication. Professionals repeatedly need to initiate end-of-life communication.

'It was like taking an inner bath': A qualitative evaluation of a collaborative advance care planning-approach

BACKGROUND

Impaired readiness may hinder purposeful advance care planning in cancer patients. To reduce barriers to participation in end-of-life decision-making, a collaborative intervention was developed combining a psycho-oncological approach of dignity-based and cognitive-behavioural interventions, followed by a standardised advance care planning-process.

AIM

To evaluate the novel collaborative advance care planning-approach by synthetising cancer patient and carer perspectives on communicational and relational effects.

DESIGN

As a sub-project of a mixed-methods evaluation study, we conducted an inductive content analysis of qualitative interviews with advanced cancer patients and caregivers to deeply explore the focused impact of a collaborative advance care planning-approach on communication and relationship dynamics.

SETTING/PARTICIPANTS

Twelve patients with advanced cancer and 13 carers who participated in a collaborative advance care planning-intervention.

RESULTS

The collaborative advance care planning-approach was consistently evaluated positively by participants. Transcriptions of the semi-structured interviews were coded, analysed and merged under three main themes concerning communicational and relationship dynamics: action readiness, content readiness and impact on future communication and relationship.

CONCLUSIONS

The novel intervention served to foster individual readiness - including action and content readiness - for advance care planning-discussions by addressing highly individualised barriers to participation, as well as specific end-of-life issues. In addition, societal readiness could be promoted. Although the brief psycho-oncological intervention could not fully meet the needs of all participants, it can be used to develop individual psychotherapeutic strategies to improve different facets of readiness. The collaborative advance care planning-approach might require more time and human resources, but could pioneer successful advance care planning.

Matters of Life and Death: An Experimental Study Investigating Psychological Interventions to Encourage the Readiness for End-of-Life Conversations

INTRODUCTION

Talking about death and dying is evoking discomfort in many persons, resulting in avoidance of this topic. However, end-of-life discussions can alleviate distress and uncertainties in both old and young adults, but only a minority uses this option in palliative care. Even in healthy populations, talking about death is often seen as alleviative and worthwhile, but rarely initiated.

OBJECTIVE

To investigate different psychological interventions (a) encouraging the readiness for end-of-life discussions and (b) changing death attitudes in healthy adults of different ages.

METHODS

168 participants were randomized to four different interventions (IG1: value-based intervention with end-of-life perspective, IG2: motivation-based intervention with end-of-life perspective, IG3: combination of IG1 and IG2, CG: control group). Primary outcome was the readiness to engage in end-of-life topics. Secondary outcomes were fear of death, fear of dying and death acceptance. Assessments took place before, directly after the intervention and at 2 weeks of follow up.

RESULTS

IG2 and IG3 reported significantly more changes in the readiness to engage in end-of-life discussions than the CG (F[5.61, 307] = 4.83, p < 0.001, ηp2 = 0.081) directly after the intervention. The effect of IG3 remained stable at the follow-up. There were no significant effects of the interventions on end-of-life fears or death acceptance. Acceptability of the interventions was very high.

CONCLUSIONS

Short interventions can be useful to encourage end-of-life discussions and could be integrated in health care programs. The efficacy and effectiveness of these short interventions in palliative patients are currently examined.

The Difficulties in End-of-Life Discussions - Family Inventory (DEOLD-FI): Development and Initial Validation of a Self-Report Questionnaire in a Sample of Terminal Cancer Patients

CONTEXT

Open end-of-life communication is especially important within the patient-family unit of care and can positively affect their medical, psychological, and relational outcomes. Nevertheless, end-of-life discussions are often perceived as difficult and avoided.

OBJECTIVES

To develop and validate the Difficulties in End-of-Life Discussions - Family Inventory (DEOLD-FI) to allow a systematic assessment of reasons why people shy away from end-of-life discussions.

METHODS

Patients with advanced cancer were recruited and completed the DEOLD-FI and measures of avoidance of cancer communication, quality of life and distress, and the experienced difficulty as well as the occurrence of end-of-life discussions. Standard item analyses and an exploratory factor analysis were conducted. Construct validity was analysed through associations between the DEOLD-FI and the aforementioned measures.

RESULTS

Questionnaires were obtained from 112 participants (53% response rate; male 54%, mean age 64.9 years [range 33-94]). In the final 23-item version two factors were extracted: 'emotional burden due to end-of-life discussions' (α = 0.90) and "negative attitudes towards end-of-life discussions" (α = 0.91) explaining 69% of the variance (total scale α = 0.93). Construct validity was supported by its significant correlations with the reported difficulty in end-of-life discussions (r = 0.42) and avoidance of cancer communication (r = 0.40 to r = 0.46) and insignificant correlations with quality of life (r = -0.11), distress (r = 0.16), and physical well-being (r = 0.02). Those who had already engaged in end-of-life discussions showed significantly fewer communication barriers.

CONCLUSION

Results provide evidence that the DEOLD-FI is a valid and reliable instrument for the assessment of difficulties in end-of-life discussions. Benefits for clinical practice and research are discussed.

Development and Validation of the Readiness for End-of-Life Conversations (REOLC) Scale

Background: Engaging in end-of-life care considerations is beneficial when the time is right. The purpose of this study is to provide a valid instrument to assess peoples readiness for end-of-life conversations before they are initiated. Materials and Methods: A community sample was recruited in study one for exploratory factor analysis of a 13-item questionnaire. In study two, psychometric properties were analyzed with structural equation modeling in a population affected by cancer. Convergent and discriminant validity were assessed with questionnaires measuring distress, depression, anxiety, fear of progression, and distress of death and dying. Results: In study one (N = 349) exploratory factor analysis resulted in three subscales readiness (α = 0.84), communication (α = 0.76), and values (α = 0.56) with a possible common factor (α = 0.84) for a community sample. In study two (N = 84) the three-factor solution with 13 items was not supported for cancer patients. Factor structure was adapted to 12 items with one common factor readiness (α = 0.87). Model fit was good: χ²(50) = 59.18, p>0.05 (Satorra-Bentler-correction = 1.27), with χ²/df = 1.184, rRMSEA = 0.053 (90%-CI[0.000;0.100]), and rSRMR = 0.072. Convergent validity was supported by moderate correlations to trait gratitude, ratings of readiness to provide a living will or talk with family about the end of life. Divergent validity was supported by no or small correlation with distress, depression, general and death anxiety and fear of progression, respectively. Conclusions: Results support usage of the REOLC Scale in different settings with adapted factor structure. The questionnaire is interpreted as valid and reliable instrument to assess objective readiness for end-of-life conversations.

["We are Heading Towards that Now" - A Qualitative Analysis of the Perspectives of Healthy Older Adults on Conditions, Difficulties and Benefits of Early End-of-Life Conversations]

OBJECTIVE

Early conversations about the end of life can contribute to patient-centered care at the end of life. Too often, however, these conversations do not take place or if they do, they are too late. The aim of this qualitative research was to identify the prerequisites, difficulties and usefulness of such conversations from the point of view of healthy older adults. The findings might be of use in primary health care to provide early and open end-of-life discussions.

METHODS

The interviews stem from an experimental study concerning the readiness of end-of-life conversations with healthy adults. Six transcripts (2 male and 4 female participants, 65-78 years) were evaluated by using the thematic analysis by Braun and Clarke.

RESULTS

Conditions for the initiation of conversations were thematically separated into beliefs and attitudes, intrinsic motivation, experience, family communication and practical realization. Difficulties were found in the areas of cognitive barriers, practical realization, emotional barriers, relational factors and environmental conditions. Participants saw the usefulness of such conversations in the areas of relationship quality, organizational profit, values, as well as cognitive and emotional areas.

DISCUSSION

The results are in agreement with past research. From the perspective of older healthy people, family conversations about the end of life can be "too late". However, it also appears that there are specific barriers to early discussions. The findings on helpful conditions and barriers can be used for the development of interventions to increase readiness for such discussions.

CONCLUSION

Early conversations about the end of life should be offered in the sense of preventive care in a low-threshold way. Providers of primary health care can identify a "need to talk", reduce communication barriers and encourage confrontation with one's own mortality. Adequate information should be provided if necessary, and a structured communication approach should be employed.

Systematic mixed-method review of barriers to end-of-life communication in the family context

Background

Communication about the end of life is especially important in the family context, as patients and their families are considered as the care unit in palliative care. Open end-of-life communication can positively affect medical, psychological and relational outcomes during the dying process for patient and family. Regardless of the benefits of end-of-life conversations, many patients and their family caregivers speak little about relevant end-of-life issues.

Aim

To identify barriers that hinder or influence the discussion of end-of-life issues in the family context.

Design

A systematic mixed-method review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

Data sources

A systematic search of PsycInfo, CINAHL, PubMed and Web of Science was conducted and extended with a hand search. Peer-reviewed primary studies reporting on the barriers to or difficulties in end-of-life conversations experienced by terminally ill patients and/or family caregivers were included in this review.

Results

18 qualitative and two quantitative studies met the inclusion criteria. The experiences of n=205 patients and n=738 family caregivers were analysed qualitatively; n=293 patients and n=236 caregivers were surveyed in the questionnaire studies. Five overarching categories emerged from the extracted data: emotional, cognitive, communicative, relational and external processes can hinder end-of-life communication within the family. The most frequently reported barriers are emotional and cognitive processes such as protective buffering or belief in positive thinking.

Conclusions

Research on end-of-life communication barriers in the family context is scarce. Further research should enhance the development of appropriate assessment tools and interventions to support families with the challenges experienced regarding end-of-life conversations.

Collaborative advance care planning in advanced cancer patients: col-ACP -study - study protocol of a randomised controlled trial

BACKGROUND

To assure patient-centred end-of-life care, palliative interventions need to account for patients' preferences. Advance care planning (ACP) is a structured approach that allows patients, relatives and physicians to discuss end-of-life decisions. Although ACP can improve several patient related outcomes, the implementation of ACP remains difficult. The col-ACP-study (collaborative advance care planning) will investigate a new ACP procedure (col-ACP-intervention (German: Hand-in-Hand Intervention)) in palliative cancer patients and their relatives that addresses individual values and targets barriers of communication before an ACP process.

METHODS

In a randomised controlled trial, 270 cancer patients without curative treatment options and their relatives will receive either 1) col-ACP 2) a supportive intervention (active control group) or 3) standard medical care (TAU). col-ACP comprises two steps: a) addressing various barriers of patients and relatives that discourage them from discussing end-of-life issues followed by b) a regular, structured ACP procedure. The col-ACP-intervention consists of 6 sessions. Primary endpoint is the patients' quality of life 16 weeks after randomisation. Secondary endpoints include measurements of distress; depression; communication barriers; caregivers' quality of life; existence of ACP or advance directives; the consistence of end of life care; and others. Patients will be followed up for 13 months. Multivariate analyses will be carried out. Qualitative evaluation of the intervention will be conducted.

DISCUSSION

Augmentation of a regular ACP program by a structured psycho-oncological intervention is an innovative approach to target barriers of communication about end-of-life issues. Study findings will help to understand the value of such a combined intervention in palliative care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03387436 (Date of registration: 01/02/2018, retrospectively registered.

Assessing patients´ preferences for breaking Bad News according to the SPIKES-Protocol: the MABBAN scale

OBJECTIVE

Quality of breaking bad news can seriously affect the course of disease. A frequently applied guideline is the SPIKES-Protocol that have been designed from the physician's perspective. Little is known about patients' preferences in breaking bad news. Our aim was to develop a questionnaire based on the SPIKES-protocol to detect patients´ preferences for breaking bad news communication.

METHODS

TheMarburg Breaking Bad News Scale (MABBAN) was developed and administered to 336 cancer patients. We used exploratory factor analysis. To examine potential relationships according to demographic and medical variables, regression analyses were conducted.

RESULTS

The novel questionnaire supported the six SPIKES-components of breaking bad news: Setting, Perception, Invitation, Knowledge, Emotions, and Strategy. Perception and Invitation clustered together to one subscale. Depending on clinical and demographic variables different components were rated as important.

CONCLUSION

Communication preferences in breaking bad news can be assessed using a SPIKES-based questionnaire. Physicians should improve the setting, share knowledge in all clarity, involve the patients in further planning, and consider demographical variables.

PRACTICE IMPLICATIONS

Using SPIKES as a framework can optimize breaking bad news conversations but it seems important to emphasize the individual preferences beyond the six steps and tailor the communication process to the individual.

[Barriers to Conversations About Death and Dying in the Medicine]

Conversations about death, dying and the end of life are usually difficult. They can turn out to be both a burden and a challenge for those engaging in these talks. There is evidence that talking early about end-of-life-topics shows positive effects concerning medical and psychological conditions of patients. Open communication addressing these topics can be part of family- and patient-centered talks in an intensive care department, known as a quality indicator of intensive care medicine. Further, these conversations are important and necessary in palliative care for providing a "good death". Nevertheless, these conversations are delayed or do not take place due to communication barriers of doctors, patients and caregivers. Barriers to end of life communication of physicians contain individual, personal or role-specific factors, lack of medical knowledge, including insecurities of prognosis, professional attitudes, clinical routines and the worry of harming patients with these talks. Regarding barriers to communication of patients and their family members, it could be differentiated between emotional, cognitive, relationship-related and external factors. It could be valuable to recognize these barriers to increase the possibility of end of life conversations in the near future.In daily medical routine end of life topics should be addressed early and actively. Especially the readiness for these conversations should be tested repeatedly and talks should be offered regularly. Critical events such as relapse, modulating therapy concepts and knowledge of unrealistic treatment expectations should be regarded as prompts to offer conversations about dying and end-of-life care actively.

Cancer patient utilisation of psychological care in Germany: The role of attitudes towards seeking help

OBJECTIVE

Even if significantly distressed, many patients with cancer do not seek psychological help. There is growing evidence that attitudes are central barriers for help-seeking, and instruments to assess cancer patients' attitudes towards help-seeking are urgently needed. This study aimed to evaluate the German Attitudes towards Seeking Help after Cancer Scale (ASHCa-G) and investigated the relationship between patients' attitudes and psychological care utilisation.

METHODS

The ASHCa-G was presented to 270 patients with cancer (age 63.0 ± 12.7 years, 44.8% women). Item analyses, principal component analysis and associations with age, social support, help-seeking intention and psychological care utilisation were calculated. A hierarchical logistic regression was performed to ascertain the leading role of attitudes in explaining psychological care utilisation.

RESULTS

Principal component analysis supported a two-component solution, which showed good internal consistency for the positive attitudes (α = 0.80) and negative attitudes (α = 0.75) subscales. The associations with age, distress and help-seeking intention confirmed the validity of the ASHCa-G. Positive attitudes explained most variance of cancer patients' current psychological care utilisation.

CONCLUSION

The ASHCa-G seems to be a reliable and valid questionnaire for assessing attitudes towards seeking psychological help among patients with cancer. Clinical practice might profit from identifying attitudinal barriers that hinder patients with cancer from seeking psychological help.

Facilitating adherence to endocrine therapy in breast cancer: stability and predictive power of treatment expectations in a 2-year prospective study

PURPOSE

To identify modifiable factors predictive of long-term adherence to adjuvant endocrine therapy (AET).

METHODS

As part of a 2-year cohort study in primary care (n = 116), we investigated whether initial treatment expectations predict adherence at 24 months after controlling for demographic, medical, and psychosocial variables. Treatment expectations were measured as necessity-concern beliefs, expected side-effect severity, and expected coping with side effects. Their stability over time and differences of trajectories between the adherent and nonadherent group were examined.

RESULTS

Nonadherence at 24 months was 14.7% (n = 17). Side-effect severity at 3 months [OR 0.25, 95% CI (0.08, 0.81), p = 0.02] and necessity-concern beliefs [OR 2.03, 95% CI (1.11, 3.72), p = 0.02] were the sole predictors of adherence. Necessity-concern beliefs remained stable over 2 years, whereas expected side-effect severity (p = 0.01, η p2  = 0.07) and expected coping with side effects became less optimistic over time (p < 0.001, η p2  = 0.19), the latter particularly among nonadherers (p < 0.01, η p2  = 0.10).

CONCLUSIONS

Patients' initial necessity-concern beliefs about the AET and early severity of side effects affect long-term adherence. Expecting poor management of side effects may also facilitate nonadherence. We suggest that discussing benefits, addressing concerns of AET, and providing side-effect coping strategies could constitute a feasible and promising option to improve adherence in clinical practice.

What do women with breast cancer expect from their treatment? Correlates of negative treatment expectations about endocrine therapy

OBJECTIVES

Patients' negative treatment expectations can lead to nocebo-related side effects and non-initiation of treatment. This study aims to identify correlates of treatment expectations in patients with breast cancer before the start of endocrine therapy.

METHODS

Expectations were assessed in a cross-sectional sample of 166 patients with breast cancer after receiving treatment information. Side effect expectations (one item) and treatment necessity-concern balance (Beliefs about Medicines Questionnaire) were assessed. Correlates were analyzed using regression analyses. The structure of treatment expectations was investigated using a network analysis.

RESULTS

About 25% of patients expressed negative expectations. Higher side effect expectations were associated with lower treatment efficacy expectations (ß = -0.20, p = 0.01), higher medication overuse beliefs (ß = 0.17, p = 0.01), and a negative treatment appraisal before study treatment information (ß = -0.17, p = 0.02). A negative necessity-concern balance was associated with lower treatment efficacy expectations (ß = 0.36, p < 0.001), lower adherence intention (ß = 0.21, p < 0.001), and no knowledge of tumor's receptor status (ß = 0.21, p < 0.001); furthermore, it was associated with higher medication harmfulness beliefs (ß = -0.16, p = 0.02), negative treatment pre-appraisal (ß = 0.15, p = 0.01), higher somatosensory amplification (ß = -0.14, p = 0.02), and higher education (ß = -0.12, p = 0.02). The most important network node was the concern that endocrine therapy disrupts life.

CONCLUSION

Negative treatment expectations before treatment start are mainly associated with psychological variables. These results are relevant for patient education in clinical settings. To improve expectations, clinicians might emphasize treatment efficacy and discuss general and specific medication concerns. Improving treatment knowledge could also be beneficial. Copyright © 2016 John Wiley & Sons, Ltd.

Informing women with breast cancer about endocrine therapy: effects on knowledge and adherence

OBJECTIVE

Adherence to adjuvant endocrine therapy in women with breast cancer is low, and patients are not informed sufficiently. This study analyzes the effects of a structured treatment information on patients' satisfaction, knowledge, and adherence.

METHODS

An interventional single cohort study of postoperative women with estrogen-receptor-positive breast cancer was conducted to study the effects of enhanced information about endocrine therapy given additionally to clinical routine information. Knowledge and satisfaction with additional information given 1-3 weeks after surgery were assessed before and after informing patients; adherence and knowledge were measured 3 months after start of treatment.

RESULTS

A total of 137 patients were analyzed before and after provision of enhanced treatment information as well as 3 months after start of endocrine therapy. Enhanced information increased satisfaction with information and knowledge. The percentage of patients who knew their estrogen receptor status increased from 50% to 93%. At 3 months follow-up, 60% still had correct knowledge. Patients who learned their receptor status were older, and those who forgot had lower cognitive abilities and lower educational level. Patients with higher satisfaction, better learning, and comprehension directly after enhanced information showed better adherence at 3 months follow-up.

CONCLUSION

Patients, especially older ones, can benefit from enhanced treatment information given additionally to routine care. Enhanced information about mode of action and potential side effects of endocrine therapy when included into clinical routine might foster patient autonomy and prevent early disruptions in adherence.

Quality of life in cancer rehabilitation: the role of life goal adjustment

OBJECTIVE

A cancer diagnosis affects patients' quality of life (QOL) as well as their pursuit of life goals. However, numerous studies have shown surprisingly stable QOL measures in cancer patients over time. We propose that life goal adjustment can act as the missing link in explaining this response shift. Thus, the aim of this study was to examine associations between life goal adjustment and patients' QOL at baseline and over the course of 20 months.

METHODS

Eighty-six cancer patients were recruited during rehabilitation and reassessed at follow-up 20 months later. Life goals were measured using the Life Goals Questionnaire and analyzed in relation to global QOL as assessed with the World Health Organization Quality of Life Questionnaire - Short Form.

RESULTS

The overall attainment of life goals was associated with QOL. Moreover, over a period of 20 months, perceived QOL and goal attainment remained stable, whereas importance of life goals decreased. Lesser importance and improved goal attainment were predictors of increases in QOL.

CONCLUSIONS

Results suggest that downgrading unattainable goals and making more progress in accomplishing attainable goals may be possible mechanisms of response shift as an adaption to illness. Thus, integrating life goal adjustment into rehabilitation services for cancer patients seems to be worthwhile to enhance an adaptive self-regulation and QOL.

Optimizing expectations to prevent side effects and enhance quality of life in breast cancer patients undergoing endocrine therapy: study protocol of a randomized controlled trial

BACKGROUND

Adjuvant endocrine therapy can improve disease-free survival and time before recurrence in breast cancer patients. However, it is associated with considerable side effects that negatively affect patients' quality of life and cause non-adherence. The recently demonstrated effect of individual expectations on side-effect development (nocebo effect) suggests that psychological factors play a role in the prevention of side effects. The aim of this study is to evaluate cognitive-behavioral side-effect prevention training (SEPT) for breast cancer patients. This article describes the study protocol and applied research methods.

METHODS/DESIGN

In a randomized controlled trial, 184 female breast cancer patients are assigned to receive either SEPT, standard medical care or a manualized supportive therapy at the start of adjuvant endocrine treatment. SEPT consists of three sessions of cognitive-behavioral training including psychoeducation to provide a realistic view of endocrine therapy, imagination-training to integrate positive aspects of medication into daily life, and side-effect management to enhance expectations about coping ability. Side effects three months after the start of endocrine therapy serve as primary outcomes. Secondary outcomes include quality of life, coping ability and patients' medication adherence. Patients' expectations (i.e., expectations about side effects, coping ability, treatment and illness) are analyzed as mediators.

DISCUSSION

The optimization of expectations might be a potential pathway in health care to improve patients' quality of life during long-term medication intake. The results will provide implications for a possible integration of evidence-based prevention training into clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov, (NCT01741883).