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Dionne-Odom JN, Taylor R, Rocque G, Chambless C, Ramsey T, Azuero A, Ivankova N, Martin MY, Bakitas MA. Adapting an Early Palliative Care Intervention to Family Caregivers of Persons With Advanced Cancer in the Rural Deep South: A Qualitative Formative Evaluation. J Pain Symptom Manage 2018; 55:1519-1530. [PMID: 29474939 PMCID: PMC5951755 DOI: 10.1016/j.jpainsymman.2018.02.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [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: 12/21/2017] [Revised: 02/12/2018] [Accepted: 02/13/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT There is a scarcity of early palliative care interventions to support family caregivers of persons with advanced cancer living in the rural Southern U.S. OBJECTIVE The objective of this study was to adapt the content, format, and delivery of a six session, palliative care, telehealth intervention with monthly follow-up for rural family caregivers to enhance their own self-care and caregiving skills. METHODS Qualitative formative evaluation consisting of one-on-one, semistructured interviews with rural-dwelling persons with metastatic cancer (n = 18), their primary family caregiver (n = 20), and lay patient navigators (n = 26) were conducted to elicit feedback on a family caregiver intervention outline based on published evidence-based interventions. Transcribed interviews were analyzed using a thematic analysis approach. Coinvestigators reviewed and refined preliminary themes. RESULTS Participants recommended that intervention topical content be flexible and has an adaptable format based on continuous needs assessment. Sessions should be 20 minutes long at minimum, and additional sessions should be offered if requested. Faith and spirituality is essential to address but should not be an overarching intervention theme. Content needs to be communicated in simple language. Intervention delivery via telephone is acceptable, but face-to-face contact is desired to establish relationships. Other Internet-based technologies (e.g., video-conferencing) could be helpful, but many rural dwellers may not be technology savvy or have Internet access. Most lay navigators believed they could lead the intervention with additional training, protocols for professional referral, and supervision by specialty-trained palliative care clinicians. CONCLUSIONS A potentially scalable palliative care intervention is being adapted for family caregivers of rural-dwelling persons with advanced cancer and will undergo piloting in a small-scale randomized controlled trial.
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Affiliation(s)
- J Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA; Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, UAB Center for Palliative and Supportive Care, Birmingham, Alabama, USA.
| | - Richard Taylor
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Gabrielle Rocque
- Division of Hematology and Oncology, Department of Medicine, UAB, Birmingham, Alabama
| | | | - Thomas Ramsey
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Nataliya Ivankova
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA; Department of Health Services Administration, UAB, Birmingham, Alabama, USA
| | - Michelle Y Martin
- Department of Preventive Medicine, Center for Innovation in Health Equity Research, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA; Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, UAB Center for Palliative and Supportive Care, Birmingham, Alabama, USA
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Dionne-Odom JN, Applebaum AJ, Ornstein KA, Azuero A, Warren PP, Taylor RA, Rocque GB, Kvale EA, Demark-Wahnefried W, Pisu M, Partridge EE, Martin MY, Bakitas MA. Participation and interest in support services among family caregivers of older adults with cancer. Psychooncology 2017; 27:969-976. [PMID: 29226997 DOI: 10.1002/pon.4603] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [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: 06/23/2017] [Revised: 10/31/2017] [Accepted: 11/30/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to describe distressed and underprepared family caregiver's use of and interest in formal support services (eg, professional counseling, education, organizational assistance). METHOD Cross-sectional mail survey conducted in communities of 8 cancer centers in Tennessee, Alabama, and Florida (response rate: 42%). Family caregivers of Medicare beneficiaries with pancreatic, lung, brain, ovarian, head and neck, hematologic, and stage IV cancers reported support service use and completed validated measures of depression, anxiety, burden, preparedness, and health. RESULTS Caregivers (n = 294) were on average age 65 years and mostly female (73%), White (91%), and care recipients' spouse/partner (60%); patients averaged 75 years were majority male (54%) with lung cancer (39%). Thirty-two percent of caregivers reported accessing services while 28% were "mostly" or "extremely" interested. Thirty-five percent of caregivers with high depressive symptoms (n = 122), 33% with high anxiety symptoms (n = 100), and 25% of those in the lowest quartile of preparedness (n = 77) accessed services. Thirty-eight percent of those with high depressive symptoms, 47% with high anxiety symptoms, and 36% in the lowest quartile of preparedness were "mostly" or "extremely" interested in receiving services. Being interested in support services was significantly associated with being a minority, shorter durations of caregiving, and with higher stress burden. CONCLUSIONS A large proportion of family caregivers, including those experiencing depression and anxiety symptoms and who were underprepared, are not using formal support services but have a strong interest in services. Strategies to increase service use may include targeting distressed caregivers early in their caregiving experience.
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Affiliation(s)
| | | | | | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | | | - Richard A Taylor
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Gabrielle B Rocque
- UAB Comprehensive Cancer Center, Birmingham, AL, USA.,Department of Medicine, Division of Hematology and Oncology, Birmingham, AL, USA
| | - Elizabeth A Kvale
- Department of Medicine, Division of Geriatrics, Gerontology, and Palliative Care, UAB Center for Palliative and Supportive Care, Birmingham, AL, USA.,Birmingham Veterans Administration Medical Center, Birmingham, AL, USA
| | | | - Maria Pisu
- Department of Preventive Medicine, UAB, Birmingham, AL, USA
| | | | - Michelle Y Martin
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL, USA.,Department of Medicine, Division of Geriatrics, Gerontology, and Palliative Care, UAB Center for Palliative and Supportive Care, Birmingham, AL, USA
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Abstract
In 2001, as the Trish Greene Quality of Life lecturer, I described coming to a career crossroads and cited a metaphor from Robert Frost's poem "The Road Not Taken," realizing that, as I chose to leave the path of bone marrow transplantation clinician and go to that of palliative care nurse, there was no turning back. In this article based on my 2016 Oncology Nursing Society Congress Distinguished Nurse Researcher Award lecture, I would like to continue the Frost metaphor as I describe what has transpired since taking "the one less traveled by"-that of palliative care nurse scientist.
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Prescott AT, Hull JG, Dionne-Odom JN, Tosteson TD, Lyons KD, Li Z, Li Z, Dragnev KH, Hegel MT, Steinhauser KE, Ahles TA, Bakitas MA. The role of a palliative care intervention in moderating the relationship between depression and survival among individuals with advanced cancer. Health Psychol 2017; 36:1140-1146. [PMID: 29048177 DOI: 10.1037/hea0000544] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Randomized controlled trials (RCTs) of early palliative care interventions in advanced cancer have positively impacted patient survival, yet the mechanisms remain unknown. This secondary analysis of 2 RCTs assessed whether an early palliative care intervention moderates the relationship between depressive symptoms and survival. METHOD The relationships among mood, survival, and early palliative care intervention were studied among 529 advanced cancer patients who participated in 2 RCTs. The first (N = 322) compared intervention versus usual care. The second (N = 207) compared early versus delayed intervention (12 weeks after enrollment). The interventions included an in-person consultation, weekly nurse coach-facilitated phone sessions, and monthly follow-up. Mood was measured using the Center for Epidemiologic Studies-Depression (CES-D) scale. Cox proportional hazard analyses were used to examine the effects of baseline CES-D scores, the intervention, and their interaction on mortality risk while controlling for demographic variables, cancer site, and illness severity. RESULTS The combined sample was 56% male (M = 64.7 years). Higher baseline CES-D scores were significantly associated with greater mortality risk (hazard ratio [HR] = 1.042, 95% confidence interval [CI] [1.017, 1.067], p = .001). However, participants with higher CES-D scores who received the intervention had a lower mortality risk (HR = .963, CI [0.933, 0.993], p = .018) even when controlling for demographics, cancer site, and illness-related variables. CONCLUSION This study is the first to demonstrate that patients with advanced cancer who also have depressive symptoms benefit the most from early palliative care. Future research should be devoted to exploring the mechanisms responsible for these relationships. (PsycINFO Database Record
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Affiliation(s)
- Anna T Prescott
- Department of Psychological and Brain Sciences, Dartmouth College
| | - Jay G Hull
- Department of Psychological and Brain Sciences, Dartmouth College
| | | | - Tor D Tosteson
- Biostatistics Shared Resource, Norris Cotton Cancer Center
| | | | - Zhigang Li
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth
| | - Zhongze Li
- Biostatistics Shared Resource, Norris Cotton Cancer Center
| | - Konstantin H Dragnev
- Department of Medicine, Section of Hematology/Oncology, Dartmouth-Hitchcock Medical Center
| | - Mark T Hegel
- Department of Psychiatry, Geisel School of Medicine at Dartmouth
| | - Karen E Steinhauser
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center
| | - Tim A Ahles
- Department of Psychiatry, Memorial Sloan-Kettering Cancer Center
| | - Marie A Bakitas
- School of Nursing and Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham
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Kavalieratos D, Gelfman LP, Tycon LE, Riegel B, Bekelman DB, Ikejiani DZ, Goldstein N, Kimmel SE, Bakitas MA, Arnold RM. Palliative Care in Heart Failure: Rationale, Evidence, and Future Priorities. J Am Coll Cardiol 2017; 70:1919-1930. [PMID: 28982506 PMCID: PMC5731659 DOI: 10.1016/j.jacc.2017.08.036] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [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: 06/14/2017] [Revised: 07/28/2017] [Accepted: 08/21/2017] [Indexed: 12/25/2022]
Abstract
Patients with heart failure (HF) and their families experience stress and suffering from a variety of sources over the course of the HF experience. Palliative care is an interdisciplinary service and an overall approach to care that improves quality of life and alleviates suffering for those living with serious illness, regardless of prognosis. In this review, we synthesize the evidence from randomized clinical trials of palliative care interventions in HF. While the evidence base for palliative care in HF is promising, it is still in its infancy and requires additional high-quality, methodologically sound studies to clearly elucidate the role of palliative care for patients and families living with the burdens of HF. Yet, an increase in attention to primary palliative care (e.g., basic physical and emotional symptom management, advance care planning), provided by primary care and cardiology clinicians, may be a vehicle to address unmet palliative needs earlier and throughout the illness course.
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Affiliation(s)
- Dio Kavalieratos
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Geriatric Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Laura E Tycon
- University of Pittsburgh Medical Center Palliative and Supportive Institute, Pittsburgh, Pennsylvania
| | - Barbara Riegel
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David B Bekelman
- Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
| | - Dara Z Ikejiani
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nathan Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephen E Kimmel
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert M Arnold
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
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Bakitas MA, El-Jawahri A, Farquhar M, Ferrell B, Grudzen C, Higginson I, Temel JS, Zimmermann C, Smith TJ. The TEAM Approach to Improving Oncology Outcomes by Incorporating Palliative Care in Practice. J Oncol Pract 2017; 13:557-566. [DOI: 10.1200/jop.2017.022939] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Palliative care (PC) concurrent with usual oncology care is now the standard of care that is recommended for any patient with advanced cancer to begin within 8 weeks of diagnosis on the basis of evidence-driven national clinical practice guidelines; however, there are not enough interdisciplinary palliative care teams to provide such care. How and what can an oncology office incorporate into usual care, borrowing the tools used in PC randomized clinical trials (RCTs), to improve care for patients and their caregivers? We reviewed the multiple RCTs for common practical elements and identified methods and techniques that oncologists can use to deliver some parts of concurrent interdisciplinary PC. We recommend the standardized assessment of patient-reported outcomes, including the evaluation of symptoms with such tools as the Edmonton or Memorial Symptom Assessment Scales, spirituality with the FICA Spiritual History Tool or similar questions, and psychosocial distress with the Distress Thermometer. All patients should be assessed for how they prefer to receive information, their current understanding of their situation, and if they have considered some advance care planning. Approximately 1 hour of additional time with the patient is required each month. If the oncologist does not have established ties with spiritual care and social work, he or she should establish these relationships for counseling as required. Caregivers should be asked about coping and support needs. Oncologists can adapt PC techniques to achieve results that are similar to those in the RCTs of PC plus usual care compared with usual care alone. This is comparable to using data from RCTs of trastuzamab or placebo, adopting what was used in the RCTs without modification or dilution.
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Affiliation(s)
- Marie A. Bakitas
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Areej El-Jawahri
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Morag Farquhar
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Betty Ferrell
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Corita Grudzen
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Irene Higginson
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Jennifer S. Temel
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Camilla Zimmermann
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Thomas J. Smith
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
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Nicholas Dionne-Odom J, Hooker SA, Bekelman D, Ejem D, McGhan G, Kitko L, Strömberg A, Wells R, Astin M, Metin ZG, Mancarella G, Pamboukian SV, Evangelista L, Buck HG, Bakitas MA. Family caregiving for persons with heart failure at the intersection of heart failure and palliative care: a state-of-the-science review. Heart Fail Rev 2017; 22:543-557. [PMID: 28160116 PMCID: PMC5544594 DOI: 10.1007/s10741-017-9597-4] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Many of the 23 million individuals with heart failure (HF) worldwide receive daily, unpaid support from a family member or friend. Although HF and palliative care practice guidelines stipulate that support be provided to family caregivers, the evidence base to guide care for this population has not been comprehensively assessed. In order to appraise the state-of-the-science of HF family caregiving and recommend areas for future research, the aims of this review were to summarize (1) how caregivers influence patients, (2) the consequences of HF for caregivers, and (3) interventions directed at HF caregivers. We reviewed all literature to December 2015 in PubMed and CINAHL using the search terms "heart failure" AND "caregiver." Inclusion criteria dictated that studies report original research of HF family caregiving. Articles focused on children or instrument development or aggregated HF with other illnesses were excluded. We identified 120 studies, representing 5700 caregivers. Research on this population indicates that (1) caregiving situations vary widely with equally wide-ranging tasks for patients to help facilitate their health behaviors, psychological health and relationships, and quality of life (QoL); (2) caregivers have numerous unmet needs that fluctuate with patients' unpredictable medical status, are felt to be ignored by the formal healthcare system, and can lead to distress, burden, and reduced QoL; and (3) relatively few interventions have been developed and tested that effectively support HF family caregivers. We provide recommendations to progress the science forward in each of these areas that moves beyond descriptive work to intervention development and clinical trials testing.
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Affiliation(s)
- J Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South, 2M019H, Birmingham, AL, 35294-1210, USA.
| | - Stephanie A Hooker
- Department of Psychology, University of Colorado, Denver, Campus Box 173, PO Box 173364, Denver, CO, 80217, USA
| | - David Bekelman
- Veterans Affairs Eastern Colorado Health Care System, Department of Medicine, Anschutz Medical Campus, University of Colorado School of Medicine, 1055 Clermont Street, Research 151, Denver, CO, 80220, USA
| | - Deborah Ejem
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South, 2M019H, Birmingham, AL, 35294-1210, USA
| | - Gwen McGhan
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South, 2M019H, Birmingham, AL, 35294-1210, USA
| | - Lisa Kitko
- College of Nursing, Pennsylvania State University, 201 Nursing Sciences Building, University Park, PA, 16802, USA
| | - Anna Strömberg
- Department of Medical and Health Sciences, Division of Nursing, Campus University Hospital, Linköping University, Building 511-001, 581 85, Linköping, Sweden
| | - Rachel Wells
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South, 2M019H, Birmingham, AL, 35294-1210, USA
| | - Meka Astin
- School of Public Health, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Zehra Gok Metin
- Department of Internal Medicine Nursing, Hacettepe University, 06100, Ankara, Turkey
| | - Gisella Mancarella
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South, 2M019H, Birmingham, AL, 35294-1210, USA
| | - Salpy V Pamboukian
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd, THT 321, Birmingham, AL, 35294, USA
| | - Lorraine Evangelista
- Program in Nursing Science, University of California, Irvine, 299E Berk Hall, Irvine, CA, 92697-3959, USA
| | - Harleah G Buck
- College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd. MDC22, Tampa, FL, 33612-4766, USA
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South, 2M019H, Birmingham, AL, 35294-1210, USA
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Dionne-Odom JN, Bakitas MA, Zubkoff L. Highlighting Implementation Findings in Early Palliative Care. J Oncol Pract 2017; 13:599-600. [DOI: 10.1200/jop.2017.025742] [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)
- J. Nicholas Dionne-Odom
- University of Alabama at Birmingham, Birmingham, AL; White River Junction VA Medical Center, White River Junction, VT; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Marie A. Bakitas
- University of Alabama at Birmingham, Birmingham, AL; White River Junction VA Medical Center, White River Junction, VT; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Lisa Zubkoff
- University of Alabama at Birmingham, Birmingham, AL; White River Junction VA Medical Center, White River Junction, VT; Geisel School of Medicine at Dartmouth, Hanover, NH
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Hay CM, Lefkowits C, Crowley-Matoka M, Bakitas MA, Clark LH, Duska LR, Urban RR, Creasy SL, Schenker Y. Strategies for Introducing Outpatient Specialty Palliative Care in Gynecologic Oncology. J Oncol Pract 2017; 13:e712-e720. [PMID: 28763259 DOI: 10.1200/jop.2017.020818] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Concern that patients will react negatively to the idea of palliative care is cited as a barrier to timely referral. Strategies to successfully introduce specialty palliative care to patients have not been well described. We sought to understand how gynecologic oncologists introduce outpatient specialty palliative care. METHODS We conducted a national qualitative interview study at six geographically diverse academic cancer centers with well-established palliative care clinics between September 2015 and March 2016. Thirty-four gynecologic oncologists participated in semistructured telephone interviews focusing on attitudes, experiences, and practices related to outpatient palliative care. A multidisciplinary team analyzed interview transcripts using constant comparative methods to inductively develop and refine a coding framework. This analysis focuses on practices for introducing palliative care. RESULTS Mean participant age was 47 years (standard deviation, 10 years). Mean interview length was 25 minutes (standard deviation, 7 minutes). Gynecologic oncologists described the following three main strategies for introducing outpatient specialty palliative care: focus initial palliative care referral on symptom management to dissociate palliative care from end-of-life care and facilitate early relationship building with palliative care clinicians; use a strong physician-patient relationship and patient trust to increase acceptance of referral; and explain and normalize palliative care referral to address negative associations and decrease patient fear of abandonment. These strategies aim to decrease negative patient associations and encourage acceptance of early referral to palliative care specialists. CONCLUSION Gynecologic oncologists have developed strategies for introducing palliative care services to alleviate patient concerns. These strategies provide groundwork for developing system-wide best practice approaches to the presentation of palliative care referral.
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Affiliation(s)
- Casey M Hay
- Magee-Women's Hospital of the University of Pittsburgh Medical Center; University of Pittsburgh Graduate School of Public Health; University of Pittsburgh, Pittsburgh, PA; University of Colorado Denver, Aurora, CO; Northwestern University, Chicago, IL; University of Alabama at Birmingham, Birmingham, AL; University of North Carolina, Chapel Hill, NC; University of Virginia School of Medicine, Charlottesville, VA; and University of Washington, Seattle, WA
| | - Carolyn Lefkowits
- Magee-Women's Hospital of the University of Pittsburgh Medical Center; University of Pittsburgh Graduate School of Public Health; University of Pittsburgh, Pittsburgh, PA; University of Colorado Denver, Aurora, CO; Northwestern University, Chicago, IL; University of Alabama at Birmingham, Birmingham, AL; University of North Carolina, Chapel Hill, NC; University of Virginia School of Medicine, Charlottesville, VA; and University of Washington, Seattle, WA
| | - Megan Crowley-Matoka
- Magee-Women's Hospital of the University of Pittsburgh Medical Center; University of Pittsburgh Graduate School of Public Health; University of Pittsburgh, Pittsburgh, PA; University of Colorado Denver, Aurora, CO; Northwestern University, Chicago, IL; University of Alabama at Birmingham, Birmingham, AL; University of North Carolina, Chapel Hill, NC; University of Virginia School of Medicine, Charlottesville, VA; and University of Washington, Seattle, WA
| | - Marie A Bakitas
- Magee-Women's Hospital of the University of Pittsburgh Medical Center; University of Pittsburgh Graduate School of Public Health; University of Pittsburgh, Pittsburgh, PA; University of Colorado Denver, Aurora, CO; Northwestern University, Chicago, IL; University of Alabama at Birmingham, Birmingham, AL; University of North Carolina, Chapel Hill, NC; University of Virginia School of Medicine, Charlottesville, VA; and University of Washington, Seattle, WA
| | - Leslie H Clark
- Magee-Women's Hospital of the University of Pittsburgh Medical Center; University of Pittsburgh Graduate School of Public Health; University of Pittsburgh, Pittsburgh, PA; University of Colorado Denver, Aurora, CO; Northwestern University, Chicago, IL; University of Alabama at Birmingham, Birmingham, AL; University of North Carolina, Chapel Hill, NC; University of Virginia School of Medicine, Charlottesville, VA; and University of Washington, Seattle, WA
| | - Linda R Duska
- Magee-Women's Hospital of the University of Pittsburgh Medical Center; University of Pittsburgh Graduate School of Public Health; University of Pittsburgh, Pittsburgh, PA; University of Colorado Denver, Aurora, CO; Northwestern University, Chicago, IL; University of Alabama at Birmingham, Birmingham, AL; University of North Carolina, Chapel Hill, NC; University of Virginia School of Medicine, Charlottesville, VA; and University of Washington, Seattle, WA
| | - Renata R Urban
- Magee-Women's Hospital of the University of Pittsburgh Medical Center; University of Pittsburgh Graduate School of Public Health; University of Pittsburgh, Pittsburgh, PA; University of Colorado Denver, Aurora, CO; Northwestern University, Chicago, IL; University of Alabama at Birmingham, Birmingham, AL; University of North Carolina, Chapel Hill, NC; University of Virginia School of Medicine, Charlottesville, VA; and University of Washington, Seattle, WA
| | - Stephanie L Creasy
- Magee-Women's Hospital of the University of Pittsburgh Medical Center; University of Pittsburgh Graduate School of Public Health; University of Pittsburgh, Pittsburgh, PA; University of Colorado Denver, Aurora, CO; Northwestern University, Chicago, IL; University of Alabama at Birmingham, Birmingham, AL; University of North Carolina, Chapel Hill, NC; University of Virginia School of Medicine, Charlottesville, VA; and University of Washington, Seattle, WA
| | - Yael Schenker
- Magee-Women's Hospital of the University of Pittsburgh Medical Center; University of Pittsburgh Graduate School of Public Health; University of Pittsburgh, Pittsburgh, PA; University of Colorado Denver, Aurora, CO; Northwestern University, Chicago, IL; University of Alabama at Birmingham, Birmingham, AL; University of North Carolina, Chapel Hill, NC; University of Virginia School of Medicine, Charlottesville, VA; and University of Washington, Seattle, WA
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Dionne-Odom JN, Demark-Wahnefried W, Taylor RA, Rocque GB, Azuero A, Acemgil A, Martin MY, Astin M, Ejem D, Kvale E, Heaton K, Pisu M, Partridge EE, Bakitas MA. The self-care practices of family caregivers of persons with poor prognosis cancer: differences by varying levels of caregiver well-being and preparedness. Support Care Cancer 2017; 25:2437-2444. [PMID: 28247128 DOI: 10.1007/s00520-017-3650-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [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: 10/27/2016] [Accepted: 02/17/2017] [Indexed: 12/13/2022]
Abstract
PURPOSE Little is known about the impact of family caregiving for adults with poor prognosis cancer on caregivers' own individual self-care practices. We explored differences in caregivers' discrete self-care practices associated with varying levels of caregiver well-being, preparedness, and decision-making self-efficacy. METHODS Cross-sectional survey within eight community-based southeastern U.S. cancer centers was conducted. Family caregivers of Medicare beneficiaries ≥65 years with pancreatic, lung, brain, ovarian, head and neck, hematologic, or stage IV cancer completed measures of individual self-care practices (health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, stress management, and sleep), well-being (anxiety, depression, and health-related quality of life [HRQoL]), preparedness, and decision-making self-efficacy. RESULTS Caregivers (n = 294) averaged 66 years, were mostly female (72.8%), white (91.2%), Protestant (76.2%), retired (54.4%), and patients' spouse/partner (60.2%). Approximately, half were rural-dwellers (46.9%) with incomes <$50,000 (53.8%). Most provided support 6-7 days/week (71%) for >1 year (68%). Nearly a quarter (23%) reported high depression and 34% reported borderline or high anxiety. Low engagement in all self-care practices was associated with worse caregiver anxiety, depression, and mental HRQoL (all p values < .05). Caregivers with lower health responsibility, spiritual growth, interpersonal relation, and stress management scores had lower preparedness and decision-making self-efficacy. CONCLUSIONS A significant proportion of caregivers simultaneously report low engagement in all forms of self-care practices, high depression and anxiety, and low HRQoL mental health scores. Caregiver well-being, preparedness, and decision-making self-efficacy might be optimized through interventions targeted at enhancing health responsibility, stress management, interpersonal relationships, and spiritual growth self-care practices.
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Affiliation(s)
- J Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham (UAB), 1720 2nd Avenue South, 2M019H, Birmingham, AL, 35294-1210, USA.
| | | | - Richard A Taylor
- School of Nursing, University of Alabama at Birmingham (UAB), 1720 2nd Avenue South, 2M019H, Birmingham, AL, 35294-1210, USA
| | - Gabrielle B Rocque
- UAB Comprehensive Cancer Center, 1824 6th Avenue South, Birmingham, AL, 35233, USA
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham (UAB), 1720 2nd Avenue South, 2M019H, Birmingham, AL, 35294-1210, USA
| | - Aras Acemgil
- Department of Preventive Medicine, UAB, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Michelle Y Martin
- Department of Preventive Medicine, University of Tennessee Health Science Center, 66 N. Pauline Street, Memphis, TN, 38163, USA
| | - Meka Astin
- School of Nursing, University of Alabama at Birmingham (UAB), 1720 2nd Avenue South, 2M019H, Birmingham, AL, 35294-1210, USA
| | - Deborah Ejem
- School of Nursing, University of Alabama at Birmingham (UAB), 1720 2nd Avenue South, 2M019H, Birmingham, AL, 35294-1210, USA
| | - Elizabeth Kvale
- Department of Medicine, Division of Geriatrics, Gerontology, and Palliative Care, UAB Center for Palliative and Supportive Care, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Karen Heaton
- School of Nursing, University of Alabama at Birmingham (UAB), 1720 2nd Avenue South, 2M019H, Birmingham, AL, 35294-1210, USA
| | - Maria Pisu
- Department of Preventive Medicine, UAB, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Edward E Partridge
- UAB Comprehensive Cancer Center, 1824 6th Avenue South, Birmingham, AL, 35233, USA
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham (UAB), 1720 2nd Avenue South, 2M019H, Birmingham, AL, 35294-1210, USA.,Department of Medicine, Division of Geriatrics, Gerontology, and Palliative Care, UAB Center for Palliative and Supportive Care, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
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Walker DK, Edwards RL, Bagcivan G, Bakitas MA. Cancer and Palliative Care in the United States, Turkey, and Malawi: Developing Global Collaborations. Asia Pac J Oncol Nurs 2017; 4:209-219. [PMID: 28695167 PMCID: PMC5473092 DOI: 10.4103/apjon.apjon_31_17] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 11/29/2022] Open
Abstract
As the global cancer burden grows, so too will global inequities in access to cancer and palliative care increase. This paper will describe the cancer and palliative care landscape relative to nursing practice, education, and research, and emerging global collaborations in the United States (U.S.), Turkey, and Malawi. It is imperative that nurses lead efforts to advance health and strengthen education in these high-need areas. Leaders within the University of Alabama at Birmingham School of Nursing, through a Pan American Health Organization/World Health Organization Nursing Collaborating Center, have initiated collaborative projects in cancer and palliative care between the U.S., Turkey, and Malawi to strengthen initiatives that can ultimately transform practice. These collaborations will lay a foundation to empower nurses to lead efforts to reduce the global inequities for those with cancer and other serious and life-limiting illnesses.
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Affiliation(s)
| | - Rebecca L Edwards
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gulcan Bagcivan
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Nursing, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Medicine, Division of Geriatrics, Gerontology, and Palliative Care, UAB Center for Palliative and Supportive Care, Birmingham, AL, USA
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Bakitas MA, Elk R, Astin M, Ceronsky L, Clifford KN, Dionne-Odom JN, Emanuel LL, Fink RM, Kvale E, Levkoff S, Ritchie C, Smith T. Systematic Review of Palliative Care in the Rural Setting. Cancer Control 2016; 22:450-64. [PMID: 26678972 DOI: 10.1177/107327481502200411] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Many of the world's population live in rural areas. However, access and dissemination of the advances taking place in the field of palliative care to patients living in rural areas have been limited. METHODS We searched 2 large databases of the medical literature and found 248 relevant articles; we also identified another 59 articles through networking and a hand search of reference lists. Of those 307 articles, 39 met the inclusion criteria and were grouped into the following subcategories: intervention (n = 4), needs assessment (n = 2), program planning (n = 3), program evaluation (n = 4), education (n = 7), financial (n = 8), and comprehensive/systematic literature reviews (n = 11). RESULTS We synthesized the current state of rural palliative care research and practice to identify important gaps for future research. Studies were conducted in the United States, Australia, Canada, Africa, Sweden, and India. Two randomized control trials were identified, both of which used telehealth approaches and had positive survival outcomes. One study demonstrated positive patient quality of life and depression outcomes. CONCLUSIONS Research to guide rural palliative care practice is sparse. Approaches to telehealth, community- academic partnerships, and training rural health care professionals show promise, but more research is needed to determine best practices for providing palliative care to patients living in rural settings.
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Affiliation(s)
- Marie A Bakitas
- School of Nursing, Center for Palliative and Supportive Care, University of Alabama at Birmingham, AL.
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63
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Dionne-Odom JN, Azuero A, Lyons KD, Hull JG, Prescott AT, Tosteson T, Frost J, Dragnev KH, Bakitas MA. Family Caregiver Depressive Symptom and Grief Outcomes From the ENABLE III Randomized Controlled Trial. J Pain Symptom Manage 2016; 52:378-85. [PMID: 27265814 PMCID: PMC5023481 DOI: 10.1016/j.jpainsymman.2016.03.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [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: 12/29/2015] [Revised: 02/16/2016] [Accepted: 03/07/2016] [Indexed: 10/21/2022]
Abstract
CONTEXT Little is known about whether early palliative care (EPC) support for family caregivers (CGs) impacts depressive symptoms and grief after care recipients die. OBJECTIVES To assess after-death CG depressive symptom and grief scores for early compared to delayed group CGs. METHODS We conducted a randomized controlled trial (10/2010-9/2013) of an EPC telehealth intervention for CGs (n = 123) initiated at the time of care recipients' advanced cancer diagnosis (early group) or 12 weeks later (delayed group) in a rural comprehensive cancer center, affiliated clinics, and a Veterans Administration medical center. The ENABLE [Educate, Nurture, Advise, Before Life Ends] CG intervention consisted of three weekly sessions, monthly follow-up, and a bereavement call. CGs completed the Center for Epidemiological Study-Depression (CES-D) scale and the Prigerson Inventory of Complicated Grief-Short Form (PG13) 8-12 weeks after care recipients' deaths. Crude and covariate-adjusted between-group differences were estimated and tested using general linear models. RESULTS For care recipients who died (n = 70), 44 CGs (early: n = 19; delayed: n = 25) completed after-death questionnaires. Mean depressive symptom scores (CES-D) for the early group was 14.6 (SD = 10.7) and for the delayed group was 17.6 (SD = 11.8). Mean complicated grief scores (PG13) for the early group was 22.7 (SD = 4.9) and for the delayed group was 24.9 (SD = 6.9). Adjusted between-group differences were not statistically significant (CES-D: d = 0.07, P = 0.88; PG13: d = -0.21, P = 0.51). CONCLUSION CGs' depressive symptom and complicated grief scores 8-12 weeks after care recipients' deaths were not statistically different based on the timing of EPC support. The impact of timing of CG EPC interventions on CGs bereavement outcomes requires further investigation.
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Affiliation(s)
- J Nicholas Dionne-Odom
- School of Nursing, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andres Azuero
- School of Nursing, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kathleen D Lyons
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Jay G Hull
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire, USA
| | - Anna T Prescott
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire, USA
| | - Tor Tosteson
- Biostatistics Shared Resource, Norris Cotton Cancer Center, Lebanon, New Hampshire, USA
| | - Jennifer Frost
- Department of Medicine, Hematology/Oncology, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, New Hampshire, USA
| | - Konstantin H Dragnev
- Department of Medicine, Hematology/Oncology, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, New Hampshire, USA
| | - Marie A Bakitas
- School of Nursing, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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64
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Rhudy JP, Alexandrov AW, Hyrkäs KE, Jablonski-Jaudon RA, Pryor ER, Wang HE, Bakitas MA. Geographic access to interventional cardiology services in one rural state. Heart Lung 2016; 45:434-40. [DOI: 10.1016/j.hrtlng.2016.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 06/29/2016] [Accepted: 07/02/2016] [Indexed: 10/21/2022]
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65
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Dionne-Odom JN, Hull JG, Martin MY, Lyons KD, Prescott AT, Tosteson T, Li Z, Akyar I, Raju D, Bakitas MA. Associations between advanced cancer patients' survival and family caregiver presence and burden. Cancer Med 2016; 5:853-62. [PMID: 26860217 PMCID: PMC4864814 DOI: 10.1002/cam4.653] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [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] [Received: 10/06/2015] [Revised: 12/18/2015] [Accepted: 01/03/2016] [Indexed: 12/25/2022] Open
Abstract
We conducted a randomized controlled trial (RCT) of an early palliative care intervention (ENABLE: Educate, Nurture, Advise, Before Life Ends) for persons with advanced cancer and their family caregivers. Not all patient participants had a caregiver coparticipant; hence, we explored whether there were relationships between patient survival, having an enrolled caregiver, and caregiver outcomes prior to death. One hundred and twenty‐three patient‐caregiver dyads and 84 patients without a caregiver coparticipant participated in the ENABLE early versus delayed (12 weeks later) RCT. We collected caregiver quality‐of‐life (QOL), depression, and burden (objective, stress, and demand) measures every 6 weeks for 24 weeks and every 3 months thereafter until the patient's death or study completion. We conducted survival analyses using log‐rank and Cox proportional hazards models. Patients with a caregiver coparticipant had significantly shorter survival (Wald = 4.31, HR = 1.52, CI: 1.02–2.25, P = 0.04). After including caregiver status, marital status (married/unmarried), their interaction, and relevant covariates, caregiver status (Wald = 6.25, HR = 2.62, CI: 1.23–5.59, P = 0.01), being married (Wald = 8.79, HR = 2.92, CI: 1.44–5.91, P = 0.003), and their interaction (Wald = 5.18, HR = 0.35, CI: 0.14–0.87, P = 0.02) were significant predictors of lower patient survival. Lower survival in patients with a caregiver was significantly related to higher caregiver demand burden (Wald = 4.87, CI: 1.01–1.20, P = 0.03) but not caregiver QOL, depression, and objective and stress burden. Advanced cancer patients with caregivers enrolled in a clinical trial had lower survival than patients without caregivers; however, this mortality risk was mostly attributable to higher survival by unmarried patients without caregivers. Higher caregiver demand burden was also associated with decreased patient survival.
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Affiliation(s)
| | - Jay G Hull
- Departments of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire
| | - Michelle Y Martin
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Preventive Medicine, University of Tennessee Health Science Cente, Memphis, Tennessee
| | - Kathleen Doyle Lyons
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Anna T Prescott
- Departments of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire
| | - Tor Tosteson
- Biostatistics Shared Resource, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Zhongze Li
- Biostatistics Shared Resource, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Imatullah Akyar
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama.,School of Nursing, Hacettepe University, Ankara, Turkey
| | - Dheeraj Raju
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama
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66
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Rhudy JP, Bakitas MA, Hyrkäs K, Jablonski-Jaudon RA, Pryor ER, Wang HE, Alexandrov AW. Effectiveness of regionalized systems for stroke and myocardial infarction. Brain Behav 2015; 5:e00398. [PMID: 26516616 PMCID: PMC4614047 DOI: 10.1002/brb3.398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/18/2015] [Accepted: 08/16/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI. METHODS Literature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non- or pre-regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking "regionalization" and "myocardial infarction" or citation as a model system by any American Heart Association statement. RESULTS For AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre- or nonregionalized state. The final yield was nine papers from six systems. CONCLUSION Although regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.
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Affiliation(s)
- James P Rhudy
- School of Nursing University of Alabama at Birmingham Alabama
| | - Marie A Bakitas
- School of Nursing University of Alabama at Birmingham Alabama
| | - Kristiina Hyrkäs
- Center for Nursing Research and Quality Outcomes Maine Medical Center Birmingham Alabama
| | | | - Erica R Pryor
- School of Nursing University of Alabama at Birmingham Alabama
| | - Henry E Wang
- Department of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama
| | - Anne W Alexandrov
- College of Nursing University of Tennessee Health Sciences Center Memphis Tennessee
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Abstract
Veterans receive care across the entire health system. Therefore, the workforce needs knowledge and awareness of whether patients are Veterans and the impact of their military service on their physical and mental health. Recent reports of limitations in access for Veterans seeking health care have highlighted this need across all health care settings. Academic-practice partnerships are one mechanism to align the need for improved health care services within the Veteran population while advancing nursing practice in the Veterans Health Administration and surrounding communities. The key to strong partnerships and sustained collaboration is shared goals, mutual trust and respect, the development of formal relationships, and support of senior leadership that fosters the joint vision and mission to improve nursing care for Veterans. This article describes the evolving partnership between one Veterans Health Administration Medical Center and a School of Nursing, which aligned strategic goals across both organizations to increase the capacity and capability of services provided to Veterans.
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Affiliation(s)
- Rebecca S Miltner
- School of Nursing, University of Alabama at Birmingham (Drs Miltner, Selleck, Bakitas, and Harper); and Birmingham VA Medical Center, Birmingham, Alabama (Drs Miltner, Froelich, Bakitas, Cleveland, and Harper)
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68
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Kheirbek RE, Fletcher RD, Bakitas MA, Fonarow GC, Parvataneni S, Bearden D, Bailey FA, Morgan CJ, Singh S, Blackman MR, Zile MR, Patel K, Ahmed MB, Tucker RO, Brown CJ, Love TE, Aronow WS, Roseman JM, Rich MW, Allman RM, Ahmed A. Discharge Hospice Referral and Lower 30-Day All-Cause Readmission in Medicare Beneficiaries Hospitalized for Heart Failure. Circ Heart Fail 2015; 8:733-40. [PMID: 26019151 DOI: 10.1161/circheartfailure.115.002153] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [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: 11/04/2014] [Accepted: 05/11/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Heart failure (HF) is the leading cause for hospital readmission. Hospice care may help palliate HF symptoms but its association with 30-day all-cause readmission remains unknown. METHODS AND RESULTS Of the 8032 Medicare beneficiaries hospitalized for HF in 106 Alabama hospitals (1998-2001), 182 (2%) received discharge hospice referrals. Of the 7850 patients not receiving hospice referrals, 1608 (20%) died within 6 months post discharge (the hospice-eligible group). Propensity scores for hospice referral were estimated for each of the 1790 (182+1608) patients and were used to match 179 hospice-referral patients with 179 hospice-eligible patients who were balanced on 28 baseline characteristics (mean age, 79 years; 58% women; 18% non-white). Overall, 22% (1742/8032) died in 6 months, of whom 8% (134/1742) received hospice referrals. Among the 358 matched patients, 30-day all-cause readmission occurred in 5% and 41% of hospice-referral and hospice-eligible patients, respectively (hazard ratio associated with hospice referral, 0.12; 95% confidence interval, 0.06-0.24). Hazard ratios (95% confidence intervals) for 30-day all-cause readmission associated with hospice referral among the 126 patients who died and 232 patients who survived 30-day post discharge were 0.03 (0.04-0.21) and 0.17 (0.08-0.36), respectively. Although 30-day mortality was higher in the hospice referral group (43% versus 27%), it was similar at 90 days (64% versus 67% among hospice-eligible patients). CONCLUSIONS A discharge hospice referral was associated with lower 30-day all-cause readmission among hospitalized patients with HF. However, most patients with HF who died within 6 months of hospital discharge did not receive a discharge hospice referral.
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Affiliation(s)
- Raya E Kheirbek
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Ross D Fletcher
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Marie A Bakitas
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Gregg C Fonarow
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Sridivya Parvataneni
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Donna Bearden
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Frank A Bailey
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Charity J Morgan
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Steven Singh
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Marc R Blackman
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Michael R Zile
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Kanan Patel
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Momanna B Ahmed
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Rodney O Tucker
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Cynthia J Brown
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Thomas E Love
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Wilbert S Aronow
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Jeffrey M Roseman
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Michael W Rich
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Richard M Allman
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.)
| | - Ali Ahmed
- From the Veterans Affairs Medical Center, Washington, DC (R.E.K., R.D.F., S.S., M.R.B., A.A.); Department of Medicine, George Washington University, Washington, DC (R.E.K., M.R.B.); Department of Medicine, Georgetown University, Washington, DC (R.D.F., S.S., M.R.B., A.A.); School of Nursing (M.A.B.) and Departments of Medicine (M.A.B., D.B., M.B.A., R.O.T., C.J.B., A.A.), Biostatistics (C.J.M.), and Epidemiology (J.M.R.), University of Alabama at Birmingham; Department of Medicine, University of California, Los Angeles (G.C.F.); Department of Medicine, East Tennessee State University, Johnson City (S.P.); Department of Medicine, University of Colorado, Denver (F.A.B.); Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.); Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC (M.R.Z.); Department of Medicine, University of California, San Francisco (K.P.); Department of Medicine, Veterans Affairs Medical Center, Birmingham, AL (C.J.B.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, New York Medical College, Valhalla (W.S.A.); Department of Medicine, Washington University, St. Louis, MO (M.W.R.); and Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, DC (R.M.A.).
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Dionne-Odom JN, Azuero A, Lyons KD, Hull JG, Tosteson T, Li Z, Li Z, Frost J, Dragnev KH, Akyar I, Hegel MT, Bakitas MA. Benefits of Early Versus Delayed Palliative Care to Informal Family Caregivers of Patients With Advanced Cancer: Outcomes From the ENABLE III Randomized Controlled Trial. J Clin Oncol 2015; 33:1446-52. [PMID: 25800762 PMCID: PMC4404423 DOI: 10.1200/jco.2014.58.7824] [Citation(s) in RCA: 300] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To determine the effect of early versus delayed initiation of a palliative care intervention for family caregivers (CGs) of patients with advanced cancer. PATIENTS AND METHODS Between October 2010 and March 2013, CGs of patients with advanced cancer were randomly assigned to receive three structured weekly telephone coaching sessions, monthly follow-up, and a bereavement call either early after enrollment or 3 months later. CGs of patients with advanced cancer were recruited from a National Cancer Institute cancer center, a Veterans Administration Medical Center, and two community outreach clinics. Outcomes were quality of life (QOL), depression, and burden (objective, stress, and demand). RESULTS A total of 122 CGs (early, n = 61; delayed, n = 61) of 207 patients participated; average age was 60 years, and most were female (78.7%) and white (92.6%). Between-group differences in depression scores from enrollment to 3 months (before delayed group started intervention) favored the early group (mean difference, -3.4; SE, 1.5; d = -.32; P = .02). There were no differences in QOL (mean difference, -2; SE, 2.3; d = -.13; P = .39) or burden (objective: mean difference, 0.3; SE, .7; d = .09; P = .64; stress: mean difference, -.5; SE, .5; d = -.2; P = .29; demand: mean difference, 0; SE, .7; d = -.01; P = .97). In decedents' CGs, a terminal decline analysis indicated between-group differences favoring the early group for depression (mean difference, -3.8; SE, 1.5; d = -.39; P = .02) and stress burden (mean difference, -1.1; SE, .4; d = -.44; P = .01) but not for QOL (mean difference, -4.9; SE, 2.6; d = -.3; P = .07), objective burden (mean difference, -.6; SE, .6; d = -.18; P = .27), or demand burden (mean difference, -.7; SE, .6; d = -.23; P = .22). CONCLUSION Early-group CGs had lower depression scores at 3 months and lower depression and stress burden in the terminal decline analysis. Palliative care for CGs should be initiated as early as possible to maximize benefits.
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Affiliation(s)
- J Nicholas Dionne-Odom
- J. Nicholas Dionne-Odom, Andres Azuero, Imatullah Akyar, and Marie A. Bakitas, University of Alabama at Birmingham, Birmingham, AL; Kathleen D. Lyons, Jay G. Hull, Zhigang Li, and Mark T. Hegel, Dartmouth College; Tor Tosteson and Zhongze Li, Norris Cotton Cancer Center, Hanover; and Jennifer Frost and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Andres Azuero
- J. Nicholas Dionne-Odom, Andres Azuero, Imatullah Akyar, and Marie A. Bakitas, University of Alabama at Birmingham, Birmingham, AL; Kathleen D. Lyons, Jay G. Hull, Zhigang Li, and Mark T. Hegel, Dartmouth College; Tor Tosteson and Zhongze Li, Norris Cotton Cancer Center, Hanover; and Jennifer Frost and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Kathleen D Lyons
- J. Nicholas Dionne-Odom, Andres Azuero, Imatullah Akyar, and Marie A. Bakitas, University of Alabama at Birmingham, Birmingham, AL; Kathleen D. Lyons, Jay G. Hull, Zhigang Li, and Mark T. Hegel, Dartmouth College; Tor Tosteson and Zhongze Li, Norris Cotton Cancer Center, Hanover; and Jennifer Frost and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jay G Hull
- J. Nicholas Dionne-Odom, Andres Azuero, Imatullah Akyar, and Marie A. Bakitas, University of Alabama at Birmingham, Birmingham, AL; Kathleen D. Lyons, Jay G. Hull, Zhigang Li, and Mark T. Hegel, Dartmouth College; Tor Tosteson and Zhongze Li, Norris Cotton Cancer Center, Hanover; and Jennifer Frost and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Tor Tosteson
- J. Nicholas Dionne-Odom, Andres Azuero, Imatullah Akyar, and Marie A. Bakitas, University of Alabama at Birmingham, Birmingham, AL; Kathleen D. Lyons, Jay G. Hull, Zhigang Li, and Mark T. Hegel, Dartmouth College; Tor Tosteson and Zhongze Li, Norris Cotton Cancer Center, Hanover; and Jennifer Frost and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Zhigang Li
- J. Nicholas Dionne-Odom, Andres Azuero, Imatullah Akyar, and Marie A. Bakitas, University of Alabama at Birmingham, Birmingham, AL; Kathleen D. Lyons, Jay G. Hull, Zhigang Li, and Mark T. Hegel, Dartmouth College; Tor Tosteson and Zhongze Li, Norris Cotton Cancer Center, Hanover; and Jennifer Frost and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Zhongze Li
- J. Nicholas Dionne-Odom, Andres Azuero, Imatullah Akyar, and Marie A. Bakitas, University of Alabama at Birmingham, Birmingham, AL; Kathleen D. Lyons, Jay G. Hull, Zhigang Li, and Mark T. Hegel, Dartmouth College; Tor Tosteson and Zhongze Li, Norris Cotton Cancer Center, Hanover; and Jennifer Frost and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jennifer Frost
- J. Nicholas Dionne-Odom, Andres Azuero, Imatullah Akyar, and Marie A. Bakitas, University of Alabama at Birmingham, Birmingham, AL; Kathleen D. Lyons, Jay G. Hull, Zhigang Li, and Mark T. Hegel, Dartmouth College; Tor Tosteson and Zhongze Li, Norris Cotton Cancer Center, Hanover; and Jennifer Frost and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Konstantin H Dragnev
- J. Nicholas Dionne-Odom, Andres Azuero, Imatullah Akyar, and Marie A. Bakitas, University of Alabama at Birmingham, Birmingham, AL; Kathleen D. Lyons, Jay G. Hull, Zhigang Li, and Mark T. Hegel, Dartmouth College; Tor Tosteson and Zhongze Li, Norris Cotton Cancer Center, Hanover; and Jennifer Frost and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Imatullah Akyar
- J. Nicholas Dionne-Odom, Andres Azuero, Imatullah Akyar, and Marie A. Bakitas, University of Alabama at Birmingham, Birmingham, AL; Kathleen D. Lyons, Jay G. Hull, Zhigang Li, and Mark T. Hegel, Dartmouth College; Tor Tosteson and Zhongze Li, Norris Cotton Cancer Center, Hanover; and Jennifer Frost and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mark T Hegel
- J. Nicholas Dionne-Odom, Andres Azuero, Imatullah Akyar, and Marie A. Bakitas, University of Alabama at Birmingham, Birmingham, AL; Kathleen D. Lyons, Jay G. Hull, Zhigang Li, and Mark T. Hegel, Dartmouth College; Tor Tosteson and Zhongze Li, Norris Cotton Cancer Center, Hanover; and Jennifer Frost and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Marie A Bakitas
- J. Nicholas Dionne-Odom, Andres Azuero, Imatullah Akyar, and Marie A. Bakitas, University of Alabama at Birmingham, Birmingham, AL; Kathleen D. Lyons, Jay G. Hull, Zhigang Li, and Mark T. Hegel, Dartmouth College; Tor Tosteson and Zhongze Li, Norris Cotton Cancer Center, Hanover; and Jennifer Frost and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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Bakitas MA, Tosteson TD, Li Z, Lyons KD, Hull JG, Li Z, Dionne-Odom JN, Frost J, Dragnev KH, Hegel MT, Azuero A, Ahles TA. Early Versus Delayed Initiation of Concurrent Palliative Oncology Care: Patient Outcomes in the ENABLE III Randomized Controlled Trial. J Clin Oncol 2015; 33:1438-45. [PMID: 25800768 PMCID: PMC4404422 DOI: 10.1200/jco.2014.58.6362] [Citation(s) in RCA: 742] [Impact Index Per Article: 82.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Randomized controlled trials have supported integrated oncology and palliative care (PC); however, optimal timing has not been evaluated. We investigated the effect of early versus delayed PC on quality of life (QOL), symptom impact, mood, 1-year survival, and resource use. PATIENTS AND METHODS Between October 2010 and March 2013, 207 patients with advanced cancer at a National Cancer Institute cancer center, a Veterans Affairs Medical Center, and community outreach clinics were randomly assigned to receive an in-person PC consultation, structured PC telehealth nurse coaching sessions (once per week for six sessions), and monthly follow-up either early after enrollment or 3 months later. Outcomes were QOL, symptom impact, mood, 1-year survival, and resource use (hospital/intensive care unit days, emergency room visits, chemotherapy in last 14 days, and death location). RESULTS Overall patient-reported outcomes were not statistically significant after enrollment (QOL, P = .34; symptom impact, P = .09; mood, P = .33) or before death (QOL, P = .73; symptom impact, P = .30; mood, P = .82). Kaplan-Meier 1-year survival rates were 63% in the early group and 48% in the delayed group (difference, 15%; P = .038). Relative rates of early to delayed decedents' resource use were similar for hospital days (0.73; 95% CI, 0.41 to 1.27; P = .26), intensive care unit days (0.68; 95% CI, 0.23 to 2.02; P = .49), emergency room visits (0.73; 95% CI, 0.45 to 1.19; P = .21), chemotherapy in last 14 days (1.57; 95% CI, 0.37 to 6.7; P = .27), and home death (27 [54%] v 28 [47%]; P = .60). CONCLUSION Early-entry participants' patient-reported outcomes and resource use were not statistically different; however, their survival 1-year after enrollment was improved compared with those who began 3 months later. Understanding the complex mechanisms whereby PC may improve survival remains an important research priority.
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Affiliation(s)
- Marie A Bakitas
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY.
| | - Tor D Tosteson
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Zhigang Li
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Kathleen D Lyons
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jay G Hull
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Zhongze Li
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - J Nicholas Dionne-Odom
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jennifer Frost
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Konstantin H Dragnev
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Mark T Hegel
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Andres Azuero
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Tim A Ahles
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
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Smith AK, Thai JN, Bakitas MA, Meier DE, Spragens LH, Temel JS, Weissman DE, Rabow MW. The diverse landscape of palliative care clinics. J Palliat Med 2013; 16:661-8. [PMID: 23662953 DOI: 10.1089/jpm.2012.0469] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Many health care organizations are interested in instituting a palliative care clinic. However, there are insufficient published data regarding existing practices to inform the development of new programs. OBJECTIVE Our objective was to obtain in-depth information about palliative care clinics. METHODS We conducted a cross-sectional survey of 20 outpatient palliative care practices in diverse care settings. The survey included both closed- and open-ended questions regarding practice size, utilization of services, staffing, referrals, services offered, funding, impetus for starting, and challenges. RESULTS Twenty of 21 (95%) practices responded. Practices self-identified as: hospital-based (n=7), within an oncology division/cancer center (n=5), part of an integrated health system (n=6), and hospice-based (n=2). The majority of referred patients had a cancer diagnosis. Additional common diagnoses included chronic obstructive pulmonary disease, neurologic disorders, and congestive heart failure. All practices ranked "pain management" and "determining goals of care" as the most common reasons for referrals. Twelve practices staffed fewer than 5 half-days of clinic per week, with 7 operating only one half-day per week. Practices were staffed by a mixture of physicians, advanced practice nurses or nurse practitioners, nurses, or social workers. Eighteen practices expected their practice to grow within the next year. Eleven practices noted a staffing shortage and 8 had a wait time of a week or more for a new patient appointment. Only 12 practices provide 24/7 coverage. Billing and institutional support were the most common funding sources. Most practices described starting because inpatient palliative providers perceived poor quality outpatient care in the outpatient setting. The most common challenges included: funding for staffing (11) and being overwhelmed with referrals (8). CONCLUSIONS Once established, outpatient palliative care practices anticipate rapid growth. In this context, outpatient practices must plan for increased staffing and develop a sustainable financial model.
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Affiliation(s)
- Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA.
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Li Z, Tosteson TD, Bakitas MA. Joint modeling quality of life and survival using a terminal decline model in palliative care studies. Stat Med 2013; 32:1394-406. [PMID: 23001893 PMCID: PMC3623280 DOI: 10.1002/sim.5635] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [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: 02/14/2012] [Accepted: 09/04/2012] [Indexed: 12/25/2022]
Abstract
Palliative medicine is a relatively new specialty that focuses on preventing and relieving the suffering of patients facing life-threatening illness. For cancer patients, clinical trials have been carried out to compare concurrent palliative care with usual cancer care in terms of longitudinal measurements of quality of life (QOL) until death, and overall survival is usually treated as a secondary endpoint. It is known that QOL of patients with advanced cancer decreases as death approaches; however, in previous clinical trials, this association has generally not been taken into account when inferences about the effect of an intervention on QOL or survival have been made. We developed a new joint modeling approach, a terminal decline model, to study the trajectory of repeated measurements and survival in a recently completed palliative care study. This approach takes the association of survival and QOL into account by modeling QOL retrospectively from death. For those patients whose death times are censored, marginal likelihood is used to incorporate them into the analysis. Our approach has two submodels: a piecewise linear random intercept model with serial correlation and measurement error for the retrospective trajectory of QOL and a piecewise exponential model for the survival distribution. Maximum likelihood estimators of the parameters are obtained by maximizing the closed-form expression of log-likelihood function. An explicit expression of quality-adjusted life years can also be derived from our approach. We present a detailed data analysis of our previously reported palliative care randomized clinical trial.
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Affiliation(s)
- Zhigang Li
- Section of Biostatistics and Epidemiology, Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA.
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Smith EML, Bakitas MA, Homel P, Piehl M, Kingman L, Fadul CE, Bookbinder M. Preliminary assessment of a neuropathic pain treatment and referral algorithm for patients with cancer. J Pain Symptom Manage 2011; 42:822-38. [PMID: 21820851 DOI: 10.1016/j.jpainsymman.2011.03.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [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: 09/17/2010] [Revised: 03/03/2011] [Accepted: 03/04/2011] [Indexed: 11/21/2022]
Abstract
CONTEXT The purpose of this case series study was to pilot test an evidence-based neuropathic pain (NP) treatment and referral algorithm for use by oncology nurses when managing cancer-related NP. OBJECTIVES The primary study objective was to assess patient-reported outcomes (pain severity, changes in activities of daily living, and satisfaction) resulting from algorithm use. METHODS Outpatients (n=20) with cancer-related NP scores ≥4 on a 0-10 numeric rating scale participated in the study. NP assessment, treatment, and referral to ancillary providers were guided by an evidence-based NP algorithm that was implemented by oncology nurse practitioners. Based on efficacy evidenced through randomized clinical trials published at the time of study implementation, the following drugs were included in the algorithm: lidocaine patch, gabapentin, oxycodone, tramadol, morphine, methadone, duloxetine, pregabalin, and nortriptyline. Recommendations for starting dose, dose escalation, drug combinations, treatment duration, and contraindications were included for first-tier drugs. Patient-reported outcomes (pain severity, functional capacity, and satisfaction) were assessed monthly over 12 weeks. RESULTS Average NP severity (P=0.001), general activity (P<0.001), mood (P=0.002), walking ability (P=0.01), ability to perform normal work (P=0.002), relationships (P=0.002), sleep (P=0.01), life enjoyment (P<0.001), and patient satisfaction (P=0.003) all improved by 12 weeks. CONCLUSION Evidence from this pilot study suggests that NP evidence-based treatment may result in improved symptoms, function, and patient satisfaction. A randomized controlled trial is needed to further assess algorithm efficacy.
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Lavoie Smith EM, Bakitas MA, Homel P, Fadul C, Meyer L, Skalla K, Bookbinder M. Using quality improvement methodology to improve neuropathic pain screening and assessment in patients with cancer. J Cancer Educ 2009; 24:135-140. [PMID: 19431031 DOI: 10.1080/08858190902854715] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Quality improvement methodology was used to improve neuropathic pain (NP) screening at a comprehensive cancer center. METHODS Nurses participated in educational sessions about screening and assessment. Clinical systems to facilitate documentation of NP severity scores were developed. RESULTS Pretest and posttest score results demonstrated nurse acquisition of new knowledge. A 90% NP screening adherence rate was achieved (N = 3831). Patients with no reported general pain (n = 291) were found to have moderate to severe NP. CONCLUSIONS Keys to success are (1) health care professional education and periodic reinforcement of learning and (2) system infrastructure changes.
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Affiliation(s)
- Ellen M Lavoie Smith
- Department Hematology/Oncology, One Medical Center Drive, Dartmouth-Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH 03756, USA.
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Abstract
BACKGROUND A substantial portion of the 1.3 million persons diagnosed annually with cancer receive neurotoxic chemotherapy that may produce distressful symptoms and changes in functional ability. However, little is known about the symptom experience and daily life effects of chemotherapy-induced peripheral neuropathy (CIPN). OBJECTIVE To describe the CIPN symptom experience and the influence of symptoms on everyday life. METHODS This was a qualitative, exploratory, interpretive, descriptive study with semistructured interviews. A purposive sample of 28 participants was recruited from a rural National Cancer Institute-designated comprehensive cancer center. Interviews were audiotaped, transcribed verbatim, and imported into Atlas.ti software. Content analysis and constant comparative method were used to analyze the data. RESULTS Participants represented diversity in age (46-81 years), cancer type, time since diagnosis (3-198 months), neuropathy severity, and neurotoxic chemotherapy agents received. Content analysis yielded a rich, thick description of CIPN symptoms and the influence of the symptoms on functional ability and everyday life. Further interpretive analysis provided a description of the symptom experience through an overarching metaphor, Background Noise, and four major themes: (a) Becoming Aware; (b) Learning New Lyrics; (c) Functional, Emotional, and Social Role Cacophony; and (d) Learning to Live With It. Participants described significant physical limitations, emotional distress, and social role impairments due to CIPN. CONCLUSIONS Having CIPN results in diverse symptom patterns and degrees of physical symptom distress from mild to severe, emotional distress, alterations in functional ability, and social role impairment. Comprehensive clinical and research measures are needed to assess the full spectrum of CIPN effects on everyday life.
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Affiliation(s)
- Marie A Bakitas
- School of Nursing, Yale University, New Haven, Connecticut, USA.
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Bakitas MA, Lyons KD, Dixon J, Ahles TA. Palliative care program effectiveness research: developing rigor in sampling design, conduct, and reporting. J Pain Symptom Manage 2006; 31:270-84. [PMID: 16563321 DOI: 10.1016/j.jpainsymman.2005.07.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2005] [Indexed: 10/24/2022]
Abstract
Research on palliative care presents some unique sampling challenges. The purpose of this paper is to articulate the sampling challenges that palliative care researchers face during phases of study design, conduct, and the reporting of results. Challenges include identifying a target population, avoiding selection bias in the face of clinician and patient denial of serious illness, developing eligibility criteria for a seriously ill population, minimizing high patient refusals due to illness, and accurate reporting of all screened and eligible participants. These challenges are explored within the context of a randomized clinical trial testing a palliative care intervention. Suggestions for improving scientific rigor in sampling design include 1) defining a target population that is consistent with research goals; 2) identifying eligibility criteria that are objective and understandable to clinicians to yield the desired sample; and 3) reporting results about the target population, sample eligibility/exclusions, and participation using standardized criteria.
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Affiliation(s)
- Marie A Bakitas
- Norris Cotton Cancer Center, Lebanon, New Hampshire 03756, and Yale University, New Haven, Connecticut, USA.
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Bakitas MA. Self-determination: analysis of the concept and implications for research in palliative care. Can J Nurs Res 2005; 37:22-49. [PMID: 16092777] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
This paper analyzes the evolution and the definition, current use, and application of the concept of self-determination in palliative care research and practice. Undertaken as a foundation for the development of a palliative care research program, the analysis considers selected historical, bioethical, legal, clinical, and relevant medical and nursing health-care literature on adults with chronic and terminal illness. Based on a synthesis of the literature, a conceptual definition is proposed and ways of integrating the concept of self-determination into palliative care intervention research are identified.
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Affiliation(s)
- Marie A Bakitas
- Darmouth Medical School, Dartmouth-Hitchcock Medical Center, Section of Palliative Medicine, Lebanon, New Hampshire 03756, USA.
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