Associations between United States acculturation and the end-of-life experience of caregivers of patients with advanced cancer

BACKGROUND

Cultural beliefs and values influence treatment preferences for and experiences with end-of-life (EOL) care among racial and ethnic groups. Within-group variations, however, may exist based on level of acculturation.

OBJECTIVES

To examine the extent to which EOL treatment factors (EOL treatment preferences and physician-caregiver communication) and select psychosocial factors (mental health, complementary therapies, and internal and external social support) differ based on the level of acculturation of caregivers of patients with advanced cancer.

METHODS

One hundred sixty-seven primary caregivers of patients with advanced cancer were interviewed as part of the multisite, prospective Coping with Cancer Study.

RESULTS

Caregivers who were less acculturated were more positively predisposed to use of a feeding tube at EOL (odds ratio [OR] 0.99 [p = 0.05]), were more likely to perceive that they received too much information from their doctors (OR 0.95 [p = 0.05]), were less likely to use mental health services (OR 1.03 [p = 0.003] and OR 1.02 [p = 0.02]), and desire additional services (OR 1.03 [p = 0.10] to 1.05 [p = 0.009]) than their more acculturated counterparts. Additionally, caregivers who were less acculturated cared for patients who were less likely to report having a living will (OR 1.03 [p = 0.0003]) or durable power of attorney for health care (OR 1.02 [p = 0.007]) than more acculturated caregivers. Caregivers who were less acculturated felt their religious and spiritual needs were supported by both the community (beta -0.28 [p = 0.0003]) and medical system (beta -0.38 [p < 0.0001]), had higher degrees of self-efficacy (beta -0.22 [p = 0.005]), and had stronger family relationships and support (beta -0.27 [p = 0.0004]).

CONCLUSIONS

The level of acculturation of caregivers of patients with advanced cancer does contribute to differences in EOL preferences and EOL medical decision-making.

Distinguishing symptoms of grief and depression in a cohort of advanced cancer patients

Several studies have shown that the symptoms of grief are different from symptoms of depression among bereaved family members. This study is an attempt to replicate this finding among advanced cancer patients and examine clinical correlates of patient grief and depression. Analyses were conducted on data from interviews with 123 advanced cancer patients. Grief was measured using symptoms from the patient version of the Inventory of Complicated Grief-Revised (ICG-R) and symptoms of depression were assessed using the Structured Clinical Interview for DSM-IV (SCID). A factor analysis revealed that symptoms of patient grief formed a coherent factor that was distinct from a depression factor. Patient grief "caseness" (defined as being in the top 10% of the distribution of grief scores), but not major depressive disorder, was uniquely associated with the wish to die (odds ratio [OR] 10.13 [0.1.08-95.06]). Both depression and grief were significantly associated with mental health service use (OR 16.07 [1.68, 153.77] vs. 4.82; CI = [1.09, 21.41]) and negative religious coping (OR 1.36 [1.06, 1.73] vs. 1.25 [1.05, 1.49]); neither was associated with terminal illness acknowledgement.

End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences

PURPOSE

Physicians have an ethical obligation to honor patients' values for care, including at the end of life (EOL). We sought to evaluate factors that help patients to receive care consistent with their preferences.

METHODS

This was a longitudinal multi-institutional cohort study. We measured baseline preferences for life-extending versus symptom-directed care and actual EOL care received in 325 patients with advanced cancer. We also measured associated sociodemographic, health, and communication characteristics, including EOL discussions between patients and physicians.

RESULTS

Preferences were assessed a median of 125 days before death. Overall, 68% of patients (220 of 325 patients) received EOL care consistent with baseline preferences. The proportion was slightly higher among patients who recognized they were terminally ill (74%, 90 of 121 patients; P = .05). Patients who recognized their terminal illness were more likely to prefer symptom-directed care (83%, 100 of 121 patients; v 66%, 127 of 191 patients; P = .003). However, some patients who were aware they were terminally ill wished to receive life-extending care (17%, 21 of 121 patients). Patients who reported having discussed their wishes for EOL care with a physician (39%, 125 of 322 patients) were more likely to receive care that was consistent with their preferences, both in the full sample (odds ratio [OR] = 2.26; P < .0001) and among patients who were aware they were terminally ill (OR = 3.94; P = .0005). Among patients who received no life-extending measures, physical distress was lower (mean score, 3.1 v 4.1; P = .03) among patients for whom such care was consistent with preferences.

CONCLUSION

Patients with cancer are more likely to receive EOL care that is consistent with their preferences when they have had the opportunity to discuss their wishes for EOL care with a physician.

Tailoring Cognitive-Behavioral Therapy to Treat Anxiety Comorbid with Advanced Cancer

Patients with advanced cancer often experience debilitating anxiety symptoms that interfere with quality of life and relate to worse medical outcomes. Although cognitive behavioral therapy (CBT) is an empirically-validated, first-line treatment for anxiety disorders, clinical trials of CBT for anxiety typically exclude patients with medical comorbidities in general, and those with terminal illnesses, such as advanced cancer, in particular. Moreover, CBT has generally targeted unrealistic fears and worries in otherwise healthy individuals with clinically significant anxiety symptoms. Consequently, traditional CBT does not sufficiently address the cognitive components of anxiety in patients with cancer, especially negative thought patterns that are rational but nonetheless intrusive and distressing, such as concerns about pain, disability and death, as well as management of multiple stressors, changes in functional status and burdensome medical treatments. In this paper, we describe a treatment approach for tailoring CBT to the needs of this population. Three case examples of patients diagnosed with terminal lung cancer are presented to demonstrate the treatment methods along with outcome measures for anxiety and quality of life.

The clinical course of advanced dementia

BACKGROUND

Dementia is a leading cause of death in the United States but is underrecognized as a terminal illness. The clinical course of nursing home residents with advanced dementia has not been well described.

METHODS

We followed 323 nursing home residents with advanced dementia and their health care proxies for 18 months in 22 nursing homes. Data were collected to characterize the residents' survival, clinical complications, symptoms, and treatments and to determine the proxies' understanding of the residents' prognosis and the clinical complications expected in patients with advanced dementia.

RESULTS

Over a period of 18 months, 54.8% of the residents died. The probability of pneumonia was 41.1%; a febrile episode, 52.6%; and an eating problem, 85.8%. After adjustment for age, sex, and disease duration, the 6-month mortality rate for residents who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%. Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last 3 months of life, 40.7% of residents underwent at least one burdensome intervention (hospitalization, emergency room visit, parenteral therapy, or tube feeding). Residents whose proxies had an understanding of the poor prognosis and clinical complications expected in advanced dementia were much less likely to have burdensome interventions in the last 3 months of life than were residents whose proxies did not have this understanding (adjusted odds ratio, 0.12; 95% confidence interval, 0.04 to 0.37).

CONCLUSIONS

Pneumonia, febrile episodes, and eating problems are frequent complications in patients with advanced dementia, and these complications are associated with high 6-month mortality rates. Distressing symptoms and burdensome interventions are also common among such patients. Patients with health care proxies who have an understanding of the prognosis and clinical course are likely to receive less aggressive care near the end of life.

Racial differences in predictors of intensive end-of-life care in patients with advanced cancer

PURPOSE

Black patients are more likely than white patients to receive life-prolonging care near death. This study examined predictors of intensive end-of-life (EOL) care for black and white advanced cancer patients.

PATIENTS AND METHODS

Three hundred two self-reported black (n = 68) and white (n = 234) patients with stage IV cancer and caregivers participated in a US multisite, prospective, interview-based cohort study from September 2002 to August 2008. Participants were observed until death, a median of 116 days from baseline. Patient-reported baseline predictors included EOL care preference, physician trust, EOL discussion, completion of a Do Not Resuscitate (DNR) order, and religious coping. Caregiver postmortem interviews provided information regarding EOL care received. Intensive EOL care was defined as resuscitation and/or ventilation followed by death in an intensive care unit.

RESULTS

Although black patients were three times more likely than white patients to receive intensive EOL care (adjusted odds ratio [aOR] = 3.04, P = .037), white patients with a preference for this care were approximately three times more likely to receive it (aOR = 13.20, P = .008) than black patients with the same preference (aOR = 4.46, P = .058). White patients who reported an EOL discussion or DNR order did not receive intensive EOL care; similar reports were not protective for black patients (aOR = 0.53, P = .460; and aOR = 0.65, P = .618, respectively).

CONCLUSION

White patients with advanced cancer are more likely than black patients with advanced cancer to receive the EOL care they initially prefer. EOL discussions and DNR orders are not associated with care for black patients, highlighting a need to improve communication between black patients and their clinicians.

Stigmatization and receptivity to mental health services among recently bereaved adults

Severe grief symptoms, treatment receptivity, attitudes about grief, and stigmatization concerns were assessed in a community-based sample of 135 widowed participants in the Yale Bereavement Study. There was a statistically significant association between the severity of grief symptoms and reported negative reactions from friends and family members. However, more than 90% of the respondents with complicated grief, a severe grief disorder, reported that they would be relieved to know that having such a diagnosis was indicative of a recognizable psychiatric condition, and 100% reported that they would be interested in receiving treatment for their severe grief symptoms.

Measuring therapeutic alliance between oncologists and patients with advanced cancer: the Human Connection Scale

BACKGROUND

Patients consider their human connection with a physician an important aspect of end-of-life (EOL) care. In this study, the authors sought to develop and validate a measure of therapeutic alliance between patients with advanced cancer and their physicians and to evaluate the effects of therapeutic alliance on EOL experiences and care.

METHODS

The Human Connection (THC) scale was developed to measure the extent to which patients felt a sense of mutual understanding, caring, and trust with their physicians. The scale was administered to 217 patients with advanced cancer along with measures of attributes that have been related hypothetically to therapeutic alliance, including emotional acceptance of terminal illness. EOL outcomes in 90 patients who died during the study also were examined.

RESULTS

The 16-item THC questionnaire was consistent internally (Cronbach alpha = .90) and valid based on its expected positive association with emotional acceptance of terminal illness (r = .31; P < .0001). THC scores were related inversely to symptom burden (r = -.19; P = .006), functional status (Karnofsky performance status; r = .22; P = .001), and mental illness (THC score: 50.69 for patients with any Diagnostic and Statistical Manual [DSM] diagnosis vs 55.22 for patients with no DSM diagnosis; P = .03). THC scores were not associated significantly with EOL discussions (P = .68). Among the patients who died, EOL intensive care unit (ICU) care was associated inversely with therapeutic alliance (THC score: 46.5 for patients who received ICU care vs 55.5 for patients without ICU care; P = .002), so that patients with higher THC scores were less likely to spend time in the ICU during the last week of life.

CONCLUSIONS

The THC scale is a valid and reliable measure of therapeutic alliance between patients with advanced cancer and their physicians. In addition, there was no evidence to suggest that EOL discussions harm patients' therapeutic alliance. A strong therapeutic alliance was associated with emotional acceptance of a terminal illness and with decreased ICU care at the EOL among patients with advanced cancer.

Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11

BACKGROUND

Bereavement is a universal experience, and its association with excess morbidity and mortality is well established. Nevertheless, grief becomes a serious health concern for a relative few. For such individuals, intense grief persists, is distressing and disabling, and may meet criteria as a distinct mental disorder. At present, grief is not recognized as a mental disorder in the DSM-IV or ICD-10. The goal of this study was to determine the psychometric validity of criteria for prolonged grief disorder (PGD) to enhance the detection and potential treatment of bereaved individuals at heightened risk of persistent distress and dysfunction.

METHODS AND FINDINGS

A total of 291 bereaved respondents were interviewed three times, grouped as 0-6, 6-12, and 12-24 mo post-loss. Item response theory (IRT) analyses derived the most informative, unbiased PGD symptoms. Combinatoric analyses identified the most sensitive and specific PGD algorithm that was then tested to evaluate its psychometric validity. Criteria require reactions to a significant loss that involve the experience of yearning (e.g., physical or emotional suffering as a result of the desired, but unfulfilled, reunion with the deceased) and at least five of the following nine symptoms experienced at least daily or to a disabling degree: feeling emotionally numb, stunned, or that life is meaningless; experiencing mistrust; bitterness over the loss; difficulty accepting the loss; identity confusion; avoidance of the reality of the loss; or difficulty moving on with life. Symptoms must be present at sufficiently high levels at least six mo from the death and be associated with functional impairment.

CONCLUSIONS

The criteria set for PGD appear able to identify bereaved persons at heightened risk for enduring distress and dysfunction. The results support the psychometric validity of the criteria for PGD that we propose for inclusion in DSM-V and ICD-11. Please see later in the article for Editors' Summary.

Health care costs in the last week of life: associations with end-of-life conversations

BACKGROUND

Life-sustaining medical care of patients with advanced cancer at the end of life (EOL) is costly. Patient-physician discussions about EOL wishes are associated with lower rates of intensive interventions.

METHODS

Funded by the National Institute of Mental Health and the National Cancer Institute, Coping With Cancer is a longitudinal multi-institutional study of 627 patients with advanced cancer. Patients were interviewed at baseline and were followed up through death. Costs for intensive care unit and hospital stays, hospice care, and life-sustaining procedures (eg, mechanical ventilator use and resuscitation) received in the last week of life were aggregated. Generalized linear models were applied to test for cost differences in EOL care. Propensity score matching was used to reduce selection biases.

RESULTS

Of 603 participants, 188 (31.2%) reported EOL discussions at baseline. After propensity score matching, the remaining 415 patients did not differ in sociodemographic characteristics, recruitment sites, illness acknowledgment, or treatment preferences. Further analyses, adjusted by quintiles of propensity scores and significant confounders, revealed that the mean (SE) aggregate costs of care (in 2008 US dollars) were $1876 ($177) for patients who reported EOL discussions compared with $2917 ($285) for patients who did not, a cost difference of $1041 (35.7% lower among patients who reported EOL discussions) (P =.002). Patients with higher costs had worse quality of death in their final week (Pearson production moment correlation partial r = -0.17, P =.006).

CONCLUSIONS

Patients with advanced cancer who reported having EOL conversations with physicians had significantly lower health care costs in their final week of life. Higher costs were associated with worse quality of death.

Do rates of mental disorders and existential distress among advanced stage cancer patients increase as death approaches?

OBJECTIVE

To determine whether the prevalence of mental disorders and related factors increase as advanced cancer patients get closer to death.

METHOD

Baseline, cross-sectional data from 289 patients who were assessed prior to their death as part of a multi-site, longitudinal, prospective cohort study of advanced cancer patients. Major depressive disorder, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-IV Axis I Disorders. Other factors examined included existential well-being, patient grief about their illness, physical symptom burden, terminal illness acknowledgment, peacefulness, and the wish to live or die.

RESULTS

Closeness to death was not associated with higher rates of mental disorders. Patients closer to death exhibited increased existential distress and physical symptom burden, were more likely to acknowledge being terminally ill, and were more likely to report an increased wish to die.

CONCLUSION

Results do not provide support for the common clinical assumption that the prevalence of depressive and anxiety disorders increases as death nears. However, patients' level of physical distress, acknowledgment of terminal illness, and wish to die, possibly reflecting acceptance of dying, increased as death approached. Longitudinal studies are needed to confirm individual changes in rates of mental disorder as patients approach death.

Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer

CONTEXT

Patients frequently rely on religious faith to cope with cancer, but little is known about the associations between religious coping and the use of intensive life-prolonging care at the end of life.

OBJECTIVE

To determine the way religious coping relates to the use of intensive life-prolonging end-of-life care among patients with advanced cancer.

DESIGN, SETTING, AND PARTICIPANTS

A US multisite, prospective, longitudinal cohort of 345 patients with advanced cancer, who were enrolled between January 1, 2003, and August 31, 2007. The Brief RCOPE assessed positive religious coping. Baseline interviews assessed psychosocial and religious/spiritual measures, advance care planning, and end-of-life treatment preferences. Patients were followed up until death, a median of 122 days after baseline assessment.

MAIN OUTCOME MEASURES

Intensive life-prolonging care, defined as receipt of mechanical ventilation or resuscitation in the last week of life. Analyses were adjusted for demographic factors significantly associated with positive religious coping and any end-of-life outcome at P < .05 (ie, age and race/ethnicity). The main outcome was further adjusted for potential psychosocial confounders (eg, other coping styles, terminal illness acknowledgment, spiritual support, preference for heroics, and advance care planning).

RESULTS

A high level of positive religious coping at baseline was significantly associated with receipt of mechanical ventilation compared with patients with a low level (11.3% vs 3.6%; adjusted odds ratio [AOR], 2.81 [95% confidence interval {CI}, 1.03-7.69]; P = .04) and intensive life-prolonging care during the last week of life (13.6% vs 4.2%; AOR, 2.90 [95% CI, 1.14-7.35]; P = .03) after adjusting for age and race. In the model that further adjusted for other coping styles, terminal illness acknowledgment, support of spiritual needs, preference for heroics, and advance care planning (do-not-resuscitate order, living will, and health care proxy/durable power of attorney), positive religious coping remained a significant predictor of receiving intensive life-prolonging care near death (AOR, 2.90 [95% CI, 1.07-7.89]; P = .04).

CONCLUSIONS

Positive religious coping in patients with advanced cancer is associated with receipt of intensive life-prolonging medical care near death. Further research is needed to determine the mechanisms for this association.

Mental health, treatment preferences, advance care planning, location, and quality of death in advanced cancer patients with dependent children

BACKGROUND

Clinicians observe that advanced cancer patients with dependent children agonize over the impact their death will have on their children. The objective of this study was to determine empirically whether advanced cancer patients with and without dependent children differ in treatment preferences, mental health, and end-of-life (EOL) outcomes.

METHODS

Coping with Cancer is a National Cancer Institute/National Institute of Mental Health-funded, multi-institutional, prospective cohort study of 668 patients with advanced cancer. Patients with and without dependent children were compared on rates of psychiatric disorders, advance care planning (ACP), EOL care, quality of their last week of life, and location of death.

RESULTS

In adjusted analyses, patients with advanced cancer who had dependent children were more likely to meet panic disorder criteria (adjusted odds ratio [AOR], 5.41; 95% confidence interval [95% CI], 2.13-13.69), more likely to be worried (mean difference in standard deviations [delta], 0.09; P=.006), and more likely to prefer aggressive treatment over palliative care (AOR, 1.77; 95% CI, 1.07-2.93). Patients with dependent children were less likely to engage in ACP (eg, do not resuscitate orders: AOR, 0.44; 95% CI, 0.26-0.75) and had a worse quality of life in the last week of life (delta, 0.15; P=.007). Among spousal caregivers, those with dependent children were more likely to meet criteria for major depressive disorder (AOR, 4.53; 95% CI, 1.47-14) and generalized anxiety disorder (AOR, 3.95; 95% CI, 1.29-12.16).

CONCLUSIONS

Patients with dependent children were more anxious, were less likely to engage in ACP, and were more likely to have a worse quality of life in their last week of life. Advanced cancer patients and spousal caregivers with dependent children represent a particularly distressed group that warrants further clinical attention, research, and support.

Communication in end-stage cancer: review of the literature and future research

Concerns have been raised about the quality of life and health care received by cancer patients at the end of life (EOL). Many patients die with pain and other distressing symptoms inadequately controlled, receiving burdensome, aggressive care that worsens quality of life and limits patient exposure to palliative care, such as hospice. Patient-physician communication is likely a very important determinate of EOL care. Discussions of EOL with physicians are associated with an increased likelihood of the following (1) acknowledgment of terminal illness, (2) preferences for comfort care over life extension, and (3) receipt of less intensive, life-prolonging and more palliative EOL care; while this appears to hold for White patients, it is less clear for Black, advanced cancer patients. These results highlight the importance of communication in determining EOL cancer care and suggest that communication disparities may contribute to Black-White differences in EOL care. We review the pertinent literature and discuss areas for future research.

The role of the clinician in cancer clinical communication

Clinician communication is critical to positive outcomes for patients and families in most health contexts. Researchers have investigated areas such as defining and teaching effective communication and identifying specific outcomes that can be improved through more effective communication. In the area of cancer care, advances in detection and treatment require that clinicians develop new skills to adapt to the evolving needs of patients, families, and other members of the health care team. Some areas that require the attention of researchers are defining, assessing, and teaching effective communication in the context of the specific desires and preferences of individual patients and special populations; and meeting the needs of patients across the cancer continuum from screening, diagnosis, treatment to palliative care and survivorship. This report highlights three areas of research in cancer clinician communication including key areas of current and emerging research and theories and approaches for future research.

Peer-to-peer communication, cancer prevention, and the internet

Online communication among patients and consumers through support groups, discussion boards, and knowledge resources is becoming more common. In this article, the summary of a workgroup discussion, we discuss key methods through which such web-based peer-to-peer communication may affect health promotion and disease prevention behavior (exchanges of information, emotional and instrumental support, and establishment of group norms and models). We also discuss several theoretical models for studying online peer communication, including social theory, health communication models, and health behavior models. Although online peer communication about health and disease is very common, research evaluating effects on health behaviors, mediators, and outcomes is still relatively sparse. We suggest that future research in this field should include formative evaluation and studies of effects on mediators of behavior change, behaviors, and outcomes. It also will be important to examine spontaneously emerging peer communication efforts to see how they can be integrated with theory-based efforts initiated by researchers.

Grief and acceptance as opposite sides of the same coin: setting a research agenda to study peaceful acceptance of loss

Reflections on results of a recent study suggest that stages of grief might more accurately be described as states of grief. Resolution of grief coincides with increasing acceptance of loss. Research indicating how grief resolution promotes acceptance may prove clinically useful in easing emotional pain associated with loss.

Unresolved grief in a national sample of bereaved parents: impaired mental and physical health 4 to 9 years later

PURPOSE

To assess unresolved parental grief, the associated long-term impact on mental and physical health, and health service use.

PATIENTS AND METHODS

This anonymous, mail-in questionnaire study was performed as a population-based investigation in Sweden between August 2001 and October 2001. Four hundred forty-nine parents who lost a child as a result of cancer 4 to 9 years earlier completed the survey (response rate, 80%). One hundred ninety-one (43%) of the bereaved parents were fathers, and 251 (56%) were mothers. Bereaved parents were asked whether or not, and to what extent, they had worked through their grief. They were also asked about their physical and psychological well-being. For outcomes of interest, we report relative risk (RR) with 95% CIs as well as unadjusted odds ratios and adjusted odds ratios.

RESULTS

Parents with unresolved grief reported significantly worsening psychological health (fathers: RR, 3.6; 95% CI, 2.0 to 6.4; mothers: RR, 2.9; 95% CI, 1.9 to 4.4) and physical health (fathers: RR, 2.8; 95% CI, 1.8 to 4.4; mothers: RR, 2.3; 95% CI, 1.6 to 3.3) compared with those who had worked through their grief. Fathers with unresolved grief also displayed a significantly higher risk of sleep difficulties (RR, 6.7; 95% CI, 2.5 to 17.8). Mothers, however, reported increased visits with physicians during the previous 5 years (RR, 1.7; 95% CI, 1.1 to 2.6) as well as a greater likelihood of taking sick leave when they had not worked through their grief (RR, 2.1; 95% CI, 1.2 to 3.5).

CONCLUSION

Parents who have not worked through their grief are at increased risk of long-term mental and physical morbidity, increased health service use, and increased sick leave.

Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment

CONTEXT

Talking about death can be difficult. Without evidence that end-of-life discussions improve patient outcomes, physicians must balance their desire to honor patient autonomy against a concern of inflicting psychological harm.

OBJECTIVE

To determine whether end-of-life discussions with physicians are associated with fewer aggressive interventions.

DESIGN, SETTING, AND PARTICIPANTS

A US multisite, prospective, longitudinal cohort study of patients with advanced cancer and their informal caregivers (n = 332 dyads), September 2002-February 2008. Patients were followed up from enrollment to death, a median of 4.4 months later. Bereaved caregivers' psychiatric illness and quality of life was assessed a median of 6.5 months later.

MAIN OUTCOME MEASURES

Aggressive medical care (eg, ventilation, resuscitation) and hospice in the final week of life. Secondary outcomes included patients' mental health and caregivers' bereavement adjustment.

RESULTS

One hundred twenty-three of 332 (37.0%) patients reported having end-of-life discussions before baseline. Such discussions were not associated with higher rates of major depressive disorder (8.3% vs 5.8%; adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 0.54-3.32), or more worry (mean McGill score, 6.5 vs 7.0; P = .19). After propensity-score weighted adjustment, end-of-life discussions were associated with lower rates of ventilation (1.6% vs 11.0%; adjusted OR, 0.26; 95% CI, 0.08-0.83), resuscitation (0.8% vs 6.7%; adjusted OR, 0.16; 95% CI, 0.03-0.80), ICU admission (4.1% vs 12.4%; adjusted OR, 0.35; 95% CI, 0.14-0.90), and earlier hospice enrollment (65.6% vs 44.5%; adjusted OR, 1.65;95% CI, 1.04-2.63). In adjusted analyses, more aggressive medical care was associated with worse patient quality of life (6.4 vs 4.6; F = 3.61, P = .01) and higher risk of major depressive disorder in bereaved caregivers (adjusted OR, 3.37; 95% CI, 1.12-10.13), whereas longer hospice stays were associated with better patient quality of life (mean score, 5.6 vs 6.9; F = 3.70, P = .01). Better patient quality of life was associated with better caregiver quality of life at follow-up (beta = .20; P = .001).

CONCLUSIONS

End-of-life discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient quality of life and worse bereavement adjustment.

Racial and ethnic differences in advance care planning among patients with cancer: impact of terminal illness acknowledgment, religiousness, and treatment preferences

PURPOSE

Despite well-documented racial and ethnic differences in advance care planning (ACP), we know little about why these differences exist. This study tested proposed mediators of racial/ethnic differences in ACP.

PATIENTS AND METHODS

We studied 312 non-Hispanic white, 83 non-Hispanic black, and 73 Hispanic patients with advanced cancer in the Coping with Cancer study, a federally funded multisite prospective cohort study designed to examine racial/ethnic disparities in ACP and end-of-life care. We assessed the impact of terminal illness acknowledgment, religiousness, and treatment preferences on racial/ethnic differences in ACP.

RESULTS

Compared with white patients, black and Hispanic patients were less likely to have an ACP (white patients, 80%; black patients, 47%; Hispanic patients, 47%) and more likely to want life-prolonging care even if he or she had only a few days left to live (white patients, 14%; black patients, 45%; Hispanic patients, 34%) and to consider religion very important (white patients, 44%; black patients, 88%; Hispanic patients, 73%; all P < .001, comparison of black or Hispanic patients with white patients). Hispanic patients were less likely and black patients marginally less likely to acknowledge their terminally ill status (white patients, 39% v Hispanic patients, 11%; P < .001; white v black patients, 27%; P = .05). Racial/ethnic differences in ACP persisted after adjustment for clinical and demographic factors, terminal illness acknowledgment, religiousness, and treatment preferences (has ACP, black v white patients, adjusted relative risk, 0.64 [95% CI, 0.49 to 0.83]; Hispanic v white patients, 0.65 [95% CI, 0.47 to 0.89]).

CONCLUSION

Although black and Hispanic patients are less likely to consider themselves terminally ill and more likely to want intensive treatment, these factors did not explain observed disparities in ACP.

Peace, Equanimity, and Acceptance in the Cancer Experience (PEACE): validation of a scale to assess acceptance and struggle with terminal illness

BACKGROUND

The role of emotional acceptance of a terminal illness in end-of-life (EOL) care is not known. The authors developed a measure of peaceful acceptance at the EOL, and evaluated the role of peaceful acceptance in EOL decision-making and care.

METHODS

The authors developed the Peace, Equanimity, and Acceptance in the Cancer Experience (PEACE) questionnaire to measure the extent to which patients with advanced cancer have a sense of peaceful acceptance of their terminal illness. The scale was administered to 160 patients with advanced cancer along with measures of other attributes that hypothetically are related to acceptance, including cognitive acceptance of terminal illness. EOL outcomes in 56 patients who died during the study also were examined.

RESULTS

The 12-item PEACE questionnaire had 2 subscales: a 7-item Struggle With Illness subscale (Cronbach alpha = .81) and a 5-item Peaceful Acceptance subscale (alpha = .78). Both subscales were associated with patients' self-reported peacefulness (correlation coefficient [r] = 0.66 for acceptance [P <.0001]; r = -0.37 for struggle [P < .0001]). Struggle With Illness scores were associated with cognitive terminal illness acknowledgment (mean scores, 14.9 vs 12.4 for patients who were not aware that their illness was terminal; P = .001) and with some aspects of advance care planning (living will or healthcare proxy: mean scores, 13.9 vs 11.5; P = .02). In addition, among patients who had died, the use of a feeding tube at the EOL was associated inversely with Peaceful Acceptance (P = .015).

CONCLUSIONS

The current study indicated that the PEACE questionnaire is a valid and reliable measure of peaceful acceptance and struggle with illness. Scores were associated with some choices for EOL care among patients with advanced cancer.

Investigation of a developmental model of risk for depression and suicidality following spousal bereavement

Data from a community-based multi-wave investigation were used to examine a developmental model of risk for depression and suicidality following the death of a spouse. Measures of perceived parental affection and control during childhood were administered to 218 widowed adults 11 months after the death of the spouse. Self-esteem, spousal dependency, depression, and suicidality were assessed 9 months later. Dependency on the deceased spouse mediated a significant association between retrospectively reported parental control during childhood and post-loss depressive symptoms. Depressive symptoms mediated significant associations of dependency on the deceased spouse and low self-esteem with suicidal ideation and behavior.

Associations between caregiver-perceived delirium in patients with cancer and generalized anxiety in their caregivers

BACKGROUND

Delirium, a common complication of advanced cancer, may put caregivers at risk for poor mental health outcomes. We looked for a relationship between caregiver-perceived delirium in a patient with advanced cancer and rates of caregiver psychiatric disorders.

METHODS

Using cross-sectional data from 200 caregivers of patients with cancer with a life expectancy of less than 6 months, we determined the frequency of caregiver-perceived delirium, which was defined as caregivers who reported witnessing the patient "confused, delirious" on the Stressful Caregiving Response to Experiences of Dying (SCARED) weekly or more often. We tested for associations between caregiver-reported delirium and presence of caregiver mental disorders, using the Structured Clinical Interview for the DSM-IV to diagnose mental disorders and caregiver burden, as measured by the caregiver burden scale (CBS).

RESULTS

Of the 200 caregivers who completed the SCARED, 38 (19.0%) reported seeing the patient "confused, delirious" at least once per week in the month prior to study enrollment and 7 (3.5%) met criteria for generalized anxiety (GA). Caregivers of patients with caregiver-perceived delirium were 12 times more likely to have GA (odds ratio [OR] 12.12; p < 0.01). The relationship between caregiver-perceived delirium and caregiver GA persisted after adjusting for caregiver burden and exposure to other stressful patient experiences (OR = 9.99; p = 0.04).

CONCLUSIONS

This is the first report of an association between caregiver-perceived delirium and a caregiver mental health outcome. Further studies, using improved measures of delirium, are needed.

Elevated rates of prolonged grief disorder in African Americans

The prevalence of Prolonged Grief Disorder (PGD) in non-Whites is currently unknown. This study was performed to explore the prevalence of PGD in African Americans (AAs). Multivariable analysis of two studies of recently bereaved individuals found AAs to have significantly higher rates of PGD than Whites (21% [14 of 66] vs. 12% [55 of 471], respectively; p = 0.03). Experiencing a loved one's death as sudden or unexpected was also significantly associated with PGD over and above the effects of race/ethnicity. AAs may be at increased risk for the development of PGD. The development of effective interventions to treat PGD highlights the need to identify high-risk individuals and refer them to therapy and suggests the potential need for such therapies to adopt culturally sensitive approaches to care.

The influence of symptoms of prolonged grief disorder, depression, and anxiety on quality of life among bereaved adults: a prospective study

OBJECTIVE

Research has shown that symptoms of Prolonged Grief Disorder (PGD, formerly called Complicated Grief) are distinct from those of depression and anxiety, and have incremental validity in that they predict impairments in functioning, independent of depression and anxiety. This study sought to replicate these findings using a prospective design, a heterogeneous sample of mourners, and the most recent criteria to define PGD.

METHOD

Data from 346 mourners who were bereaved between 6 months and 2 years and who were recruited from professional and lay mental health care workers and the Internet, were used in a confirmatory factor analysis to determine the distinctiveness of symptoms of PGD, depression, and anxiety. Regression analyses estimated the effects of symptoms of PGD, depression, and anxiety on quality of life and mental health 6 months (T2) and 15 months (T3) after baseline, in a subgroup of 96 mourners assessed at follow-up.

RESULTS

PGD, depression, and anxiety represented three distinct factors. When we controlled the influence of relevant background variables but not the shared variance between the factors, all three factors predicted quality of life and mental health outcomes at T2 and T3. When we controlled the shared variance between factors, the PGD factor at T1 predicted unique variance in four outcomes at T2 (mental health, suicidal ideation, PGD severity, and depression severity) and two outcomes at T3 (mental health and PGD severity), the depression factor in one outcome at T2 (depression severity) but none at T3, and the anxiety factor in six outcomes at T2 (mental health, energy, general health perception, sleeping problems, depression severity, and anxiety severity) and one at T3 (anxiety severity).

CONCLUSIONS

We found PGD (defined according to the newest criteria) to be distinct from depression and anxiety and to be predictive of reduced quality of life and mental health. The concept of PGD is needed to detect mourners at risk for health impairments, who would go undetected with an exclusive focus on depression or anxiety.

Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics

The purpose of this study was to identify empirically patterns of grief among 141 older bereaved spouses. A longitudinal hierarchical cluster procedure with the Ward agglomeration method was used to identify distinct clusters based on grief scores. Three clusters were identified: common (49%), resilient (34%), and chronic (17%) grief. Members of the common grief cluster experienced elevated levels of grief and depressive symptoms that decreased over time. Members of the resilient cluster experienced the lowest levels of grief and depression and the highest quality of life. The chronic grief cluster experienced the highest levels of grief and depression, more sudden deaths, the lowest self-esteem, and the highest marital dependency. The majority in this chronic cluster also met proposed criteria for a diagnosis of complicated grief. Five out of every six bereaved spouses adjusted well over time, and about a third of these showed considerable resilience without negative consequences. One out of six experienced a chronic grief syndrome. Early identification of this syndrome can lead to referral to newly emergent treatments specific for grief.

Adverse childhood experiences, smoking and mental illness in adulthood: a preliminary study

BACKGROUND

Adverse childhood experiences (ACE) are associated with mental illness and smoking in adulthood, but ACE has not been studied as a determinant of this comorbidity. This study was designed to examine effects of ACE on the expression of smoking behavior and mental illness in adulthood.

METHODS

We examined the relationship between ACE, smoking status, and the expression of serious mental illness in adults (n = 101). Subjects were evaluated with a semi-structured interview that included psychiatric status, smoking status, substance abuse and presence and severity of ACE. Subjects were grouped into four categories based on psychiatric and smoking status: psychiatric smokers (PS), psychiatric nonsmokers (PNS), control smokers (CS) and control nonsmokers (CNS).

RESULTS

ACE was associated with serious mental illness or smoking behaviors in adulthood, and to a lesser extent with co-morbid mental illness and smoking. Cumulative number of ACE was highest in the order of PS > PNS > CS > CNS.

CONCLUSIONS

These preliminary results suggest an association between the presence of ACE and the expression of severe mental illness in adulthood, and possibly to comorbid smoking and mental illness. Longitudinal research using larger samples is needed to determine the causal relationship between ACE and co-morbid smoking and mental illness.

Bereavement services for family caregivers: how often used, why, and why not

BACKGROUND

Bereavement services are central to high-quality end-of-life care, however, little is known about how frequently and why such bereavement services are used and not used. We examined family caregiver reports about how often they used bereavement services, predictors of their use, and reported reasons for not using bereavement services.

METHODS

Prospective cohort study of family caregivers (n = 161) of patients with cancer enrolled with hospice between October 1999 and September 2001. We conducted bivariate and multivariable analyses to determine predictors of bereavement service use, adjusted for a broad range of factors including caregiving experiences, major depressive disorder (MDD), relationship with the deceased, and demographic factors. We used content analysis to summarize responses to open-ended questions concerning why individuals did not use bereavement services.

RESULTS

We found that approximately 30% of family caregivers used bereavement services in the year postloss, and the majority of these caregivers used services in the first 6 months postloss. Even among bereaved caregivers with MDD, less than half (47.6%) used bereavement services. Factors associated with using bereavement services included being a spouse caregiver, younger age, having MDD at study enrollment, witnessing highly distressing events pertaining to the patient's death, having assisted the patient with more Instrumental Activities of Daily Living (IADLs) prior to the patient's death, having greater availability of instrumental support for oneself, and physician communication with the caregiver about the patient's prognosis before the patient's death. The most common given reason for nonuse was the perception that bereavement services were not needed or would not help.

CONCLUSION

Addressing caregiver receptivity to bereavement services will be an important aspect of increasing appropriate use of such services. Future studies might examine specific interventions for reducing barriers and increasing receptivity to bereavement service use.

Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life

PURPOSE

Religion and spirituality play a role in coping with illness for many cancer patients. This study examined religiousness and spiritual support in advanced cancer patients of diverse racial/ethnic backgrounds and associations with quality of life (QOL), treatment preferences, and advance care planning.

METHODS

The Coping With Cancer study is a federally funded, multi-institutional investigation examining factors associated with advanced cancer patient and caregiver well-being. Patients with an advanced cancer diagnosis and failure of first-line chemotherapy were interviewed at baseline regarding religiousness, spiritual support, QOL, treatment preferences, and advance care planning.

RESULTS

Most (88%) of the study population (N = 230) considered religion to be at least somewhat important. Nearly half (47%) reported that their spiritual needs were minimally or not at all supported by a religious community, and 72% reported that their spiritual needs were supported minimally or not at all by the medical system. Spiritual support by religious communities or the medical system was significantly associated with patient QOL (P = .0003). Religiousness was significantly associated with wanting all measures to extend life (odds ratio, 1.96; 95% CI, 1.08 to 3.57).

CONCLUSION

Many advanced cancer patients' spiritual needs are not supported by religious communities or the medical system, and spiritual support is associated with better QOL. Religious individuals more frequently want aggressive measures to extend life.

Peaceful awareness in patients with advanced cancer

BACKGROUND

Previous studies have shown that prognostic awareness may be harmful to mental health yet beneficial for end of life care planning. The effects of prognostic awareness coupled with a sense of inner peace are unknown.

METHODS

In the multisite, longitudinal Coping with Cancer Study, 280 patients with advanced cancer were interviewed at baseline. Patients defining themselves as "terminally ill" and/or "at peace" most days were paired with others on sociodemographic, mental health and advance care planning. Primary caregivers of deceased patients were interviewed 6 months postloss and compared on their physical and mental health and their perceptions of patients' end-of-life care and death.

RESULTS

Overall, 17.5% of patients reported being both peaceful and aware. Peacefully aware patients had lower rates of psychological distress and higher rates of advance care planning (e.g., completing do-not-resuscitate [DNR] orders, advance care planning discussions with physicians) than those who were not peacefully aware. Additionally, peacefully aware patients had the highest overall quality of death as reported by their caretakers in a postmortem evaluation. Surviving caregivers of peacefully aware patients were more physically and mentally healthy 6 months postloss than caregivers of patients who were "aware" but not peaceful.

CONCLUSIONS

Patients with advanced cancer who are peacefully aware have better mental health and quality of death outcomes, and their surviving caregivers have better bereavement outcomes. Peaceful awareness is associated with modifiable aspects of medical care (e.g., discussions about terminal treatment preferences).

An empirical examination of the stage theory of grief

CONTEXT

The stage theory of grief remains a widely accepted model of bereavement adjustment still taught in medical schools, espoused by physicians, and applied in diverse contexts. Nevertheless, the stage theory of grief has previously not been tested empirically.

OBJECTIVE

To examine the relative magnitudes and patterns of change over time postloss of 5 grief indicators for consistency with the stage theory of grief.

DESIGN, SETTING, AND PARTICIPANTS

Longitudinal cohort study (Yale Bereavement Study) of 233 bereaved individuals living in Connecticut, with data collected between January 2000 and January 2003.

MAIN OUTCOME MEASURES

Five rater-administered items assessing disbelief, yearning, anger, depression, and acceptance of the death from 1 to 24 months postloss.

RESULTS

Counter to stage theory, disbelief was not the initial, dominant grief indicator. Acceptance was the most frequently endorsed item and yearning was the dominant negative grief indicator from 1 to 24 months postloss. In models that take into account the rise and fall of psychological responses, once rescaled, disbelief decreased from an initial high at 1 month postloss, yearning peaked at 4 months postloss, anger peaked at 5 months postloss, and depression peaked at 6 months postloss. Acceptance increased throughout the study observation period. The 5 grief indicators achieved their respective maximum values in the sequence (disbelief, yearning, anger, depression, and acceptance) predicted by the stage theory of grief.

CONCLUSIONS

Identification of the normal stages of grief following a death from natural causes enhances understanding of how the average person cognitively and emotionally processes the loss of a family member. Given that the negative grief indicators all peak within approximately 6 months postloss, those who score high on these indicators beyond 6 months postloss might benefit from further evaluation.

Differences in risk factors for suicidality between African American and White patients vulnerable to suicide

Risk factors for suicidal ideation and attempts have been shown to differ between African Americans and Whites across the lifespan. In the present study, risk factors for suicidality were examined separately by race/ethnicity in a population of 131 older adult patients considered vulnerable to suicide due to substance abuse and/or medical frailty. In adjusted analyses, social support was significantly associated with suicidality in African American patients, while younger age and the presence of an anxiety disorder were significantly associated with suicidality in White patients. The results suggest that race/ethnicity-specific risk profiles may improve the detection of suicidality in vulnerable populations.

Preparing caregivers for the death of a loved one: a theoretical framework and suggestions for future research

Caring for a terminally ill loved one and the death of that person are two of the most stressful human experiences. Recent research suggests that a substantial number of caregivers are unprepared for the death and that these caregivers may be at greater risk of psychological distress. The literature on preparedness and mental health, however, is in its infancy. The purpose of this paper, therefore, is to summarize the literature in order to stimulate discussion and research on preparedness. It is our view that preparedness for the death of a loved one is an important contributor to caregiver well-being and bereavement outcomes and that more work in this area is needed in order to improve the care provided to caregivers of seriously or terminally ill patients. We briefly review the literature on preparedness, present a theoretical model delineating the relationships between preparedness, caregiver-health care provider communication, and caregiver well-being, and provide suggestions for future research.

Religious coping among caregivers of terminally ill cancer patients: main effects and psychosocial mediators

This study investigated the association between religious coping, mental health and the caring experience, as well as potential explanatory mechanisms, among 162 informal caregivers of terminally ill cancer patients. Regression analyses indicated that, controlling for socio-demographic variables, more use of positive religious coping strategies was associated with more burden, yet, also more satisfaction. In contrast, more use of negative religious coping strategies was related to more burden, poorer quality of life and less satisfaction, and correlated with an increased likelihood of Major Depressive Disorder and anxiety disorders. In a number of models, negative religious coping was related to outcomes through its relationship with social support, optimism and self-efficacy. Implications for research and healthcare are discussed.

Parental control, partner dependency, and complicated grief among widowed adults in the community

Data from the Yale Bereavement Study, a community-based longitudinal study, were used to investigate the association of 192 widowed individuals' recollections of parenting affection and control during childhood with dependency on the deceased spouse and the development of severe grief symptoms following bereavement. The hypothesis that dependency on the deceased spouse mediates the association of parental affection and control during childhood with the development of severe grief following bereavement was investigated. Findings indicated that a high level of perceived parental control during childhood was associated with elevated levels of dependency on the deceased spouse and with symptoms of complicated grief. Dependency on the deceased spouse mediated the association of perceived parental control with the development of complicated grief following bereavement.

The validity and reliability of scales for the evaluation of end-of-life care in advanced dementia

The lack of valid and reliable instruments designed to measure the experiences of older persons with advanced dementia and those of their health care proxies has limited palliative care research for this condition. This study evaluated the reliability and validity of 3 End-of-Life in Dementia (EOLD) scales that measure the following outcomes: (1) satisfaction with the terminal care (SWC-EOLD), (2) symptom management (SM-EOLD), and (3) comfort during the last 7 days of life (CAD-EOLD). Data were derived from interviews with the health care proxies (SWC-EOLD) and primary care nurses (SM-EOLD, CAD-EOLD) for 189 nursing home residents with advanced dementia living in 15 Boston-area facilities. The scales demonstrated satisfactory to good reliability: SM-EOLD (alpha=0.68), SWC-EOLD (alpha=0.83), and CAD-EOLD (alpha=0.82). The convergent validity of these scales, as measured against other established instruments assessing similar constructs, was good (correlation coefficients ranged from 0.50 to 0.81). The results of this study demonstrate that the 3 EOLD scales demonstrate "internal consistency" reliability and demonstrate convergent validity, and further establish their utility in palliative care dementia research.

Religious coping is associated with the quality of life of patients with advanced cancer

BACKGROUND

For patients confronting a life-threatening illness such as advanced cancer, religious coping can be an important factor influencing their quality of life (QOL).

OBJECTIVE

The study's main purpose was to examine the association between religious coping and QOL among 170 patients with advanced cancer. Both positive religious coping (e.g., benevolent religious appraisals) and negative religious coping (e.g., anger at God) and multiple dimensions of QOL (physical, physical symptom, psychological, existential, and support) were studied.

DESIGN

Structured interviews were conducted with 170 patients recruited as part of an ongoing multi-institutional longitudinal evaluation of the prevalence of mental illness and patterns of mental health service utilization in advanced cancer patients and their primary informal caregivers.

MEASUREMENTS

Patients completed measures of QOL (McGill QOL questionnaire), religious coping (Brief Measure of Religious Coping [RCOPE] and Multidimensional Measure of Religion/ Spirituality), self-efficacy (General Self-Efficacy Scale), and sociodemographic variables.

RESULTS

Linear regression analyses revealed that after controlling for sociodemographic variables, lifetime history of depression and self-efficacy, greater use of positive religious coping was associated with better overall QOL as well as higher scores on the existential and support QOL dimensions. Greater use of positive religious coping was also related to more physical symptoms. In contrast, greater use of negative religious coping was related to poorer overall QOL and lower scores on the existential and psychological QOL dimensions.

CONCLUSIONS

Findings show that religious coping plays an important role for the QOL of patients and the types of religious coping strategies used are related to better or poorer QOL.

Update on Bereavement Research: Evidence-Based Guidelines for the Diagnosis and Treatment of Complicated Bereavement

The past decade has witnessed considerable growth in the evidence-base from which clinical recommendations for bereavement care can be made. Research now provides guidance to assist clinicians in: a) recognizing differences between complicated and uncomplicated bereavement reactions, b) identifying risk factors that may make certain individuals more vulnerable to bereavement-related complications, c) appreciating and monitoring for potential adverse outcomes associated with bereavement and d) taking actions to prevent or minimize maladjustment to the loss. In this article we distinguish between the course of normal grief and abnormally prolonged, or complicated grief; clarify distinctions between Complicated Grief Disorder and other mental disorders secondary to bereavement; review outcomes associated with Complicated Grief Disorder; describe research on resilience in bereavement; present findings on stigmatization and the use of mental health services among recently bereaved persons; and summarize where the field is with respect to establishing the efficacy and effectiveness of bereavement interventions. Promising new psychotherapies for Complicated Grief Disorder have shown clinical efficacy. Nevertheless, further research is needed to enhance the detection of vulnerable bereaved persons, to promote resilience following significant interpersonal loss, and to tailor interventions to address the attachment issues that lie at the heart of this disorder.

Mutuality and specificity of mental disorders in advanced cancer patients and caregivers

BACKGROUND

We sought to determine mutuality and specificity in rates of mental disorders between advanced cancer patients and their caregivers.

METHOD

Data from 168 non-genetically related patient-caregiver dyads participating in the multi-site Coping with Cancer (CWC) study were included in this analysis. Multivariate logistic regression analyses were conducted to examine associations between diagnoses of a psychiatric disorder in patients with diagnoses of psychiatric disorders in caregivers, and vice versa, controlling for confounders.

RESULTS

When patients met criteria for any psychiatric diagnosis, then caregivers were 7.9 times (P < 0.0001) more likely to meet criteria for any psychiatric diagnosis, and vice versa. Caregiver Panic Disorder (PD) diagnosis was associated with patient Generalized Anxiety Disorder (GAD). Patient GAD was also associated with caregiver PD. Finally, patient PD was associated with caregiver GAD and caregiver Post-Traumatic Stress Disorder (PTSD).

CONCLUSIONS

To our knowledge, this is the first study that demonstrates the mutuality of psychiatric disorders in both advanced cancer patients and their informal caregivers. Specifically, the presence of anxiety disorders in one partner (either caregiver or patient) was associated with a greater likelihood of anxiety disorders in the other. Results suggest that psychiatric distress should be assessed in both patients and their caregivers, and that mental illness in one should raise concern about the possibility of a psychiatric disorder in the other. Results also suggest that targeted interventions to address shared fears and concerns of patients and caregivers might reduce anxiety in the end phases of the patient's illness.

Resident approaches to advance care planning on the day of hospital admission

BACKGROUND

Advance care planning is the process of establishing a patient's goals and preferences for future care. Previous research has demonstrated a need to improve patient-physician communication around advance care planning. A critical time for advance care planning conversations is the day of admission to the hospital.

METHODS

A survey of internal medicine residents was administered at Duke University Medical Center and the Brigham and Women's Hospital, 2 major academic teaching centers. Residents were questioned about their approaches to advance care planning on their last on-call admitting day.

RESULTS

Of 347 residents solicited, 292 (84.1%) participated in the survey. Residents reported that they established preferences for cardiopulmonary resuscitation (CPR) with 70.5% of patients, established a health care proxy with 33.7% of patients, discussed goals and values concerning end-of-life care with 32.0% of patients, and asked 35.6% of patients if they had an advance directive. Although 89.0% of residents had observed an advance care planning discussion model, only 66.4% had received teaching and 36.6% had received feedback about advance care planning conversations. In multivariable analysis, having received feedback about advance care planning conversations was associated with a higher percentage of conversations about health care proxy and goals and values related to the end of life.

CONCLUSIONS

Residents discuss patient preferences for CPR on the day of admission with most patients. Preparing residents, particularly through feedback, may improve communication around other elements of advance care planning.

An exploration of associations between separation anxiety in childhood and complicated grief in later life

Recent studies have suggested that the vulnerability to complicated grief (CG) may be rooted in insecure attachment styles developed in childhood. The aim of this study was to examine the etiologic relevance of childhood separation anxiety (CSA) to the onset of CG relative to major depressive disorder, posttraumatic stress disorder, and generalized anxiety disorder in bereaved individuals. The Structured Clinical Interview for the DSM-IV, Inventory of Complicated Grief-Revised, and CSA items from the Panic Agoraphobic Spectrum Questionnaire were administered to 283 recently bereaved community-dwelling residents at an average of 10.6 months postloss. CSA was significantly associated with CG (OR = 3.2; 95% CI, 1.2-8.9), adjusting for sex, level of education, kinship relationship to the deceased, prior history of psychiatric disorder, and history of childhood abuse. CSA was not significantly associated with major depressive disorder, posttraumatic stress disorder, or generalized anxiety disorder.

Communication between physicians and family caregivers about care at the end of life: when do discussions occur and what is said?

BACKGROUND

Few studies have examined physician-family caregiver communication at the end of life, despite the important role families have in end-of-life care decisions. We examined family caregiver reports of physician communication about incurable illness, life expectancy, and hospice; the timing of these discussions; and subsequent family understanding of these issues.

DESIGN

Mixed methods study using a closed-ended survey of 206 family caregivers and open-ended, in-depth interviews with 12 additional family caregivers.

SETTING/SUBJECTS

Two hundred eighteen primary family caregivers of patients with cancer enrolled with hospice between October 1999 and June 2002.

MEASUREMENTS

Family caregiver reports provided at the time of hospice enrollment of physician discussions of incurable illness, life expectancy, and hospice.

RESULTS

Many family caregivers reported that a physician never told them the patient's illness could not be cured (20.8%), never provided life expectancy (40% of those reportedly told illness was incurable), and never discussed using hospice (32.2%). Caregivers reported the first discussion of the illness being incurable and of hospice as a possibility occurred within 1 month of the patient's death in many cases (23.5% and 41.1%, respectively). In open-ended interviews, however, family caregivers expressed ambivalence about what they wanted to know, and their difficulty comprehending and accepting "bad news" was apparent in both qualitative and quantitative data.

CONCLUSION

Our findings suggest that ineffective communication about end-of-life issues likely results from both physician's lack of discussion and family caregiver's difficulty hearing the news. Future studies should examine strategies for optimal physician-family caregiver communication about incurable illness, so that families and patients can begin the physical, emotional, and spiritual work that can lead to acceptance of the irreversible condition.

Religiousness and major depression among bereaved family caregivers: a 13-month follow-up study

OBJECTIVE

To examine the association between a multi-item measure of religiousness and major depressive disorder (MDD) in bereaved family caregivers of patients with cancer.

DESIGN

A prospective longitudinal study of primary caregivers of consecutive patients (n = 175) with cancer enrolled in the largest hospice in Connecticut.

RESULTS

Caregivers with a high religiousness summary score were significantly less likely to have MDD at the 13-month follow-up interview (OR = 0.79, 95% CI: 0.68-0.91). This finding remained significant (OR = 0.74, 95% CI: 0.59-0.91) after adjustment for caregiver MDD at baseline, caregiver age, caregiver burden, and number of activities restricted due to caregiving roles.

CONCLUSIONS

Family caregivers who reported greater religiousness at baseline had lower rates of depression in the 13-month follow up after their loss. Collaboration with religious support groups or community groups during bereavement could offer an effective mechanism for speeding the process of recovery for some caregivers.

Psychiatric disorders and mental health service use in patients with advanced cancer: a report from the coping with cancer study

BACKGROUND

Psychological morbidity has been proposed as a source of distress in cancer patients. This study aimed to: 1) determine the prevalence of diagnosable psychiatric illnesses, and 2) describe the mental health services received and predictors of service utilization in patients with advanced cancer.

METHODS

This was a cross-sectional, multi-institutional study of 251 eligible patients with advanced cancer. Eligibility included: distant metastases, primary therapy failure, nonpaid caregiver, age > or =20 years, stamina for the interview, English or Spanish-speaking, and adequate cognitive ability. Trained interviewers administered the Structured Clinical Interview for the Diagnostic Statistical Manual IV (DSM-IV) modules for Major Depressive Disorder, Generalized Anxiety Disorder, Panic Disorder, Post-Traumatic Stress Disorder, and a detailed questionnaire regarding mental health service utilization.

RESULTS

Overall, 12% met criteria for a major psychiatric condition and 28% had accessed a mental health intervention for a psychiatric illness since the cancer diagnosis. Seventeen percent had discussions with a mental health professional; 90% were willing to receive treatment for emotional problems. Mental health services were not accessed by 55% of patients with major psychiatric disorders. Cancer patients who had discussed psychological concerns with mental health staff (odds ratio [OR] = 19.2; 95% confidence interval [95% CI], 8.90-41.50) and non-Hispanic white patients (OR = 2.7; 95% CI, 1.01-7.43) were more likely to receive mental health services in adjusted analysis.

CONCLUSIONS

Advanced cancer patients experience major psychiatric disorders at a prevalence similar to the general population, but affected individuals have a low rate of utilizing mental health services. Oncology providers can enhance utilization of mental health services, and potentially improve clinical outcomes, by discussing mental health concerns with their patients.

Complicated grief and suicidal ideation in adult survivors of suicide

While the prevalence of complicated grief has been demonstrated to be elevated in survivors of suicide, the association between complicated grief and suicidal ideation among adult survivors of suicide has not been explored. The purpose of the present study is to examine the association between complicated grief and suicidal ideation in suicide survivors. The Inventory of Complicated Grief and the Beck Depression Inventory were administered to 60 adult survivors within 1 month of a death by suicide of a family member or significant other. Complicated grief was associated with a 9.68 (CI: 1.036, 90.417) times greater likelihood of suicidal ideation after controlling for depression, suggesting that syndromal complicated grief heightens vulnerability to suicidal ideation. Clinicians may provide more comprehensive assessments by recognizing the possibility of suicidal ideation in those with complicated grief.

Psychiatric disorders and mental health service use among caregivers of advanced cancer patients

PURPOSE

Despite research demonstrating the psychological burden of caregiving for advanced cancer patients, limited information exists on the prevalence of psychiatric disorders and mental health service use among these informal caregivers.

METHODS

Two hundred informal caregivers of advanced cancer patients were interviewed and administered the Structured Clinical Interview of the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition and an assessment of mental health service use.

RESULTS

Thirteen percent of caregivers met criteria for a psychiatric disorder; 25% accessed treatment for mental health concerns since the patient's cancer diagnosis. The frequencies of current psychiatric disorders were as follows: panic disorder, 8.0% (95% CI, 4.6% to 12.7%), major depressive disorder, 4.5% (95% CI, 2.1% to 8.4%), post-traumatic stress disorder, 4.0% (95% CI, 1.7% to 7.7%), and generalized anxiety disorder, 3.5% (95% CI, 1.4% to 7.1%). Among caregivers with a current psychiatric disorder, 81% discussed mental health concerns with a health professional before the patient's cancer diagnosis compared with 46% after the diagnosis (McNemar test = 5.40; P = .02). Only 46% of caregivers with a current psychiatric disorder accessed mental health services. Caregivers who discussed mental health concerns with a clinician before the patient's cancer diagnosis (odds ratio [OR] = 3.51; 95% CI, 1.42 to 8.71) and after the diagnosis (OR = 21.23; 95% CI, 9.02 to 49.94) were more likely than caregivers not having these discussions to receive mental health services.

CONCLUSION

Many caregivers of advanced cancer patients either meet criteria or are being treated for psychiatric problems. Discussing mental health issues positively influences the receipt of mental health services and should be actively pursued in this vulnerable population.

Health behaviors associated with better quality of life for older bereaved persons

BACKGROUND

Bereavement is a risk factor for declines in health, adverse health behaviors, increased physician visits, and mortality, and occurs with greatest frequency in later life. Little is known about health behaviors that are associated with better quality of life among recently bereaved older persons.

OBJECTIVE

The objective of this community-based longitudinal, observational study was to examine the influence of health behaviors on the quality of life of 200 elderly bereaved persons.

DESIGN AND MEASUREMENTS

Health behaviors (i.e., exercise, monitoring caloric intake, sleep, daily vitamin intake, annual health check-ups) were examined at approximately 6 months postloss (baseline) and 11 months postloss (Wave 2). Quality of life was assessed at approximately 11 months postloss and 19 months postloss (Wave 3), using the RAND 36-Item Health Survey, which measures 8 domains of health and functioning, plus a single item assessing change in health.

RESULTS

Consistently exercising 1 or more days per week at Waves 1 and 2 significantly (p < .05) predicted better self-rated health, physical functioning, fewer physical role limitations, and greater energy at Wave 3 in models that adjusted for age, gender, prior psychiatric disorder, baseline reports of functional disabilities and chronic conditions. Consistently monitoring caloric intake at Waves 1 and 2 predicted better self-rated health (p < .05), greater energy (p < .01), and positive change in health (p < .05) at Wave 3 in models that adjusted for the above set of control variables. Sleeping 6.5-9 hours per night at baseline alone predicted better social functioning (p < .001), fewer emotional role limitations (p < .01), better emotional health (p < .001), and greater energy (p < .01).

CONCLUSIONS

Should future research confirm these results, clinicians would be advised to recommend the identified preventive and protective health behaviors to recently bereaved older patients.

A case for establishing complicated grief as a distinct mental disorder in DSM-V

In this paper, we contend that complicated grief (CG) constitutes a distinct psychopathological diagnostic entity and thus warrants a place in standardized psychiatric diagnostic taxonomies. CG is characterized by a unique pattern of symptoms following bereavement that are typically slow to resolve and can persist for years if left untreated. This paper will demonstrate that existing diagnoses are not sufficient, as the phenomenology, risk factors, clinical correlates, course, and outcomes for CG are distinct from those of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and adjustment disorder (AD). It is argued that the establishment of CG as a diagnostic entity is essential because its symptoms are associated with enduring mental and physical health morbidity and require specifically designed clinical interventions. We conduct a critical review of all published evidence on this topic to date, demonstrating that the advantages of standardizing the diagnostic criteria of CG outweigh the disadvantages. In addition, recommendations for future lines of research are made. This paper concludes that CG must be established in the current nosology to address the needs of individuals who are significantly suffering and impaired by this disorder.