Effective communication skills are the key to good cancer care

Patients' communication preferences for receiving a cancer diagnosis: Differences depending on cancer stage

OBJECTIVE

This study aimed to identify communication preferences for receiving a cancer diagnosis in South Korean patients and explore differences depending on cancer stage-with or without recurrence/metastasis.

METHODS

A total of 312 patients from five cancer centers in South Korea completed the Korean version of the Measure of Patients' Preferences questionnaire, Mini-Mental Adjustment to Cancer scale, Insomnia Severity Index, and Hospital Anxiety and Depression Scale.

RESULTS

Among patients without recurrence/metastasis, four factors were indicated: "additional information," "medical information," "emotional support," and "supportive environment." Among patients with recurrence/metastasis, five factors were indicated: "medical information and explanation," "emotional support," "supportive environment," "additional information," and "informing family." In the group without recurrence/metastasis, a positive attitude was a significant predictor of the preference for all four factors and a lower anxiety level was a predictor of the preference for additional information. Patients who reported a high level of anxious preoccupation preferred supportive environments. In the group with recurrence/metastasis, patients who showed a high level of cognitive avoidance preferred to receive medical and additional information and emotional support.

CONCLUSIONS

Cancer patients' preferences for communication when receiving bad news differ whether recurrence/metastasis or not in South Korea. Especially, patients with recurrence/metastasis preferred a clear explanation of medical information, and physicians informing patients' families about their diagnosis and prognosis. Thus, physicians should take patients' medical and psychological characteristics into consideration when delivering the news regarding their condition.

Genetic Counseling, Testing, and Management of HBOC in India: An Expert Consensus Document from Indian Society of Medical and Pediatric Oncology

PURPOSE

Hereditary breast and ovarian cancer (HBOC) syndrome is primarily characterized by mutations in the BRCA1/2 genes. There are several barriers to the implementation of genetic testing and counseling in India that may affect clinical decisions. These consensus recommendations were therefore convened as a collaborative effort to improve testing and management of HBOC in India.

DESIGN

Recommendations were developed by a multidisciplinary group of experts from the Indian Society of Medical and Pediatric Oncology and some invited experts on the basis of graded evidence from the literature and using a formal Delphi process to help reach consensus. PubMed and Google Scholar databases were searched to source relevant articles.

RESULTS

This consensus statement provides practical insight into identifying patients who should undergo genetic counseling and testing on the basis of assessments of family and ancestry and personal history of HBOC. It discusses the need and significance of genetic counselors and medical professionals who have the necessary expertise in genetic counseling and testing. Recommendations elucidate requirements of pretest counseling, including discussions on genetic variants of uncertain significance and risk reduction options. The group of experts recommended single-site mutation testing in families with a known mutation and next-generation sequencing coupled with multiplex ligation probe amplification for the detection of large genomic rearrangements for unknown mutations. Recommendations for surgical and lifestyle-related risk reduction approaches and management using poly (ADP-ribose) polymerase inhibitors are also detailed.

CONCLUSION

With rapid strides being made in the field of genetic testing/counseling in India, more oncologists are expected to include genetic testing/counseling as part of their clinical practice. These consensus recommendations are anticipated to help homogenize genetic testing and management of HBOC in India for improved patient care.

Challenges on the provision of palliative care for patients with cancer in low- and middle-income countries: a systematic review of reviews

BACKGROUND

Despite the significant benefits of palliative care (PC) services for cancer patients, multiple challenges hinder the provision of PC services for these patients. Low- and middle-income countries (LMICs) are witnessing a sharp growth in the burden of non-communicable diseases. There is a significant gap between demand and supply of PC in LMICs in current health services. This review aims to synthesise evidence from previous reviews and deliver a more comprehensive mapping of the existing literature about personal, system, policy, and organisational challenges and possible facilitators on the provision of PC services for cancer patients in LMICs.

METHODS

A systematic review of reviews was performed following PRISMA guidelines. PubMed, EMBASE, SCOPUS, PsycINFO, Web of Sciences, CINAHL, and Cochrane Library databases were searched to identify review papers published between 2000 and 2018 that considered challenges and possible facilitators to PC provision. A modified socioecological model was used as a framework for analysing and summarising findings.

RESULTS

Fourteen reviews were included. The reviews varied in terms of aim, settings, and detail of the challenges and possible facilitators. The main challenges of personal and health care systems included knowledge deficits and misunderstandings from patients, families, the general public, and health care providers about PC; and inadequate number of trained workforce. Besides, limited physical infrastructure, insufficient drugs for symptom relief and lack of a comprehensive national plan for implementing PC were the core organisational and policy level challenges that were recognised. Furthermore, the main possible facilitators that were identified included provision of adequate training for health care providers and health education for patients, families and the general public to enhance their knowledge, beliefs, and attitudes to PC. Finally, involvement of policymakers and making drugs available for symptom relief should also be in place to improve the health care systems.

CONCLUSIONS

Understanding challenges to the provision of PC for people with cancer could help in the development of a PC pathway in LMICs. This knowledge could be used as a guide to develop an intervention programme to improve PC. Political influence and support are also required to ensure the sustainability and the provision of high-quality PC.

The impact of an educational video about radiotherapy and its toxicities in head and neck cancer patients. Evaluation of patients' understanding, anxiety, depression, and quality of life

OBJECTIVES

Head and neck radiotherapy can cause several toxicities, and its management has important treatment implications. Proper information about treatment is crucial to assist patients by preparing them and enhancing their ability to manage their illness. Thus, this study aimed to verify the impact of an educational video on the improvement of the patient's understanding, satisfaction, quality of life, and influence on their emotional state in different moments of treatment.

METHODS

A 10 min video about head and neck radiotherapy and its toxicities was produced. A prospective randomized clinical trial was performed in two groups: a control group (n = 65), which received standard verbal and written information, and an experimental group (n = 65), which received standard information and the video. Appropriated questionnaires (HADS, UW-QOLv4, IRTU, and Post-RTU) were applied in four different moments in order to evaluate patients' understanding, anxiety, depression, and quality of life.

RESULTS

The video improved the understanding of treatment and its side effects. Also, the video group reported better awareness about oral health care during the treatment. Osteoradionecrosis and radiation-related caries were the most unknown side effects. On the other hand, the educational video did not modify the patients' anxiety, depression, and quality of life. All patients reported high satisfaction with the video.

CONCLUSIONS

Audiovisual tools may improve patients' understanding of radiotherapy and were shown to be a useful tool when used in association with verbal and written information in cancer centers. In addition, information about osteoradionecrosis and radiation-related caries must be reinforced to patients.

Correlates of Adjuvant Therapy Attitudes in African American Breast Cancer Patients

PURPOSE

Black breast cancer patients delay and underutilize adjuvant breast cancer therapies; yet, very few studies have specifically examined Black women's attitudes toward breast cancer therapy. This study observed the influence of self-reported interpersonal processes of care (e.g. self-efficacy) clinical and sociodemographic factors and sociocultural (e.g. religiosity), related to Black breast cancer patients' attitudes toward radiation and systemic therapies (chemotherapy and adjuvant endocrine therapy - "AET").

METHODS

This was a secondary analysis of data from the Narrowing Gaps in Adjuvant Therapy Study (2006-2011). The analysis included 210 Black women who were newly diagnosed with breast cancer. Bivariate and multiple regression analyses were performed between independent variables (e.g., demographics) and three outcome variables (chemotherapy, AET, and radiation therapy) to asses women's perceptions of therapy type. The lasso method was used to select variables correlated with therapy attitudes.

RESULTS

Most women reported negative attitudes toward AET (56%) and radiation (54%); fewer negative attitudes were observed toward chemotherapy (47%). Higher education and greater perceived susceptibility of a recurrence were associated with more positive attitudes toward chemotherapy. Regarding radiation therapy, women with greater patient satisfaction were more likely to have more positive attitudes.

CONCLUSIONS

Our study findings may aid in the development of behavioral interventions targeted to mitigate Black women breast cancer treatment disparities. We found modifiable factors (e.g. communication, satisfaction ratings) that support opportunities for clinicians to better address Black women's needs regarding adjuvant treatment options. The development of tailored interventions for newly diagnosed Black breast cancer patients on patient related factors in health care are warranted for Black women with lower educational levels.

Cancer caregivers' experiences of prognosis in Australia: a qualitative interview study

OBJECTIVES

Forecasting survival in cancer is a particularly challenging facet of oncological work and can involve complex interactions with patients and their families. While there is considerable research on patient experiences of being provided with, or becoming aware of, their prognosis, there has been much less emphasis placed on the experiences of caregivers. The aim of this paper was to examine caregivers' experiences of prognosis.

DESIGN

This study used semistructured interviews; transcripts were analysed thematically using the framework approach. These data are part of a larger research project focused on experiences of cancer survivorship.

SETTING

Recruitment was from two metropolitan hospitals in Queensland, Australia.

PARTICIPANTS

50 caregivers of patients living with cancer and receiving treatment at two metropolitan hospitals (32% male, 68% female) participated in this study.

RESULTS

Four main themes were identified: (1) caregivers' uncertainty around the meaning and implications of prognosis, (2) caregivers' sense of exclusion in prognostic conversations, (3) the practice of situating prognosis within a context of hope and (4) the precarious balance between realism, optimism and strategic 'ignorance'.

CONCLUSIONS

Caregivers are in many respects the unseen third party of prognostic communication. Developing a better understanding of caregivers' perceptions of prognosis, including how this may be challenged, accepted or otherwise, is important in engaging caregivers in the process of communicating prognostic information. Facilitating greater participation by caregivers in prognostic conversations could potentially address evident complexities and even improve the experiences of all stakeholders in cancer care settings.

Patient-physician discordance in goals of care for patients with advanced cancer

Background

Shared decision-making at end of life (eol) requires discussions about goals of care and prioritization of length of life compared with quality of life. The purpose of the present study was to describe patient and oncologist discordance with respect to goals of care and to explore possible predictors of discordance.

Methods

Patients with metastatic cancer and their oncologists completed an interview at study enrolment and every 3 months thereafter until the death of the patient or the end of the study period (15 months). All interviewees used a 100-point visual analog scale to represent their current goals of care, with quality of life (scored as 0) and survival (scored as 100) serving as anchors. Discordance was defined as an absolute difference between patient and oncologist goals of care of 40 points or more.

Results

The study enrolled 378 patients and 11 oncologists. At baseline, 24% discordance was observed, and for patients who survived, discordance was 24% at their last interview. For patients who died, discordance was 28% at the last interview before death, with discordance having been 70% at enrolment. Dissatisfaction with eol care was reported by 23% of the caregivers for patients with discordance at baseline and by 8% of the caregivers for patients who had no discordance (p = 0.049; ϕ = 0.20).

Conclusions

The data indicate the presence of significant ongoing oncologist-patient discordance with respect to goals of care. Early use of a simple visual analog scale to assess goals of care can inform the oncologist about the patient's goals and lead to delivery of care that is aligned with patient goals.

The Value of Progression-Free Survival as a Treatment End Point Among Patients With Advanced Cancer: A Systematic Review and Qualitative Assessment of the Literature

IMPORTANCE

It is unclear whether patients with advanced cancer value surrogate end points, particularly progression-free survival (PFS). Despite this uncertainty, surrogate end points form the basis of regulatory approval for the majority of new cancer treatments.

OBJECTIVE

To summarize and qualitatively assess studies evaluating whether patients with advanced cancer understand and value PFS.

EVIDENCE REVIEW

MEDLINE, Embase, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature databases were searched from database inception to November 12, 2018. Articles eligible for inclusion investigated patient understanding, preference, or perceived value of disease progression or PFS in the setting of advanced cancer. Three authors independently reviewed and extracted data from all studies eligible for inclusion.

FINDINGS

In total, 17 studies representing 3646 patients were included. Of these studies, 15 specifically aimed to assess patients' values toward, and their willingness to trade off toxic effects for gains or losses in the end point of PFS. All studies examined used widely disparate definitions when attempting to describe the meaning of PFS to patients. Ten studies specifically presented patients with the term progression-free survival as an attribute choice. In the words used to define the attribute of PFS, 6 studies used the term survival. Five studies clarified that PFS may not translate into better overall survival, and 5 studies explained that improvements in PFS may not reflect how well the patient may feel. No study clarified that a PFS event could represent either progression or death, and no study defined for the patient what constituted progression. The studies assessed herein underrepresented ethnic and racial minorities (mean percentage of white patients, 88%; range, 77%-96%). Values and preferences may vary across cultural backgrounds given that different relative preferences were assigned to cost and efficacy outcomes in North American vs Asian studies, although only a few studies were evaluated.

CONCLUSIONS AND RELEVANCE

The existing literature evaluating patients' understanding, preferences, and values toward the end point of PFS was severely limited by the heterogeneity of methods, attribute selection, and descriptions used to define PFS to patients. High-quality studies are needed that clearly define PFS for patients and that systematically document their understanding of the term. Only then can it be assessed whether PFS is an end point of value to patients with advanced cancer.

Outcomes and outcome measures used in evaluation of communication training in oncology - a systematic literature review, an expert workshop, and recommendations for future research

BACKGROUND

Communication between health care provider and patients in oncology presents challenges. Communication skills training have been frequently developed to address those. Given the complexity of communication training, the choice of outcomes and outcome measures to assess its effectiveness is important. The aim of this paper is to 1) perform a systematic review on outcomes and outcome measures used in evaluations of communication training, 2) discuss specific challenges and 3) provide recommendations for the selection of outcomes in future studies.

METHODS

To identify studies and reviews reporting on the evaluation of communication training for health care professionals in oncology, we searched seven databases (Ovid MEDLINE, CENTRAL, CINAHL, EMBASE, PsychINFO, PsychARTICLES and Web of Science). We extracted outcomes assessed and the respective assessment methods. We held a two-day workshop with experts (n = 16) in communication theory, development and evaluation of generic or cancer-specific communication training and/or outcome measure development to identify and address challenges in the evaluation of communication training in oncology. After the workshop, participants contributed to the development of recommendations addressing those challenges.

RESULTS

Out of 2181 references, we included 96 publications (33 RCTs, 2 RCT protocols, 4 controlled trials, 36 uncontrolled studies, 21 reviews) in the review. Most frequently used outcomes were participants' training evaluation, their communication confidence, observed communication skills and patients' overall satisfaction and anxiety. Outcomes were assessed using questionnaires for participants (57.3%), patients (36.0%) and observations of real (34.7%) and simulated (30.7%) patient encounters. Outcomes and outcome measures varied widely across studies. Experts agreed that outcomes need to be precisely defined and linked with explicit learning objectives of the training. Furthermore, outcomes should be assessed as broadly as possible on different levels (health care professional, patient and interaction level).

CONCLUSIONS

Measuring the effects of training programmes aimed at improving health care professionals' communication skills presents considerable challenges. Outcomes as well as outcome measures differ widely across studies. We recommended to link outcome assessment to specific learning objectives and to assess outcomes as broadly as possible.

Defining the patient experience in medical oncology

PURPOSE

Higher patient satisfaction is associated with improved health outcomes, treatment adherence, and quality of life. The goal of this study was to explore oncology patients' perceptions on their hospital experience, focusing on the quality of care in medical oncology.

METHODS

A qualitative and quantitative study design was implemented with a sample of 58 patients at Smilow Yale New Haven Hospital. Data were collected from patient interviews and observation of rounds.

RESULTS

Two themes emerged: hospital experience and physician communication skills. Within hospital experience, subthemes identified include: attended to (49%), facility/staff (35%), nurses (33%), long wait time (29%), doctors (20%), coordination of care (18%), unnecessary medical procedures (10%), medications (6%), night awakenings (4%), pain (4%), not getting better (4%), and decreased mobility (2%). Within physician communication skills, subthemes identified include: involving the patient and/or family in the care process (41%), method of information sharing (18%), lack of coordination of care (15%), use of medical jargon (10%), attending to patient's needs (8%), and lack of patient's perspective (8%). Patients reported that effective engagement of patients in the care process and attending to patient-specific needs were desired qualities in their hospital experience as well as patient-centered communication with their physician. The quantitative data supported qualitative results with 72% of patients giving the highest score in overall satisfaction with their patient experience.

CONCLUSION

Physician attentiveness or lack thereof is a defining aspect of the quality of patient experience and physician communication. The results are intended to inform clinical and operational interventions that care providers might incorporate into practice.

COMSKIL Communication Training in Oncology-Adaptation to German Cancer Care Settings

Medical communication is a skill which can be learned and taught and which can substantially improve treatment outcomes, especially if patients' communication preferences are taken into account. Here, we give an overview of communication training research and outline the COMSKIL program as a state-of-the-art communication skills training in oncology. COMSKIL has a solid theoretical foundation and teaches core elements of medical communication in up to ten fully operationalized modules. These address typical situations ranging from breaking bad news to responding to difficult emotions, shared decision-making, and communicating via interpreters.

Heading in a new direction? Recommendations for future research on patient decision aids

Decision aids can improve a number of patient outcomes, but they are not commonly used in clinical practice. This commentary paper provides suggestions for potential next steps of decision aid research, with the aim to facilitate their implementation. We suggest to further standardise clinically meaningful outcomes and outcome measures that should be used to examine the impact of decision aids. Second, using mediation analysis and active control groups could help tease out and explore variables that influence decision aids' effectiveness to help healthcare providers decide when and how to use them in clinical practice. Third, effectiveness trials should be clearly reported and replicated to investigate under what circumstances decision aids work best. Specific checklists for decision aid trials should be used to ensure that all relevant factors are reported in detail. Addressing the above issues will help identify what specific components of decision aids are effective and should be implemented. We can then move towards conducting implementation trials which help increase the use of decision aids in "real-world" healthcare.

Palliative Pain Management: When Both Pain and Suffering Hurt

Patients with advanced cancer frequently experience intractable pain without sufficient response to a conventional pharmacological approach. One reason for refractory pain at the end of life can be the bidirectional nature of pain and suffering. Three terminally ill patients were assessed using a multidimensional palliative pain concept, including sensory, affective, cognitive, and existential components. In these patients, resistant pain did not equal insufficient eradication of the nociceptive input, but also suffering. Unrelieved emotions, depressive or anxious symptoms, delirium, difficulties communicating, or chemical coping influenced the expression of pain, illuminating the phenomenon of somatization. Palliative pain treatment integrated analgesic treatments, psychological, rehabilitative, and existential interventions, in consideration of individual expectations and outcomes. With the disciplined assessment and alternative multidisciplinary palliative approach, the quality of life of three terminally ill cancer patients with intractable pain could be enhanced, and unnecessary interventions and escalation of medications avoided.

Communication about genetic testing with breast and ovarian cancer patients: a scoping review

Genetic testing of patients with cancer is increasingly offered to guide management, resulting in a growing need for oncology health professionals to communicate genetics information and facilitate informed decision-making in a short time frame. This scoping review aimed to map and synthesise what is known about health professionals' communication about genetic testing for hereditary breast and ovarian cancer with cancer patients. Four databases were systematically searched using a recognised scoping review method. Areas and types of research were mapped and a narrative synthesis of the findings was undertaken. Twenty-nine papers from 25 studies were included. Studies were identified about (i) information needs, (ii) process and content of genetic counselling, (iii) cognitive and emotional impact, including risk perception and recall, understanding and interpretation of genetic test results, and anxiety and distress, (iv) patients' experiences, (v) communication shortly after diagnosis and (vi) alternatives to face-to-face genetic counselling. Patients' need for cancer-focused, personalised information is not always met by genetic counselling. Genetic counselling tends to focus on biomedical information at the expense of psychological support. For most patients, knowledge is increased and anxiety is not raised by pre-test communication. However, some patients experience anxiety and distress when results are disclosed, particularly those tested shortly after diagnosis who are unprepared or unsupported. For many patients, pre-test communication by methods other than face-to-face genetic counselling is acceptable. Research is needed to identify patients who may benefit from genetic counselling and support and to investigate communication about hereditary breast and ovarian cancer by oncology health professionals.

Communication Skills Training for Professionals Working with Adolescent Patients with Cancer Based on Participants' Needs: A Pilot

Purpose: We aimed to pilot and evaluate communication skills training (CST) for health care professionals (HCPs) interacting with adolescent patients with cancer and their parents based on participants' needs. Methods: We developed and piloted a 2-day CST with physicians and nurses in adolescent oncology. The CST's agenda was determined by the critical incidents reported by the participants. Training consisted of experiential learning based on role-play between HCPs and simulated patients and parents. Whenever suited, short lectures were given on specific communication techniques. Skills were self-assessed by questionnaires before, immediately after, and 6 months after training. We compared the proportion of participants who felt confident in 19 predefined areas of difficult communication before and 6 months after training. Responses to open-ended questions were analyzed qualitatively by thematic analysis. Results: Twenty-six physicians and 24 nurses participated in 6 CSTs. The proportion of participants who felt confident increased significantly in 6 of 19 communication items (p < 0.05). Positive feedback outweighed negative in quantity and quality. Predominant themes immediately after training were the training's practical orientation and intensity, and 6 months later, increased self-confidence and applied communication techniques. Participants noted that the effect diminishes with time, and expressed their need for booster trainings. Conclusion: The results of CST tailored to the specific needs of HCPs in adolescent oncology were promising. We suggest that similar training opportunities are implemented elsewhere.

ComOn-Coaching: The effect of a varied number of coaching sessions on transfer into clinical practice following communication skills training in oncology: Results of a randomized controlled trial

OBJECTIVE

To investigate the effect of the number of coaching sessions after communication skills training on the medical communicative performance of oncologists in clinical practice.

METHODS/DESIGN

The training, consisting of a workshop and one (control group) vs. four (intervention group) sessions of individual coaching, was evaluated in a randomized controlled trial. Eligible participants included physicians working in any setting where patients with oncological diseases were treated. Real medical consultations were video recorded at three time points: before the workshop (t0), after the workshop (t1) and after completion of coaching (t2). The 1.5-day workshop was based on role-playing in small groups; in the coaching sessions, the videos recorded at t1 were analyzed in detail by both the trainer and the physician. The coaching sessions were manualized and based on the physician's learning goals. The primary hypothesis was that the intervention group would improve to a higher extent than the control group, as assessed by external raters using rating scales specially developed for this project. Physicians were stratified for sex and setting and randomized by an independent statistician. The group assignment was revealed for physicians and trainers at the end of the workshop, while the raters were blinded to group assignments and assessment points.

RESULTS

A total of 72 physicians participated in one of 8 workshops and could be allocated to either the control or intervention group. The intervention group showed a statistically significant improvement (ES d = 0.41, p<.01) in the All items domain of the rating scales between t1 and t2 and showed a significant advantage compared with the CG (ES = .41, p = .04). The impact on diverse specified skills was heterogeneous; a larger sample is necessary for more detailed analysis.

CONCLUSIONS

The training achieved some observable and significant changes in the communicative behavior of oncologists in clinical practice. The four coaching sessions showed some significant advantages compared to the single coaching session. Considerable effort is necessary to achieve sustained changes in communication in clinical every-day practice. Thus, our coaching concept is a promising method for this purpose.

Initial Perceptions about Palliative Care in Patients with Advanced Cancer: A Prospective Cross-Sectional Audit

INTRODUCTION

There is enough evidence to suggest that early introduction to palliative care (PC) for patients with advanced cancer is beneficial. However, despite this, the patients often come late to PC physicians. There are a number of studies examining the preferences and practices of the physicians with respect to PC. However, there is limited literature exploring the patients' preferences and awareness regarding the PC services. This audit was done to identify the understanding and perceptions of PC in patients visiting PC outpatient department (OPD) and identify strategies to enhance their understanding.

MATERIALS AND METHODS

This prospective cross-sectional study was conducted in 200 advanced cancer patients visiting PC OPD in a tertiary care hospital. The patients were asked to fill a questionnaire to assess their knowledge and expectations form PC on their first visit.

RESULTS

Majority of the patients were from nearby areas and around 20% of them had to travel more than 300 km to receive palliative consultation. Unfortunately, majority of the patients had not heard the term PC before and were not aware of its meaning. Most of them (90%) were send to control pain which was too severe to be managed by the oncologists. We think that the major reason for the lack of awareness about PC services is limited availability across the country and lack of coordinated approach.

CONCLUSIONS

The main problem identified in the audit was the inadequate information, lack of PC setups, and late referral of the patients to PC. Hence, we should make a model where PC services are integrated with the curative services and offered throughout the illness after cancer diagnosis.

Significant aspects of nursing within the process of end-of-life communication in an oncological context

The complexity of end-of-life communications has previously been described and found to be given late in the patient’s palliative care. There is a need for earlier and more continuous end-of-life-communications throughout the patient’s care to reduce anxiety, confusion, and promote participation. Registered nurses (RNs) have a unique closeness to the patient and the ability to identify early the need for end-of-life communication. The aim of this study was to describe crucial aspects of nursing in end-of-life communication in an oncology context. The study was designed as a qualitative content analysis of in-depth interviews with RNs working in oncology in-patient care units. Two domains were identified: before, and after end-of-life communications, with the categories importance of being well prepared to identify both the patient’s and their family’s needs. Cooperation and interaction between physicians and RNs were crucial to be able to support patients and their relatives around the clock. The presence of RNs encouraged further conversations about the patients’ conditions to gain insight into the new situation. End-of-life communication should not only be medicine oriented and performed by physicians. Involvement of RNs’ expertise enables increased patient/relative participation as well as reduced anxiety and suffering, creating clarity and safety for all involved in care.

Social Support and Depression in Iranian Cancer Patients: the Role of Demographic Variables

Introduction: Depression is the most frequent mental disorder in cancer patients, which is, unfortunately, less noticeable. Despite extensive researches, we only have scant knowledge about the influence of social support on depression in cancer patients. The aim of this study is to examine the relationship between perceived social support and depression and demographic variables on cancer patients. Methods: This is a descriptive correlational study on two hundred cancer patients in Isfahan, Iran. The study subjects were selected through convenient sampling method and data were collected using questionnaires (demographic questionnaire, Multidimensional Scale of Perceived Social Support (MSPSS) and Beck Depression Scale (BDS). Data were analyzed by SPSS software (Frequency distribution, Chi-Square and Spearman correlation). Results: The findings showed that social support and depression in cancer patients are significantly correlated with each other (r = - 0.785, P <0.001). Furthermore, the findings indicated that there are statistically significant correlations between degrees of education with depression and also between the numbers of children with social support and depression in cancer patients. For all analyses, was considered significant. Conclusion: In conclusion, we suggest that interventions to alleviate depression in cancer patients may be designed with consideration of demographic characteristics especially the level of education and the number of supporters of the patient to increase the quality of life in cancer patients and minimize the negative consequences of cancer diagnosis.

Barriers and facilitators to health care professionals discussing child weight with parents: A meta-synthesis of qualitative studies

INTRODUCTION

Childhood obesity is one of the most serious global public health challenges. However, obesity and its consequences are largely preventable. As parents play an important role in their children's weight-related behaviours, good communication between parents and health care professionals (HCPs) is essential. This systematic review provides a meta-synthesis of qualitative studies exploring the barriers and facilitators experienced by HCPs when discussing child weight with parents.

METHODS

Searches were conducted using the following databases: MEDLINE (OVID), Psych INFO (OVID), EMBASE (OVID), Web of Knowledge and CINAHL. Thirteen full-text qualitative studies published in English language journals since 1985 were included. Included studies collected data from HCPs (e.g., nurses, doctors, dieticians, psychologists, and clinical managers) concerning their experiences of discussing child weight-related issues with parents. An inductive thematic analysis was employed to synthesize findings.

FINDINGS

Emerging subthemes were categorized using a socio-ecological framework into intra/interpersonal factors, organizational factors, and societal factors. Perceived barriers and facilitators most commonly related to intra/interpersonal level factors, that is, relating to staff factors, parental factors, or professional-parent interactions. HCPs also attributed a number of barriers, but not facilitators, at the organizational and societal levels.

CONCLUSION

The findings of this review may help to inform the development of future weight-related communication interventions. Whilst intra/interpersonal interventions may go some way to improving health care practice, it is crucial that all stakeholders consider the wider organizational and societal context in which these interactions take place. Statement of contribution What is already known on the subject? Childhood obesity is one of the United Kingdom's most serious current public health challenges. Health care professionals are in a prime position to identify child weight issues during routine consultations. However, they often feel unable or unequipped to raise the topic and provide information on child weight management. What does this study add? To our knowledge, this is the first review to synthesize barriers and facilitators to discussing child weight. This review interprets key barriers and facilitators in the context of the socio-ecological model. Supports the development of interventions matched to the appropriate level of the socio-economic model.

Exploring Health Information-Seeking Preferences of Older Adults With Hypertension: Quasi-Experimental Design

BACKGROUND

Patients' engagement in health care decision making is constituted by at least two behaviors: health information seeking and active involvement in medical decisions. Previous research reported that older adults desire a lot of information, but want to participate in decision making to a lesser degree. However, there is only limited evidence on the effect of desire for health information on seniors' perceived confidence in making an informed choice (ie, decision self-efficacy).

OBJECTIVE

The goal of this study was to investigate the role desire for health information has for older patients. More specifically, it tested whether decision self-efficacy increases as a function of an assisted computer-based information search. Additionally, the study allowed insights into the sources seniors with hypertension prefer to consult.

METHODS

A sample of 101 senior citizens (aged ≥60 years) with high blood pressure in the Italian-speaking part of Switzerland answered a questionnaire before and after an informational intervention was applied. The intervention consisted of offering additional information on hypertension from five different sources and of providing the information the participant desired. Preference for receiving this information was the major independent variable. The main outcome measure was decision self-efficacy (assessed at baseline and posttest). Analyses of covariance were conducted to detect differences between and within who desired additional hypertension-related content (intervention group) and "information avoiders" (control group).

RESULTS

Health care professionals firmly remain the preferred and most trusted source of health information for senior patients. The second most consulted source was the internet (intervention group only). However, among the total sample, the internet obtained the lowest credibility score. A significant increase in decision self-efficacy occurred in seniors consulting additional information compared to information avoiders (F1,93=28.25, P<.001).

CONCLUSIONS

Consulting health information on a computer screen, and assistance by a computer-savvy person, may be a helpful activity to increase perceived confidence in making treatment decisions in seniors with hypertension.

Barriers to Colorectal Cancer Screening in a Racially Diverse Population Served by a Safety-Net Clinic

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the US, yet screening rates remain low among minority populations. The purpose of the current study was to identify differences in the endorsement of barriers to CRC screening and to evaluate the association between provider recommendation and CRC screening adherence among Hispanic, Pacific Islander and White patients. This study utilized a cross sectional survey design to identify patient-reported barriers to CRC screening. Logistic regression was utilized to evaluate the association between patient demographic characteristics (race/ethnicity, gender, age), having received provider recommendation, and patient awareness of CRC screening. The study sample was comprised of a diverse population (N = 197); 48% Hispanic, 25% White, 10% Pacific Islander, 4% Black and 13% other races/ethnicity. The median age of participants was 58, yet fewer than 30% were up-to-date for CRC screening. The most commonly cited barriers included fear of test results (27.6%), inability to leave work for a CRC screening appointment (26.9%), being unaware of the need for colonoscopy (25.4%), and lack of provider recommendation for CRC screening (24.9%). Only 16.2% of participants reported that a provider had discussed CRC screening options with them. After adjusting for age and gender, Hispanic patients were less likely to report having had a provider discuss CRC screening options compared to White patients (OR = 0.24, 95% CI: 0.09-0.68, p < 0.05). The findings from this study indicate that patient's perceived screening barriers, lack of awareness and a lack of provider communication about CRC screening options may contribute to low screening rates among minority populations.

Patient Anxiety Before and Immediately After Imaging-Guided Breast Biopsy Procedures: Impact of Radiologist-Patient Communication

PURPOSE

The aim of this study was to evaluate patient anxiety and its association with perceived radiologist-patient communication in the setting of imaging-guided breast biopsy.

METHODS

After informed consent was obtained, 138 women recommended for imaging-guided breast procedures completed questionnaires immediately before and after biopsies, measuring state anxiety using the State-Trait Anxiety Inventory (range, 20-80). Before biopsies, women also completed questionnaires regarding their perceived communication with the radiologists recommending the procedures (modified Questionnaire on the Quality of Physician-Patient Interaction), demographic characteristics, and medical history; immediately after the biopsies, they completed a measure of perceived communication with the radiologists performing the biopsies. Experience levels (eg, attending radiologist, fellow) of the radiologists recommending and performing the biopsies were recorded. Data were analyzed using paired and independent t tests, one-way analysis of variance, Pearson's correlations, and multiple linear regression analyses.

RESULTS

Average prebiopsy anxiety was 44.5 ± 12.4 (range, 20-77) on a scale ranging from 20 to 80 points. Perceived communication with radiologists recommending biopsies averaged 52.4 ± 11.5 (range, 18-65). Better communication with radiologists recommending biopsies was significantly associated with lower levels of prebiopsy anxiety (r = -0.22, P = .01). After the biopsies, women's anxiety significantly decreased (paired t = -7.32, P < .001). Better communication with radiologists performing biopsies (mean, 57.8 ± 8.4; range, 32-65) was associated with lower postbiopsy anxiety after accounting for patients' baseline anxiety levels (β = -0.17, P = .04). White women reported higher prebiopsy and postbiopsy anxiety; nonwhite women reported poorer communication with recommending radiologists.

CONCLUSIONS

Patients' perceptions of better communication with radiologists were associated with lower levels of anxiety before and after biopsies. These results have implications for radiologist training and adherence to mammographic screening.

Need for information, honesty and respect: patient perspectives on health care professionals communication about cancer and fertility

BACKGROUND

Individuals affected by cancer report a need for information about fertility from health care professionals (HCPs), in order to inform decision making and alleviate anxiety. However, there is evidence that many health professionals do not engage in such discussions.

METHOD

A mixed method design was used to examine the construction and subjective experience of communication with health professionals about fertility in the context of cancer, from the perspective of patients. A survey was completed by 693 women and 185 men, across a range of cancer tumour types and age groups, and in-depth one-to-one interviews conducted with a purposively selected subsample of survey respondents, 61 women and 17 men. The chi square test for independence was used to test for group differences between women and men on closed survey items. Thematic analysis was used to examine the open ended survey responses and interviews.

RESULTS

Significantly more women (57%, n = 373) than men (46%, n = 80) (X2(2517) = 6.54, p = .011) reported that they had discussed fertility with a HCP since diagnosis of cancer. Satisfaction with the discussion was reported by 65% (n = 242) of women and 69% (n = 54) (ns) of men. This discussion was reported to have been initiated by the patient or their partner in 44% (n = 165) of women and 47% (n = 37) (ns) of men. In the interviews and open ended surveys three themes were identified: Feeling heard and informed about fertility after cancer: Positive experiences of HCP communication; "I was never given full disclosure": HCP silence or reticence about discussing fertility after cancer, including the sub-theme "Their primary concern is getting me cancer free": Constructions of absence of fertility communication by HCPs; and Confusion and lack of compassion: Unsatisfactory information provision about fertility and cancer.

CONCLUSION

Discussion with a HCP about fertility concerns, and satisfaction with the discussion, was associated with reports of lower patient distress, greater knowledge and understanding of the consequences of cancer on fertility, involvement in the decision making process about fertility preservation, and satisfaction with health care.

Are future medical oncologists sufficiently trained to communicate about palliative care? The medical oncology curriculum in Flanders, Belgium

BACKGROUND

Palliative care is considered an integral part of oncology and communicating this with patients is an unavoidable task for oncologists. This contribution investigated to what extent communication skills for communicating palliative care with patients are trained in the formal academic training program in medical oncology in Flanders, Belgium. The programme is based on the recommendations for a Global Core Curriculum in Medical Oncology, developed by The American Society of Clinical Oncology (ASCO) together with the European Society for Medical Oncology (ESMO).

METHODS

For this qualitative study, data were collected using document analysis from the ESMO/ASCO recommendations and the documents of the Flanders' medical oncology programme complemented with interviews with Flemish medical oncology trainees.

RESULTS

Few recommendations for training communication skills to communicate about palliative care were found in the ASMO/ASCO recommendations and even less in the Flanders' programme documents. Trainees are mainly exposed to palliative care communication during the clinical practice of their training. Only very few lectures or seminars are devoted to palliative care and even less on communication about palliative care. They reported several barriers to communicate about palliative care.

CONCLUSIONS

This study revealed promising developments for the training of Flemish medical oncologists to discuss palliative care. However, there is still a need for more theoretical training on palliative care complemented with communication skills trainings. Communication training in general needs to be fully integrated as a core skill within the medical curriculum at large and should be promoted as lifelong learning and competency development.

Effective Communication among Globally Distributed Software Development Teams

Global software development, an emerging software development methodology within a technology-enabled environment has recently received increased attention from scholars and practitioners. Despite the fact that the lack of effective communication is a major challenge of globally distributed teams, communication research related to the scale development is still very limited in existing literature. Considering the communication challenges and increasing need to measure the effectiveness of communication, this research is focused to develop a scale for “Effective Communication” for globally distributed software development teams. Systematic literature review is performed to identify the best practices of effective communication for the development of “Effective Communication” scale. A questionnaire survey consisting of 29 items is administered in globally distributed software development teams. Confirmatory factor analysis and statistical results depicted that the four-factor model (e.g. stakeholders' involvement, acculturation, usage of appropriate tools and technology, and information availability) is more parsimonious and an optimal model fit.

Rapport between Cancer Patients and Their Physicians is Critical for Patient Satisfaction with Treatment Decisions

BACKGROUND

Cancer patients' satisfaction with their treatment decisions has been demonstrated to be associated with improved health outcomes, but few studies of this issue have been conducted in Japan.

OBJECTIVE

To explore key factors in enhancing patient satisfaction, we assessed the association between their satisfaction and their relationships with their physicians.

METHODS

We conducted cross-sectional questionnaire surveys among patients who had received cancer treatment. One source was outpatients from a cancer center hospital, and the other was through the website of Japan's most popular newspaper. The questionnaire included demographic questions and general self-rated life status issues, such as peace of mind, quality of life, daily activities, family relationships, rapport with attending physician, assessment of the physician's explanations, and feelings of happiness during the previous week.

RESULTS

Of 576 respondents, 383 subjects said they were satisfied and 193 dissatisfied. It was confirmed that the online survey was comparable to the paper-based survey in examining patient satisfaction. The dissatisfied group included more females and fewer subjects who were forced to retire from jobs than the satisfied group. The patients in the satisfied group had a more favorable subjective opinion of their recent life. The patients in the dissatisfied group received more chemotherapy and had more side effects than those in the satisfied group. Assessment of the physician's role showed significant differences between the two groups; the patients in the satisfied group felt more than those in the dissatisfied group that their physicians' explanations of treatment were sufficient and were satisfied with their rapport with their physicians. Multiple logistic regression analysis revealed that rapport with physicians was a significant factor (odds ratio=3.79, 95% CI=2.25-6.39).

CONCLUSIONS

Rapport between physicians and patients is one of the most important factors in patient satisfaction with treatment decisions.

The clinical communication and information challenges associated with the psychosexual aspects of prostate cancer treatment

RATIONALE

Prostate cancer and its treatment have significant sexual side effects that necessitate timely patient information and open communication with healthcare professionals. However, very little is known about men's experiences of talking to clinicians about the psychosexual difficulties associated with the disease.

OBJECTIVE

This study aims to advance understanding of men's perceptions of the communication and information challenges associated with the psychosexual aspects of prostate cancer and its treatment.

METHOD

Between October 2013 and April 2014, semi-structured interviews were conducted with 21 men from the UK who had been treated for prostate cancer. Interview transcripts were analysed using thematic analysis.

RESULTS

Three themes describe the communication challenges men face: (1) It can be too soon to talk about sex; (2) the psychology of sex is missing; (3) communication is not individually tailored.

CONCLUSIONS

Clinicians might usefully (1) consider and discuss with patients how their psychosexual communication needs and information processing abilities may fluctuate across the cancer timeline; (2) initiate discussions about the consequences of treatment that extend beyond biological and mechanical aspects to include emotional and relational factors; (3) tailor communication to the dynamic mix of attributes that shape men's individual psychosexual needs, including their relationship status, sexual orientation, sexual motivations and values. Skills-based training in communication and psychosexual awareness may facilitate the proactive and permissive stance clinicians need to discuss sexual side effects with a heterogeneous group of patients.

Patients' learning and understanding during their breast cancer trajectory

OBJECTIVE

To explore how women learn and understand their disease, treatment, care, and life-situation during a breast cancer trajectory.

METHOD

Semi-structured individual interviews were performed with 16 women suffering from breast cancer. Qualitative content analysis of data was performed.

RESULTS

Three themes describe the women's learning; Interacting with a diversity of information: women interact with a vast amount of information, including perceptions of bodily sensations and events. Concealed and expressed understandings: women interpret information that results in understanding which is either concealed or expressed. Struggling to understand and manage the new life situation: pre-understanding, driving forces to learn, contemplation and dialogue with healthcare staff influence the women's learning.

CONCLUSIONS

General theories of learning are applicable to learning during a breast cancer trajectory. Significant features of learning during a life-threatening illness are strong personal drivers to understand and deal with all that occurs. Vulnerability remains a challenge in developing understanding as a cancer diagnosis infers uncertainty.

PRACTICAL IMPLICATIONS

Patients need time to assimilate and process complex bodies of information in dialogue with health care staff. Patients' understanding needs to be assessed and pedagogical competence in the interprofessional team is assumed to facilitate patients' learning and participation in treatment and care.

Exploring ways to manage healthcare professional-patient communication issues

Effective communication between clinicians and their patients has a positive impact not only on clinical outcomes but also on their experience of care. Communication skills are a core clinical skill, which can be taught by a number of methods. Understanding the impact of one's own communication skills has on a patient and their family can help hone a clinician's skills to improve both patient and clinician satisfaction.

A new paradigm for clinical communication: critical review of literature in cancer care

OBJECTIVES

To: (i) identify key assumptions of the scientific 'paradigm' that shapes clinical communication research and education in cancer care; (ii) show that, as general rules, these do not match patients' own priorities for communication; and (iii) suggest how the paradigm might change to reflect evidence better and thereby serve patients better.

METHODS

A critical review, focusing on cancer care. We identified assumptions about patients' and clinicians' roles in recent position and policy statements. We examined these in light of research evidence, focusing on inductive research that has not itself been constrained by those assumptions, and considering the institutionalised interests that the assumptions might serve.

RESULTS

The current paradigm constructs patients simultaneously as needy (requiring clinicians' explicit emotional support) and robust (seeking information and autonomy in decision making). Evidence indicates, however, that patients generally value clinicians who emphasise expert clinical care rather than counselling, and who lead decision making. In denoting communication as a technical skill, the paradigm constructs clinicians as technicians; however, communication cannot be reduced to technical skills, and teaching clinicians 'communication skills' has not clearly benefited patients. The current paradigm is therefore defined by assumptions that that have not arisen from evidence. A paradigm for clinical communication that makes its starting point the roles that mortal illness gives patients and clinicians would emphasise patients' vulnerability and clinicians' goal-directed expertise. Attachment theory provides a knowledge base to inform both research and education.

CONCLUSIONS

Researchers will need to be alert to political interests that seek to mould patients into 'consumers', and to professional interests that seek to add explicit psychological dimensions to clinicians' roles. New approaches to education will be needed to support clinicians' curiosity and goal-directed judgement in applying this knowledge. The test for the new paradigm will be whether the research and education it promotes benefit patients.

Second Flexner Century: The Democratization of Medical Knowledge: Repurposing a General Pathology Course Into Multigrade-Level "Gateway" Courses

Starting in 1910, the "Flexner Revolution" in medical education catalyzed the transformation of the US medical education enterprise from a proprietary medical school dominated system into a university-based medical school system. In the 21st century, what we refer to as the "Second Flexner Century" shifts focus from the education of medical students to the education of the general population in the "4 health literacies." Compared with the remarkable success of the first Flexner Revolution, retrofitting medical science education into the US general population today, starting with K-12 students, is a more daunting task. The stakes are high. The emergence of the patient-centered medical home as a health-care delivery model and the revelation that medical errors are the third leading cause of adult deaths in the United States are drivers of population education reform. In this century, patients will be expected to assume far greater responsibility for their own health care as full members of health-care teams. For us, this process began in the run-up to the "Second Flexner Century" with the creation and testing of a general pathology course, repurposed as a series of "gateway" courses on mechanisms of diseases, suitable for introduction at multiple insertion points in the US education continuum. In this article, we describe nomenclature for these gateway courses and a "top-down" strategy for creating pathology coursework for nonmedical students. Finally, we list opportunities for academic pathology departments to engage in a national "Democratization of Medical Knowledge" initiative.

Coordination of Care for Breast Reconstruction Patients: A Provider Survey

OBJECTIVES

Communication between medical oncologists (MOs) and plastic surgeons (PSs) is important to optimize outcomes for patients with breast cancer seeking breast reconstruction. We sought to evaluate the knowledge MOs and PSs have of each others' fields, roles expected of each other, and frequency of communication.

METHODS

A cross-sectional survey was conducted in a convenience sample of MOs and PSs. The survey included knowledge questions about reconstruction and chemotherapy, questions about provider and patient responsibilities for timely chemotherapy initiation, and questions about communication with other specialties.

RESULTS

MOs and PSs had similar knowledge scores (MOs, 59%; PSs, 56%; P = .5), but both lacked knowledge about aspects of the other specialty's field related to breast reconstruction. The MOs and PSs agreed on the MOs' degree of responsibility for timely chemotherapy initiation (MOs mean, 4.6; PSs mean, 4.4 (out of 5); P = .2). However, they disagreed about the PS's responsibility for timely chemotherapy initiation (MOs mean, 3.8; PSs mean, 3.0; P = .01). Communication occurred about 2.5 times more often for patients with complications than patients without complications (P < .0001).

CONCLUSION

MOs and PSs have deficits in knowledge about each other fields and differ in their opinion regarding the burden of responsibility in ensuring timely chemotherapy initiation, suggesting room for improvement in communication and understanding.

Making a difference? Teaching communication skills in preregistration nurse education in England. A comparison of Project 2000 and Making a Difference curricula

This paper reports on a survey of the teaching of communication skills on pre-registration nursing programmes in England in 2000. Questionnaires were devised for the Common Foundation Programme and the four Branch Programmes. These were sent to academic staff responsible for both Project 2000 and Making a Difference curricula. Comparisons are made between the two curricula, between matched pairs of curricula in institutions offering them both, and according to whether the institutions were designated as pilot sites for the Making a Difference curricula. The overwhelming finding was that there was no difference between any of the particular comparisons made. Lecturer-practitioners were more likely to be used to teach communication skills on Making a Difference curricula, but otherwise the picture was one of inconsistency and widespread differences between curricula and institutions. The lack of a greater emphasis on communication skills in Making a Difference curricula is surprising, given that it is intended to be skills-based. Recommendations are made for further research.

Interpersonal complaints regarding cancer care through a gender lens

Purpose

– The purpose of this paper is to investigate healthcare customer complaints concerning interpersonal matters in cancer care.

Design/methodology/approach

– Complaints from cancer patients and their relatives (n=116) that dealt with interpersonal matters registered between 2009 and 2011 at four local Patients’ Advisory Committees in Western Sweden were sampled and analyzed using qualitative content analysis.

Findings

– Complaints concerned lack of information and consideration from healthcare providers. Lack of empathy and civility also caused dissatisfaction, the latter particularly for women. Relatives complained that they did not feel included in the care process or were not offered proper support. Most complaints by relatives were filed by a female relative and concerned a male patient.

Research limitations/implications

– Information about patient demographics other than gender could not be investigated due to database limitations. Hence, factors such as age, country of birth, and geographical residence were not included for analysis. In addition, neither the type nor stage of cancer among the sampled patients was able to be addressed.

Practical implications

– Patient complaints should not only be viewed as a post-consumption judgment, but also as a service interaction activity. This may require healthcare providers to enhance their interpersonal skills, allowing patients and relatives to provide feedback during service interaction to satisfactorily address dissatisfaction. Visualizing gender disparities may help healthcare providers prevent stereotypical encounters. In addition, the provider should be invited to participate in the customer’s value creating network, which may also include knowledge and skills from other sources, such as relatives.

Originality/value

– Value co-creation offers a different view on patient complaints. Incorporating social construction into value co-creation may reveal socially constructed disparities. The paper provides aggregated information on cancer patients’ and relatives’ complaints concerning interpersonal issues, which can increase knowledge about patient healthcare service perceptions.

The Impact of a Novel Tool for Comprehensive Assessment of Palliative Care (MPCAT) on Assessment Outcome at 6- and 12-Month Follow-Up

CONTEXT

Assessment in palliative care settings should be focused, sensitive, specific, and effective to minimize discomfort to vulnerable and often highly morbid patients. This report describes the development of an admission assessment protocol for a Specialist Palliative Care Inpatient Unit and its implementation into clinical practice.

OBJECTIVES

The aim of this study was to develop and investigate the impact of the implementation of a Specialist Palliative Care admission assessment tool on documentation of key patient needs.

METHODS

The outcome of a systematic literature review was used to develop an admission assessment protocol (the intervention) in a Specialist Palliative Care Inpatient Unit. Mixed methods were used to facilitate a comprehensive evaluation pre- and post-intervention to test the effectiveness, feasibility, and acceptability of the intervention.

RESULTS

The documented evidence of pain assessment improved from a baseline rate of 71% to 100% post-intervention. This improvement was maintained 12 months post-introduction of the tool (P < 0.001). The documented evidence of screening for spiritual distress increased from a baseline rate of 23% to 70% at 6 months and to 82% at 12 months (P < 0.001). The number of referrals made in the first 24 hours after assessment increased post-intervention (physiotherapy, P = 0.001; occupational therapy, P = 0.001; social work, P = 0.005; pastoral care, P = 0.005); this was maintained at 12 months. Significantly, more clinicians (88%) agreed that palliative care domains were comprehensively assessed post-intervention in comparison with 59% pre-intervention (P = 0.01).

CONCLUSION

Introducing the Milford Palliative Care Assessment Tool was associated with significant improvement in assessment of multiple important aspects of patient need.

What are the barriers faced by medical oncologists in initiating discussion of palliative care? A qualitative study in Flanders, Belgium

INTRODUCTION

Before referring patients to a palliative care service, oncologists need to inform them about disease stage and discuss prognosis, treatment options and possible advantages of specialized palliative care (SPC). They often find this a complex and emotionally difficult task. As a result, they may refer their patients to SPC too late in the disease course or even not at all. This study reports findings from interviews with Belgian medical oncologists identifying the barriers they experience to introduce palliative care to their patients with advanced cancer.

METHODS

The interviews were semi-structured with open-ended questions and were supported by a topic list. The transcripts were analysed during an iterative process using the grounded theory principles of open and axial coding until a final coding framework was reached.

RESULTS

The study identified seven heterogeneous categories of barriers which discourage oncologists from discussing palliative care: oncologist-related barriers, patient-related barriers, family-related barriers, barriers relating to the physician referring the patient to the medical oncologist, barriers relating to disease or treatment, institutional/organizational barriers and societal/policy barriers. These categories are further refined into subcategories.

DISCUSSION

These findings provide an explanation for the possible reasons why medical oncologists feel hampered in initiating palliative care and consequently discuss it rather late in the disease trajectory. The exploration and description of these barriers may serve as a starting point for revising the medical education of oncologists. They are also a reminder to hospital management and policy makers to be aware of the impact of these barriers on the daily practice of oncology.