Goals of care discussions: perceptions of radiation and medical oncologists

The PACT Project: Feasibility of a Multidisciplinary, Multi-Faceted Intervention to Promote Goals of Care Conversations

BACKGROUND

Patients living with serious illness generally want their physicians to facilitate Goals of Care conversations (GoCc), yet physicians may lack time and skills to engage in these conversations in the outpatient setting. The problem may be addressed by supporting multiple members of the clinical team to facilitate GoCc with the patient while admitted to the hospital.

METHODS

A multi-modal training and mentored implementation program was developed. A group of 10 hospitals were recruited to participate. Each hospital selected a primary inpatient unit on which to start the intervention, then expanded to a secondary unit later in the project. The number of trained facilitators (champions) and the number of documented GoCc were tracked over time.

RESULTS

Nine of 10 hospitals completed the 3-year project. Most of the units were general medical-surgical units. Forty-eight champions were trained at the kick-off conference, attended primarily by nurses, physicians, and social workers. By the end of the project, 153 champions had been trained. A total of 51 087 patients were admitted to PACT units with 85.4% being screened for eligibility. Of the patients who were eligible, over 68% had documented GoCc.

CONCLUSION

A multifaceted quality improvement intervention focused on serious illness communication skills can support a diverse clinical workforce to facilitate inpatient GoCc over time.

The Relationship between Supportive Care Needs and Health-Related Quality of Life in Cancer Patients

The aim of this study was to analyze the relationship between quality of life (QoL) and supportive care needs (SCNs) in cancer patients. It is difficult to relate SCNs to detriments in QoL since SCNs and QoL assessment tools generally comprise different dimensions that cannot be directly related to each other. Therefore, we developed a short questionnaire with eight dimensions for uniformly measuring SCNs, QoL, and the subjective importance of these dimensions. A total of 1108 cancer patients with mixed diagnoses assessed eight dimensions of health-related QoL concerning SCNs, satisfaction, and importance. Among the eight dimensions of QoL, physical functioning received the highest SCN assessments (M = 3.4), while autonomy (M = 20.7) and social relationships (M = 1.88) were the dimensions with the lowest SCN mean scores on the 1-5 scale. For each of the eight dimensions, high levels of SCNs were reported by those patients who had low levels of satisfaction with that dimension (r between -0.32 and -0.66). The subjective importance of the dimensions was not consistently correlated with SCNs (r between -0.19 and 0.20). Females reported higher SCNs than males in six of the eight specific dimensions. Patients with prostate and male genital cancers reported the lowest SCNs. These results suggest gender-specific SCN patterns that warrant further exploration. This study highlights the value of a unified assessment instrument for SCNs and QoL, providing a robust basis for future cancer care strategies.

Supportive care needs and health-related quality of life in cancer patients receiving palliative care

Objective

Cancer patients receiving palliative care experience a variety of impairments in their quality of life (QoL), and have corresponding supportive care needs (SCNs). The aim of this study was to analyze the relationship between SCNs, satisfaction with QoL dimensions, and the perceived importance of these dimensions.

Method

A sample of 152 cancer patients receiving palliative care were included in this cross-sectional study. Eight dimensions of QoL were defined and assessed concerning SCNs, satisfaction, and subjective importance using a new assessment instrument with five-point scales (range 1-5) for each dimension.

Results

Among the eight specific domains examined, the greatest SCNs were observed for absence of pain (M = 3.18; SD = 1.29). The patients were least satisfied with their physical functioning (M = 2.60; SD = 0.84), and the dimension social relationships (M = 4.14; SD = 0.72) received the highest perceived importance ratings. The eight dimensions' SCNs scores were significantly correlated with each other (r between 0.29 and 0.79); the lowest correlations were found for social relationships. The correlations between the satisfaction scores and the SCNs differed from dimension to dimension, with coefficients between -0.32 (absence of pain) and - 0.57 (sleep quality).

Conclusion

The results show that detriments in QoL do not automatically indicate high levels of SCNs in those dimensions. Health care providers should consider both factors, QoL (as measured with QoL questionnaires) and subjectively expressed SCNs, to optimize their patients' care regimens.

Prognostic Understanding and Goals of Palliative Radiotherapy: A Qualitative Study

CONTEXT

There is a paucity of data describing patients' expectations of goals of palliative radiotherapy (RT) and overall prognosis.

OBJECTIVES

To explore patients' perceptions of and preferences for communication surrounding goals of palliative RT and cancer prognosis.

METHODS

We conducted a qualitative study utilizing semi-structured interviews with seventeen patients with either bone or lung metastases receiving their first course of palliative RT at a comprehensive cancer center. All patient interviews were recorded, transcribed verbatim, and thematically analyzed.

RESULTS

Themes of goals of palliative RT centered on either restoration, such as through improving quality of life or minimizing pain, or on a desire to combat cancer by eliminating tumor. While most patients perceived that palliative RT would palliate symptoms but not cure their cancer, some patients believed that the goal of palliative RT was to cure. Themes that emerged surrounding patients' understanding of prognosis and what lies ahead included uncertainty and apprehension about the future, a focus on additional treatment, and confronting mortality. Most patients preferred to receive information about goals of treatment and prognosis from their doctors, including radiation oncologists, rather than other members of the medical team. Patients also expressed a desire for written patient education materials on palliative RT.

CONCLUSION

Unclear perceptions of goals of treatment and prognosis may motivate some patients to pursue unnecessarily aggressive cancer treatments. Patients desire prognostic information from their doctors, including radiation oncologists, who are important contributors to goals of care discussions and may improve patient understanding and well-being by using restorative rather than combat-oriented language.