“You have to be sure that the patient has the full picture”: Adaptation of the Best Case/Worst Case communication tool for geriatric oncology

Instruments for Value Elucidation in Older Adults in Clinical Practice-A Scoping Review

BACKGROUND

To ensure appropriate care for the individual older adult, an ideal treatment should align with patients' values. However, healthcare professionals struggle with how to elucidate patient values effectively. To offer guidance to healthcare professionals, we performed a scoping review, thereby mapping and categorizing instruments specifically developed to elucidate values of older adults in clinical practice.

METHODS

A systematic search was conducted from inception up to October 2023 in PubMed, Psychinfo, CINAHL, and Cochrane Library. Articles on instruments clarifying older adults' values in a clinical setting were included. Articles on instruments elucidating patients' wishes, preferences, or goals were excluded.

RESULTS

After screening 7759 eligible studies, we included 37 studies outlining unique instruments. Instruments were subdivided into the following categories, based on the setting in which the instruments were used: "instruments with a general scope," "health record-based interventions," "advance directives," "advance care planning programs," and "decision support tools." Values were made plain in different ways, and instruments promoted different approaches. We further categorized these approaches alongside different axes: "open versus closed," "process-oriented versus decision-oriented," "confronting versus nonconfronting," and "explicit versus implicit." Some instruments focused on establishing a process of deliberation, whereas others focused on achieving treatment decisions.

CONCLUSION

We found and categorized a large range of instruments, which promoted different ways to elucidate older adults' values. This scoping review serves as an introduction for healthcare professionals to available instruments, which help to clarify patients' values. By categorizing the instruments along different axes of approaching value clarification, we offer healthcare professionals guidance for selecting an appropriate instrument.

Patient and Caregiver Experience With the Hope and Prognostic Uncertainty of Immunotherapy: A Qualitative Study

PURPOSE

Immunotherapy has improved survival for patients with melanoma and non-small cell lung cancer (NSCLC). Yet, as responses vary widely, immunotherapy also introduces challenges in prognostic communication. In this study, we sought to explore how patients and caregivers learned about the goal of immunotherapy and their experience of living with uncertainty.

MATERIALS AND METHODS

We conducted a qualitative study of patients with stage III or IV melanoma or stage IV NSCLC within 12 weeks of initiating or 12 months of discontinuing immunotherapy, and their caregivers. We conducted in-depth interviews with participants to explore how they learned about immunotherapy from oncology clinicians and how they experienced uncertainty. We used a framework approach to analyze interview transcripts and synthesized concepts into themes.

RESULTS

Forty-two patients and 10 caregivers participated; median age was 67 years and most were male (68%), white (95%), married (61%), and had melanoma (62%). We identified four themes: (1) the oncology team shaped participants' hopeful expectations of immunotherapy, including as a potential cure among those with melanoma; (2) distress related to prognostic uncertainty particularly affected patients who experienced toxicity or progressive disease; (3) patients who did not have long-term responses experienced overwhelming disappointment; and (4) some patients and caregivers had conflicting preferences for prognostic information. Participants provided suggestions to improve education and underscored unmet psychosocial needs.

CONCLUSION

Patients and caregivers held optimistic expectations of immunotherapy, which resulted in heightened disappointment among the subset with progression or toxicity. Clinicians should elicit information preferences of both patients and caregivers, as these may be disparate. Our results highlight the need to optimize prognostic communication and support for living with uncertainty among patients receiving immunotherapy.

"So, what are you saying?": A qualitative study of surgeon-patient communication in the rectal cancer consultations

INTRODUCTION

Patients with rectal cancer face a potentially life-limiting disease with multi-modal treatment options conferring substantial symptom burdens. Treatment decisions frequently require trade-offs and input from a multidisciplinary team: ideal cases for shared decision-making. Using qualitative analysis, we characterized the content of communication between surgeons and patients who have rectal cancer.

METHODS

We performed secondary analysis of audio-recorded clinic visits of patients with rectal cancer (n ​= ​18) with colorectal surgeons (n ​= ​8) at 5 academic centers. Four coders used inductive content analysis with an analytical emphasis on communication about decision-making.

RESULTS

Surgeons focused on communicating technical details of potential treatment pathways. Patients sought information around prognosis, functional changes, long-term recovery, and next steps. Surgeons laid groundwork for shared decision-making; patient goals were not routinely clarified. Decisions were typically deferred due to uncertainty and missing information needed to determine appropriate treatment options.

CONCLUSIONS

Our findings suggest avenues for surgeons to enhance communication around rectal cancer decision-making: acknowledging uncertainty and providing concrete information when able, focusing on topics such as prognosis, tradeoffs, and long-term recovery, and clarifying patient preferences.

Pre-Surgical Education and Discharge Planning for Head and Neck Cancer: A Qualitative Study of Patient and Caregiver Perspectives

IntroductionResearch on pre-surgical education and discharge planning for head and neck cancer (HNC) remains limited. To address this gap, this qualitative study aims to assess patient and caregiver perspectives on pre-surgical education and discharge planning in HNC surgery.Methods and MaterialsSemi-structured interviews were conducted with 13 individuals who received HNC surgery and 10 of their caregivers after hospital discharge. Participants were recruited from an NCI-designated Comprehensive Cancer Center and a community oncology setting.ResultsFive key recommendations for HNC surgical care emerged from the data: (1) improve communication about anticipated side effects; (2) provide targeted education through multiple modalities; (3) connect patients and caregivers with individuals who have gone through HNC surgery; (4) improve patient-provider communication for individuals with speech, vision, and hearing impairment; and (5) present the best and worst case scenarios to prepare individuals for post-surgical recovery. ConclusionParticipants identified gaps in pre-surgical education and discharge planning and provided recommendations to improve HNC surgical care.

Challenges in hospice and end-of-life care in the transfusion-dependent patient

Despite promising advances leading to improved survival, many patients with hematologic malignancies end up dying from their underlying disease. Their end-of-life (EOL) care experience is often marked by worsening symptoms, late conversations about patient values, increased healthcare utilization, and infrequent involvement of palliative care and hospice services. There are several challenges to the delivery of high-quality EOL care that span across disease, patient, clinician, and system levels. These barriers include an unpredictable prognosis, the patient's prognostic misunderstandings and preference to focus on the immediate future, and the oncologist's hesitancy to initiate EOL conversations. Additionally, many patients with hematologic malignancies have increasing transfusion requirements at the end of life. The hospice model often does not support ongoing blood transfusions for patients, creating an additional and substantial hurdle to hospice utilization. Ultimately, patients who are transfusion-dependent and elect to enroll in hospice do so often within a limited time frame to benefit from hospice services. Strategies to overcome challenges in EOL care include encouraging repeated patient-clinician conversations that set expectations and incorporate the patient's goals and preferences and promoting multidisciplinary team collaboration in patient care. Ultimately, policy-level changes are required to improve EOL care for patients who are transfusion-dependent. Many research efforts to improve the care of patients with hematologic malignancies at the end of life are underway, including studies directed toward patients dependent on transfusions.

It Starts With a Story: A Four-Step Narrative-Based Framework for Serious Illness Conversations

Background: As a key component of advance care planning, serious illness conversations form a core intervention in palliative care. To achieve effective serious illness conversations, acknowledgment and inclusion of patient sense of self and identity are critical. However, no framework exists to describe how goals, values, and choices relate to patient identity. This conceptual gap hinders the advancement of palliative care education and practice. Objective: This philosophical investigation aimed to explicate two items: first, a novel conceptual framework for serious illness conversations; second, a structured approach to optimize these conversations within the palliative care clinical context. Methods: A philosophical and theoretical analysis was performed within an interdisciplinary context, by scholars in palliative care, medical humanities, philosophy, and bioethics. Key literature in psychology, qualitative research on the experience of serious illness, medical ethics, and choice architecture in medical decision-making were reviewed, and a structured conceptual and narrative analysis was performed. Results: An original and innovative identity-centered conceptual framework for serious illness conversations was developed. The framework consists of a four-step, reproducible approach: (1) attend to patient narrative identity, (2) identify values, (3) cocreate goals, and (4) actively promote choices. In short: attend, identify, create, and promote (AICP). Discussion: By using this conceptual framework and four-step approach, clinicians can accomplish goal-concordant serious illness care and build rich clinical relationships that foster trust and goodwill.

Common mistakes and evidence-based approaches in goals-of-care conversations for seriously ill older adults in cardiac care unit

For older adults with serious, life-limiting illnesses near the end of life, clinicians frequently face difficult decisions about the medical care they provide because of clinical uncertainty. This difficulty is further complicated by unique challenges and medical advancements for patients with advanced heart diseases. In this article, we describe common mistakes encountered by clinicians when having goals-of-care conversations (e.g. conversations between clinicians and seriously ill patients/surrogates to discuss patient's values and goals for clinical care near the end of life.). Then, we delineate an evidence-based approach in goals-of-care conversations and highlight the unique challenges around decision-making in the cardiac intensive care unit.

Integrating Palliative Care Into the Management of Genitourinary Malignancies

Palliative care (PC) plays a critical role in managing the difficulties associated with genitourinary malignancies. Its primary aim is to improve the overall health of patients, provide support to both patients and their caregivers, and help individuals to navigate the complex decisions about treatment and end-of-life care. PC takes a holistic approach to patient care, recognizing that genitourinary malignancies affect multiple aspects of a person's life. By addressing physical, emotional, social, and spiritual needs, PC aims to provide comprehensive support that is consistent with the patient's values and preferences. The goal is to optimize comfort, minimize distress, and enhance the patient's quality of life throughout the course of the illness. PC is not a one-off intervention, but an ongoing source of support. This article aims to provide a thorough overview of the critical elements involved in addressing the challenges posed by genitourinary cancers, emphasizing the importance of palliative interventions. We will highlight the multifaceted aspects of care and explore strategies to optimize the overall well-being of patients throughout the course of treatment for genitourinary malignancies.

Shared decision-making and social science: A patient perspective

Shared decision making (SDM) between doctors and patients has been deemed important when providing care. Yet, it can be difficult to achieve. Specific examples from a patient perspective are integrated with the social science literature to provide an overview of components of SDM including the role of fit, trust, information asymmetry, cognitive decision frames and balancing medical and patient outcomes. Consideration of these issues should facilitate higher quality SDM conversations.

Informed Consent and Shared Decision Making in the Perioperative Environment

Informed consent and shared decision making (SDM) are crucial portions of preoperative patient management. Informed consent is a standard for surgery from both a legal and ethical standpoint, involving disclosure of potential risks of a procedure and ensuring patient understanding of these risks. SDM is a process in which a clinician and patients decide between two or more treatment plans, taking into account the patient's goals and values. SDM is a particularly important aspect of patient-centered care when two or more treatment options exist or in situations where an indicated treatment may not align with the patient's long-term goals. This article details aspects of and issues surrounding informed consent and SDM.

Advance Care Planning, Shared Decision Making, and Serious Illness Conversations in Onconephrology

Advance care planning, shared decision making, and serious illness conversations are communication processes designed to promote patient-centered care. In onconephrology, patients face a series of complex medical decisions regarding their care at the intersection of oncology and nephrology. Clinicians who aim to ensure that patient preferences and values are integrated into treatment planning must work within a similarly complex care team comprising multiple disciplines. In this review, we describe key decision points in a patient's care trajectory, as well as guidance on how and when to engage in advance care planning, shared decision making, and serious illness discussions. Further research on these processes in the complex context of onconephrology is needed.

Geriatric assessment and treatment decision-making in surgical oncology

PURPOSE OF REVIEW

Present an approach for surgical decision-making in cancer that incorporates geriatric assessment by building upon the common categories of tumor, technical, and patient factors to enable dual assessment of disease and geriatric factors.

RECENT FINDINGS

Conventional preoperative assessment is insufficient for older adults missing important modifiable deficits, and inaccurately estimating treatment intolerance, complications, functional impairment and disability, and death. Including geriatric-focused assessment into routine perioperative care facilitates improved communications between clinicians and patients and among interdisciplinary teams. In addition, it facilitates the detection of geriatric-specific deficits that are amenable to treatment. We propose a framework for embedding geriatric assessment into surgical oncology practice to allow more accurate risk stratification, identify and manage geriatric deficits, support decision-making, and plan proactively for both cancer-directed and non-cancer-directed therapies. This patient-centered approach can reduce adverse outcomes such as functional decline, delirium, prolonged hospitalization, discharge to long-term care, immediate postoperative complications, and death.

SUMMARY

Geriatric assessment and management has substantial benefits over conventional preoperative assessment alone. This article highlights these advantages and outlines a feasible strategy to incorporate both disease-based and geriatric-specific assessment and treatment when caring for older surgical patients with cancer.

The Case for Advance Care Planning in the NICU

Many NICUs have reached an inflection point where infant deaths following limitation of life-sustaining treatments outnumber those following unsuccessful resuscitations, and many infants who survive continue to require intensive supports. Families of such infants with serious illness may benefit from a standardized, process-oriented approach in decisional-support. Advance care planning (ACP), or communication that supports patients, or their surrogate decision-makers, in sharing values, goals, and preferences for future medical care, is recognized as a valuable strategy in supporting adults with serious and chronic illness. Although the role of ACP in older children and adolescents is evolving, its utility has not been systematically explored in the perinatal context. This article builds a case for formalizing a role for ACP in the NICU by defining ACP and appraising recent outcomes research, reviewing the current state of parental needs for decisional support and serious illness in the NICU, and describing how ACP may address current limitations in primary and specialty pediatric palliative care and challenges for decision-making in the newborn period.

Prognostic Discussion for Infants with Neurologic Conditions: Qualitative Analysis of Family Conferences

OBJECTIVE

We characterize the content and role of prognostic discussion for infants with neurologic conditions.

METHODS

In this descriptive qualitative study, we prospectively enrolled infants (age < 1 year) in the intensive care unit with a neurologic condition anticipated to have ≥1 family conference about prognosis or goals of care. We audiorecorded family conferences as they occurred. We used a rapid-cycle qualitative approach to identify and refine themes.

RESULTS

Forty infants and 61 parents were enrolled; 68 family conferences occurred for 24 infants. The majority of infant cases (n = 23/24, 96%) and conferences (n = 64/68, 94%) included discussion of neurologic prognosis. Common infant diagnoses included prematurity (n = 12, 52%), genetic conditions (n = 9, 35%), and brain malformations (n = 7, 30%). We identified 2 themes relating to the characterization of the infant's prognosis: (1) predictions of impairment and (2) rationale for prognostic predictions. We identified 3 themes characterizing the role of prognostic discussion: (1) aligning parent and clinician understanding of infant outcome, (2) influencing decision-making, and (3) preparing for life at home. We identified 2 themes characterizing discussion of prognostic uncertainty: (1) multilayered types of uncertainty and (2) holding space for hope alongside uncertainty.

INTERPRETATION

In this cohort of infants with neurologic conditions and their parents, we identified salient themes characterizing the content and role of discussion about neurologic outcome. Our findings highlight that prognostic discussion focuses on anticipated impairments, informs decision-making, and helps families prepare for home life. Future work should characterize whether these findings align with parent preferences for prognostic disclosure. ANN NEUROL 2022;92:699-709.