Disclosure of Prognosis to Terminally Ill Patients: Attitudes and Practices Among French Physicians

Pilot Trial of a Combined Oncologist-Patient-Caregiver Communication Intervention in Singapore

PURPOSE

High-quality end-of-life cancer care requires oncologists to communicate effectively and patients/caregivers to be participatory. However, most communication interventions target either but not both. We aimed to pilot a potentially disseminable combined oncologist-patient/caregiver intervention to improve oncologist empathic responses, discussions of prognosis and goals of care, and patient/caregiver participation. We assessed its feasibility, acceptability, and preliminary efficacy.

METHODS

Between June 2018 and January 2019, we conducted a pilot 2-arm cluster trial in Singapore, randomly assigning 10 oncologists in a 1:1 ratio to receive the combined intervention or usual care. Intervention arm oncologists received online communication skills training, and their patients received a brief prompt sheet before consultations. We audio recorded consultations with 60 patients with stage IV solid malignancy and analyzed 30 in the postintervention phase. The study was not powered for statistical significance.

RESULTS

Participation rates for oncologists and patients were 100% and 63%, respectively. All oncologists completed the online training within an average of 4.5 weeks; 73% of the patients selected at least 1 question in the prompt sheet. Compared with the control arm, intervention arm oncologists had more empathic responses in total (relative risk [RR], 1.66) and for every patient/caregiver negative emotion (RR, 2.01). Their consultations were more likely to involve discussions of prognosis (RR, 3.00) and goals of care, and their patients were more likely to ask a prognosis-related question (RR, 2.00; P > .05 for all).

CONCLUSION

The combined oncologist-patient/caregiver intervention is feasible and acceptable and has the potential to improve communication within consultations.

Early palliative care for patients with metastatic cancer

PURPOSE OF REVIEW

At present, clinicians and healthcare providers are increasingly urged to advance the provision of state-of-the-art palliative care for patients with incurable cancer. This review provides an overview about the recent findings and practical suggestions.

RECENT FINDINGS

In the last decade, the awareness about the logistic and personal resources needed to meet the somatic and psychological needs of patients with progressive and life-threatening diseases has increased and in parallel, palliative care concepts and expertise have evolved substantially. Care concepts for patients with metastatic cancer emphasized the potential of interdisciplinary care. For example, in 2010, a randomized trial reported a benefit for patients with lung cancer who received early palliative care in addition to routine care. It is discussed that this was because of increased quality of life and detailed exploration of patient preferences.

SUMMARY

Patients, families and physicians benefit from shared care concepts of oncology and specialized palliative care. Although this concept is already becoming increasingly implemented in tertiary (comprehensive cancer-) care settings, the potential of this approach should be explored for other clinical settings such as office-based oncology.

Burden on oncologists when communicating the discontinuation of anticancer treatment

Objective

Communicating the discontinuation of anticancer treatment to patients is a difficult task. The primary aim of this study was to clarify the level of oncologist-reported burden when communicating about discontinuation of an anticancer treatment. The secondary aims were (i) to identify the sources of burden contributing to their levels and (ii) to explore the useful strategies to alleviate their burden.

Methods

A multicenter nationwide questionnaire survey was conducted on 620 oncologists across Japan (response rate, 67%).

Results

High levels of perceived burden were reported by 47% of respondents, and 17% reported that they sometimes, often or always wanted to stop oncology work because of this burden. There was a significant association between high levels of burden and: a feeling that breaking bad news would deprive the patient of hope; concern that the patient's family would blame the oncologist; concern that the patient may lose self-control; and a feeling that there was not enough time to break the bad news. Strategies perceived to be useful by oncologists included training in how to effectively communicate to patients discontinuation of anticancer treatment, a reduction in total workload to allow sufficient time to break bad news, and development of a multidisciplinary model to facilitate cooperation with other professionals and facilities.

Conclusions

Many oncologists reported high levels of burden relating to communication of discontinuation of anticancer treatment. A specific communication skills training program, sufficient time for communication and development of a multidisciplinary model could help alleviate the burden on oncologists.

Information disclosure to terminally ill patients and their relatives: self-reported practice of Belgian clinical specialists and general practitioners

Objective of this study is to examine physicians' practices regarding information disclosure to terminally ill patients and to their relatives, without informing the patient. A questionnaire had been sent to a random sample of 3014 Belgian physicians from different specialties frequently involved in end-of-life care. Responses were analysed using weighted percentages, Chi-square, Mann-Whitney U-tests and a multivariate ordinal logistic regression. Response rate was 58%. Both clinical specialists and general practitioners (GPs) discuss most topics related to terminal illness with their patients except end-of-life hastening options, spirituality, life expectancy and options to withhold/withdraw life-sustaining treatment. The topics which most physicians always discuss with relatives without informing the patient are the aim of treatment, palliative care and incurability. There is a significant difference between clinical specialists and GPs. Clinical specialists and GPs discuss most end-of-life topics with the patient but omit important issues such as end-of-life hastening options and life-expectancy.

What are terminally ill cancer patients told about their expected deaths? A study of cancer physicians' self-reports of prognosis disclosure

PURPOSE

Little is known about how physicians discuss prognosis with terminally ill cancer patients. Thus, we sought to obtain cancer physicians' self-reports of their prognosis communication practices.

METHODS

A survey seeking self-reports regarding prognosis communication with their terminally ill cancer patients was mailed to a systematic sample of medical oncologists in the United States.

RESULTS

Of 1,137 physicians, 729 completed and returned surveys (64% response rate). Median age of respondents was 51 years (range, 33 to 80 years); 82% were men. Respondents had practiced cancer care for a median of 18 years (range, 1.5 to 50 years) and reported seeing a median of 60 patients per week (range, 0 to 250 patients per week). Although 98% said their usual practice is to tell terminally ill patients that they will die, 48% specifically described communicating terminal prognoses to patients only when specific preferences for prognosis information were expressed. Forty-three percent said they always or usually communicate a medical estimate of time as to when death is likely to occur, and 57% reported sometimes, rarely, or never giving a time frame. Seventy-three percent said prognosis communication education was either absent or inadequate during their training, and 96% believed it should be part of cancer care training.

CONCLUSION

Medical oncologists report routinely informing their terminally ill patients that they will die. However, they are divided in describing themselves as either always discussing a terminal prognosis or doing so if it is consistent with their patients' preferences for prognostic information. Most medical oncologists say they do not routinely communicate an estimated survival time to their patients.

Concerns about Losing Control When Breaking Bad News to Terminally Ill Patients with Cancer: Physicians' Perspective

OBJECTIVE

To study and explore problems perceived by physicians when breaking bad news to advanced cancer patients about discontinuing or not offering tumor-specific treatment due to incurable cancer.

DESIGN

A qualitative phenomenographic interview study.

SETTING

The county of Ostergötland in Sweden.

PARTICIPANTS

Thirty physicians with different demographic characteristics.

RESULTS

According to the physicians' answers breaking bad news was perceived as involving a risk of losing control in different ways, regarding emotions, oneself, confidence, professionalism and patient trust. Four different main categories described as problems were identified; perceptions focusing on existential thoughts, relationships, knowledge, and perceptions related to time and environmental disturbances.

CONCLUSION

Physicians perceived that breaking bad news to dying patients with cancer involved a risk of losing control. Existential thoughts and a lack of knowledge contribute to this risk. Theoretical education in existentiality/spirituality and clinical practice in a palliative context may help maintaining control.