Reframing the goals of care conversation: "we're in a different place"

Colorectal Cancer Patients' Reported Frequency, Content, and Satisfaction with Advance Care Planning Discussions

(1) Background: This observational cohort study describes the frequency, content, and satisfaction with advance care planning (ACP) conversations with healthcare providers (HCPs), as reported by patients with advanced colorectal cancer. (2) Methods: The patients were recruited from two tertiary cancer centers in Alberta, Canada. Using the My Conversations survey with previously validated questions, the patients were asked about specific ACP elements discussed, with which HCPs these elements were discussed, their satisfaction with these conversations, and whether they had a goals of care designation (GCD) order. We surveyed and analyzed data from the following four time points: enrollment, months 1, 2, and 3. (3) Results: In total, 131 patients were recruited. At enrollment, 24% of patients reported discussing at least one ACP topic. From enrollment to month 3, patients reported a high frequency of discussions (80.2% discussed fears, 71.0% discussed prognosis, 54.2% discussed treatment preferences at least once); however, only 44.3% of patients reported discussing what is important to them in considering health care preferences. Patients reported having ACP conversations most often with their oncologists (84.7%) and cancer clinic nurses (61.8%). Patients reported a high level of satisfaction with their ACP conversations, with over 80% of patients reported feeling heard and understood. From enrollment to month 3, there was an increase in the number of patients with a GCD order from 53% to 74%. (4) Conclusions: Patients reported more frequent conversations compared to the literature and clinical documentation. While the satisfaction with these conversations is high, there is room for quality improvement, particularly in eliciting patients' personal goals for their treatment.

Silent Conversations: Goals of Care and End-of-Life Quality in Relapsed High-Risk Leukemia

Background

Advanced practice providers (APPs) affect high-quality health care through leadership, evidence-based practice implementation, and quality improvement projects. When planning solutions to clinical problems, leadership must solicit APP input to promote success. Hematology patients are more likely to receive poor-quality end-of-life (EOL) care than those with solid tumors. Regardless of disease, aggressive EOL care is increasing despite evidence that it is often inconsistent with patients' goals of care (GOC). Data regarding this phenomenon in hematology specifically is lacking. The distorted association of "end of life" with "goals of care" has "silenced" crucial goals discussions in patients with relapsed or refractory high-risk leukemia, which raises concerns for the provision of care that is inconsistent with patients' values and preferences. Hematologists may possess certain traits and distinct barriers leading to what one might call an aversion to GOC discussions in the inpatient setting.

Aims

(1) Quantify hematologists' rate of participation in a GOC pathway initiative during two separate months. (2) Explore the hematologists' definition of and barriers to having GOC discussions.

Design

This is a mixed-methods, explanatory sequential design (follow-up explanations variant).

Sample

Quantitative: Hematology inpatient admissions during two nonconsecutive months in 2021. Qualitative: Eighteen leukemia hematologists from one dedicated cancer center.

Results

During the 2 months, an average of 36% of admissions met the criteria for GOC pathway initiation, 19% of those had an appropriate initiation order, and < 1% had a properly documented and billed GOC discussion. Nine hematologists responded to a SurveyMonkey poll with two questions. All nine included clinical situation and communication in their definition of GOC discussions. Time limitations and prognostic uncertainty were the two most reported barriers.

Discussion

The findings demonstrate that the apprehension of hematologists to have GOC conversations is similarly seen in the APPs' reluctance to initiate a pathway intended to lead to GOC conversations. The percentage of eligible inpatient admissions meeting the specified criteria was similar between the 2 months; however, the number of appropriate referrals and documented or billed GOC discussions was higher in the earlier month, demonstrating temporal decline. Further research inquiry is needed to explore causation of this phenomenon.

A Novel Curriculum to Improve Medical Student Preparedness to have Advance Care Planning Discussions

Background: Physicians report inadequate training in advance care planning (ACP) discussions despite the importance of these skills for practicing physicians including new residents. Objectives: To evaluate the effectiveness of a novel curriculum to prepare graduating medical students to have ACP discussions. Design: An ACP curriculum was implemented within a new fourth-year medical student elective with a focus on interactive educational methods and simulated experiences. Setting/Subjects: Forty-seven students received the curriculum over 3 years at a medium-sized, urban medical school. Measurements: Students were surveyed regarding attitudes and comfort related to ACP discussions and end-of-life (EOL) topics before and after the course. Additionally, students were asked about baseline experiences in the pre-course survey and perceived effectiveness of the educational methods in the post-course survey. Results: Comfort discussing EOL care decisions without supervision rose from 4% to 36% after the course with none of the students feeling they needed maximal help from a supervisor after the course compared to 51% before the course. All students agree or strongly agreed (Likert 4 or 5) that they felt prepared to discuss patient's wishes and values in EOL care with a real patient or family after the course. Conclusions: An ACP curriculum can increase student comfort and preparedness to have these conversations as residents. Students found small group discussions and the chance for direct practice with simulated patients to be most helpful. These findings can help guide implementation of ACP curricula in medical education.

We were in the fight together: The expectations of bereaved caregivers of patients with acute myeloid leukemia from diagnosis to death

PURPOSE

Patients with hematologic malignancies are more optimistic than their oncologists and their expectations may be a barrier to timely hospice care. Patient expectations toward the end of life (EOL), however, have not been characterized. In this study, we analyzed interviews of bereaved caregivers to understand the expectations of patients diagnosed with acute myeloid leukemia and the factors that influenced those expectations, from diagnosis until death.

METHODS

Bereaved caregivers (n = 19) participated in an in-depth interview that included open-ended and semi-structured prompts, within 18 months following patient death. Interviews were analyzed using a modified grounded theory qualitative approach and constant comparative methods.

RESULTS

We identified three themes relevant to expectations: Taking Stock, Being Stuck, and Disruption. Caregivers described clear and optimistic early expectations that AML is treatable. It was understood that treatment was required to survive. Later, when treatment options were limited, patients and caregivers became stuck in a belief that the patient could continue to live indefinitely on supportive care or at least until new more effective treatments were available. Caregivers often realized that the patient was at the end of life only when faced with a disruption, an event or conversation that changed their expectations for indefinite patient survival.

CONCLUSIONS

Caregivers described continued expectations for patient survival until presented with irrefutable evidence to the contrary. The study suggests patients and caregivers may make better EOL care decisions if their early optimism is deliberately moderated by ongoing conversations with clinicians that highlight the sentinel events that signal treatment failure and explain how expectations and goals are changing from living a longer life to dying a more comfortable death.

Palliative care after stroke survival

Stroke is a leading cause of both death and disability worldwide. While most research has focused on the first hours to days after acute stroke, much less is known about the experience of patients and their families living after a stroke. Stroke survivors have a high burden of physical and psychological symptoms such as pain, fatigue, and depression that are often not addressed in the postacute setting. Similarly, goals-of-care conversations that may have started during the acute hospitalization are often not followed up later. This chapter outlines the prevalence and management of common poststroke symptoms, approaches to postacute goals-of-care conversations, family needs after stroke, and provides an overview of stroke-specific hospice and end-of-life care aspects. We emphasize the need for research in each of these areas.

Quality Versus Quantity of Life: Beyond the Dichotomy

A restrictive and dichotomous question has become the primary approach in many goals of care discussions. Is the primary goal of care quantity of life through aggressive therapy or quality of life through comfort care and hospice? Even though many health care providers recognize that quality vs quantity of life (QvQ) is a false dichotomy, in practice QvQ underlies many goals of care discussions and can negatively impact patient care. This article offers strategies for assessing patients at the end of life, presenting a first-line conversation process that can support a range of treatment options as well as a diversity of dynamic patient values. Based on decades of experience in palliative care and a review of relevant literature, we recommend four practical questions to serve as values "vital signs," monitoring dynamic notions of quality of life and harmonizing patient values with treatment options.

Advance care planning for patients with cancer and family caregivers in Indonesia: a qualitative study

Background

Individuals’ willingness to engage in advance care planning is influenced by factors such as culture and religious beliefs. While most studies on advance care planning in Asia have been performed in high-income countries, Indonesia is a lower-middle-income country, with a majority of strongly collectivist and religiously devout inhabitants. We studied the perspectives of Indonesian patients with cancer and family caregivers regarding advance care planning by first exploring their experiences with medical information-disclosure, decision-making, and advance care planning and how these experiences influence their perspectives on advance care planning.

Methods

We conducted semi-structured interviews among 16 patients with cancer and 15 family caregivers in a national cancer center in Jakarta and a tertiary academic general hospital in Yogyakarta. We performed an inductive thematic analysis using open, axial, and selective coding. The rigor of the study was enhanced by reflective journaling, dual coding, and investigator triangulation.

Results

Twenty-six of 31 participants were younger than 60 years old, 20 were Muslim and Javanese, and 17 were college or university graduates. Four major themes emerged as important in advance care planning: (1) participants’ perceptions on the importance or harmfulness of cancer-related information, (2) the importance of communicating bad news sensitively (through empathetic, implicit, and mediated communication), (3) participants’ motives for participating in medical decision-making (decision-making seen as patients’ right or responsibility, or patients’ state of dependency on others), and (4) the complexities of future planning (e.g., due to its irrelevance to participants’ religious beliefs and/or their difficulties in seeing the relevance of future planning).

Conclusions

Culturally sensitive approaches to advance care planning in Indonesia should address the importance of facilitating open communication between patients and their families, and the various perspectives on information provision, bad news communication, and decision-making. Advance care planning should focus on the exploration of patients’ values, rather than drafting treatment plans in advance.

Goals of care communication and higher-value care for patients with advanced-stage cancer: A systematic review of the evidence

CONTEXT

Goals-of-care communication (GOCC) is recommended to increase the value of cancer care near the end of life (EOL).

OBJECTIVES

Conduct a systematic review of the evidence that GOCC is associated with higher-value care.

METHODS

We searched PubMed, Scopus, Ovid MEDLINE, EMBASE, EMB Reviews, CINAHL, and PsycInfo from inception to July 2019. We analyzed the population,design, and results and the authors' definitions of GOCC. Risk of bias was assessed.

RESULTS

Thirty-two articles were selected. Ten articles reported results from 8 interventions; 17 characterized participants' perspectives; and 5 were retrospective The topics, behaviors, timing, and anticipated outcomes of GOCC varied significantly and were indistinguishable from practices such as advance care planning. GOCC typically focused on treatment outcomes rather than patients' goals. Four of 5 interventions increased evidence of GOCC after clinician training. Only one reported improved patient outcomes.

CONCLUSION

No consensus exists about what GOCC entails. There is limited evidence that GOCC increases the value of EOL care.

PRACTICE IMPLICATIONS

Future studies should focus on how to engage patients in conversations about their personal goals and integrate their goals into care planning. Clinicians can encourage GOCC by explaining how patients' goals influence decisions especially as treatment options become limited.

The Healthcare Journey of Women With Advanced Gynecological Cancer From Diagnosis Through Terminal Illness: Qualitative Analysis of Progress Note Data

OBJECTIVE

To examine women's journeys with gynecologic cancer from before diagnosis through death and identify elements of their healthcare experience that warrant improvement.

METHODS

This exploratory study used longitudinal progress notes data from a multispecialty practice in Northern California. The sample included women with stage IV gynecological cancer diagnosed after 2011 and who died before 2018. Available progress notes from prior to diagnosis to death were qualitatively analyzed.

RESULTS

We identified 32 women, (median age 61 years) with mostly uterine (n=17) and ovarian (n=9) cancers and median survival of 9.2 months (min:2.9 and max:47.5). Sixteen (50%) received outpatient palliative care and 18 (56%) received hospice care. The analysis found wide variation in documentation about communication about diagnosis, prognosis, goals of care, stopping treatment, and starting hospice care. Challenges included escalating/severe symptoms, repeated urgent care/emergency department/hospital encounters, and lack of or late access to palliative and hospice care. Notes also illustrated how patient background and goals influenced care trajectory and communication. Documentation styles varied substantially, with palliative care notes more consistently documenting conversations about goals of care and psychosocial needs.

CONCLUSION

This analysis of longitudinal illness experience of women with advanced gynecological cancer suggests that clinicians may want to (1) prioritize earlier discussion about goals of care; (2) provide supplemental support to patients with higher needs, possibly through palliative care or navigation; and (3) write notes to enhance patient understanding now that patients may access all notes.

Hospice Use Among Patients With Cancer: Trends, Barriers, and Future Directions

Patients with advanced cancer and their families frequently encounter clinical and logistical challenges related to end-of-life care. Hospice provides interdisciplinary and holistic care to meet patients' biomedical, psychosocial, and spiritual needs in the last phases of life. Despite increasing general acceptance and use among patients with cancer, hospice remains underused. Underuse stems from ongoing misconceptions regarding hospice and its purpose, coupled with the rapid development of novel anticancer treatments, such as immunotherapies and targeted therapies, that have changed the landscape of possibilities. Furthermore, rapid evolutions in how end-of-life care is structured and reimbursed for will affect how oncology patients will intersect with hospice care. In this review, we explore the current and future challenges to greater integration of hospice care in the care of patients with advanced cancer and propose five recommendations as part of the path forward.

Prioritizing Communication in the Provision of Palliative Care for the Trauma Patient

Purpose of Review

Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU.

Recent Findings

The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication.

Summary

We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.

Chemotherapy decision-making in advanced lung cancer: a prospective qualitative study

OBJECTIVE

To study how treatment decisions are made alongside the lung cancer clinical pathway.

METHODS

A prospective, multicentre, multimethods, five-stage, qualitative study. Mediated discourse, thematic, framework and narrative analysis were used to analyse the transcripts.

RESULTS

51 health professionals, 15 patients with advanced lung cancer, 15 family members and 18 expert stakeholders were recruited from three UK NHS trusts. Multidisciplinary team (MDT) members constructed treatment recommendations around patient performance status, pathology, clinical information and imaging. Information around patients' social context, needs and preferences were limited. The provisional nature of MDTs treatment recommendations was not always linked to future discussions with the patient along the pathway, that is, patients' interpretation of their prognosis, treatment discussions occurring prior to seeing the oncologist. This together with the rapid disease trajectory placed additional stress on the oncologist, who had to introduce a different treatment option from that recommended by the MDT or patient's expectations. Palliative treatment was not referred to explicitly as such, due to its potential for confusion. Patients were unaware of the purpose of each consultation and did not fully understand the non-curative intent of treatment pathways. Patients' priorities were framed around social and family needs, such as being able to attend a family event.

CONCLUSION

Missed opportunities for information giving, affect both clinicians and patients; the pathway for patients with non-small cell lung cancer focuses on clinical management at the expense of patient-centred care. Treatment decisions are a complex process and patients draw conclusions from healthcare interactions prior to the oncology clinic, which prioritises aggressive treatment and influences decisions.

Palliative Chemotherapy or Radiation and Prognostic Understanding among Advanced Cancer Patients: The Role of Perceived Treatment Intent

Background: As patients' accurate understanding of their prognosis is essential for informed end-of-life planning, identifying associated factors is important. Objective: We examine if receiving palliative chemotherapy or radiation, and the perception of those treatments as curative or noncurative, is associated with prognostic understanding. Design: Cross-sectional analyses from a multisite, observational study. Setting/Subjects: Patients with advanced cancers refractory to at least one chemotherapy regimen (N = 334). Measurements: In structured interviews, patients reported whether they were receiving chemotherapy or radiation, and whether its intent was curative or not. Their responses were categorized into three groups: patients not receiving chemotherapy/radiation (no cancer treatment group); patients receiving chemotherapy/radiation and misperceiving it as curative (treatment misperception group); and patients receiving chemotherapy/radiation and accurately perceiving it as noncurative (accurate treatment perception group). Patients also reported on various aspects of their prognostic understanding (e.g., life expectancy). Results: Eighty-six percent of the sample was receiving chemotherapy or radiation; of those, 16.7% reported the purpose of treatment to be curative. The no-treatment group had higher prognostic understanding scores compared with the treatment misperception group (adjusted odds ratio [AOR] = 5.00, p < 0.001). However, the accurate treatment perception group had the highest prognostic understanding scores in comparison to the no-treatment group (AOR = 2.04, p < 0.05) and the treatment misperception group (AOR = 10.19, p < 0.001). Conclusions: Depending on patient perceptions of curative intent, receipt of palliative chemotherapy or radiation is associated with better or worse prognostic understanding. Research should examine if enhancing patients' understanding of treatment intent can improve accurate prognostic expectations.

Advanced communication: A critical component of high quality gynecologic cancer care: A Society of Gynecologic Oncology evidence based review and guide

Effective communication between gynecologic oncology providers and patients is vital to patient-centered care. Skilled communication improves the patient's knowledge retention, builds trust in providers, enhances shared decision-making, and alleviates anxiety of both patients and caregivers. Effective communication is also associated with reduced provider burnout due to improved comfort from possessing the skills to handle emotionally charged situations. Therefore, training in serious illness communication skills is critically important to gynecologic oncology practice and benefits patients, providers, and the healthcare system. Like surgical skills, communication skills can be learned and improved upon, particularly by making use of communication skills courses and other resources. While the purpose of each conversation will vary based on the medical setting, most communication roadmaps incorporate four basic components: 1) Assess patient knowledge and understanding, 2) inform patient in accordance with her communication preferences, 3) recognize and respond to emotion 4) elicit patient values, and create a plan that aligns with those values. Improved patient outcomes associated with addressing patient emotions underscore a critical need to recognize and address emotional cues during difficult conversations. We present strategies for delivering serious news, and for discussing prognosis and goals of care. In each strategy, we highlight skills for recognizing and responding to patient and family emotional cues.

Engaging a Community Chaplaincy Resource for Interprofessional Health Care Provider Training in Facilitating Family Decision Making for Children at End-of-Life

Coordinating the care of terminally ill children is difficult for both parents and the health care team. An underutilized resource is spiritual care, such as that provided by Pacific Health Ministry, a community-based nonprofit established to develop hospital ministry training programs in Hawai'i and provide chaplaincy services to local facilities. This paper describes a training exercise, called the Pediatric Interprofessional Program (PIPP), which is modeled after an adult program, the Hawai'i Interprofessional Training for End of Life Communication in the intensive care unit (HITEC-ICU). Both programs were developed to introduce teams of learners consisting of Pacific Health Ministry spiritual care residents, internal medicine or pediatric residents, undergraduate students in nursing, and graduate students in social work to techniques in delivering serious, life-altering information, and the dynamics of working as an interprofessional team through use of progressively unfolding clinical simulations. PIPP facilitators included chaplaincy instructors at Pacific Health Ministry, university faculty, and community practitioners in pediatrics, nursing, and social work. The simulations were conducted at the Translational Health Science Simulation Center (THSSC) of the University of Hawai'i at Mānoa (UHM) School of Nursing and Dental Hygiene (SONDH), with simulated patients from the HealthCAST (Collaborative Acting Simulation Training) program, a collaborative agreement between SONDH and the UHM Department of Theatre and Dance. The training is ongoing, but has thus far demonstrated that interprofessional education programs are feasible across community, academic, and clinical lines, and benefit from the engagement of community resources.

Patients' attitude and knowledge towards resuscitation and advance care planning at the palliative care unit

Objective

There is a lack of information about patients’ attitudes towards and knowledge of resuscitation and advance care planning (ACP) in the palliative care unit (PCU). The aims of this study were to examine (a) patients’ attitudes towards and knowledge of the topic of resuscitation, (b) patients’ level of education about their illness and (c) their concept of ACP.

Methods

This study used a qualitative methodology that involved semi‐structured interviews with advanced cancer patients admitted to the PCU. Interviews were conducted during the first week after admission, recorded digitally and transcribed verbatim. Data were analysed through content analysis using NVivo 12.

Results

Eighteen interviews revealed the following themes: (a) ambivalence regarding preference for or refusal of resuscitation, (b) patient confidence concerning their level of education, (c) lack of information about ACP and (d) positive perception of the stay in the PCU. The data showed that a high percentage of PCU patients desired resuscitation even though education about their illness was mostly perceived as good. Many patients did not receive information about ACP. Patients perceived the stay in the PCU positively.

Conclusion

The study results reveal that there is lack of knowledge about ACP and resuscitation in patients in the PCU.

Metasynthesis: Dying adults' transition process from cure-focused to comfort-focused care

AIM

To describe and explain the process of transition from cure-focused to comfort-focused health care as perceived and reported by patients, family members, and healthcare providers.

BACKGROUND

Moving into the last phase of life due to advanced illness constitutes a developmental transition with increased vulnerability for patients and family.

DESIGN

Qualitative metasynthesis.

DATA SOURCES

Medline, CINAHL, and PsycInfo databases searched from inception through March 2016. Primary research reports published from 1990 to 2015, using qualitative designs to report transition experiences of patients, family members, and/or healthcare providers were included.

REVIEW METHODS

Key elements were extracted and organized into matrices. Findings from each report were analysed using qualitative coding.

RESULTS

The sample was 56 unique reports from 50 primary studies. Patients and families emphasized the importance of receiving understandable information, emotional support, respect for personhood and control. The critical juncture of 'realizing terminality' preceded a transition to comfort-focused care. Subsequently, a shift in goals of care emphasizing comfort and quality of life could occur. Continued provision of information, effective support, respect and control promoted 'reframing perceptions' and capacity to embrace a changed identity. Reframing allowed patient and family to find meaning and value in this last phase of life and to embrace the opportunity to prepare for death, nurture relationships, and focus on quality of living.

CONCLUSION

Understanding the developmental process that can be engaged by patients and families at the end of life provides a theoretical basis that can inform choice and timing of interventions to reduce suffering and enhance positive outcomes.

Breast Cancer Patients' Preferences for Truth Versus Hope Are Dynamic and Change During Late Lines of Palliative Chemotherapy

CONTEXT

Women with metastatic breast cancer often receive many lines of palliative chemotherapy, which might be beneficial but also harmful. Still, little is known about the patients' perception of the patient-doctor communication regarding late lines of noncurative treatment.

OBJECTIVES

Our aim was to explore breast cancer patients' preferences and perceptions of patient-doctor communication regarding continuous late lines of palliative chemotherapy.

PATIENTS AND METHODS

A qualitative study was conducted with semiguided face-to-face interviews with 20 women, 40-80 years old, on at least their second line of palliative chemotherapy (second to eighth line). We used a qualitative conventional content analysis.

RESULTS

All women knew they had incurable breast cancer but expressed hope for cure. Patients' definition of a good compassionate doctor was one who gives positive news and leaves room for hope. Ongoing chemotherapy, positive news from the doctors, and support from relatives encouraged hope. The women often expressed they accepted chemotherapy to please their doctor and relatives. The informants appreciated the doctor to be honest, but within positive limits. Over time, they stopped asking questions afraid of getting bad news, and left more and more treatment decisions to the doctor.

CONCLUSIONS

The women's preferences for truth versus hope in patient-doctor communication changed over time, which increase the risk for continuous late lines of palliative chemotherapy by common collusion. Doctors need to individualize information, help patients make sense of their life, and allow hope to endure without further chemotherapy.

Management of Emotionally Challenging Responses of Hospitalized Patients with Cancer

Cancer is the second leading cause of death in the United States, and the majority of hospital admissions of patients with cancer occur because of uncontrolled, urgent symptoms. In addition to complex physical presentations, these patients often manifest a number of complex emotional and psychological responses resulting in a unique set of healthcare needs and expectations. Inpatient generalists or hospitalists frequently serve as the primary providers of medical care for these patients. Formal training for nononcologists on effective communication strategies in managing patients with cancer in a hospital setting may not fully prepare generalists for challenging patient encounters, however. This review assists generalists in approaching emotionally charged encounters when caring for patients with cancer on the wards. We explore patient factors that negatively affect successful communication, some of which can be addressed through a multidisciplinary approach. In addition, we present a checklist of preventive strategies in addressing emotionally charged patient responses and offer a number of preventive and restorative management approaches for dealing with such encounters. We provide a practical framework for recognition and management of the psychosocial and emotional challenges in the care of hospitalized patients with cancer.

Oncologists' and Patients' Perceptions of Initial, Intermediate, and Final Goals of Care Conversations

CONTEXT

Although recommendations are for goals of care (GoC) conversations to happen early and often, their timing and content over the disease course remain unclear.

OBJECTIVES

To describe perceptions of the timing and content of GoC conversations among oncologists and patients with advanced cancer.

METHODS

Semi-structured interviews with oncologists and patients at four hospitals in New York and Connecticut. We analyzed data using interpretive description.

RESULTS

Oncologists (n = 21) were 67% male, averaged 46 years old (range 34-68 years), and had a mean 20 years (range 8-42 years) in practice. Advanced cancer patients (n = 39) were 59% female with a mean age of 58 years (range 26-88 years). Oncologists and patients viewed GoC conversations along an initial, intermediate, and final continuum. Oncologists reported having initial GoC conversations to build rapport, provide disease information, and clarify and consider treatment intent and options. Intermediate conversations focused on changes in treatment and side effects. Final conversations occurred when patients were hospice-eligible and covered the shift to comfort care, a treatment summary, and advance directives. Timing and content were influenced by cancer type, disease status, and emotional state. Patients supported beginning GoC conversations early, but had different preferences for content of initial conversations. Some wanted complete information; others found this overwhelming. Patients felt intermediate GoC conversations should occur at decision points with time for processing. Content of intermediate and final conversations was dependent on patients' prognosis, questions, and treatment decisions.

CONCLUSION

Although GoC conversations should follow individual patient preferences, our findings offer structure for their timing and content.

Combining Best Practices and Patient, Caregiver, and Healthcare Provider Perspectives for Late-Life Supportive Care: LifeCourse

Healthcare systems seek effective ways to support and treat the growing number of individuals living with serious illness. The nature of these care episodes challenges delivery systems to attain proficiency in dealing with the multiplicity of chronic conditions in individuals and populations through understanding and attending to patients' medical and nonmedical aspects of health. This article describes LifeCourse, a healthcare approach that provides palliative care practices to patients with serious illness years prior to death.

Conveying hope in consultations with patients with life-threatening diseases: the balance between supporting and challenging the patient

OBJECTIVE

There is limited knowledge about the communication of hope and denial in consultations with patients with life-threatening diseases on a practical level. In this study, we explored a real-life medical consultation between a doctor and a patient with incurable cancer, focusing on conveying hope.

DESIGN AND METHODS

We found one consultation especially suited for illustrating how a physician can convey and reinforce hope without attaching it to curative treatment. The consultation was analysed using a method for discourse analysis, where we took as a point of departure that discourse means language in use.

RESULTS

The doctor communicated in a recognising manner, expressing respect for the patient as a subject and an authority of his own experiences. The doctor and patient succeeded in creating a good working alliance characterised by warmth and trust. Within this context, there was room for the doctor to challenge the patient's views and communicate disagreement.

CONCLUSIONS

The doctor succeeds in conveying and maintaining hope. Within a good working alliance with the patient the doctor can convey hope by balancing between supporting and challenging him. Exploring and grasping the patient's real concerns is essential for being able to relieve and comfort him and convey hope.

Searching for wisdom in oncology care: A scoping review

OBJECTIVE

The concept of "wisdom" is beginning to emerge in the oncology literature, raising questions concerning: (1) how the concept of wisdom is used in oncology literature; (2) the ways in which wisdom has been a focus of inquiry within oncology care; and (3) how wisdom is characterized when the term is used.

METHOD

A scoping review, using Arksey and O'Malley's five-step framework, was undertaken to address these questions. In consultation with oncology reference librarians, "wisdom"- and "oncology"-related search terms were identified, and four electronic databases were searched: CINAHL, SocINDEX, PubMed, and PsychINFO. After removal of duplicates and application of inclusion and exclusion criteria, 58 records were identified and included for analysis.

RESULTS

The concept of wisdom was employed with a breadth of meanings, and 58 records were schematized into 7 genres, including: (1) empirical research with wisdom foregrounded as a study focus (n = 2); (2) empirical research articles where "wisdom" appears in the findings (n = 16); (3) a quality-improvement project where wisdom is an embedded concept (n = 1); (4) essays where wisdom is an aspect of the discussion (n = 5); (5) commentary/opinion pieces where wisdom is an aspect of its focus (n = 6); (6) personal stories describing wisdom as something gleaned from lived experience with cancer (n = 2); and (7) everyday/taken-for-granted uses of wisdom (n = 26).

SIGNIFICANCE OF RESULTS

The notion of wisdom has a taken-for-granted presence in the published oncology literature and holds promise for future research into patient and clinician wisdom in oncology care. Nonetheless, the terminology is varied and unclear. A scholarly focus on wisdom has not been brought to bear in cancer care to the degree it has in other fields, and research is in the early stages. Various characterizations of wisdom are present. If such a resource as "wisdom" exists, dwelling in human experiences and practices, there may be benefit in recognizing wisdom as informing the epistemologies of practice in oncology care.

What Makes a Good Palliative Care Physician? A Qualitative Study about the Patient's Expectations and Needs when Being Admitted to a Palliative Care Unit

Objective

The aims of the study were to examine a) patients’ knowledge of palliative care, b) patients’ expectations and needs when being admitted to a palliative care unit, and c) patient’s concept of a good palliative care physician.

Methods

The study was based on a qualitative methodology, comprising 32 semistructured interviews with advanced cancer patients admitted to the palliative care unit of the Medical University of Vienna. Interviews were conducted with 20 patients during the first three days after admission to the unit and after one week, recorded digitally, and transcribed verbatim. Data were analyzed using NVivo 10 software, based on thematic analysis enhanced with grounded theory techniques.

Results

The results revealed four themes: (1) information about palliative care, (2) supportive care needs, (3) being treated in a palliative care unit, and (4) qualities required of palliative care physicians. The data showed that patients lack information about palliative care, that help in social concerns plays a central role in palliative care, and attentiveness as well as symptom management are important to patients. Patients desire a personal patient-physician relationship. The qualities of a good palliative care physician were honesty, the ability to listen, taking time, being experienced in their field, speaking the patient’s language, being human, and being gentle. Patients experienced relief when being treated in a palliative care unit, perceived their care as an interdisciplinary activity, and felt that their burdensome symptoms were being attended to with emotional care. Negative perceptions included the overtly intense treatment.

Conclusions

The results of the present study offer an insight into what patients expect from palliative care teams. Being aware of patient’s needs will enable medical teams to improve professional and individualized care.

The effects of distress and the dimensions of coping strategies on physicians' satisfaction with competence

Objectives:

The purposes of this study were to (1) articulate the dimensions of Coping strategies used by physicians, and (2) determine whether Coping strategies alleviated Distress and enhanced Satisfaction with Competence.

Methods:

Comprehensive questionnaires on factors associated with Satisfaction with Competence were sent to a stratified sample of 5300 physicians across Canada. The response rate was 57% with negligible bias. Factor analysis was used to articulate the dimensions of Coping strategies. The classic Baron and Kenny regression series was used to establish whether Coping mediates the effects of Distress on Satisfaction with Competence. Years in Practice, Self-Reported Health, and Duties of Physicians were control factors.

Results:

A reliable 15-item measure of Coping was confirmed (α = .76) with four reasonably reliable dimensions: Collegiality (α = .80), Attitude (α = .63), Managing Work (α = .60), and Self-Care (α = .62). Physicians reported a mean Satisfaction with Competence of (M = 4.26 out of 6.0, standard deviation (SD) = 0.64) with General practitioners reporting slightly lower levels of Satisfaction with Competence than average. Conversely, chronic disease, clinical, and procedural specialists reported higher levels of Satisfaction with Competence. The mean Distress level for all physicians was (M = 3.66 out of 7.0, SD = 0.93). The highest levels of distress were reported by emergency physicians, general practitioners, and surgeons. Clinical specialists, anesthesiologists, and psychiatrists reported the lowest levels of distress. Physicians reported (M = 4.48 out of 7.0, SD = 0.78) as the mean level of Coping ability with clinical specialists and general practitioners reporting lower than average abilities to cope. Laboratory and chronic care specialists reported greater than average coping abilities. Regression analyses established Coping as a mediator of Distress which predicted physicians’ Satisfaction with Competence.

Conclusion:

Four groups of coping strategies were significant in relieving the pressures of work: (1) Collegiality, (2) Self-Care, (3) Managing Work, and (4) Positive Attitude.

Liminality in Pediatric Palliative Care

Palliative care for infants, children, and adolescents encompasses numerous transitions and thresholds of uncertainty that challenge conventional clinical medicine. Palliative care clinicians have opportunities to be more comfortable amid such challenges, or perhaps even overcome them, if they are attuned to the unique times and places in which patients, their families, and caregivers find themselves throughout illness and recovery or transitioning toward the end of life. Patient-clinician encounters often dwell in these liminal places. The concept of liminality gives validation to the patient or family's being "stuck in places betwixt and between" a past life rich with relationship and purpose and an acute, chronic, or critical illness. Or having resolved the acute crisis of hospitalization that place between the past bounds of illness and the uncertain path forward, perhaps even toward death. Liminality provides a framework for addressing the unbound spaces that patients and families occupy: What is past is behind-the present place is tenuous and temporary, and what is ahead uncertain. This place is where palliative care clinicians can offer clinicians and families guidance.

Palliative Care in Lung Cancer

Lung cancer is the most common cancer worldwide and is the leading cause of cancer death for both men and women in the USA. Symptom burden in patients with advanced lung cancer is very high and has a negative impact on their quality of life (QOL). Palliative care with its focus on the management of symptoms and addressing physical, psychosocial, spiritual, and existential suffering, as well as medically appropriate goal setting and open communication with patients and families, significantly adds to the quality of care received by advanced lung cancer patients. The Provisional Clinical Opinion (PCO) of American Society of Clinical Oncology (ASCO) as well as the National Cancer Care Network's (NCCN) clinical practice guidelines recommends early integration of palliative care into routine cancer care. In this chapter, we will provide an overview of palliative care in lung cancer and will examine the evidence and recommendations with regard to a comprehensive and interdisciplinary approach to symptom management, as well as discussions of goals of care, advance care planning, and care preferences.

Patients' perspectives on information from physicians during palliative chemotherapy: A qualitative study

Objective:

During the course of their disease, patients with cancer receiving palliative chemotherapy receive extensive amounts of information from physicians. The objective of our study was to describe patients' perspectives on the information they received from physicians during palliative chemotherapy with regard to their cancer diagnosis, treatments, prognosis, and future planning.

Method:

A total of 15 semistructured face-to-face interviews with patients who had incurable cancer were conducted, transcribed verbatim, and analyzed with qualitative content analysis.

Results:

Three categories were defined during the analytical process: “having a chronic disease,” “depending on chemotherapy,” and “living with an unpredictable future.”

Significance of results:

Our study demonstrated that patients undergoing palliative chemotherapy perceived that their disease was incurable and chronic, that they were dependent on chemotherapy, and that their future was uncertain. Compared with other studies, the patients in our study seemed to be more aware of their prognosis and the goals of care.

Psycho-oncology: Searching for practical wisdom?

The debate is vigorous in psycho-oncology about whether spiritual, existential, and psychosocial are the most comprehensive terms for academic research discourses investigating meaning and purpose. A call-to-action email from the International Society of Psycho-Oncology included the term soul. The current essay highlights the historical and contemporary uses of "soul" to suggest that the re-emergent soul signifies a tacit quest for an "intangible" that seems missing in current constructs of clinical domains reflected in the vigor of the debates. It is suggested that the re-emergence of the pre-Medieval meaning(s) of the notion of soul affirms a growing need for integrative paradigms on "being human" to guide psycho-oncology practitioners and their research. As a paradigmatic example, a clinical support group entitled Soul Medicine is described as employing the term soul to open up the more marginal discourses about experiences of illness arising from philosophical reflection, arts, humanities, and spirituality within a clinical oncology context. A link between soul and wisdom is suggested for further exploration with the view that phronesis ("the virtue of practical wisdom"), an emerging concept in health professional education research, is of ultimate value to the people psycho-oncology seeks to serve. This group holds that garnering wisdom from the expertise of those living with cancer should be a central aim of our field.

Personalizing death in the intensive care unit: the 3 Wishes Project: a mixed-methods study

BACKGROUND

Dying in the complex, efficiency-driven environment of the intensive care unit can be dehumanizing for the patient and have profound, long-lasting consequences for all persons attendant to that death.

OBJECTIVE

To bring peace to the final days of a patient's life and to ease the grieving process.

DESIGN

Mixed-methods study.

SETTING

21-bed medical-surgical intensive care unit.

PARTICIPANTS

Dying patients and their families and clinicians.

INTERVENTION

To honor each patient, a set of wishes was generated by patients, family members, or clinicians. The wishes were implemented before or after death by patients, families, clinicians (6 of whom were project team members), or the project team.

MEASUREMENTS

Quantitative data included demographic characteristics, processes of care, and scores on the Quality of End-of-Life Care-10 instrument. Semistructured interviews of family members and clinicians were transcribed verbatim, and qualitative description was used to analyze them.

RESULTS

Participants included 40 decedents, at least 1 family member per patient, and 3 clinicians per patient. The 159 wishes were implemented and classified into 5 categories: humanizing the environment, tributes, family reconnections, observances, and "paying it forward." Scores on the Quality of End-of-Life Care-10 instrument were high. The central theme from 160 interviews of 170 persons was how the 3 Wishes Project personalized the dying process. For patients, eliciting and customizing the wishes honored them by celebrating their lives and dignifying their deaths. For families, it created positive memories and individualized end-of-life care for their loved ones. For clinicians, it promoted interprofessional care and humanism in practice.

LIMITATION

Impaired consciousness limited understanding of patients' viewpoints.

CONCLUSION

The 3 Wishes Project facilitated personalization of the dying process through explicit integration of palliative and spiritual care into critical care practice.

PRIMARY FUNDING SOURCE

Hamilton Academy of Health Science Research Organization, Canadian Intensive Care Foundation.

'Conditional candour' and 'knowing me': an interpretive description study on patient preferences for physician behaviours during end-of-life communication

OBJECTIVE

To understand patients' preferences for physician behaviours during end-of-life communication.

METHODS

We used interpretive description methods to analyse data from semistructured, one-on-one interviews with patients admitted to general medical wards at three Canadian tertiary care hospitals. Study recruitment took place from October 2012 to August 2013. We used a purposive, maximum variation sampling approach to recruit hospitalised patients aged ≥55 years with a high risk of mortality within 6-12 months, and with different combinations of the following demographic variables: race (Caucasian vs non-Caucasian), gender and diagnosis (cancer vs non-cancer).

RESULTS

A total of 16 participants were recruited, most of whom (69%) were women and 70% had a non-cancer diagnosis. Two major concepts regarding helpful physician behaviour during end-of-life conversations emerged: (1) 'knowing me', which reflects the importance of acknowledging the influence of family roles and life history on values and priorities expressed during end-of-life communication, and (2) 'conditional candour', which describes a process of information exchange that includes an assessment of patients' readiness, being invited to the conversation, and sensitive delivery of information.

CONCLUSIONS

Our findings suggest that patients prefer a nuanced approach to truth telling when having end-of-life discussions with their physician. This may have important implications for clinical practice and end-of-life communication training initiatives.