1
|
Shilling DM, Manz CR, Strand JJ, Patel MI. Let Us Have the Conversation: Serious Illness Communication in Oncology: Definitions, Barriers, and Successful Approaches. Am Soc Clin Oncol Educ Book 2024; 44:e431352. [PMID: 38788187 DOI: 10.1200/edbk_431352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Serious illness communications are crucial elements of care delivery for patients with cancer. High-quality serious illness communications are composed of open, honest discussions between patients, caregivers, and clinicians regarding patient's communication preferences, expected illness trajectory, prognosis, and risks and benefits of any recommended care. High-quality communication ideally starts at the time of a patients' cancer diagnosis, allows space for and response to patient emotions, elicits patients' values and care preferences, and is iterative and longitudinal. When integrated into cancer care, such communication can result in improved patient experiences with their care, care that matches patients' goals, and reduced care intensity at the end of life. Despite national recommendations for routine integration of these communication into cancer care, a minority of patients with cancer receive such communication. In this chapter, we describe elements of high-quality serious illness communication, patient-, clinician-, institution-, and payer-level barriers, and successful strategies that can routinely integrate such communication into cancer care delivery.
Collapse
Affiliation(s)
- Danielle M Shilling
- Division of Community Internal Medicine, Geriatrics & Palliative Care, Mayo Clinic, Rochester, MN
| | - Christopher R Manz
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Jacob J Strand
- Division of Community Internal Medicine, Geriatrics & Palliative Care, Mayo Clinic, Rochester, MN
| | - Manali I Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
- VA Palo Alto Health Care System, Palo Alto, CA
| |
Collapse
|
2
|
Baxter R, Pusa S, Andersson S, Sandgren A. Perils and payoffs for patients in serious illness conversations as described by physicians: a qualitative study. BMJ Open Qual 2024; 13:e002734. [PMID: 38782485 PMCID: PMC11116881 DOI: 10.1136/bmjoq-2023-002734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND The Serious Illness Care Programme was developed to promote more, better and earlier serious illness conversations. Conversations about goals and values are associated with improved experiences and outcomes for seriously ill patients. Clinicians' attitudes and beliefs are thought to influence the uptake and performance of serious illness conversations, yet little is known about how clinicians perceive the impact of these conversations on patients. This study aimed to explore physicians' perceptions regarding the impact of serious illness conversations for patients. METHODS The Serious Illness Care Programme was implemented as a quality improvement project in two hospitals in Southern Sweden. Focus group evaluation discussions were conducted with 14 physicians and inductive thematic analysis was undertaken. RESULTS The results revealed that physicians considered potential perils and optimised potential payoffs for patients when engaging in serious illness conversations. Potential perils encompassed inappropriate timing, damaging emotions and shattering hopes. Potential payoffs included reflection time, secure space, and united understandings. CONCLUSIONS Physicians depicted a balance in evaluating the perils and payoffs of serious illness conversations for patients and recognised the interrelation of these possibilities through continual assessment and adjustment.
Collapse
Affiliation(s)
- Rebecca Baxter
- Department of Health and Caring Sciences, Linneaus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Susanna Pusa
- Department of Health and Caring Sciences, Linneaus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Sofia Andersson
- Department of Health and Caring Sciences, Linneaus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Anna Sandgren
- Department of Health and Caring Sciences, Linneaus University, Växjö, Sweden
| |
Collapse
|
3
|
Pusa S, Baxter R, Andersson S, Fromme EK, Paladino J, Sandgren A. Core Competencies for Serious Illness Conversations: An Integrative Systematic Review. J Palliat Care 2024:8258597241245022. [PMID: 38557369 DOI: 10.1177/08258597241245022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Objective: The Serious Illness Care Program was developed to support goals and values discussions between seriously ill patients and their clinicians. The core competencies, that is, the essential clinical conversation skills that are described as requisite for effective serious illness conversations (SICs) in practice, have not yet been explicated. This integrative systematic review aimed to identify core competencies for SICs in the context of the Serious Illness Care Program. Methods: Articles published between January 2014 and March 2023 were identified in MEDLINE, PsycINFO, CINAHL, and PubMed databases. In total, 313 records underwent title and abstract screening, and 96 full-text articles were assessed for eligibility. The articles were critically appraised using the Joanna Briggs Institute Critical Appraisal Guidelines, and data were analyzed using thematic synthesis. Results: In total, 53 articles were included. Clinicians' core competencies for SICs were described in 3 themes: conversation resources, intrapersonal capabilities, and interpersonal capabilities. Conversation resources included using the conversation guide as a tool, together with applying appropriate communication skills to support better communication. Intrapersonal capabilities included calibrating one's own attitudes and mindset as well as confidence and self-assurance to engage in SICs. Interpersonal capabilities focused on the clinician's ability to interact with patients and family members to foster a mutually trusting relationship, including empathetic communication with attention and adherence to patient and family members views, goals, needs, and preferences. Conclusions: Clinicians need to efficiently combine conversation resources with intrapersonal and interpersonal skills to successfully conduct and interact in SICs.
Collapse
Affiliation(s)
- Susanna Pusa
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Rebecca Baxter
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Sofia Andersson
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Erik K Fromme
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joanna Paladino
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| |
Collapse
|
4
|
Dhawale T, Johnson PC, Boateng K, Barata A, Traeger L, Nelson AM, Lavoie MW, Holmbeck K, Choe J, Nabily A, Tripathi A, Amonoo HL, Frigault M, El-Jawahri A. Communication About Chimeric Antigen Receptor T-Cell (CAR-T) Therapy. Transplant Cell Ther 2024; 30:402.e1-402.e12. [PMID: 38262530 DOI: 10.1016/j.jtct.2024.01.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 01/25/2024]
Abstract
Chimeric Antigen Receptor T-cell (CAR-T) therapy has revolutionized the treatment of patients with hematologic malignancies, yet treatment may coincide with the potential for life-threatening toxicities. Currently, no studies have investigated how oncologists communicate with patients about CAR-T therapy or what patients and their caregivers want to know prior to consenting for CAR-T therapy. This study characterizes the content of oncologist communication with patients and caregivers about the risks and benefits of CAR-T therapy and explore the information preferences of patients and their caregivers about CAR-T therapy. We conducted a multimethod study of 20 patients with hematologic malignancies referred for CAR-T therapy at the Massachusetts General Hospital and 10 caregivers. We audio recorded the initial outpatient visit with the oncologist to review and sign consent for CAR-T therapy. We subsequently surveyed patients and caregivers about information gaps that remained after consent. We then interviewed patients and caregiver about their perceptions of oncologist communication and information preferences after the consent visit, 1 month, and 3 months post-CAR-T therapy treatment. Qualitative data analysis was conducted using the framework approach. Six major themes regarding communication about CAR-T therapy were identified: (1) oncologists create a narrative of power and innovation about CAR-T therapy, (2) oncologists set clear expectations regarding CAR-T therapy, (3) oncologists preferentially discuss positive treatment outcomes and less frequently address treatment failures or uncertainties, (4) oncologists couple their discussion about risks of CAR-T therapy with assurances about risk mitigation strategies, (5) oncologists engage in empathetic communication throughout the consent visit, (6) patients and caregivers vary in their preferences regarding communication about CAR-T therapy but largely favor a positive discourse during the consent visit and (7) patients who completed CAR-T therapy and their caregivers report significant knowledge gaps during and after treatment. Overall, patients and caregivers felt well informed about CAR T-therapy yet identified communication gaps regarding, advanced care planning, treatment failure and treatment toxicities. A predominantly positive discourse between patients, caregivers, and oncologists around CAR-T therapy leaves patients and caregivers with significant knowledge gaps about negative outcomes. Further research is needed to help oncologists communicate about treatment uncertainties and help patients and their caregivers prepare for negative outcomes of CAR-T therapy.
Collapse
Affiliation(s)
- Tejaswini Dhawale
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts.
| | - P Connor Johnson
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Kofi Boateng
- Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Anna Barata
- Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Lara Traeger
- Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Ashley M Nelson
- Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Mitchell W Lavoie
- University of Massachusetts T.H. Chan School of Medicine, Worcester, Massachusetts
| | - Katherine Holmbeck
- Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Joanna Choe
- Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Anisa Nabily
- Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Astha Tripathi
- Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Hermioni L Amonoo
- Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Matt Frigault
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
5
|
Bange EM, Li Y, Kumar P, Doucette A, Gabriel P, Parikh R, Li EH, Mamtani R, Getz KD. The association between telemedicine, advance care planning, and unplanned hospitalizations among high-risk patients with cancer. Cancer 2024; 130:636-644. [PMID: 37987207 PMCID: PMC10922036 DOI: 10.1002/cncr.35116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/31/2023] [Accepted: 10/15/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Despite the widespread implementation of telemedicine, there are limited data regarding its impact on key components of care for patients with incurable or high-risk cancer. For these patients, high-quality care requires detailed conversations regarding treatment priorities (advance care planning) and clinical care to minimize unnecessary acute care (unplanned hospitalizations). Whether telemedicine affects these outcomes relative to in-person clinic visits was examined among patients with cancer at high risk for 6-month mortality. METHODS This retrospective cohort study included adult patients with cancer with any tumor type treated at the University of Pennsylvania who were newly identified between April 1 and December 31, 2020, to be at high risk for 6-month mortality via a validated machine learning algorithm. Separate modified Poisson regressions were used to assess the occurrence of advance care planning and unplanned hospitalizations for telemedicine as compared to in-person visits. Additional analyses were done comparing telemedicine type (video or phone) as compared to in-person clinic visits. RESULTS The occurrence of advance care planning was similar between telemedicine and in-person visits (6.8% vs. 6.0%; adjusted risk ratio [aRR], 1.25; 95% CI, 0.92-1.69). In regard to telemedicine subtype, patients exposed to video encounters were modestly more likely to have documented advance care planning in comparison to those seen in person (7.5% vs. 6.0%; aRR, 1.48; 95% CI, 1.03-2.11). The 3-month risk for unplanned hospitalization was comparable for telemedicine compared to in-person clinic encounters (21% vs. 18%; aRR, 1.06; 95% CI, 0.81-1.38). CONCLUSIONS In this study, care delivered by telemedicine, compared to in-person clinic visits, produced comparable rates of advance care planning conversations without increasing hospitalizations, which suggests that vulnerable patients can be managed safely by telemedicine.
Collapse
Affiliation(s)
- Erin M Bange
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yimei Li
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Pallavi Kumar
- Palliative and Hospice Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Abigail Doucette
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter Gabriel
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ravi Parikh
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Hematology/Oncology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Eric H Li
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ronac Mamtani
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kelly D Getz
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
6
|
Baxter R, Pusa S, Andersson S, Fromme EK, Paladino J, Sandgren A. Core elements of serious illness conversations: an integrative systematic review. BMJ Support Palliat Care 2024:spcare-2023-004163. [PMID: 37369576 DOI: 10.1136/spcare-2023-004163] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Ariadne Labs' Serious Illness Care Program (SICP), inclusive of the Serious Illness Conversation Guide (SICG), has been adapted for use in a variety of settings and among diverse population groups. Explicating the core elements of serious illness conversations could support the inclusion or exclusion of certain components in future iterations of the programme and the guide. AIM This integrative systematic review aimed to identify and describe core elements of serious illness conversations in relation to the SICP and/or SICG. DESIGN Literature published between 1 January 2014 and 20 March 2023 was searched in MEDLINE, PsycINFO, CINAHL and PubMed. All articles were evaluated using the Joanna Briggs Institute Critical Appraisal Guidelines. Data were analysed with thematic synthesis. RESULTS A total of 64 articles met the inclusion criteria. Three themes were revealed: (1) serious illness conversations serve different functions that are reflected in how they are conveyed; (2) serious illness conversations endeavour to discover what matters to patients and (3) serious illness conversations seek to align what patients want in their life and care. CONCLUSIONS Core elements of serious illness conversations included explicating the intention, framing, expectations and directions for the conversation. This encompassed discussing current and possible trajectories with a view towards uncovering matters of importance to the patient as a person. Preferences and priorities could be used to inform future preparation and recommendations. Serious illness conversation elements could be adapted and altered depending on the intended purpose of the conversation.
Collapse
Affiliation(s)
- Rebecca Baxter
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Susanna Pusa
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Sofia Andersson
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Erik K Fromme
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Joanna Paladino
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| |
Collapse
|
7
|
Serna MK, Yoon C, Fiskio J, Lakin JR, Schnipper JL, Dalal AK. A Mixed Methods Analysis of Standardized Documentation of Serious Illness Conversations Within an Electronic Health Record Module During Hospitalization. Am J Hosp Palliat Care 2024:10499091241228269. [PMID: 38334010 DOI: 10.1177/10499091241228269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Analysis of documented Serious Illness Conversations (SICs) in the inpatient setting can help clinicians align management to address patient and caregiver needs. METHODS We conducted a mixed methods analysis of the first instance of standardized documentation of a SIC within a structured module among hospitalized general medicine patients from 2018 to 2019. Percentage of documentations that included a description of patient or family understanding of the patient's medical condition and use of radio buttons to answer the "prognostic information shared," "hopes," and "worries" modules are reported. Using grounded theory approach, physicians analyzed free text entries to: "What is important to the patient/family?" and "Recommendations or next steps planned." RESULTS Out of 5142 patients, 59 patients had a documented SIC. Patient or family understanding of the medical condition(s) was reported in 56 (95%). For "prognostic information shared," the most frequently selected radio buttons were: 49 (83%) incurable disease and 28 (48%) prognosis of weeks to months while those for "hopes" were: 52 (88%) be comfortable and 27 (46%) be at home and for "worries" were: 49 (83%) other physical suffering and 36 (61%) pain. Themes generated from entries to "What's important to patient/family?" included being with loved ones; comfort; mentally and physically present; and reliable care while those for "Recommendations" were coordinating support services; symptom management; and support and communication. CONCLUSIONS SIC content indicated concern about pain and reliable care suggesting the complex, intensive nature of caring for seriously ill patients and the need to consider SICs earlier in the life course of patients.
Collapse
Affiliation(s)
- Myrna Katalina Serna
- Division of General Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Catherine Yoon
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Julie Fiskio
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jeffrey L Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anuj K Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| |
Collapse
|
8
|
Lavecchia M, Myers J, Bainbridge D, Incardona N, Levine O, Steinberg L, Schep D, Vautour J, Kumar SJ, Seow H. Education modalities for serious illness communication training: A scoping review on the impact on clinician behavior and patient outcomes. Palliat Med 2024; 38:170-183. [PMID: 37424275 PMCID: PMC10865772 DOI: 10.1177/02692163231186180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
BACKGROUND Several clinician training interventions have been developed in the past decade to address serious illness communication. While numerous studies report on clinician attitudes and confidence, little is reported on individual education modalities and their impact on actual behavior change and patient outcomes. AIM To examine what is known about the education modalities used in serious illness communication training and their impact on clinician behaviors and patient outcomes. DESIGN A scoping review using the Joanna Briggs Methods Manual for Scoping Reviews was conducted to examine studies measuring clinician behaviors or patient outcomes. DATA SOURCES Ovid MEDLINE and EMBASE databases were searched for English-language studies published between January 2011 and March 2023. RESULTS The search identified 1317 articles: 76 met inclusion criteria describing 64 unique interventions. Common education modalities used were: single workshop (n = 29), multiple workshops (n = 11), single workshop with coaching (n = 7), and multiple workshops with coaching (n = 5); though they were inconsistently structured. Studies reporting improved clinician skills tended to be in simulation settings with neither clinical practice nor patient outcomes explored. While some studies reported behavior changes or improved patient outcomes, they did not necessarily confirm improvements in clinician skills. As multiple modalities were commonly used and often embedded within quality improvement initiatives, the impact of individual modalities could not be determined. CONCLUSION This scoping review of serious illness communication interventions found heterogeneity among education modalities used and limited evidence supporting their effectiveness in impacting patient-centered outcomes and long-term clinician skill acquisition. Well-defined educational modalities and consistent measures of behavior change and standard patient-centered outcomes are needed.
Collapse
Affiliation(s)
- Melissa Lavecchia
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada
| | - Jeff Myers
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Daryl Bainbridge
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Nadia Incardona
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Oren Levine
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Leah Steinberg
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel Schep
- Division of Radiation Oncology, Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Joanna Vautour
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
9
|
Murakami N, Reich AJ, He K, Gelfand SL, Leiter RE, Sciacca K, Adler JT, Lu E, Ong SC, Concepcion BP, Singh N, Murad H, Anand P, Ramer SJ, Dadhania DM, Lentine KL, Lakin JR, Alhamad T. Kidney Transplant Clinicians' Perceptions of Palliative Care for Patients With Failing Allografts in the US: A Mixed Methods Study. Am J Kidney Dis 2024; 83:173-182.e1. [PMID: 37726050 DOI: 10.1053/j.ajkd.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/03/2023] [Accepted: 07/09/2023] [Indexed: 09/21/2023]
Abstract
RATIONALE & OBJECTIVE Kidney transplant patients with failing allografts have a physical and psychological symptom burden as well as high morbidity and mortality. Palliative care is underutilized in this vulnerable population. We described kidney transplant clinicians' perceptions of palliative care to delineate their perceived barriers to and facilitators of providing palliative care to this population. STUDY DESIGN National explanatory sequential mixed methods study including an online survey and semistructured interviews. SETTING & PARTICIPANTS Kidney transplant clinicians in the United States surveyed and interviewed from October 2021 to March 2022. ANALYTICAL APPROACH Descriptive summary of survey responses, thematic analysis of qualitative interviews, and mixed methods integration of data. RESULTS A total of 149 clinicians completed the survey, and 19 completed the subsequent interviews. Over 90% of respondents agreed that palliative care can be helpful for patients with a failing kidney allograft. However, 46% of respondents disagreed that all patients with failing allografts benefit from palliative care, and two-thirds thought that patients would not want serious illness conversations. More than 90% of clinicians expressed concern that transplant patients and caregivers would feel scared or anxious if offered palliative care. The interviews identified three main themes: (1) transplant clinicians' unique sense of personal and professional responsibility was a barrier to palliative care engagement, (2) clinicians' uncertainty regarding the timing of palliative care collaboration would lead to delayed referral, and (3) clinicians felt challenged by factors related to patients' cultural backgrounds and identities, such as language differences. Many comments reflected an unfamiliarity with the broad scope of palliative care beyond end-of-life care. LIMITATIONS Potential selection bias. CONCLUSIONS Our study suggests that multiple barriers related to patients, clinicians, health systems, and health policies may pose challenges to the delivery of palliative care for patients with failing kidney transplants. This study illustrates the urgent need for ongoing efforts to optimize palliative care delivery models dedicated to kidney transplant patients, their families, and the clinicians who serve them. PLAIN-LANGUAGE SUMMARY Kidney transplant patients experience physical and psychological suffering in the context of their illnesses that may be amenable to palliative care. However, palliative care is often underutilized in this population. In this mixed-methods study, we surveyed 149 clinicians across the United States, and 19 of them completed semistructured interviews. Our study results demonstrate that several patient, clinician, system, and policy factors need to be addressed to improve palliative care delivery to this vulnerable population.
Collapse
Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amanda J Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katherine He
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Samantha L Gelfand
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joel T Adler
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Emily Lu
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Song C Ong
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana
| | - Haris Murad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Prince Anand
- Medical University of South Carolina, Greenville, South Carolina
| | | | | | - Krista L Lentine
- Saint Louis University Transplant Center, SSM-Saint Louis University Hospital, St Louis, Missouri
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St. Louis, St. Louis, Missouri.
| |
Collapse
|
10
|
Vitous CA, Shabet C, Ferguson C, Edwards S, Duby A, Suwanabol PA. Family perspectives on end-of-life care after surgery: A qualitative analysis of the veteran affairs bereaved family surveys. Am J Surg 2023:S0002-9610(23)00662-1. [PMID: 38168605 DOI: 10.1016/j.amjsurg.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Using open-text responses from the Bereaved Family Survey (BFS), we sought to explore Veteran family experiences on end-of-life care after surgery. METHODS We evaluated 936 open-text responses for all decedents who underwent any high-risk surgical procedure across 124 Veterans Affairs facilities between 2010 and 2019. Data were analyzed using thematic analysis. RESULTS Respondents expressed a belief in the decedent's unnecessary pain, expressing distrust in the treatment decisions of the care team. Limited communication regarding the severity of disease or risks of surgery caused conflicting and unresolved narratives regarding the cause or timing of death. Respondents described feelings of disempowerment when they were not involved in decision-making and when their wishes were not respected. CONCLUSIONS Timely and sensitive conversations, including acknowledging uncertainty in outcomes, may ensure a more positive experience for bereaved families.
Collapse
Affiliation(s)
- C Ann Vitous
- Department of Surgery, University of Michigan, Ann Arbor, United States; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, United States.
| | | | - Cara Ferguson
- University of Michigan Medical School, Ann Arbor, United States
| | - Sydney Edwards
- University of Michigan Medical School, Ann Arbor, United States
| | - Ashley Duby
- Department of Surgery, University of Michigan, Ann Arbor, United States; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, United States
| | - Pasithorn A Suwanabol
- Department of Surgery, University of Michigan, Ann Arbor, United States; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, United States
| |
Collapse
|
11
|
Aller A, Shirazi A, Pedell L, Altschuler A, Hauser K, Cheslock M, Wei J, Duffens A, Whitehead H, Lim P, Katzel J, Martinez F, Lin A, Aller S, Aller C, Jones T, Yen SM, Liu R. What Matters Most: The Documented Goals, Values and Motivators of Advanced Cancer Patients. Am J Hosp Palliat Care 2023:10499091231223144. [PMID: 38112439 DOI: 10.1177/10499091231223144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Goals of care conversations are essential to delivery of goal concordant care. Infrequent and inconsistent goals of care documentation potentially limit delivery of goal concordant care. METHODS At Kaiser Permanente San Francisco Cancer Center, a standardized documentation template was designed and implemented to increase goals of care documentation by oncologists. The centralized, prompt-based template included value clarification of the goals and values of advanced cancer patients beyond treatment preferences. Documented conversations using the template during the initial pilot period were reviewed to characterization the clinical context in which conversations were recorded. Common goals and motivators were also identified. RESULTS A total of 178 advanced cancer patients had at least 1 documented conversation by a medical oncologist using the goals of care template. Oncologists consistently documented within the template goals of therapy and motivating factors in decision making. The most frequently documented goals of care were "Avoiding Pain and Suffering," "Physical Independence," and "Living as Long as Possible." The least recorded goal was "Comfort Focused Treatment Only." CONCLUSIONS Review of oncologist documented goals of care conversations using a prompt-based template allowed for characterization of the clinical context, therapy goals and motivators of advanced cancer patients. Communication of goals of care conversations by oncologists using a standardized prompt-based template within a centralized location has the potential to improve delivery of goal concordant care.
Collapse
Affiliation(s)
- Ashley Aller
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Aida Shirazi
- Department of Graduate Medical Education, Kaiser Permanente Northern California, San Francisco, CA, USA
| | | | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Karen Hauser
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Megan Cheslock
- Department of Geriatrics Medicine, Edith Nourse Rogers Memorial Veterans' Hospital, Bedford, MA, USA
| | - Jenny Wei
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Ali Duffens
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Hannah Whitehead
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Peggy Lim
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Jed Katzel
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Francisco Martinez
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Amy Lin
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Steve Aller
- Department of Hematology-Oncology, Seattle Children's Hospital, Seattle, WA, USA
| | - Cynthia Aller
- Department of Hematology, Providence Regional Cancer System Lacey Cancer Clinic, Lacey, WA, USA
| | - Tyler Jones
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Sue May Yen
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Raymond Liu
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| |
Collapse
|
12
|
Tranberg M, Brodin EM. Physicians' Lived Experience of Breaking Bad News in Clinical Practice: Five Essentials of a Relational Process. QUALITATIVE HEALTH RESEARCH 2023; 33:1349-1359. [PMID: 37793062 PMCID: PMC10666517 DOI: 10.1177/10497323231197534] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
The purpose of this study was to develop deeper knowledge about physicians' lived experiences of breaking bad news by identifying their common meanings and interrelatedness along with their potential alignment with process-oriented and relational aspects. Based on the methodology of descriptive phenomenology, in-depth interviews were conducted with 22 physicians from a wide variety of specialties. The participants were invited to freely reflect upon their experiences of breaking bad news by describing situations that had worked well and less well. Results showed that breaking bad news was fundamentally experienced as a relational process constituted by the five essentials of Becoming the bad messenger, Expecting the unpredictable, Being on stage, Professionally managing hope, and Mindfulness of the emotional relationship. In line with recent research, this study confirms that clinical communication involves much more than just delivering the message. However, it also contributes to existing knowledge by focusing on the phenomenology of physicians' experiences, which enables deeper understanding of the medical profession and the relational process of breaking bad news. As such, our findings are important to enable broader learning in, for example, medical education and continuing courses for clinical staff.
Collapse
Affiliation(s)
- Mattias Tranberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
| | - Eva M. Brodin
- Department of Educational Sciences, Lund University, Lund, Sweden
- Centre for Higher and Adult Education (CHAE), Stellenbosch University, Stellenbosch, South Africa
| |
Collapse
|
13
|
Yang L, Zhu N, Wang X, Tan J, Chen L, Su C, Dong T, Long B, Qiu Y, Deng R. Experiences and perspectives of healthcare professionals, patients and caregivers toward the serious illness conversation guide: protocol for a qualitative meta-synthesis. BMJ Open 2023; 13:e073171. [PMID: 38011974 PMCID: PMC10685960 DOI: 10.1136/bmjopen-2023-073171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 11/03/2023] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION Exploring the experiences and perspectives of healthcare professionals, patients and caregivers toward serious illness conversations based on the Serious Illness Care Program is vital for improving communication with patients who are seriously ill, as has been shown in previous studies. However, few studies have carried out a systematic review to examine common themes, strengthen conclusions and identify gaps in the literature, the findings of which could help steer further research, policies and practice to improve more timely and person-centred conversations about the values and priorities of patients with serious illnesses. The objective of this qualitative meta-synthesis is to explore how healthcare professionals, patients and caregivers described their own experiences of the processes of serious illness communication through a secondary analysis of published qualitative data. METHODS AND ANALYSIS Meta-aggregation will be used to conduct a systematic review of qualitative studies. We conducted an initial search on 10 October 2023; papers published in English will be searched using electronic databases, including PubMed (MEDLINE), Web of Science, Embase, Ovid and CINAHL. Studies that satisfy the eligibility criteria will be evaluated for methodological quality using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. The meta-aggregative review will consist of the following: (1) extraction of findings of all included studies; (2) categorisation of the findings, with at least two findings per category; and (3) synthesis of one or more findings from at least two categories. Study eligibility screening, data extraction, analysis and JBI Critical Appraisal Checklist and Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research assessments will be undertaken independently by two authors. ETHICS AND DISSEMINATION Secondary data analysis of published literature does not require ethical approval. The results will be disseminated in peer-reviewed journals and presented in conference papers and elsewhere. PROSPERO REGISTRATION NUMBER CRD42022330859.
Collapse
Affiliation(s)
- Liu Yang
- Department of Emergency, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Nanxi Zhu
- Department of Emergency, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Neonatal Medicine Center, Xiamen Children's Hospital, Xiamen, China
| | - Xianlin Wang
- Department of Nursing, Zunyi Medical University, Zunyi, China
| | - Jin Tan
- Department of Nursing, Zunyi Medical University, Zunyi, China
| | - Liuliu Chen
- School of Health, Zhuhai College of Science and Technology, Zhuhai, China
| | - Cui Su
- Department of Nursing, Zunyi Medical University, Zunyi, China
| | - Tiaoxia Dong
- Department of Nursing, Zunyi Medical University, Zunyi, China
| | - Bingjie Long
- Department of Neonatal Medicine Center, Xiamen Children's Hospital, Xiamen, China
| | - Yeyin Qiu
- Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, China
| | - Renli Deng
- Department of Emergency, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Nursing, Zunyi Medical University, Zunyi, China
| |
Collapse
|
14
|
Wasp GT, Kaur-Gill S, Anderson EC, Vergo MT, Chelen J, Tosteson T, Barr PJ, Barnato AE. Evaluating Physician Emotion Regulation in Serious Illness Conversations Using Multimodal Assessment. J Pain Symptom Manage 2023; 66:351-360.e1. [PMID: 37433418 PMCID: PMC10574810 DOI: 10.1016/j.jpainsymman.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/29/2023] [Accepted: 07/02/2023] [Indexed: 07/13/2023]
Abstract
CONTEXT Emotion regulation by the physician can influence the effectiveness of serious illness conversations. The feasibility of multimodal assessment of emotion regulation during these conversations is unknown. OBJECTIVES To develop and assess an experimental framework for evaluating physician emotion regulation during serious illness conversations. METHODS We developed and then assessed a multimodal assessment framework for physician emotion regulation using a cross-sectional, pilot study on physicians trained in the Serious Illness Conversation Guide (SICG) in a simulated, telehealth encounter. Development of the assessment framework included a literature review and subject matter expert consultations. Our predefined feasibility endpoints included: an enrollment rate of ≥60% of approached physicians, >90% completion rate of survey items, and <20% missing data from wearable heart rate sensors. To describe physician emotion regulation, we performed a thematic analysis of the conversation, its documentation, and physician interviews. RESULTS Out of 12 physicians approached, 11 (92%) SICG-trained physicians enrolled in the study: five medical oncology and six palliative care physicians. All 11 completed the survey (100% completion rate). Two sensors (chest band, wrist sensor) had <20% missing data during study tasks. The forearm sensor had >20% missing data. The thematic analysis found that physicians': 1) overarching goal was to move beyond prognosis to reasonable hope; 2) tactically focused on establishing a trusting, supportive relationship; and 3) possessed incomplete awareness of their emotion regulation strategies. CONCLUSION Our novel, multimodal assessment of physician emotion regulation was feasible in a simulated SICG encounter. Physicians exhibited an incomplete understanding of their emotion regulation strategies.
Collapse
Affiliation(s)
- Garrett T Wasp
- Section of Oncology, Department of Medicine (G.T.W.), Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, USA; Dartmouth Cancer Center (DCC) (G.T.W., T.T., A.E.B.), Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, USA; The Dartmouth Institute for Health Policy & Clinical Practice (G.T.W., S.K.G., J.C., P.J.B., A.E.B.), Geisel School of Medicine, Lebanon, New Hampshire, USA.
| | - Satveer Kaur-Gill
- The Dartmouth Institute for Health Policy & Clinical Practice (G.T.W., S.K.G., J.C., P.J.B., A.E.B.), Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Eric C Anderson
- Center for Interdisciplinary Population and Health Research (E.C.A), Maine Health Institute for Research, Portland, Maine, USA; Tufts University School of Medicine (E.C.A.), Boston, MA, USA
| | - Maxwell T Vergo
- Section of Palliative Care, Department of Medicine (M.T.V., A.E.B.), Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, USA
| | - Julia Chelen
- The Dartmouth Institute for Health Policy & Clinical Practice (G.T.W., S.K.G., J.C., P.J.B., A.E.B.), Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Tor Tosteson
- Dartmouth Cancer Center (DCC) (G.T.W., T.T., A.E.B.), Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, USA; Biomedical Data Science (T.T., P.J.B.), Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Paul J Barr
- The Dartmouth Institute for Health Policy & Clinical Practice (G.T.W., S.K.G., J.C., P.J.B., A.E.B.), Geisel School of Medicine, Lebanon, New Hampshire, USA; Biomedical Data Science (T.T., P.J.B.), Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Center for Technology and Behavioral Health (P.J.B.), Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Amber E Barnato
- Dartmouth Cancer Center (DCC) (G.T.W., T.T., A.E.B.), Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, USA; The Dartmouth Institute for Health Policy & Clinical Practice (G.T.W., S.K.G., J.C., P.J.B., A.E.B.), Geisel School of Medicine, Lebanon, New Hampshire, USA; Section of Palliative Care, Department of Medicine (M.T.V., A.E.B.), Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, USA
| |
Collapse
|
15
|
Mroz EL, McDarby M, Kutner JS, Arnold RM, Bylund CL, Pollak KI. Empathic communication between clinicians, patients, and care partners in palliative care encounters. PATIENT EDUCATION AND COUNSELING 2023; 114:107811. [PMID: 37244131 PMCID: PMC10526983 DOI: 10.1016/j.pec.2023.107811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Palliative care encounters often involve empathic opportunities conveyed by patients and their care partners. In this secondary analysis, we examined empathic opportunities and clinician responses with attention to how presence of multiple care partners and clinicians shapes empathic communication. METHODS We used the Empathic Communication Coding System (ECCS) to characterize emotion-focused, challenge-focused, and progress-focused empathic opportunities and responses in 71 audio-recorded palliative care encounters in the US. RESULTS Patients expressed more emotion-focused empathic opportunities than did care partners; care partners expressed more challenge-focused empathic opportunities than did patients. Care partners initiated empathic opportunities more frequently when more care partners were present, though they expressed fewer as the number of clinicians increased. When more care partners and more clinicians were present, clinicians had fewer low-empathy responses. CONCLUSION The number of care partners and clinicians present affect empathic communication. Clinicians should be prepared for empathic communication focal points to shift depending on the number of care partners and clinicians present. PRACTICE IMPLICATIONS Findings can guide development of resources to prepare clinicians to meet emotional needs in palliative care discussions. Interventions can coach clinicians to respond empathically and pragmatically to patients and care partners, particularly when multiple care partners are in attendance.
Collapse
Affiliation(s)
- Emily L Mroz
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, United States.
| | - Meghan McDarby
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, United States
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, United States
| | - Robert M Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, United States
| | - Carma L Bylund
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, United States
| | - Kathryn I Pollak
- Cancer Prevention and Control, Duke Cancer Institute, Duke University, United States; Department of Population Health Sciences, Duke University School of Medicine, United States
| |
Collapse
|
16
|
Reich AJ, Reich JA, Mathew P. Advance Care Planning, Shared Decision Making, and Serious Illness Conversations in Onconephrology. Semin Nephrol 2023; 42:151349. [PMID: 37121171 DOI: 10.1016/j.semnephrol.2023.151349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
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.
Collapse
Affiliation(s)
- Amanda Jane Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; Department of Surgery, Harvard Medical School, Boston, MA.
| | - John Adam Reich
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Paul Mathew
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA
| |
Collapse
|
17
|
Gensheimer MF, Gupta D, Patel MI, Fardeen T, Hildebrand R, Teuteberg W, Seevaratnam B, Asuncion MK, Alves N, Rogers B, Hansen J, DeNofrio J, Shah NH, Parikh D, Neal J, Fan AC, Moore K, Ruiz S, Li C, Khaki AR, Pagtama J, Chien J, Brown T, Tisch AH, Das M, Srinivas S, Roy M, Wakelee H, Myall NJ, Huang J, Shah S, Lee H, Ramchandran K. Use of Machine Learning and Lay Care Coaches to Increase Advance Care Planning Conversations for Patients With Metastatic Cancer. JCO Oncol Pract 2023; 19:e176-e184. [PMID: 36395436 DOI: 10.1200/op.22.00128] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Patients with metastatic cancer benefit from advance care planning (ACP) conversations. We aimed to improve ACP using a computer model to select high-risk patients, with shorter predicted survival, for conversations with providers and lay care coaches. Outcomes included ACP documentation frequency and end-of-life quality measures. METHODS In this study of a quality improvement initiative, providers in four medical oncology clinics received Serious Illness Care Program training. Two clinics (thoracic/genitourinary) participated in an intervention, and two (cutaneous/sarcoma) served as controls. ACP conversations were documented in a centralized form in the electronic medical record. In the intervention, providers and care coaches received weekly e-mails highlighting upcoming clinic patients with < 2 year computer-predicted survival and no prior prognosis documentation. Care coaches contacted these patients for an ACP conversation (excluding prognosis). Providers were asked to discuss and document prognosis. RESULTS In the four clinics, 4,968 clinic visits by 1,251 patients met inclusion criteria (metastatic cancer with no prognosis previously documented). In their first visit, 28% of patients were high-risk (< 2 year predicted survival). Preintervention, 3% of both intervention and control clinic patients had ACP documentation during a visit. By intervention end (February 2021), 35% of intervention clinic patients had ACP documentation compared with 3% of control clinic patients. Providers' prognosis documentation rate also increased in intervention clinics after the intervention (2%-27% in intervention clinics, P < .0001; 0%-1% in control clinics). End-of-life care intensity was similar in intervention versus control clinics, but patients with ≥ 1 provider ACP edit met fewer high-intensity care measures (P = .04). CONCLUSION Combining a computer prognosis model with care coaches increased ACP documentation.
Collapse
Affiliation(s)
| | - Divya Gupta
- Stanford University School of Medicine, Stanford CA
| | - Manali I Patel
- Stanford University School of Medicine, Stanford CA.,VA Palo Alto Health Care System, Palo Alto, CA
| | | | | | | | | | | | - Nina Alves
- Stanford University School of Medicine, Stanford CA
| | - Brian Rogers
- Stanford University School of Medicine, Stanford CA
| | | | - Jan DeNofrio
- Stanford University School of Medicine, Stanford CA
| | - Nigam H Shah
- Stanford University School of Medicine, Stanford CA
| | - Divya Parikh
- Stanford University School of Medicine, Stanford CA
| | - Joel Neal
- Stanford University School of Medicine, Stanford CA
| | - Alice C Fan
- Stanford University School of Medicine, Stanford CA
| | - Kaidi Moore
- Stanford University School of Medicine, Stanford CA
| | - Shann Ruiz
- Stanford University School of Medicine, Stanford CA
| | - Connie Li
- Stanford University School of Medicine, Stanford CA
| | | | - Judy Pagtama
- Stanford University School of Medicine, Stanford CA
| | - Joanne Chien
- Stanford University School of Medicine, Stanford CA
| | | | | | - Millie Das
- Stanford University School of Medicine, Stanford CA
| | | | - Mohana Roy
- Stanford University School of Medicine, Stanford CA
| | | | | | - Jane Huang
- Stanford University School of Medicine, Stanford CA
| | - Sumit Shah
- Stanford University School of Medicine, Stanford CA
| | - Howard Lee
- Stanford University School of Medicine, Stanford CA
| | | |
Collapse
|
18
|
Brizzi K. Outpatient neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:29-48. [PMID: 36599513 DOI: 10.1016/b978-0-12-824535-4.00002-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Palliative care is an approach to patient care that focuses on enhancing quality of life through relief of physical, emotional, and spiritual sources of distress and patient-tailored discussions about goals of care. The palliative care approach can be delivered by any provider, and can occur alongside disease-modifying therapies. For patients with a serious neurologic illness or a neurodegenerative disease, neuropalliative care is a growing field focused on providing high-quality palliative care to neurology patients. There are three models of neuropalliative care delivery in the outpatient setting: a consultative model with a palliative care specialist, an integrated model with an embedded palliative care provider, and a primary palliative care model with the patient's neurology provider. The main components of an outpatient palliative care visit include symptom assessment and treatment, communication about serious illness, advance care planning, and assessment of caregiver needs. For patients with advanced illness, palliative care can help facilitate timely referral to hospice. Through a palliative care approach, outpatient care for patients with serious neurologic disease or neurodegenerative disease can focus on the issues most important to the patient, promote improved illness understanding and planning, and can improve the overall quality of care.
Collapse
Affiliation(s)
- Kate Brizzi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Medicine, Massachusetts General Hospital, Boston, MA, United States.
| |
Collapse
|
19
|
Goswami P. Impact of advance care planning and end-of-life conversations on patients with cancer: An integrative review of literature. J Nurs Scholarsh 2023; 55:272-290. [PMID: 35946931 DOI: 10.1111/jnu.12804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/24/2022] [Accepted: 07/08/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE The purpose was to review published articles to examine the impact of advance care planning (ACP) and end-of-life (EOL) conversations on patients with cancer, and aimed to compare the findings for congruency with the goals of ACP. DESIGN AND METHOD The study was guided by Whittemore and Knafl's integrative review methodology. Articles published between 2015 to 2020 were identified through electronic databases. The search included: Cumulative Index for Nursing Allied Health Literature (CINAHL), PubMed, MEDLINE-Ovid, and MEDLINE full text, and using the MeSH terms. Two hundred and five (205) articles were identified and screened for eligibility, and 15 articles were appraised. FINDINGS The fifteen (15) articles that met the inclusion criteria included five (5) qualitative, eight (8) quantitative, and two (2) mixed methods. The review analysis revealed six themes emerged in three categories: cancer patients' experience with advance care planning (1) patients' prognostic awareness, (2) decision making; cancer patients' perceived outcomes with advance care planning (3) patient-provider relationship, (4) concordance in care based on goals, and cancer patients' propositions related to advance care planning, (5) timings of advance care planning discussions, and (6) support during ACP and/or EOL conversations. CONCLUSION ACP and EOL conversations play a critical role in cancer patients' awareness of their disease and prognosis and help them in making end-of-life care decisions. CLINICAL RELEVANCE There exists a need for earlier ACP and EOL conversations with cancer patients with emotional support during these conversations.
Collapse
Affiliation(s)
- Poonam Goswami
- Department of Investigational Cancer Therapeutics, UT MD Anderson Cancer Center, Houston, Texas, USA.,Texas Woman's University, Denton, Texas, USA
| |
Collapse
|
20
|
LeBaron V, Flickinger T, Ling D, Lee H, Edwards J, Tewari A, Wang Z, Barnes LE. Feasibility and acceptability testing of CommSense: A novel communication technology to enhance health equity in clinician-patient interactions. Digit Health 2023; 9:20552076231184991. [PMID: 37456129 PMCID: PMC10338668 DOI: 10.1177/20552076231184991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background Quality patient-clinician communication is paramount to achieving safe and compassionate healthcare, but evaluating communication performance during real clinical encounters is challenging. Technology offers novel opportunities to provide clinicians with actionable feedback to enhance their communication skills. Methods This pilot study evaluated the acceptability and feasibility of CommSense, a novel natural language processing (NLP) application designed to record and extract key metrics of communication performance and provide real-time feedback to clinicians. Metrics of communication performance were established from a review of the literature and technical feasibility verified. CommSense was deployed on a wearable (smartwatch), and participants were recruited from an academic medical center to test the technology. Participants completed a survey about their experience; results were exported to SPSS (v.28.0) for descriptive analysis. Results Forty (n = 40) healthcare participants (nursing students, medical students, nurses, and physicians) pilot tested CommSense. Over 90% of participants "strongly agreed" or "agreed" that CommSense could improve compassionate communication (n = 38, 95%) and help healthcare organizations deliver high-quality care (n = 39, 97.5%). Most participants (n = 37, 92.5%) "strongly agreed" or "agreed" they would be willing to use CommSense in the future; 100% (n = 40) "strongly agreed" or "agreed" they were interested in seeing information analyzed by CommSense about their communication performance. Metrics of most interest were medical jargon, interruptions, and speech dominance. Conclusion Participants perceived significant benefits of CommSense to track and improve communication skills. Future work will deploy CommSense in the clinical setting with a more diverse group of participants, validate data fidelity, and explore optimal ways to share data analyzed by CommSense with end-users.
Collapse
Affiliation(s)
| | | | - David Ling
- University of Virginia School of Medicine, Charlottesville, VA
| | - Hansung Lee
- University of Virginia School of Medicine, Charlottesville, VA
| | - James Edwards
- University of Virginia School of Nursing, Charlottesville, VA
| | - Anant Tewari
- University of Virginia School of Medicine, Charlottesville, VA
| | - Zhiyuan Wang
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA
| | - Laura E Barnes
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA
| |
Collapse
|
21
|
Dalton LJ, McNiven A, Hanna JR, Rapa E. Exploring healthcare professionals' beliefs, experiences and opinions of family-centred conversations when a parent has a serious illness: A qualitative study. PLoS One 2022; 17:e0278124. [PMID: 36441706 PMCID: PMC9704560 DOI: 10.1371/journal.pone.0278124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 11/09/2022] [Indexed: 11/29/2022] Open
Abstract
This study explored healthcare professionals' perceived role in talking to adult patients about sharing their diagnosis with children. Semi-structured interviews were conducted to explore healthcare professionals' beliefs about how families could and should be supported when a parent has a serious illness. Participants were 24 healthcare professionals working in primary, secondary and tertiary NHS services in the UK with adult patients diagnosed with a serious illness. Data were analysed thematically. Many healthcare professionals reported systems to identify patients' family relationships, but this information was rarely used to initiate conversations on what and how to talk to children. It was frequently assumed that someone else in the healthcare system was supporting patients with family communication. Others reported there were more urgent priorities for the consultation or considered that talking to children was a private family matter. However, several professionals did undertake these conversations, viewing this as a central part of their role. Some healthcare professionals felt they had inadequate skills or confidence to raise talking to children with their patients and indicated a need for specific training to address this. The results highlight the importance of systematically documenting patients' relationships with children so that this information can be used to inform ongoing discussions with the healthcare team about what children have been told. Patients consistently report wanting support about how to talk to children and the benefits of effective communication are well documented. Dissemination of this evidence could encourage professionals across all specialities to include family-centred communication in routine patient care. Training resources are needed so that staff feel empowered and equipped to raise these sensitive subjects with their patients.
Collapse
Affiliation(s)
- Louise J. Dalton
- Medical Sciences Division, Department of Psychiatry, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Abigail McNiven
- Medical Sciences Division, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jeffrey R. Hanna
- Medical Sciences Division, Department of Psychiatry, University of Oxford, Oxford, United Kingdom
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, United Kingdom
| | - Elizabeth Rapa
- Medical Sciences Division, Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
22
|
Cheung KL, Smoger S, Tamura MK, Stapleton RD, Rabinowitz T, LaMantia MA, Gramling R. Content of Tele-Palliative Care Consultations with Patients Receiving Dialysis. J Palliat Med 2022; 25:1208-1214. [PMID: 35254866 PMCID: PMC9347393 DOI: 10.1089/jpm.2021.0539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background: Little is known about the content of communication in palliative care telehealth conversations in the dialysis population. Understanding the content and process of these conversations may lead to insights about how palliative care improves quality of life. Methods: We conducted a qualitative analysis of video recordings obtained during a pilot palliative teleconsultation program. We recruited patients receiving dialysis from five facilities affiliated with an academic medical center. Palliative care clinicians conducted teleconsultation using a wall-mounted screen with a camera mounted on a pole and positioned mid-screen in the line of sight to facilitate direct eye contact. Patients used an iPad that was attached to an IV pole positioned next to the dialysis chair. Conversations were coded using a preexisting framework of themes and content from the Serious Illness Conversation Guide (SICG) and revised Edmonton Symptom Assessment System-Renal. Results: We recruited 39 patients to undergo a telepalliative care consultation while receiving dialysis, 34 of whom completed the teleconsultation. Specialty palliative care clinicians (3 physicians and 1 nurse practitioner) conducted 35 visits with 34 patients. Median (interquartile range) duration of conversation was 42 (28-57) minutes. Most frequently discussed content included sources of strength (91%), critical abilities (88%), illness understanding (85%), fears and worries (85%), what family knows (85%), fatigue (77%), and pain (65%). Process features such as summarizing statements (85%) and making a recommendation (82%) were common, whereas connectional silence (56%), and emotion expression (21%) occurred less often. Conclusions: Unscripted palliative care conversations in outpatient dialysis units through telemedicine exhibited many domains recommended by the SICG, with less frequent discussion of symptoms. Emotion expression was uncommon for these conversations that occurred in an open setting.
Collapse
Affiliation(s)
- Katharine L. Cheung
- Divisions of Nephrology, Department of Medicine, Larner College of Medicine, The University of Vermont, Burlington, Vermont, USA.,Address correspondence to: Katharine L. Cheung, MD, PhD, Division of Nephrology, Department of Medicine, Larner College of Medicine at The University of Vermont, 1 South Prospect Street, 2309 UHC Med-Nephrology, Burlington, VT 05401, USA
| | - Samantha Smoger
- Department of Biology, The University of Vermont, Burlington, Vermont, USA
| | - Manjula Kurella Tamura
- Division of Nephrology, Geriatric Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Renee D. Stapleton
- Divisions of Pulmonary and Critical Care, and Department of Medicine, Larner College of Medicine, The University of Vermont, Burlington, Vermont, USA
| | - Terry Rabinowitz
- Department of Psychiatry, Larner College of Medicine, The University of Vermont, Burlington, Vermont, USA
| | - Michael A. LaMantia
- Divisions of Geriatrics, Department of Medicine, Larner College of Medicine, The University of Vermont, Burlington, Vermont, USA
| | - Robert Gramling
- Division of Palliative Medicine, Department of Family Medicine, Larner College of Medicine, The University of Vermont, Burlington, Vermont, USA
| |
Collapse
|
23
|
King M, De Lima B, Emlen E, Eckstrom E. Patient experiences of the Serious Illness Conversation Guide in a primary care setting. J Am Geriatr Soc 2022; 70:3324-3327. [PMID: 35819190 DOI: 10.1111/jgs.17943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Megan King
- Department of Family Medicine, Oregon Health & Science University, Oregon, Portland, USA
| | - Bryanna De Lima
- Division of General Internal Medicine, Oregon Health & Science University, Oregon, Portland, USA
| | - Estee Emlen
- Division of General Internal Medicine, Oregon Health & Science University, Oregon, Portland, USA
| | - Elizabeth Eckstrom
- Division of General Internal Medicine, Oregon Health & Science University, Oregon, Portland, USA
| |
Collapse
|
24
|
Tarbi EC, Blanch-Hartigan D, van Vliet LM, Gramling R, Tulsky JA, Sanders JJ. Toward a basic science of communication in serious illness. PATIENT EDUCATION AND COUNSELING 2022; 105:1963-1969. [PMID: 35410737 DOI: 10.1016/j.pec.2022.03.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/09/2022] [Accepted: 03/24/2022] [Indexed: 06/14/2023]
Abstract
High-quality communication can mitigate suffering during serious illness. Innovations in theory and technology present the opportunity to advance serious illness communication research, moving beyond inquiry that links broad communication constructs to health outcomes toward operationalizing and understanding the impact of discrete communication functions on human experience. Given the high stakes of communication during serious illness, we see a critical need to develop a basic science approach to serious illness communication research. Such an approach seeks to link "what actually happens during a conversation" - the lexical and non-lexical communication content elements, as well as contextual factors - with the emotional and cognitive experiences of patients, caregivers, and clinicians. This paper defines and justifies a basic science approach to serious illness communication research and outlines investigative and methodological opportunities in this area. A systematic understanding of the building blocks of serious illness communication can help identify evidence-informed communication strategies that promote positive patient outcomes, shape more targeted communication skills training for clinicians, and lead to more tailored and meaningful serious illness care.
Collapse
Affiliation(s)
- Elise C Tarbi
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Boston, USA.
| | | | | | - Robert Gramling
- University of Vermont. Department of Family Medicine, Burlington, USA.
| | - James A Tulsky
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Boston, USA; Brigham and Women's Hospital, Division of Palliative Medicine, Department of Medicine, Boston, USA.
| | - Justin J Sanders
- McGill University, Division of Palliative Care, Department of Family Medicine, Montreal, Canada.
| |
Collapse
|
25
|
Morberg Jämterud S, Sandgren A. Health care professionals' perceptions of factors influencing the process of identifying patients for serious illness conversations: A qualitative study. Palliat Med 2022; 36:1072-1079. [PMID: 35729752 PMCID: PMC9247430 DOI: 10.1177/02692163221102266] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Serious Illness Care Programme enables patients to receive care that is in accordance with their priorities. However, despite clarity about palliative care needs, many barriers to and difficulties in identifying patients for serious illness conversations remain. AIM To explore healthcare professionals' perceptions about factors influencing the process of identifying patients for serious illness conversations. DESIGN Qualitative design. A thematic analysis of observations and semi-structured interviews was used. SETTING/PARTICIPANTS Twelve observations at team meetings in which physicians and nurses discussed the process of identifying the patients for serious illness conversations were conducted at eight different clinics in two hospitals. Semi-structured interviews were conducted with three physicians and two nurses from five clinics. RESULTS Identifying the right patient and doing so at the right time were key to identifying patients for serious illness conversations. The continuity of relations and continuity over time could facilitate the identification process, while attitudes towards death and its relation to hope could hinder the process. CONCLUSIONS The process of identifying patients for serious illness conversations is complex and may not be captured only by generic tools such as the surprise question. It is crucial to address existential and ethical obstacles that can hinder the identification of patients for serious illness conversations.
Collapse
Affiliation(s)
- Sofia Morberg Jämterud
- Department of Thematic Studies, Linköping University, Linköping, Sweden.,Center for Collaborative Palliative Care, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
| |
Collapse
|
26
|
Yim H, Hashmi SS, Dewar B, Dyason C, Kyeremanteng K, Lamb S, Shamy M. “Everything has been tried and his heart can’t recover…”: A Descriptive Review of “Do Everything!” in the Archive of Ontario Consent and Capacity Board. BMC Med Ethics 2022; 23:66. [PMID: 35761229 PMCID: PMC9237977 DOI: 10.1186/s12910-022-00796-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 05/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background In end-of-life situations, the phrase “do everything” is sometimes invoked by physicians, patients, or substitute decision-makers (SDM), though its meaning is ambiguous. We examined instances of the phrase “do everything” in the archive of the Ontario Consent and Capacity Board (CCB) in Canada, a tribunal with judicial authority to adjudicate physician–patient conflicts in order to explore its potential meanings.
Methods We systematically searched the CCB’s online public archive from its inception to 2018 for any references to “do everything” in the context of critical care medicine and end-of-life care. Two independent assessors reviewed decisions, collected characteristics, and identified key themes. Results Of 598 cases in the archive, 41 referred to “do everything” in end-of-life situations. The phrase was overwhelmingly invoked by SDMs (38/41, 93%), typically to advocate for life-prolonging measures that contradicted physician advice. Physicians generally related “doing everything” to describe the interventions they had already performed (3/41, 7%), using it to recommend focusing on patients’ quality of life. SDMs were generally reluctant to accept death, whereas physicians found prolonging life at all costs to be morally distressing. The CCB did not interpret appeals to “do everything” legally but followed existing laws by deferring to patients’ prior wishes whenever known, or to concepts of “best interests” when not. The CCB generally recommended against life-prolonging measures in these cases (26/41, 63%), focusing on patients’ “well-being” and “best interests.”
Conclusions In this unique sample of cases involving conflict surrounding resuscitation and end-of-life care, references to “do everything” highlighted conflicts over quantity versus quality of life. These appeals were associated with signs of cognitive distress on the behalf of SDMs who were facing the prospect of a patient’s death, whereas physicians identified moral distress related to the prolongation of patients’ suffering through their use of life-sustaining interventions. This divergence in perspectives on death versus suffering was consistently the locus of conflict. These findings support the importance of tools such as the Serious Illness Conversation Guide that can be used by physicians to direct conversations on the patients’ goals, wishes, trade-offs, and to recommend a treatment plan that may include palliative care. Trial Registration Not applicable.
Collapse
|
27
|
Andersson S, Sandgren A. Organizational readiness to implement the Serious Illness Care Program in hospital settings in Sweden. BMC Health Serv Res 2022; 22:539. [PMID: 35459204 PMCID: PMC9026003 DOI: 10.1186/s12913-022-07923-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background The Serious Illness Care Program (SICP) is a model developed for structured communication, identifying patients, and training physicians to use a structured guide for conversations with patients and family members. However, there is a lack of knowledge regarding the sustainable implementation of this conversation model. Therefore, the aim of this study was to identify barriers and enablers during the implementation of the SICP in hospital settings. Methods The SICP was implemented at 20 units in two hospitals in Sweden. During the implementation process, seven individual interviews and two group interviews were conducted with seven facilitators (five physicians, one behavioral therapist, and one administrator). Data were analyzed using qualitative content analysis, first inductively, and then deductively using the organizational readiness for change as a theoretical framework. Result The analysis resulted in three factors acting as enablers and eight factors acting as enablers and/or barriers during the implementation of the SICP. The three factors considered as enablers were preliminaries, identifying patients, and facilitator’s role. The eight factors considered as enablers and/or barriers were broad implementation, leadership, time, confidence, building foundation, motivation to work change, motivation for training in serious illness conversations, and attitudes. Conclusion This study indicates limited readiness to implement the SICP in hospital settings due to considerable variation in organizational contextual factors, change efficacy, and change commitment. The identified enablers and barriers for implementation of the SICP could guide and support future implementations to be sustainable over time. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07923-5.
Collapse
Affiliation(s)
- Sofia Andersson
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden.
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| |
Collapse
|
28
|
Li EH, Ferrell W, Klaiman T, Kumar P, O'Connor N, Schuchter LM, Chen J, Patel MS, Manz CR, Parikh RB. Impact of Behavioral Nudges on the Quality of Serious Illness Conversations Among Patients With Cancer: Secondary Analysis of a Randomized Controlled Trial. JCO Oncol Pract 2022; 18:e495-e503. [PMID: 34767481 PMCID: PMC9014420 DOI: 10.1200/op.21.00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Serious Illness Conversations (SICs) are structured conversations between clinicians and patients about prognosis, treatment goals, and end-of-life preferences. Although behavioral interventions may prompt earlier or more frequent SICs, their impact on the quality of SICs is unclear. METHODS This was a secondary analysis of a randomized clinical trial (NCT03984773) among 78 clinicians and 14,607 patients with cancer testing the impact of an automated mortality prediction with behavioral nudges to clinicians to prompt more SICs. We analyzed 318 randomly selected SICs matched 1:1 by clinicians (159 control and 159 intervention) to compare the quality of intervention vs. control conversations using a validated codebook. Comprehensiveness of SIC documentation was used as a measure of quality, with higher integer numbers of documented conversation domains corresponding to higher quality conversations. A conversation was classified as high-quality if its score was ≥ 8 of a maximum of 10. Using a noninferiority design, mixed effects regression models with clinician-level random effects were used to assess SIC quality in intervention vs. control groups, concluding noninferiority if the adjusted odds ratio (aOR) was not significantly < 0.9. RESULTS Baseline characteristics of the control and intervention groups were similar. Intervention SICs were noninferior to control conversations (aOR 0.99; 95% CI, 0.91 to 1.09). The intervention increased the likelihood of addressing patient-clinician relationship (aOR = 1.99; 95% CI, 1.23 to 3.27; P < .01) and decreased the likelihood of addressing family involvement (aOR = 0.56; 95% CI, 0.34 to 0.90; P < .05). CONCLUSION A behavioral intervention that increased SIC frequency did not decrease their quality. Behavioral prompts may increase SIC frequency without sacrificing quality.
Collapse
Affiliation(s)
- Eric H. Li
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William Ferrell
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tamar Klaiman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pallavi Kumar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nina O'Connor
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lynn M. Schuchter
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Jinbo Chen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mitesh S. Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA,Penn Medicine Nudge Unit, Philadelphia, PA,Wharton School of the University of Pennsylvania, Philadelphia, PA
| | - Christopher R. Manz
- Dana Farber Cancer Institute, Boston, MA,Harvard Medical School, Harvard University, Boston, MA
| | - Ravi B. Parikh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA,Ravi B. Parikh, MD, MPP, 423 Guardian Drive, Blockley 1102, Philadelphia, PA 19104; e-mail:
| |
Collapse
|
29
|
Patient Identification for Serious Illness Conversations: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074162. [PMID: 35409844 PMCID: PMC8998898 DOI: 10.3390/ijerph19074162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 02/04/2023]
Abstract
Serious illness conversations aim to align medical care and treatment with patients’ values, goals, priorities, and preferences. Timely and accurate identification of patients for serious illness conversations is essential; however, existent methods for patient identification in different settings and population groups have not been compared and contrasted. This study aimed to examine the current literature regarding patient identification for serious illness conversations within the context of the Serious Illness Care Program and/or the Serious Illness Conversation Guide. A scoping review was conducted using the Joanna Briggs Institute guidelines. A comprehensive search was undertaken in four databases for literature published between January 2014 and September 2021. In total, 39 articles met the criteria for inclusion. This review found that patients were primarily identified for serious illness conversations using clinical/diagnostic triggers, the ’surprise question’, or a combination of methods. A diverse assortment of clinicians and non-clinical resources were described in the identification process, including physicians, nurses, allied health staff, administrative staff, and automated algorithms. Facilitators and barriers to patient identification are elucidated. Future research should test the efficacy of adapted identification methods and explore how clinicians inform judgements surrounding patient identification.
Collapse
|
30
|
Arney J, Gray C, Clark JA, Smith D, Swank A, Matlock DD, Melcher J, Kanwal F, Naik AD. Prognosis conversations in advanced liver disease: A qualitative interview study with health professionals and patients. PLoS One 2022; 17:e0263874. [PMID: 35180233 PMCID: PMC8856527 DOI: 10.1371/journal.pone.0263874] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 01/31/2022] [Indexed: 12/16/2022] Open
Abstract
Advanced Liver Disease (AdvLD) is common, morbid, and associated with high likelihood of death. Patients may not fully understand their prognosis and are often unprepared for the course of illness. Little is known about how and when to deliver prognosis-related information to patients with AdvLD, who should participate, and what should be discussed. We conducted in-depth interviews with a multi-profession sample of Hepatology clinicians and patients with AdvLD. Participants were drawn from three geographically diverse facilities (New England, Texas, California). We used inductive and deductive qualitative data analysis approaches to identify themes related to AdvLD prognosis discussions. Thematic analysis focused on content, timing, and participants’ roles in prognosis discussions. In total, 31 patients with AdvLD and 26 multi-profession clinicians completed interviews. Most participants provided a broad conceptualization of prognosis beyond predictions of survival, including expectations about illness course, ways to manage or avoid complications and a need to address patients’ emotions. Patients favored initiating discussions early in the AdvLD course and welcomed a multi-profession approach to conducting discussions. Clinicians favored a larger role for specialty physicians. All participants recognized that AdvLD prognosis discussions occur infrequently and favored a structured, standardized approach to broadly discussing prognosis. Patients with AdvLD and their clinicians favored a multifaceted approach to prognosis conversations including discussions of life expectancy, predictions about likely course of liver disease, and expected changes in function and capabilities over time. Structured and early prognosis discussions should be part of routine AdvLD care.
Collapse
Affiliation(s)
- Jennifer Arney
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Sociology, University of Houston-Clear Lake, Houston, Texas, United States of America
| | - Caroline Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, United States of America
| | - Jack A. Clark
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Donna Smith
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
| | - Annie Swank
- Department of Sociology, University of Houston-Clear Lake, Houston, Texas, United States of America
| | - Daniel D. Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, Colorado
| | - Jennifer Melcher
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
| | - Fasiha Kanwal
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Aanand D. Naik
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Medicine, Section of Geriatrics and Palliative Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, Texas, Colorado
- * E-mail:
| |
Collapse
|
31
|
Karim S, Levine O, Simon J. The Serious Illness Care Program in Oncology: Evidence, Real-World Implementation and Ongoing Barriers. Curr Oncol 2022; 29:1527-1536. [PMID: 35323328 PMCID: PMC8947515 DOI: 10.3390/curroncol29030128] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/22/2022] [Indexed: 11/16/2022] Open
Abstract
The Serious Illness Care Program (SICP), designed by Ariadne Labs, is a multicomponent intervention to improve conversations about values and goals for patients with a life-limiting illness. In oncology, implementation of the SICP achieved more, earlier, and better-quality conversations and reduced anxiety and depression among patients with advanced cancer. In this commentary, we describe the SICP, including results from the cluster-randomized trial, provide examples of real-world implementation of this program, and highlight ongoing challenges and barriers that are preventing widespread adoption of this intervention into routine practice. For the SICP to be successfully embedded into routine patient care, it will require significant effort, including ongoing leadership support and training opportunities, champions from all sectors of the interdisciplinary team, and adaptation of the program to a wider range of patients. Future research should also investigate how early conversations can be translated into personalized care plans for patients.
Collapse
Affiliation(s)
- Safiya Karim
- Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, AB T2N 4N2, Canada;
- Correspondence: ; Tel.: +1-403-521-3166; Fax: +1-402-283-1651
| | - Oren Levine
- Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, ON L8V 5C2, Canada;
| | - Jessica Simon
- Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, AB T2N 4N2, Canada;
- Department of Community Health Services, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N2, Canada
| |
Collapse
|
32
|
Kishino M, Ellis-Smith C, Afolabi O, Koffman J. Family involvement in advance care planning for people living with advanced cancer: A systematic mixed-methods review. Palliat Med 2022; 36:462-477. [PMID: 34989274 PMCID: PMC8972955 DOI: 10.1177/02692163211068282] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Advance care planning is important for people with advanced cancer. Family involvement in advance care planning may be instrumental to achieving goal-concordant care since they frequently become surrogate decision-makers. AIM To examine components, contexts, effects and linkages with intended outcomes of involving family members in advance care planning. DESIGN A mixed-methods systematic review, in which quantitative and qualitative data were extracted and synthesised using thematic synthesis leading to a logic model. Prospectively registered on PROSPERO (CRD42020208143). DATA SOURCES Primary quantitative and qualitative research regarding family-involved advance care planning for people with advanced cancer were identified using Medline, Embase, PsycINFO and CINAHL from inception to September 2020. Quality appraisal was performed with 'QualSyst'. RESULTS Fourteen articles were included. The synthesis identified perceptions of individuals and family members concerning family involvement in advance care planning and presents components for family-integrated advance care planning intervention. The logic model includes (i) addressing family members' concerns and emotions and (ii) facilitating communication between individuals and family members which are distinctive when healthcare professionals engage with individuals as well as family members. CONCLUSIONS This review provides a comprehensive understanding of family involvement in advance care planning and could inform its assessment and implementation in clinical practice. The number of included articles was limited. Therefore future research must focus on family integration and exploration of stakeholders' perceptions to identify additional components and linkages between them within family-integrated advance care planning.
Collapse
Affiliation(s)
- Megumi Kishino
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Clare Ellis-Smith
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Oladayo Afolabi
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Jonathan Koffman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| |
Collapse
|
33
|
Sanders JJ, Manson L, Constien D, Downar J. Discussing prognosis and what matters most for people with serious illness. BMJ 2022; 376:e067572. [PMID: 35228302 DOI: 10.1136/bmj-2021-067572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Justin J Sanders
- Palliative Care McGill, Department of Family Medicine, McGill University, Montreal, Canada
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Leigh Manson
- Health Quality and Safety Commission, New Zealand
| | | | - James Downar
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Bruyere Continuing Care, Ottawa, Canada
| |
Collapse
|
34
|
Xu L, Sommer RK, Nyeko L, Michael C, Traeger L, Jacobsen J. Patient Perspectives on Serious Illness Conversations in Primary Care. J Palliat Med 2022; 25:940-944. [PMID: 35196134 DOI: 10.1089/jpm.2021.0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The Serious Illness Care Program has been shown to improve quality and feasibility of value-based end-of-life conversations in primary care. Objectives: To elicit patients' perspectives on serious illness conversations conducted by primary care clinicians. Subjects and Methods: Telephone interviews were conducted with patients at an academic center in the United States, who had a recent serious illness conversation with their primary care clinician. Interviews were audio-recorded and qualitatively analyzed using thematic analysis. Results: A total of eleven patients were enrolled. We identified three major themes: (1) positive emotional experiences are facilitated by established patient-clinician relationships and/or clinicians' skills in navigating emotional challenges, (2) patients appreciate a personalized conversation, and (3) clinicians should orchestrate the experience of the conversation, from preparation through follow-up. Conclusion: Patients appreciate having serious illness conversations in the primary care setting. Future efforts can be focused on improving clinicians' skills in navigating emotional challenges during conversations and implementing system changes to optimize orchestration.
Collapse
Affiliation(s)
- Luyi Xu
- Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Robert K Sommer
- Department of Educational and Psychological Studies, University of Miami, Coral Gables, Florida, USA
| | - Liza Nyeko
- Office of Patient Experience and Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians Organization, Boston, Massachusetts, USA
| | - Carol Michael
- Massachusetts General Hospital Patient and Family Advisory Council, Boston, Massachusetts, USA
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
35
|
Chen AT, Tsui S, Sharma RK. Characterizing uncertainty in goals-of-care discussions among black and white patients: a qualitative study. Palliat Care 2022; 21:24. [PMID: 35177049 PMCID: PMC8851788 DOI: 10.1186/s12904-022-00912-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Uncertainty has been associated with distress and poorer quality of life in patients with advanced cancer. Prior studies have focused on prognostic uncertainty; little is known about other types of uncertainty that patients and family members experience when discussing goals of care. Understanding the types of uncertainty expressed and differences between Black and White patients can inform the development of uncertainty management interventions. METHODS This study sought to characterize the types of uncertainty expressed by Black and White patients and family members within the context of information needs during inpatient goals-of-care discussions. We performed a secondary analysis of transcripts from 62 recorded goals-of-care discussions that occurred between 2012 and 2014 at an urban, academic medical center in the United States. We applied an adapted taxonomy of uncertainty to data coded as describing information needs and used an inductive qualitative analysis method to analyze the discussions. We report the types of uncertainty expressed in these discussions. RESULTS Fifty discussions included patient or family expressions of information needs. Of these, 40 discussions (n=16 Black and n=24 White) included statements of uncertainty. Black and White patients and families most frequently expressed uncertainty related to processes and structures of care (system-centered uncertainty) and to treatment (scientific uncertainty). Statements of prognostic uncertainty focused on quantitative information among Whites and on qualitative information and expectations for the future among Blacks. CONCLUSIONS Black and White patients and families frequently expressed system-centered uncertainty, suggesting this may be an important target for intervention. Addressing other sources of uncertainty, such as prognostic uncertainty, may need more tailored approaches.
Collapse
Affiliation(s)
- Annie T Chen
- Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, 850 Republican St, Box 358047, 98109, Seattle, WA, United States.
| | - Shelley Tsui
- University of Washington, WA, Seattle, United States
| | - Rashmi K Sharma
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, United States
| |
Collapse
|
36
|
Bloom JR, Marshall DC, Rodriguez-Russo C, Martin E, Jones JA, Dharmarajan KV. Prognostic disclosure in oncology - current communication models: a scoping review. BMJ Support Palliat Care 2022; 12:167-177. [PMID: 35144938 DOI: 10.1136/bmjspcare-2021-003313] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/08/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prognostic disclosure is essential to informed decision making in oncology, yet many oncologists are unsure how to successfully facilitate this discussion. This scoping review determines what prognostic communication models exist, compares and contrasts these models, and explores the supporting evidence. METHOD A protocol was created for this study using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols extension for Scoping Reviews. Comprehensive literature searches of electronic databases MEDLINE, EMBASE, PsycINFO and Cochrane CENTRAL were executed to identify relevant publications between 1971 and 2020. RESULTS In total, 1532 articles were identified, of which 78 met inclusion criteria and contained 5 communication models. Three of these have been validated in randomised controlled trials (the Serious Illness Conversation Guide, the Four Habits Model and the ADAPT acronym) and have demonstrated improved objective communication measures and patient reported outcomes. All three models emphasise the importance of exploring patients' illness understanding and treatment preferences, communicating prognosis and responding to emotion. CONCLUSION Communicating prognostic estimates is a core competency skill in advanced cancer care. This scoping review highlights available communication models and identifies areas in need of further assessment. Such areas include how to maintain learnt communication skills for lifelong practice, how to assess patient and caregiver understanding during and after these conversations, and how to best scale these protocols at the institutional and national levels.
Collapse
Affiliation(s)
- Julie Rachel Bloom
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Carlos Rodriguez-Russo
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Martin
- Palliative Care Program, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Joshua Adam Jones
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kavita Vyas Dharmarajan
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
37
|
Serious Illness Discussion in Palliative Care—A Case Study Approach in an African American Patient with Cancer. Crit Care Nurs Clin North Am 2022; 34:79-90. [DOI: 10.1016/j.cnc.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
38
|
Tarbi EC, Gramling R, Bradway C, Meghani SH. "If it's the time, it's the time": Existential communication in naturally-occurring palliative care conversations with individuals with advanced cancer, their families, and clinicians. PATIENT EDUCATION AND COUNSELING 2021; 104:2963-2968. [PMID: 33992483 PMCID: PMC8578593 DOI: 10.1016/j.pec.2021.04.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/25/2021] [Accepted: 04/22/2021] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To explore how patients with advanced cancer, their families, and palliative care clinicians communicate about existential experience during palliative care conversations. METHODS We analyzed data from the Palliative Care Communication Research Initiative (PCCRI) - a multisite cohort study conducted between 2014 and 2016 involving hospitalized adults with advanced cancer who were referred for inpatient palliative care consultations at two academic medical centers. We used a qualitative descriptive approach paired with inductive content analysis to analyze a random subsample of 30 patients from the PCCRI study (contributing to 38 palliative care conversations). RESULTS We found existential communication to be woven throughout palliative care conversations, with key themes related to: 1) time as a pressing boundary; 2) maintaining a coherent self; and 3) connecting with others. CONCLUSION Communication about existential experience is omnipresent and varied in palliative care conversations between individuals with advanced cancer, their families, and clinicians. PRACTICE IMPLICATIONS Clinicians can recognize that discussion of time, routines of daily life, and relationships in the clinical context may hold profound existential relevance in palliative care conversations. Understanding how patients and families talk about existential experience in conversation can create opportunities for clinicians to better meet these needs.
Collapse
Affiliation(s)
- Elise C Tarbi
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, USA; NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, USA.
| | - Robert Gramling
- Department of Family Medicine, University of Vermont College of Medicine, Burlington, USA
| | - Christine Bradway
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, USA
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, USA
| |
Collapse
|
39
|
Wasp GT, Cullinan AM, Chamberlin MD, Hayes C, Barnato AE, Vergo MT. Implementation and Impact of a Serious Illness Communication Training for Hematology-Oncology Fellows. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2021; 36:1325-1332. [PMID: 32504362 DOI: 10.1007/s13187-020-01772-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Effective communication between providers and patients with serious illness is critical to ensure that treatment is aligned with patient goals. We developed and tested an implementation strategy for incorporating the previously developed Serious Illness Conversation Guide (SICG), a clinician script, into hematology-oncology fellowship training at a single US academic medical center. Between December 2017 and April 2018, we trained 8 oncology fellows to use and document the SICG. The training included associated communication skills-such as handling emotion and headlining-over 7 didactic sessions. Implementation strategies included training 4 oncology faculty as coaches to re-enforce fellows' skills and an electronic medical record template to document the SICG. We assessed effectiveness using 4 approaches: (1) SICG template use among fellows in the 12 months following training, (2) fellow confidence pre- and post-intervention via survey, (3) performance in 2 simulated patient encounters, and (4) semi-structured interviews after 12 months. Fellows successfully implemented the SICG in simulated patient encounters, though only 2 of 6 fellows documented any SICG in the clinical practice. Most fellows reported greater confidence in their communication after training. Thematic analysis of interviews revealed the following: (1) positive training experience, (2) improved patient preference elicitation, (3) selected SICG components used in a single encounter, (4) prioritize other clinical duties, (5) importance of emotion handling skills, (6) no faculty coaching receive outside training. Despite acquisition of communication skills, promoting new clinical behaviors remains challenging. More work is needed to identify which implementation strategies are required in this learner population.
Collapse
Affiliation(s)
- Garrett T Wasp
- Department of Internal Medicine, Section of Oncology, Dartmouth-Hitchcock Medical Center (DHMC), 1 Medical Center Dr., Lebanon, NH, 03766, USA.
| | - Amelia M Cullinan
- Department of Internal Medicine, Section of Palliative Medicine, DHMC, 1 Medical Center Dr., Lebanon, NH, USA
| | - Mary D Chamberlin
- Department of Internal Medicine, Section of Oncology, Dartmouth-Hitchcock Medical Center (DHMC), 1 Medical Center Dr., Lebanon, NH, 03766, USA
| | - Christi Hayes
- Department of Internal Medicine, Section of Hematology, DHMC, 1 Medical Center Dr., Lebanon, NH, USA
| | - Amber E Barnato
- Department of Internal Medicine, Section of Palliative Medicine, DHMC, 1 Medical Center Dr., Lebanon, NH, USA
- The Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Maxwell T Vergo
- Department of Internal Medicine, Section of Palliative Medicine, DHMC, 1 Medical Center Dr., Lebanon, NH, USA
| |
Collapse
|
40
|
Westendorp J, Evers AWM, Stouthard JML, Budding J, van der Wall E, Plum NMF, Velting M, Francke AL, van Dulmen S, Olde Hartman TC, Van Vliet LM. Mind your words: Oncologists' communication that potentially harms patients with advanced cancer: A survey on patient perspectives. Cancer 2021; 128:1133-1140. [PMID: 34762305 PMCID: PMC9298810 DOI: 10.1002/cncr.34018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Many complaints in medicine and in advanced illnesses are about communication. Little is known about which specific communications harm. This study explored the perspectives of patients with advanced cancer about potentially harmful communication behaviors by oncologists and helpful alternatives. METHODS An online survey design was used that was based on literature scoping and patient/clinician/researcher input. Patients with advanced cancer (n = 74) reflected on the potential harmfulness of 19 communication situations. They were asked whether they perceived the situation as one in which communication could be harmful (yes/no). If they answered "yes," they were asked whether they perceived the examples as harmful (yes/no) or helpful (yes/no) and to provide open comments. Results were analyzed quantitatively and qualitatively (content analysis). RESULTS Communication regarding information provision, prognosis discussion, decision-making, and empathy could be unnecessarily potentially harmful, and this occurred in various ways, such as making vague promises instead of concrete ones (92%), being too directive in decision-making (qualitative), and not listening to the patient (88%). Not all patients considered other situations potentially harmful (eg, introducing the option of refraining from anticancer therapy [49%] and giving too much [prognostic] information [60%]). Exploring each individual patients' needs/preferences seemed to be a precondition for helpful communication. CONCLUSIONS This article provides patient perspectives on oncologists' unnecessarily potentially harmful communication behaviors and offers practical tools to improve communication in advanced cancer care. Both preventable pitfalls and delicate challenges requiring an individualized approach, where exploration might help, are described. Although providing difficult and unwelcome news is a core task for clinicians, this study might help them to do so while preventing potentially unnecessary harm.
Collapse
Affiliation(s)
- Janine Westendorp
- Health, Medical, and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - Andrea W M Evers
- Health, Medical, and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | | | | | - Elsken van der Wall
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Nicole M F Plum
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Mirjam Velting
- Dutch Breast Cancer Association (BVN), Utrecht, the Netherlands
| | - Anneke L Francke
- Netherlands Institute for Health Services Research, Utrecht, the Netherlands.,Amsterdam Public Health Institute, Vrije Universiteit, Amsterdam, the Netherlands
| | - Sandra van Dulmen
- Netherlands Institute for Health Services Research, Utrecht, the Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Liesbeth M Van Vliet
- Health, Medical, and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
| |
Collapse
|
41
|
Borregaard Myrhøj C, Novrup Clemmensen S, Sax Røgind S, Jarden M, Toudal Viftrup D. Serious illness conversations in patients with multiple myeloma and their family caregivers-A qualitative interview study. Eur J Cancer Care (Engl) 2021; 31:e13537. [PMID: 34734446 DOI: 10.1111/ecc.13537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/02/2021] [Accepted: 10/13/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Patients treated for multiple myeloma often suffer from anxiety and depression related to concerns about the future. This indicates a need for improvement of communication between patients and healthcare professionals within haematology. The aim of this study was to explore how patients with multiple myeloma and their caregivers experience serious illness conversation focusing on illness understanding, concerns, values, and wishes for the future. METHODS Phenomenological, semi-structured dyad interviews were carried out in patients with multiple myeloma (n = 12) and their caregivers (n = 11) 2-20 days after participation in one serious illness conversation. interpretive phenomenological analysis was used for analysing data. RESULTS Three themes emerged (1) transforming patient-caregiver communication, (2) redeeming communication, and (3) equality in communication in an unequal relation. Furthermore, time allocated for the conversation and preparatory materials for the conversations highly influenced outcome. CONCLUSION The findings suggest that serious illness conversation can help patients and family caregivers managing living life with multiple myeloma by increasing dyadic communication and strengthen their use of existential language together with healthcare professionals. This study highlights the benefits of preparing patients and caregivers prior to the conversation and cancer care systems should strive to allocate ample time for serious illness conversations.
Collapse
Affiliation(s)
| | - Stine Novrup Clemmensen
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Signe Sax Røgind
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mary Jarden
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dorte Toudal Viftrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
42
|
Ma JE, Haverfield M, Lorenz KA, Bekelman DB, Brown-Johnson C, Lo N, Foglia MB, Lowery JS, Walling AM, Giannitrapani KF. Exploring expanded interdisciplinary roles in goals of care conversations in a national goals of care initiative: A qualitative approach. Palliat Med 2021; 35:1542-1552. [PMID: 34080488 DOI: 10.1177/02692163211020473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The United States Veterans Health Administration National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative throughout the Veterans Health Administration health care system in 2017. This policy encourages goals of care conversations, referring to conversations about patient's treatment and end-of-life wishes for life-sustaining treatments, among Veterans with serious illnesses. A key component of the initiative is expanding interdisciplinary provider roles in having goals of care conversations. AIM Use organizational role theory to explore medical center experiences with expanding interdisciplinary roles in the implementation of a goals of care initiative. DESIGN A qualitative thematic analysis of semi-structured interviews. SETTING/PARTICIPANTS Initial participants were recruited using purposive sampling of local medical center champions. Snowball sampling identified additional participants. Participants included thirty-one interdisciplinary providers from 12 geographically diverse initiative pilot and spread medical centers. RESULTS Five themes were identified. Expanding provider roles in goals of care conversations (1) involves organizational culture change; (2) is influenced by medical center leadership; (3) is supported by provider role readiness; (4) benefits from cross-disciplinary role agreement; and (5) can "overwhelm" providers. CONCLUSIONS Organizational role theory is a helpful framework for exploring interdisciplinary roles in a goals of care initiative. Support and recognition of provider role expansion in goals of care conversations was important for the adoption of a goals of care initiative. Actionable strategies, including multi-level leadership support and the use of interdisciplinary champions, facilitate role change and have potential to strengthen uptake of a goals of care initiative.
Collapse
Affiliation(s)
- Jessica E Ma
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health System, Durham, NC, USA
| | - Marie Haverfield
- Department of Communication Studies, San José State University, San José, CA, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Karl A Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - David B Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, CO, USA.,Center of Innovation for Veteran-Centered and Value Driven Care and Department of Medicine, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Natalie Lo
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Mary Beth Foglia
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA.,National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA
| | - Jill S Lowery
- National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Anne M Walling
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, West Los Angeles, CA, USA.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Karleen F Giannitrapani
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
43
|
Rapa E, Hanna JR, Mayland CR, Mason S, Moltrecht B, Dalton LJ. Experiences of preparing children for a death of an important adult during the COVID-19 pandemic: a mixed methods study. BMJ Open 2021; 11:e053099. [PMID: 34400462 PMCID: PMC8370837 DOI: 10.1136/bmjopen-2021-053099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The objectives of this study were to investigate how families prepared children for the death of a significant adult, and how health and social care professionals provided psychosocial support to families about a relative's death during the COVID-19 pandemic. DESIGN/SETTING A mixed methods design; an observational survey with health and social care professionals and relatives bereaved during the COVID-19 pandemic in the UK, and in-depth interviews with bereaved relatives and professionals were conducted. Data were analysed thematically. PARTICIPANTS A total of 623 participants completed the survey and interviews were conducted with 19 bereaved relatives and 16 professionals. RESULTS Many children were not prepared for a death of an important adult during the pandemic. Obstacles to preparing children included families' lack of understanding about their relative's declining health; parental belief that not telling children was protecting them from becoming upset; and parents' uncertainty about how best to prepare their children for the death. Only 10.2% (n=11) of relatives reported professionals asked them about their deceased relative's relationships with children. This contrasts with 68.5% (n=72) of professionals who reported that the healthcare team asked about patient's relationships with children. Professionals did not provide families with psychosocial support to facilitate preparation, and resources were less available or inappropriate for families during the pandemic. Three themes were identified: (1) obstacles to telling children a significant adult is going to die, (2) professionals' role in helping families to prepare children for the death of a significant adult during the pandemic, and (3) how families prepare children for the death of a significant adult. CONCLUSIONS Professionals need to: provide clear and honest communication about a poor prognosis; start a conversation with families about the dying patient's significant relationships with children; and reassure families that telling children someone close to them is dying is beneficial for their longer term psychological adjustment.
Collapse
Affiliation(s)
| | | | - Catriona R Mayland
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
- Palliative Care Institute Liverpool, University of Liverpool, Liverpool, UK
| | - Stephen Mason
- Palliative Care Institute Liverpool, University of Liverpool, Liverpool, UK
| | | | | |
Collapse
|
44
|
Stephens E, William L, Lim LL, Allen J, Zappa B, Newnham E, Vivekananda K. Complex conversations in a healthcare setting: experiences from an interprofessional workshop on clinician-patient communication skills. BMC MEDICAL EDUCATION 2021; 21:343. [PMID: 34126985 PMCID: PMC8204413 DOI: 10.1186/s12909-021-02785-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/03/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Communication is pivotal to the effective care and treatment of patients in our health care systems. Despite this understanding, clinicians are not sufficiently educated to confidently conduct complex discussions with patients. Communication skills workshops have been shown to be an effective educational format to improve clinician skills. However, despite the increasing interprofessional focus within modern medicine, there have been few studies looking at interprofessional communication workshops. METHODS A qualitative study was conducted to assess how an interprofessional communication skills workshop affected the communication skills of clinicians at a tertiary health service. Pre- and post-workshop surveys were undertaken by participants, followed by focus group interviews eight-weeks post workshop. RESULTS Clinicians were able to incorporate learnt communication skills into their daily practice. This was associated with an improvement in confidence of clinicians in having complex discussions, in addition to a reduction in the burden of having complex discussions. Participants responded positively to the interdisciplinary format, reporting benefits from the learning experience that translated into daily practice. CONCLUSION Clinicians' communication skills in conducting complex clinician-patient conversations can be improved by participation in interprofessional communication skills workshops. We identified that the interprofessional aspect of the workshops not only improved interprofessional understanding and relationships, but also developed increased self-awareness during complex discussions, and reduced the sense of burden felt by clinicians.
Collapse
Affiliation(s)
- Edward Stephens
- Eastern Health, Arnold Street, Box Hill, Victoria, Australia.
| | - Leeroy William
- Eastern Health, Arnold Street, Box Hill, Victoria, Australia
| | - Lyn-Li Lim
- Eastern Health, Arnold Street, Box Hill, Victoria, Australia
| | - Judy Allen
- Eastern Health, Arnold Street, Box Hill, Victoria, Australia
| | - Bernadette Zappa
- Eastern Health Cancer Services, Eastern Health, Arnold Street, Box Hill, Victoria, Australia
| | - Evan Newnham
- Eastern Health, Arnold Street, Box Hill, Victoria, Australia
| | - Kitty Vivekananda
- Monash University, Level 1 Learning and Teaching Building, 19 Ancora Imparo Way, Clayton, Victoria, Australia
| |
Collapse
|
45
|
Knutzen KE, Sacks OA, Brody-Bizar OC, Murray GF, Jain RH, Holdcroft LA, Alam SS, Liu MA, Pollak KI, Tulsky JA, Barnato AE. Actual and Missed Opportunities for End-of-Life Care Discussions With Oncology Patients: A Qualitative Study. JAMA Netw Open 2021; 4:e2113193. [PMID: 34110395 PMCID: PMC8193430 DOI: 10.1001/jamanetworkopen.2021.13193] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/13/2021] [Indexed: 11/14/2022] Open
Abstract
Importance Early discussion of end-of-life (EOL) care preferences improves clinical outcomes and goal-concordant care. However, most EOL discussions occur approximately 1 month before death, despite most patients desiring information earlier. Objective To describe successful navigation and missed opportunities for EOL discussions (eg, advance care planning, palliative care, discontinuation of disease-directed treatment, hospice care, and after-death wishes) between oncologists and outpatients with advanced cancer. Design, Setting, and Participants This study is a secondary qualitative analysis of outpatient visits audio-recorded between November 2010 and September 2014 for the Studying Communication in Oncologist-Patient Encounters randomized clinical trial. The study was conducted at 2 US academic medical centers. Participants included medical, gynecological, and radiation oncologists and patients with stage IV malignant neoplasm, whom oncologists characterized as being ones whom they "…would not be surprised if they were admitted to an intensive care unit or died within one year." Data were analyzed between January 2018 and August 2020. Exposures The parent study randomized participants to oncologist- and patient-directed interventions to facilitate discussion of emotions. Encounters were sampled across preintervention and postintervention periods and all 4 treatment conditions. Main Outcomes and Measures Secondary qualitative analysis was done of patient-oncologist dyads with 3 consecutive visits for EOL discussions, and a random sample of 7 to 8 dyads from 4 trial groups was analyzed for missed opportunities. Results The full sample included 141 patients (54 women [38.3%]) and 39 oncologists (8 women [19.5%]) (mean [SD] age for both patients and oncologists, 56.3 [10.0] years). Of 423 encounters, only 21 (5%) included EOL discussions. Oncologists reevaluated treatment options in response to patients' concerns, honored patients as experts on their goals, or used anticipatory guidance to frame treatment reevaluation. In the random sample of 31 dyads and 93 encounters, 35 (38%) included at least 1 missed opportunity. Oncologists responded inadequately to patient concerns over disease progression or dying, used optimistic future talk to address patient concerns, or expressed concern over treatment discontinuation. Only 4 of 23 oncologists (17.4%) had both an EOL discussion and a missed opportunity. Conclusions and Relevance Opportunities for EOL discussions were rarely realized, whereas missed opportunities were more common, a trend that mirrored oncologists' treatment style. There remains a need to address oncologists' sensitivity to EOL discussions, to avoid unnecessary EOL treatment.
Collapse
Affiliation(s)
- Kristin E. Knutzen
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Olivia A. Sacks
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | | | - Genevra F. Murray
- Department of General Medicine, Boston Medical Center, Boston, Massachusetts
| | - Raina H. Jain
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | | | - Shama S. Alam
- Pharmaceutical Product Development, Evidera, Bethesda, Maryland
| | - Matthew A. Liu
- School of Medicine, University of California, San Diego, La Jolla
| | | | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Amber E. Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| |
Collapse
|
46
|
Abstract
PURPOSE OF REVIEW Our goal was to provide healthcare professionals (HCPs) with evidence-based data about what can be done to handle prognostic discussions with empathy. RECENT FINDINGS First, disclosing prognosis involves a good reason to do so and making sure that the patient will be able to process the discussion. Second, communication tips are given for the three dimensions of empathy: "establishing rapport with the patient," which should not be overlooked; the emotional dimension, which involves an accurate understanding of the patient and communication skills; and the "active/positive" dimension which is about giving hope, explaining things clearly and helping patients take control with shared decision-making and a planned future. Although communication tips are helpful, empathy training should be based more on the development of HCPs' emotional skills, in order to help them regulate their emotions and thus be more comfortable with those of patients and families. Furthermore, research into empathy toward minorities and relatives is needed.
Collapse
Affiliation(s)
- Sophie Lelorain
- Univ. Lille, CNRS, UMR 9193 - SCALab - Sciences Cognitives et Sciences Affectives, F-59000, Lille, France.
| |
Collapse
|
47
|
Ernecoff NC, Wessell KL, Wood WA, Winzelberg GS, Collichio FA, Hanson LC. How well do documented goals-of-care discussions for patients with stage IV cancer reflect communication best practices? BMC Palliat Care 2021; 20:41. [PMID: 33691683 PMCID: PMC7944465 DOI: 10.1186/s12904-021-00733-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 02/25/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Written clinical communication regarding patients' disease understanding and values may facilitate goal-concordant care, yet little is known about the quality of electronic health record (EHR) documentation. We sought to (1) describe frequency of communication best practices in EHR-documented goals-of-care discussions, and (2) assess whether templated notes improve quality of documentation. METHODS Researchers pulled text of EHR-documented goals-of-care discussions for hospitalized patients with Stage IV cancer from admission to 60-days follow-up. Text was included when in a single encounter the clinician addressed: (a) prognosis and/or illness understanding; and (b) goals and/or treatment options. Researchers qualitatively coded text based on guidelines for communication best practices, and noted if an EHR template was used. RESULTS Forty-two percent (206/492) of patients had EHR-documented goals-of-care discussions. Text frequently described communication of cancer progression (89%), though rarely included prognosis (22%). Text often included patients' goals and values (83%), and at least on specific treatment decision (82%). Communication about treatments was included for 98% of patients; common examples included cancer treatment (62%), hospice (62%), resuscitation (51%), or intensive care (38%). Clinicians documented making recommendations for 40% of patients. Text addressing patient emotional and spiritual concerns was uncommon (15%). Compared to free text, use of a template was associated with increased documentation of goals and values (80% vs. 61%, p < 0.01), but not other best practices. CONCLUSION Insights from the study can be used to guide future training and research to study and improve the quality of documentation about goal of care, and its impact on goal-concordant care.
Collapse
Affiliation(s)
- Natalie C Ernecoff
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, 3600 Forbes Avenue, 405.35 Iroquois Building, Pittsburgh, PA, 15213, USA.
| | - Kathryn L Wessell
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, USA
| | - William A Wood
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina, Chapel Hill, USA
| | - Gary S Winzelberg
- Department of Medicine, Division of Geriatric Medicine and Palliative Care Program, University of North Carolina, Chapel Hill, USA
| | - Frances A Collichio
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina, Chapel Hill, USA
| | - Laura C Hanson
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, USA
- Department of Medicine, Division of Geriatric Medicine and Palliative Care Program, University of North Carolina, Chapel Hill, USA
| |
Collapse
|
48
|
Karim S, Lupichuk S, Tan A, Sinnarajah A, Simon J. Real World Implementation of the Serious Illness Care Program in Cancer Care: Results of a Quality Improvement Initiative. J Palliat Med 2021; 24:905-909. [PMID: 33434442 DOI: 10.1089/jpm.2020.0680] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: Guidelines suggest that advance care planning (ACP) and goals-of-care discussions should be conducted for patients with advanced cancer early in the course of their disease. A recent audit of our health system found that these discussions were rarely being documented in the electronic medical record (EMR). We conducted a quality improvement initiative to improve rates of documentation of goals and wishes among patients with advanced cancer. Methods: On the basis of previous analyses of this problem, we determined that provider capability and opportunity were the main barriers to conducting and documenting serious illness conversations. We implemented the serious illness care program (SICP), a systematic multicomponent intervention that has shown potential for conducting and documenting ACP discussions in two oncology clinics. Our goal was to conduct at least 24 serious illness conversations over the implementation period, with documentation of at least 95% of all conversations. Results: The SICP was implemented in two outpatient medical oncology clinics. A total of 15 serious illness care conversations occurred and 14 (93%) of these conversations were documented in the EMR. Total rates of documentation increased between the preimplementation and implementation period (4.2%-5.4% for clinician A and 0%-7.3% for clinician B). Conclusion: Implementation of the SICP resulted in increased rates of documentation, but the target number of conversations was not met. Further improvement cycles are required to address barriers to conducting and documenting routine serious illness conversations.
Collapse
Affiliation(s)
- Safiya Karim
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Sasha Lupichuk
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Amy Tan
- Department of Family Medicine, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Aynharan Sinnarajah
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada.,Department of Family Medicine, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Jessica Simon
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
49
|
Kleiner N, Zambrano SC, Eychmüller S, Zwahlen S. Early palliative care integration trial: consultation content and interaction dynamics. BMJ Support Palliat Care 2021:bmjspcare-2020-002419. [PMID: 33419859 DOI: 10.1136/bmjspcare-2020-002419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Evidence for the positive impact of the early integration of palliative care (EPC) continues to grow. Less is known about how EPC improves patient and family outcomes, including the content of EPC consultations. Therefore, we aimed to better understand the content of EPC consultations including areas addressed, percentage covered per area and interaction style. METHODS As part of a trial in which EPC in addition to oncology care was compared with oncology care alone, we audio recorded 10 interventions. The palliative care team led the interventions using SENS, a conversation structure, which stands for: Symptoms, End-of-life decision-making, Network and Support. We employed two approaches to analysis: the Roter interaction analysis system (RIAS) to analyse interaction dynamics and SENS as a framework for content analysis. RESULTS Physician-patient communication covered 91% of the interaction. According to RIAS, the consultations were evenly dominated between physicians and patients (ratio=1.04) and highly patient-centred (ratio=1.26). Content wise, rapport was the largest category covering 27% of the consultation, followed by decision-making (21%) and by symptom assessment/management (17%) including 8.1% for physical symptoms and 5.4% for psychosocial aspects. Network discussions covered 17%, and lastly, support for the family 7%. CONCLUSIONS EPC consultations cover a variety of end-of-life topics while putting a high value in establishing rapport, developing a relationship with patients, and on providing reassurance and positive emotional talk. EPC consultations using predefined structures may guarantee that a minimum of important aspects are addressed in a way in which the relationship with the patient remains at the centre.
Collapse
Affiliation(s)
- Nadine Kleiner
- University Centre for Palliative Care, Oncology Department, Inselspital University Hospital Bern, Bern, Switzerland
| | - Sofia C Zambrano
- University Centre for Palliative Care, Oncology Department, Inselspital University Hospital Bern, Bern, Switzerland
| | - Steffen Eychmüller
- University Centre for Palliative Care, Oncology Department, Inselspital University Hospital Bern, Bern, Switzerland
| | - Susanne Zwahlen
- University Centre for Palliative Care, Oncology Department, Inselspital University Hospital Bern, Bern, Switzerland
| |
Collapse
|
50
|
Qiu JM, DelVecchio Good MJ. Making the best of multidisciplinary care for patients with malignant fungating wounds: A qualitative study of clinicians' narratives. Palliat Med 2021; 35:179-187. [PMID: 33094681 DOI: 10.1177/0269216320966498] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Malignant fungating wounds occur in advanced cancer patients, often in the last 6 to 12 months of life, when malignant cells breach the skin, causing a non-healing wound. Little is known about the perspectives of clinicians who treat these patients or how collaboration is facilitated among different specialties. OBJECTIVE To understand the experiences and perceived roles of clinicians who treat patients with malignant fungating wounds from a multidisciplinary perspective. DESIGN A qualitative study using narrative interviews was conducted and data was analyzed to identify themes that encompass the experiences of clinicians who treat patients malignant fungating wounds and put these experiences in a temporal context. SETTING/SUBJECTS Ten clinicians who treat patients with malignant fungating wounds (n = 10) from various metropolitan research hospitals were interviewed. The clinicians were of different disciplines, including physicians and nurses, and different specialties, including palliative care, oncology, and wound care. RESULTS Three themes emerged that described how clinicians of varying disciplines and specialties understood their roles and navigated the transition from curative to palliative care for patients with malignant fungating wounds: (1) making the best of fragmented care (2) collaboration between oncology and wound care (3) transitioning from curative to palliative care. CONCLUSION Findings of the study present a timeline of clinical care for patients, with different specialties taking the lead at different points in clinical time. Recognizing when collaboration between specialties is essential, as well as when communication fails, or clinicians have differing perspectives is important to facilitate the best care possible for patients.
Collapse
|