Do medical oncology patients and their support persons agree about end-of-life issues?

Patient-caregiver concordance on death preparedness over Taiwanese cancer patients' last 6 months

BACKGROUND

Worldwide patient-caregiver concordance on cognitive prognostic awareness (PA) has been extensively examined, but concordance on sufficient (ie, cognitive and emotional) death preparedness is unexplored. We comprehensively examine the evolution of patient-caregiver concordance on death preparedness over the patient's last 6 months.

MATERIALS/METHODS

This study re-examined data from 2 cohort studies on 694 dyads of cancer patients and their caregivers recruited from a single medical center in Taiwan. Patient and caregiver death-preparedness states were individually identified by latent transition analysis. Patient-caregiver concordance was examined by percentages and kappa coefficients.

RESULTS

No-, cognitive-, emotional-, and sufficient-death-preparedness states were identified for both groups. The no-death-preparedness state reflects neither accurate PA nor adequate emotional preparedness for death. The sufficient-death-preparedness state reflects accurate PA and adequate emotional preparedness for death. In the cognitive- and emotional-death-preparedness states, participants had only accurate PA or adequate emotional-death preparedness, respectively. Prevalence of the sufficient-death-preparedness state increased substantially for patients but decreased slightly for caregivers. Membership in the no- and emotional-preparedness states declined throughout the last 6 months with substantially lower prevalence for caregivers than for patients, whereas the prevalence of the cognitive-death-preparedness state increased. Concordance was poor throughout the patient's last 6 months (percent concordance: 31.6% [95% CI, 24.7%, 38.5%]-43.5% [39.2%, 47.9%], kappa: 0.077 [-0.009, 0.162]-0.115 [0.054, 0.176]) with significant improvement in the last month only.

CONCLUSION

Poor patient-caregiver concordance on death-preparedness states likely reflects the cultural practice of family-consent prognostic disclosure, patients' adjustment for death, and difficulties in patient-caregiver communication on end-of-life (EOL) issues, indicating targets for improving EOL care.

Preferences for Palliative and End-of-Life Care: A Systematic Review of Discrete Choice Experiments

OBJECTIVES

Understanding what matters most to patients and their caregivers is fundamental to delivering high-quality care. This systematic review aimed to characterize and appraise the evidence from discrete choice experiments eliciting preferences for palliative care.

METHODS

A systematic literature search was undertaken for publications up until August 2022. Data were synthesized narratively. Thematic analysis was applied to categorize attributes into groups. Attribute development, frequency, and relative importance were analyzed. Subgroup analyses were conducted to compare outcomes between patient and proxy respondents.

RESULTS

Seventeen studies spanning 11 countries were included; 59% of studies solely considered preferences for patients with cancer. A range of respondent groups were represented including patients (76%) and proxies (caregivers [35%], health providers [12%], and the public [18%]). A total of 117 individual attributes were extracted and thematically grouped into 8 broad categories and 21 subcategories. Clinical outcomes including quality of life, length of life, and pain control were the most frequently reported attributes, whereas attributes relating to psychosocial components were largely absent. Both patients and proxy respondents prioritized pain control over additional survival time. Nevertheless, there were differences between respondent cohorts in the emphasis on other attributes such as access to care, timely information, and low risk of adverse effects (prioritized by patients), as opposed to cost, quality, and delivery of care (prioritized by proxies).

CONCLUSIONS

Our review underscores the vital role of pain control in palliative care; in addition, it shed light on the complexity and relative strength of preferences for various aspects of care from multiple perspectives, which is useful in developing personalized, patient-centered models of care for individuals nearing the end of life.

Decision-making conversations for life-sustaining treatment with seriously ill patients using a Danish version of the US POLST: a qualitative study of patient and physician experiences

OBJECTIVE

To explore patients' and physicians' perspectives on a decision-making conversation for life-sustaining treatment, based on the Danish model of the American Physician Orders for Life Sustaining Treatment (POLST) form.

DESIGN

Semi-structured interviews following a conversation about preferences for life-sustaining treatment.

SETTING

Danish hospitals, nursing homes, and general practitioners' clinics.

SUBJECTS

Patients and physicians.

MAIN OUTCOME MEASURES

Qualitative analyses of interview data.

FINDINGS

After participating in a conversation about life-sustaining treatment using the Danish POLST form, a total of six patients and five physicians representing different settings and age groups participated in an interview about their experience of the process. Within the main research questions, six subthemes were identified: Timing, relatives are key persons, clarifying treatment preferences, documentation across settings, strengthening patient autonomy, and structure influences conversations. Most patients and physicians found having a conversation about levels of life-sustaining treatment valuable but also complicated due to the different levels of knowledge and attending to individual patient needs and medical necessities. Relatives were considered as key persons to ensure the understanding of the treatment trajectory and the ability to advocate for the patient in case of a medical crisis. The majority of participants found that the conversation strengthened patient autonomy.

CONCLUSION

Patients and physicians found having a conversation about levels of life-sustaining treatment valuable, especially for strengthening patient autonomy. Relatives were considered key persons. The timing of the conversation and securing sufficient knowledge for shared decision-making were the main perceived challenges.KEY POINTSConversations about preferences for life-sustaining treatment are important, but not performed systematically.When planning a conversation about preferences for life-sustaining treatment, the timing of the conversation and the inclusion of relatives are key elements.Decision-making conversations can help patients feel in charge and less alone, and make it easier for health professionals to provide goal-concordant care.Using a model like the Danish POLST form may help to initiate, conduct and structure conversations about preferences for life-sustaining treatment.

Operationalizing legal rights in end-of- life decision-making: A qualitative study

BACKGROUND

For a patient's legal right to make end-of-life treatment decisions to be respected, health care practitioners, patients and their substitute decision-makers must know what rights exist and how to assert them (or support others to assert them). Yet very little is known about what enhances or obstructs the operationalization of legal rights from the perspective of patients, family members and substitute decision-makers.

AIM

To explore barriers and facilitators to the operationalization of rights in end-of-life decision-making from the perspectives of terminally-ill patients and family members and substitute decision-makers of terminally ill patients in Australia.

DESIGN

Semi-structured interviews (face to face and telephone) with patients, family or substitute decision-makers experienced in end-of-life decision-making completed between November 2016 and October 2017. A thematic content analysis of interview transcripts.

SETTING/PARTICIPANTS

Purposive sampling across three Australian states provided 16 terminally-ill patients and 33 family and/or substitute decision-makers.

RESULTS

Barriers and facilitators emerged across three overlapping domains: systemic factors; individual factors, influenced by personal characteristics and decision-making approach; and communication and information. Health care practitioners play a key role in either supporting or excluding patients, family and substitute decision-makers in decision-making.

CONCLUSION

In addition to enhancing legal literacy of community members and health practitioners about end-of-life decision-making, support such as open communication, advocacy and help with engaging with advanced care planning is needed to facilitate people operationalizing their legal rights, powers and duties. Palliative care and other support services should be more widely available to people both within and outside health systems.

Quality versus quantity in end-of-life choices of cancer patients and support persons: a discrete choice experiment

OBJECTIVES

To explore in a sample of medical oncology outpatients and their nominated support persons (SPs): (1) the relative influence of pain, consciousness and life extension on end-of-life choices using a discrete choice experiment (DCE); (2) the extent to which SPs can predict the choices of index patients and (3) whether having a previous end-of-life discussion was associated with dyad agreement.

METHODS

Adult medical oncology patients and their SPs were approached for consent to complete a survey containing a DCE. Participants chose between three unlabelled care scenarios characterised by three attributes: pain (mild, moderate or severe), consciousness (some, half or most of time) and extension of life (1, 2 or 3 weeks). Respondents selected (1) most-preferred and (2) least-preferred scenarios within each question. SPs answered the same questions but from patient's perspective.

RESULTS

A total of 110 patients and 64 SPs responded overall (42 matched patient-SP dyads). For patients, pain was the most influential predictor of most- and least-preferred scenarios (z = 12.5 and z = 12.9). For SPs, pain was the only significant predictor of most and least-preferred scenarios (z = 9.7 and z = 11.5). Dyad agreement was greater for choices about least- (69%) compared to most-preferred scenarios (55%). Agreement was slightly higher for dyads reporting a previous EOL discussion (68 versus 48%; p = 0.065).

CONCLUSION

Patients and SPs place significant value on avoiding severe pain when making end-of-life choices, over and above level of consciousness or life extension. People's views about end-of-life scenarios they most as well as least prefer should be sought.