1
|
Brotzman LE, Zikmund-Fisher BJ. Perceived Barriers Among Clinicians and Older Adults Aged 65 and Older Regarding Use of Life Expectancy to Inform Cancer Screening: A Narrative Review and Comparison. Med Care Res Rev 2023; 80:372-385. [PMID: 36800914 DOI: 10.1177/10775587231153269] [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] [Indexed: 02/20/2023]
Abstract
While cancer screening guidelines increasingly recommend incorporating life expectancy estimates to inform screening decisions for older adults, little is known about how this happens in practice. This review summarizes current knowledge about primary care clinician and older adult (65+) perspectives about use of life expectancy to guide cancer screening decisions. Clinicians report operational barriers, uncertainty, and hesitation around use of life expectancy in screening decisions. They recognize it may help them more accurately weigh benefits and harms but are unsure how to estimate life expectancy for individual patients. Older adults face conceptual barriers and are generally unconvinced of the benefits of considering their life expectancy when making screening decisions. Life expectancy will always be a difficult topic for clinicians and patients, but there are advantages to incorporating it in cancer screening decisions. We highlight key takeaways from both clinician and older adult perspectives to guide future research.
Collapse
|
2
|
Sansom-Daly UM, Zhang M, Evans HE, McLoone J, Wiener L, Cohn RJ, Anazodo A, Patterson P, Wakefield CE. Adapting the Voicing My CHOiCES Advance Care Planning Communication Guide for Australian Adolescents and Young Adults with Cancer: Appropriateness, Acceptability, and Considerations for Clinical Practice. Cancers (Basel) 2023; 15:2129. [PMID: 37046790 PMCID: PMC10093261 DOI: 10.3390/cancers15072129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/25/2023] [Accepted: 03/26/2023] [Indexed: 04/05/2023] Open
Abstract
Background: Adolescents and young adults (AYAs) with life-threatening illnesses need support to discuss and voice their end-of-life choices. Voicing My CHOiCES (VMC) is a research-informed American advanced care planning guide designed to help facilitate these difficult discussions. This multi-perspective study aimed to evaluate its appropriateness, acceptability, and clinical considerations for Australian AYAs with cancer. Procedure: Forty-three participants including AYAs who were either undergoing or recently completed cancer treatment, their parents, and multidisciplinary health professionals assessed the acceptability of each VMC section quantitatively (appropriateness-yes/no, helpfulness and whether content caused stress-1 = not at all, to 5 = very) and qualitatively (sources of stress). AYAs also assessed the benefit and burden of completing several sections of the document, to inform clinical considerations. We conducted a mixed-methods analysis to obtain descriptive statistics and to identify prominent themes. Results: In terms of acceptability, almost all participants (96%) rated VMC as appropriate overall. Perceived helpfulness to their situation (to themselves/their child/their patients), to others, and stressfulness were rated, on average, as 4.1, 4.0, and 2.7/5, respectively. Stress was attributed to individual and personal factors, as well as interpersonal worries. All sections were considered more beneficial than burdensome, except for the Spiritual Thoughts section (Section 6). Conclusions: While VMC is an acceptable advance care planning guide for AYAs with cancer, changes to the guide were suggested for the Australian context. Health professionals implementing VMC will need to address and mitigate anticipated sources of stress identified here. Future research evaluating the impact of a new culturally adapted Australian VMC guide is an important next step. Finally, the clinical implications of the present study are suggested.
Collapse
Affiliation(s)
- Ursula M. Sansom-Daly
- School of Clinical Medicine, UNSW Medicine & Health, Randwick Clinical Campus, Discipline of Paediatrics, UNSW Sydney, Kensington, NSW 2052, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children’s Hospital, Randwick, NSW 2031, Australia
- Sydney Youth Cancer Service, Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Megan Zhang
- School of Clinical Medicine, UNSW Medicine & Health, Randwick Clinical Campus, Discipline of Paediatrics, UNSW Sydney, Kensington, NSW 2052, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children’s Hospital, Randwick, NSW 2031, Australia
| | - Holly E. Evans
- School of Clinical Medicine, UNSW Medicine & Health, Randwick Clinical Campus, Discipline of Paediatrics, UNSW Sydney, Kensington, NSW 2052, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children’s Hospital, Randwick, NSW 2031, Australia
| | - Jordana McLoone
- School of Clinical Medicine, UNSW Medicine & Health, Randwick Clinical Campus, Discipline of Paediatrics, UNSW Sydney, Kensington, NSW 2052, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children’s Hospital, Randwick, NSW 2031, Australia
| | - Lori Wiener
- National Institutes of Health, Bethesda, MD 20892, USA
| | - Richard J. Cohn
- School of Clinical Medicine, UNSW Medicine & Health, Randwick Clinical Campus, Discipline of Paediatrics, UNSW Sydney, Kensington, NSW 2052, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children’s Hospital, Randwick, NSW 2031, Australia
| | - Antoinette Anazodo
- School of Clinical Medicine, UNSW Medicine & Health, Randwick Clinical Campus, Discipline of Paediatrics, UNSW Sydney, Kensington, NSW 2052, Australia
- Kids Cancer Centre, Sydney Children’s Hospital, Randwick, NSW 2031, Australia
| | - Pandora Patterson
- Canteen Australia, Sydney, NSW 2042, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - Claire E. Wakefield
- School of Clinical Medicine, UNSW Medicine & Health, Randwick Clinical Campus, Discipline of Paediatrics, UNSW Sydney, Kensington, NSW 2052, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children’s Hospital, Randwick, NSW 2031, Australia
| |
Collapse
|
3
|
Harrison KL, Ritchie CS, Hunt LJ, Patel K, Boscardin WJ, Yaffe K, Smith AK. Life expectancy for community-dwelling persons with dementia and severe disability. J Am Geriatr Soc 2022; 70:1807-1815. [PMID: 35357694 PMCID: PMC9177709 DOI: 10.1111/jgs.17767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 02/08/2022] [Accepted: 02/28/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Understanding life expectancy can help persons with dementia, their care partners, and policymakers plan for what lies ahead. We sought to determine life expectancy and predictors of mortality for community-dwelling persons with dementia and severe disability. METHODS Using the National Health and Aging Trends Study (NHATS) linked to Medicare claims, we identified community-dwelling respondents age 65+ who entered NHATS in 2011 with dementia and severe disability (defined as three impairments in activities of daily living), or who subsequently met criteria for dementia and then severe disability. We estimated time to death based on the timing of meeting severe disability criteria. We conducted parametric survival analyses using a Gompertz distribution to calculate risk of death and predicted median time to death. Predictors included demographic, functional, clinical characteristics, and behavioral symptoms (assessed among NHATS respondents with proxy interviews). RESULTS Among 842 community-dwelling persons with dementia and severe disability, 80.5% died during the study period. After adjusting for age and gender, overall predicted median time to death was 1.7 years (25th percentile 0.6, 75th percentile 3.8 years). Six notable characteristics were associated with shorter life expectancy: 1) older age (90+), with a predicted median time to death of 1.0 year (0.4, 2.1); 2) being bedbound, 1.1 years (0.4, 2.3); 3) being homebound, 1.2 years (0.5, 2.6); 4) having comorbid cancer, 1.2 years (0.5, 2.6); 5) unintended weight loss, 1.4 years (0.5, 3.1); and 6) comorbid depression, 1.5 years (0.6, 3.3). CONCLUSIONS Community-dwelling persons with dementia and severe disability lived a median of 1.7 years. Clinicians can use the study findings to provide anticipatory guidance to patients and care partners, and policymakers to inform design of longitudinal supportive services.
Collapse
Affiliation(s)
- Krista L Harrison
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
- The Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lauren J Hunt
- Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
- Department of Physiological Nursing, University of California San Francisco, San Francisco, California, USA
| | - Kanan Patel
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - W John Boscardin
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Kristine Yaffe
- Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Psychiatry, University of California San Francisco, San Francisco, California, USA
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
4
|
Jindal SK, Karamourtopoulos M, Jacobson AR, Pinheiro A, Smith AK, Hamel MB, Schonberg MA. Strategies for discussing long‐term prognosis when deciding on cancer screening for adults over age 75. J Am Geriatr Soc 2022; 70:1734-1744. [DOI: 10.1111/jgs.17723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/12/2022] [Accepted: 02/06/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Shivani K. Jindal
- New England Geriatrics Research Education, and Clinical Center, VA Boston Health Care System Boston Massachusetts USA
- Section of Geriatrics, Department of Medicine Boston University School of Medicine Boston Massachusetts USA
| | - Maria Karamourtopoulos
- Division of General Medicine and Primary Care, Department of Medicine Harvard Medical School, Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | | | - Adlin Pinheiro
- Division of General Medicine and Primary Care, Department of Medicine Harvard Medical School, Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Alexander K. Smith
- Division of Geriatrics, Department of Medicine University of California San Francisco California USA
| | - Mary Beth Hamel
- Division of General Medicine and Primary Care, Department of Medicine Harvard Medical School, Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Mara A. Schonberg
- Division of General Medicine and Primary Care, Department of Medicine Harvard Medical School, Beth Israel Deaconess Medical Center Boston Massachusetts USA
| |
Collapse
|
5
|
Lewis ET, Hammill KA, Ticehurst M, Turner RM, Greenaway S, Hillman K, Carlini J, Cardona M. How Do Patients with Life-Limiting Illness and Caregivers Want End-Of-Life Prognostic Information Delivered? A Pilot Study. Healthcare (Basel) 2021; 9:healthcare9070784. [PMID: 34206435 PMCID: PMC8303293 DOI: 10.3390/healthcare9070784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 11/16/2022] Open
Abstract
We aimed to identify the level of prognostic disclosure, type of prognostic information and delivery format of prognostic communication that older adults diagnosed with a life-limiting illness or caregivers prefer to receive. We developed and pilot tested an open-ended survey to 15 older patients and caregivers who had experience in health services for life-limiting illness either for a relative, friend or themselves. Five hypothetical clinical scenarios of prognostic options were presented to ascertain preferences. The preferred format to receive prognostic information was verbal delivery by the clinician with a written summary. Photos and videos were less favoured, and a table with numbers/percentages was least preferred. Distress levels to the prognostic scenarios were low, with the exception of a photo. We conclude that older patients/caregivers want end-of-life prognostic information delivered the traditional way, verbally by clinicians. Options to deliver prognostic information may vary across patient groups but empower clinicians in introducing end-of-life discussions with patients/caregivers. Our study illustrates the feasibility of involving terminal patients and caregivers in research that contributes to eliciting prognostic preferences. Further research is needed to understand whether the prognostic preferences of hospitalized patients with life-limiting illness differ.
Collapse
Affiliation(s)
- Ebony T. Lewis
- School of Population Health, The University of New South Wales, Sydney 2052, Australia
- School of Psychology, The University of New South Wales, Sydney 2052, Australia
- Correspondence:
| | - Kathrine A. Hammill
- School of Science and Health, Western Sydney University, Campbelltown 2560, Australia;
| | - Maree Ticehurst
- South Western Sydney Clinical School, University of New South Wales, Liverpool 2170, Australia; (M.T.); (K.H.)
| | - Robin M. Turner
- Biostatistics Unit, Otago Medical School, University of Otago, Dunedin 9054, New Zealand;
| | - Sally Greenaway
- Supportive and Palliative Medicine, Westmead Hospital, Westmead 2145, Australia;
| | - Ken Hillman
- South Western Sydney Clinical School, University of New South Wales, Liverpool 2170, Australia; (M.T.); (K.H.)
- Intensive Care Unit, Liverpool Hospital, Liverpool 2170, Australia
| | - Joan Carlini
- Department of Marketing, Griffith University, Southport 4222, Australia;
| | - Magnolia Cardona
- Institute for Evidence Based Healthcare, Bond University, Robina 4226, Australia;
- EBP Professorial Unit, Gold Coast University Hospital, Southport 4215, Australia
| |
Collapse
|
6
|
Fruijtier AD, Visser LN, Bouwman FH, Lutz R, Schoonenboom N, Kalisvaart K, Hempenius L, Roks G, Boelaarts L, Claus JJ, Kleijer M, de Beer M, van der Flier WM, Smets EM. What patients want to know, and what we actually tell them: The ABIDE project. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2020; 6:e12113. [PMID: 33344753 PMCID: PMC7744024 DOI: 10.1002/trc2.12113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/15/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND We studied to what degree and at whose initiative 25 informational topics, formerly identified as important, are discussed in diagnostic consultations. METHODS Audio recordings of clinician-patient consultations of 71 patients and 32 clinicians, collected in eight Dutch memory clinics, were independently content-coded by two coders. The coding scheme encompassed 25 informational topics. RESULTS Approximately half (Mdn = 12) of the 25 topics were discussed per patient during the diagnostic process, with a higher frequency among individuals receiving a dementia diagnosis (Mdn = 14) compared to others (Mdn = 11). Individual topics ranged from being discussed with 2/71 (3%) to 70/71 (99%) of patients. Patients and/or care partners rarely initiated topic discussion (10%). When they did, they often enquired about one of the least frequently addressed topics. CONCLUSION Most patients received information on approximately half of the important informational topics. Providing the topic list to patients and care partners beforehand could allow consultation preparation and stimulate participation.
Collapse
Affiliation(s)
- Agnetha D. Fruijtier
- Department of NeurologyAlzheimer Center AmsterdamAmsterdam NeuroscienceAmsterdam UMCVrije Universiteit AmsterdamAmsterdamthe Netherlands
- Department of Medical PsychologyAcademic Medical CenterAmsterdam UMCAmsterdam Public Health Research InstituteAmsterdamthe Netherlands
| | - Leonie N.C. Visser
- Department of NeurologyAlzheimer Center AmsterdamAmsterdam NeuroscienceAmsterdam UMCVrije Universiteit AmsterdamAmsterdamthe Netherlands
- Department of Medical PsychologyAcademic Medical CenterAmsterdam UMCAmsterdam Public Health Research InstituteAmsterdamthe Netherlands
| | - Femke H. Bouwman
- Department of NeurologyAlzheimer Center AmsterdamAmsterdam NeuroscienceAmsterdam UMCVrije Universiteit AmsterdamAmsterdamthe Netherlands
| | - Rogier Lutz
- Department of NeurologyAlzheimer Center AmsterdamAmsterdam NeuroscienceAmsterdam UMCVrije Universiteit AmsterdamAmsterdamthe Netherlands
| | - Niki Schoonenboom
- Department of Clinical GeriatricsSpaarne GasthuisHaarlemthe Netherlands
| | - Kees Kalisvaart
- Department of Clinical GeriatricsSpaarne GasthuisHaarlemthe Netherlands
| | | | - Gerwin Roks
- Department of NeurologyETZ HospitalTilburgthe Netherlands
| | - Leo Boelaarts
- Geriatric DepartmentNoordWest Ziekenhuis GroepAlkmaarthe Netherlands
| | - Jules J. Claus
- Department of NeurologyTergooi Hospital, Blaricumthe Netherlands
| | - Mariska Kleijer
- Department of NeurologyLangeLand ZiekenhuisZoetermeerthe Netherlands
| | - Marlijn de Beer
- Department of NeurologyReinier de Graaf GasthuisDelftthe Netherlands
| | - Wiesje M. van der Flier
- Department of NeurologyAlzheimer Center AmsterdamAmsterdam NeuroscienceAmsterdam UMCVrije Universiteit AmsterdamAmsterdamthe Netherlands
- Department of Epidemiology and BiostatisticsAmsterdam NeuroscienceVU University Medical CenterAmsterdamthe Netherlands
| | - Ellen M.A. Smets
- Department of Medical PsychologyAcademic Medical CenterAmsterdam UMCAmsterdam Public Health Research InstituteAmsterdamthe Netherlands
| |
Collapse
|
7
|
Schonberg MA, Karamourtopoulos M, Jacobson AR, Aliberti GM, Pinheiro A, Smith AK, Davis RB, Schuttner LC, Hamel MB. A Strategy to Prepare Primary Care Clinicians for Discussing Stopping Cancer Screening With Adults Older Than 75 Years. Innov Aging 2020; 4:igaa027. [PMID: 32793815 PMCID: PMC7413618 DOI: 10.1093/geroni/igaa027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Indexed: 01/08/2023] Open
Abstract
Background and Objectives Adults older than 75 years are overscreened for cancer, especially those with less than 10-year life expectancy. This study aimed to learn the effects of providing primary care providers (PCPs) with scripts for discussing stopping mammography and colorectal cancer (CRC) screening and with information on patient’s 10-year life expectancy on their patients’ intentions to be screened for these cancers. Research Design and Methods Patient participants, identified via PCP appointment logs, completed a questionnaire pre- and postvisit. Primary care providers were given scripts for discussing stopping screening and information on patient’s 10-year life expectancy before these visits. Primary care providers completed a questionnaire at the end of the study. Patients and PCPs were asked about discussing stopping cancer screening and patient life expectancy. Patient screening intentions (1–15 Likert scale; lower scores suggest lower intentions) were compared pre- and postvisit using the Wilcoxon signed-rank test. Results Ninety patients older than 75 years (47% of eligible patients reached by phone) from 45 PCPs participated. Patient mean age was 80.0 years (SD = 2.9), 43 (48%) were female, and mean life expectancy was 9.7 years (SD = 2.4). Thirty-seven PCPs (12 community-based) completed a questionnaire. Primary care providers found the scripts helpful (32 [89%]) and thought they would use them frequently (29 [81%]). Primary care providers also found patient life expectancy information helpful (35 [97%]). However, only 8 PCPs (22%) reported feeling comfortable discussing patient life expectancy. Patients’ intentions to undergo CRC screening (9.0 [SD = 5.3] to 6.5 [SD = 6.0], p < .0001) and mammography screening (12.9 [SD = 3.0] to 11.7 [SD = 4.9], p = .08) decreased from pre- to postvisit (significantly for CRC). Sixty-three percent of patients (54/86) were interested in discussing life expectancy with their PCP previsit and 56% (47/84) postvisit. Discussion and Implications PCPs found scripts for discussing stopping cancer screening and information on patient life expectancy helpful. Possibly, as a result, their patients older than 75 years had lower intentions of being screened for CRC. Clinical Trials Registration Number NCT03480282
Collapse
Affiliation(s)
- Mara A Schonberg
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Alicia R Jacobson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Gianna M Aliberti
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adlin Pinheiro
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California San Francisco
| | - Roger B Davis
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Linnaea C Schuttner
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Washington.,Department of Medicine, University of Washington, Seattle
| | - Mary Beth Hamel
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|