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Chuang E, Gugliuzza S, Ahmad A, Aboodi M, Gong MN, Barnato AE. "Postponing it Any Later Would not be so Great": A Cognitive Interview Study of How Physicians Decide to Initiate Goals of Care Discussions in the Hospital. Am J Hosp Palliat Care 2023:10499091231222926. [PMID: 38111300 DOI: 10.1177/10499091231222926] [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] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND There are missed opportunities to discuss goals and preferences for care with seriously ill patients in the acute care setting. It is unknown which factors most influence clinician decision-making about communication at the point of care. OBJECTIVE This study utilized a cognitive-interviewing technique to better understand what leads clinicians to decide to have a goals of care (GOC) discussion in the acute care setting. METHODS A convenience sample of 15 oncologists, intensivists and hospitalists were recruited from a single academic medical center in a large urban area. Participants completed a cognitive interview describing their thought process when deciding whether to engage in GOC discussions in clinical vignettes. RESULTS 6 interconnected factors emerged as important in determining how likely the physician was to consider engaging in GOC at that time; (1) the participants' mental model of GOC, (2) timing of GOC related to stability, acuity and reversibility of the patient's condition, (3) clinical factors such as uncertainty, prognosis and recency of diagnosis, (4) patient factors including age and emotional state, (5) participants' role on the care team, and (6) clinician factors such as emotion and communication skill level. CONCLUSION Participants were hesitant to commit to the present moment as the right time for GOC discussions based on variations in clinical presentation. Clinical decision support systems that include more targeted information about risk of clinical deterioration and likelihood of reversal of the acute condition may prompt physicians to discuss GOC, but more support for managing discomfort with uncertainty is also needed.
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Affiliation(s)
- Elizabeth Chuang
- Department of Medicine, Division of Critical Care, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sabrina Gugliuzza
- Department of Internal Medicine, NYU Langone Health, Mineola, NY, USA
| | - Ammar Ahmad
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, New York, NY, USA
| | - Michael Aboodi
- Division of Pulmonary and Critical Care, Weill Cornell Medicine, New York, NY, USA
| | - Michelle Ng Gong
- Department of Medicine, Division of Critical Care, Albert Einstein College of Medicine, Bronx, NY, USA
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Vicente RS, Freitas AR, Ferreira RMA, Prada SP, Martins TS, Martins TC, Duarte Mendes A, Vitorino MM, Chaves AF, Santos CC, Alpuim Costa D, Custódio MP, Barbosa M. Communication preferences and perceptions of cancer patient during their first medical oncology appointment. Psychooncology 2023; 32:1702-1709. [PMID: 37749768 DOI: 10.1002/pon.6220] [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: 05/03/2023] [Revised: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND The first medical oncology appointment serves as a platform for patients to comprehend their diagnosis and prognostic implications of cancer. This study aimed to determine patients' communication preferences during their first medical oncology appointment and to assess the disparities between patients' preferences and perceptions. METHODS A total of 169 cancer patients participated by completing the Communication in First Medical Oncology Appointment Questionnaire (C-FAQ), a two-section questionnaire designed to assess patients' preferences and perceptions regarding Content (information provided and its extent), Facilitation (timing and location of information delivery), and Support (emotional support) during their first medical oncology appointment. A comparative analysis was conducted to assess the variations between preferences and perceptions. RESULTS Content emerged as the most significant dimension compared to Facilitation and Support. The physician's knowledge, honesty, and ability to provide clear information were considered the most important attributes. Patients evaluated most of their preferences as "very important". Patients' perception of the communication dimensions present during their appointment was below preferences for 11 items, indicating significant discrepancies in clinical practice. CONCLUSIONS Patients highly valued their preferences concerning Content, Facilitation, and Support dimensions of communication. However, patient preferences were more prominently oriented towards the Content dimension. The discrepancies between preferences and perceptions should be viewed as an opportunity for enhancing communication skills through training.
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Affiliation(s)
- Rodrigo Santos Vicente
- Hospital Professor Doutor Fernando Fonseca, Medical Oncology, Amadora, Portugal
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Ana Rita Freitas
- Hospital Professor Doutor Fernando Fonseca, Medical Oncology, Amadora, Portugal
| | | | - Sofia Parada Prada
- Hospital Professor Doutor Fernando Fonseca, Medical Oncology, Amadora, Portugal
| | - Telma Sofia Martins
- Hospital Professor Doutor Fernando Fonseca, Medical Oncology, Amadora, Portugal
| | | | - Ana Duarte Mendes
- Hospital Professor Doutor Fernando Fonseca, Medical Oncology, Amadora, Portugal
| | | | - Andreia Filipa Chaves
- Hospital Professor Doutor Fernando Fonseca, Medical Oncology, Amadora, Portugal
- CUF Oncologia, Haematology and Medical Oncology, Lisbon, Portugal
| | | | - Diogo Alpuim Costa
- CUF Oncologia, Haematology and Medical Oncology, Lisbon, Portugal
- Hospital de Cascais Dr. José de Almeida, Medical Oncology, Alcabideche, Portugal
- NOVA Medical School, NOVA University Lisbon, Lisbon, Portugal
| | | | - Miguel Barbosa
- Faculty of Psychology, ULisboa CICPSI, Lisbon, Portugal
- ISAMB, Faculty of Medicine, ISAMB, Lisbon, Portugal
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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.
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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
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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.
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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
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Stephens GC, Karim MN, Sarkar M, Wilson AB, Lazarus MD. Reliability of Uncertainty Tolerance Scales Implemented Among Physicians and Medical Students: A Systematic Review and Meta-Analysis. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1413-1422. [PMID: 35234716 DOI: 10.1097/acm.0000000000004641] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
PURPOSE Uncertainty tolerance (UT) is a construct describing individuals' perceptions of, and responses to, uncertainty across their cognition, emotion, and behavior. Various UT scales have been designed for physician and medical student populations. However, links between UT and other variables (e.g., training stages) are inconsistent, raising concerns about scale reliability and validity. As reliability is a precondition for validity, a necessary first step in assessing UT scales' efficacy is evaluating their reliability. Accordingly, the authors conducted a meta-analysis of the reliability of UT scales designed for, and implemented among, physician and medical student populations. METHOD In 2020, the authors searched 4 electronic databases alongside a citation search of previously identified UT scales. They included English-language, peer-reviewed studies that implemented UT scales in physician and/or medical student populations and reported reliability evidence. A meta-analysis of studies' Cronbach's alphas evaluated aggregated internal consistency across studies; subgroup analyses evaluated UT scales by named scale, population, and item characteristics. RESULTS Among 4,124 records screened, 35 studies met the inclusion criteria, reporting 75 Cronbach's alphas. Four UT scales appeared in at least 3 included studies: Physicians' Reactions to Uncertainty scale 1990 (PRU1990) and 1995 (PRU1995) versions, Tolerance for Ambiguity scale (TFA), and Tolerance of Ambiguity in Medical Students and Doctors scale (TAMSAD). The scores from these scales ranged in reliability from very good (PRU1990: 0.832, PRU1995: 0.818) to respectable (TFA: 0.761, TAMSAD: 0.711). Aggregated internal consistency was significantly higher ( P < .001) among physicians (0.797) than medical students (0.711). CONCLUSIONS UT scales generally demonstrated respectable internal consistency when administered among physicians and medical students, yet the reliability among medical students was significantly lower. The authors caution against using UT scores for decision-making purposes (e.g., applicant selection, program evaluation), especially among medical student populations. Future research should explore the reasons underlying these observed population differences.
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Affiliation(s)
- Georgina C Stephens
- G.C. Stephens is a PhD student, Centre for Human Anatomy Education, Monash University, Melbourne, Australia; ORCID: https://orcid.org/0000-0001-9695-7592
| | - M Nazmul Karim
- M.N. Karim is a lecturer, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; ORCID: https://orcid.org/0000-0003-2604-9649
| | - Mahbub Sarkar
- M. Sarkar is a lecturer, Monash Centre for Scholarship in Health Education, Monash University, Melbourne, Australia; ORCID: https://orcid.org/0000-0002-6940-3946
| | - Adam B Wilson
- A.B. Wilson is associate professor, Department of Anatomy and Cell Biology, Rush University, Chicago, Illinois; ORCID: https://orcid.org/0000-0002-1221-5602
| | - Michelle D Lazarus
- M.D. Lazarus is associate professor and director, Centre for Human Anatomy Education, and curriculum integration lead, Monash Centre for Scholarship in Health Education, Monash University, Melbourne, Australia; ORCID: https://orcid.org/0000-0003-0996-4386
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Zachariah FJ, Rossi LA, Roberts LM, Bosserman LD. Prospective Comparison of Medical Oncologists and a Machine Learning Model to Predict 3-Month Mortality in Patients With Metastatic Solid Tumors. JAMA Netw Open 2022; 5:e2214514. [PMID: 35639380 PMCID: PMC9157269 DOI: 10.1001/jamanetworkopen.2022.14514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/24/2022] [Indexed: 12/29/2022] Open
Abstract
Importance To date, oncologist and model prognostic performance have been assessed independently and mostly retrospectively; however, how model prognostic performance compares with oncologist prognostic performance prospectively remains unknown. Objective To compare oncologist performance with a model in predicting 3-month mortality for patients with metastatic solid tumors in an outpatient setting. Design, Setting, and Participants This prognostic study evaluated prospective predictions for a cohort of patients with metastatic solid tumors seen in outpatient oncology clinics at a National Cancer Institute-designated cancer center and associated satellites between December 6, 2019, and August 6, 2021. Oncologists (57 physicians and 17 advanced practice clinicians) answered a 3-month surprise question (3MSQ) within clinical pathways. A model was trained with electronic health record data from January 1, 2013, to April 24, 2019, to identify patients at high risk of 3-month mortality and deployed silently in October 2019. Analysis was limited to oncologist prognostications with a model prediction within the preceding 30 days. Exposures Three-month surprise question and gradient-boosting binary classifier. Main Outcomes and Measures The primary outcome was performance comparison between oncologists and the model to predict 3-month mortality. The primary performance metric was the positive predictive value (PPV) at the sensitivity achieved by the medical oncologists with their 3MSQ answers. Results A total of 74 oncologists answered 3099 3MSQs for 2041 patients with advanced cancer (median age, 62.6 [range, 18-96] years; 1271 women [62.3%]). In this cohort with a 15% prevalence of 3-month mortality and 30% sensitivity for both oncologists and the model, the PPV of oncologists was 34.8% (95% CI, 30.1%-39.5%) and the PPV of the model was 60.0% (95% CI, 53.6%-66.3%). Area under the receiver operating characteristic curve for the model was 81.2% (95% CI, 79.1%-83.3%). The model significantly outperformed the oncologists in short-term mortality. Conclusions and Relevance In this prognostic study, the model outperformed oncologists overall and within the breast and gastrointestinal cancer cohorts in predicting 3-month mortality for patients with advanced cancer. These findings suggest that further studies may be useful to examine how model predictions could improve oncologists' prognostic confidence and patient-centered goal-concordant care at the end of life.
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Affiliation(s)
- Finly J. Zachariah
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, California
| | - Lorenzo A. Rossi
- Department of Applied AI and Data Science, City of Hope National Medical Center, Duarte, California
| | - Laura M. Roberts
- Department of Clinical Informatics, City of Hope National Medical Center, Duarte, California
| | - Linda D. Bosserman
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, California
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Janett-Pellegri C, Eychmüller AS. 'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication? PRAXIS 2021; 110:914-924. [PMID: 34814721 DOI: 10.1024/1661-8157/a003785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Uncertainty, fear to harm the patient, discomfort handling the discussion and lack of time are the most cited barriers to prognostic disclosure. Physicians can be reassured that patients desire the truth about prognosis and can manage the discussion without harm, including the uncertainty of the information, if approached in a sensitive manner. Conversational guides could provide support in preparing such difficult conversations. Communicating 'with realism and hope' is possible, and anxiety is normal for both patients and clinicians during prognostic disclosure. As a clinician pointed out: 'I had asked a mentor once if it ever got easier. - No. But you get better at it.'
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Affiliation(s)
- Camilla Janett-Pellegri
- Service de Médicine Interne, Hôpital Cantonal Fribourg, Fribourg
- Universitäres Zentrum für Palliative Care, Inselspital, Universitätsspital Bern, Bern
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8
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Berry P, Theocharidou E, Kotha S. Clinical utility of prognostic scores and models in decompensated liver disease. JOURNAL OF LIVER TRANSPLANTATION 2021. [DOI: 10.1016/j.liver.2021.100048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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9
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Yin S, Arkes HR, McCoy JP, Cohen ME, Mellers BA. Conflicting Goals Influence Physicians' Expressed Beliefs to Patients and Colleagues. Med Decis Making 2021; 41:505-514. [PMID: 33764191 DOI: 10.1177/0272989x211001841] [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: 11/16/2022]
Abstract
BACKGROUND Physicians who communicate their prognostic beliefs to patients must balance candor against other competing goals, such as preserving hope, acknowledging the uncertainty of medicine, or motivating patients to follow their treatment regimes. OBJECTIVE To explore possible differences between the beliefs physicians report as their own and those they express to patients and colleagues. DESIGN An online panel of 398 specialists in internal medicine who completed their medical degrees and practiced in the United States provided their estimated diagnostic accuracy and prognostic assessments for a randomly assigned case. In addition, they reported the diagnostic and prognostic assessments they would report to patients and colleagues more generally. Physicians answered questions about how and why their own beliefs differed from their expressed beliefs to patients and colleagues in the specific case and more generally in their practice. RESULTS When discussing beliefs about prognoses to patients and colleagues, most physicians expressed beliefs that differed from their own beliefs. Physicians were more likely to express greater optimism when talking to patients about poor prognoses than good prognoses. Physicians were also more likely to express greater uncertainty to patients when prognoses were poor than when they were good. The most common reasons for the differences between physicians' own beliefs and their expressed beliefs were preserving hope and acknowledging the inherent uncertainty of medicine. CONCLUSION To balance candor against other communicative goals, physicians tended to express beliefs that were more optimistic and contained greater uncertainty than the beliefs they said were their own, especially in discussions with patients whose prognoses were poor.
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Affiliation(s)
- Siyuan Yin
- Department of Marketing, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Hal R Arkes
- Department of Psychology, Ohio State University, Columbus, OH, USA.,The Harding Center for Risk Literacy, Berlin, Germany
| | - John P McCoy
- Department of Marketing, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Margot E Cohen
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Barbara A Mellers
- Department of Psychology and Department of Marketing, University of Pennsylvania, Philadelphia, PA, USA
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Arab A, Karimi E, Vingrys K, Shirani F. Is phase angle a valuable prognostic tool in cancer patients' survival? A systematic review and meta-analysis of available literature. Clin Nutr 2021; 40:3182-3190. [PMID: 33581951 DOI: 10.1016/j.clnu.2021.01.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 01/05/2021] [Accepted: 01/18/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS The phase angle (PA), expressed via bioelectrical impedance, is an indicator of cell membrane health and integrity, hydration, and nutritional status, and may have further application as a prognostic marker in cancer survival. However, the associations between PA and cancer survival are inconsistent and unclear. The present systematic review and meta-analysis investigated the relationship between PA and survival among adult patients diagnosed with cancer. METHODS A systematic search of observational studies up to November 2020 was conducted through PubMed, Scopus, and ISI Web of Science. The critical appraisal of the eligible studies was performed using the Newcastle-Ottawa Quality Assessment Scale. Statistical analyses were performed using STATA 11.2 software. A P-value <0.05 was considered statistically significant. RESULTS A total of 14 studies covering 2625 participants were included in this study. There was a positive and significant correlation between PA and cancer survival (Fisher's Z: 0.30; 95% CI, 0.21-0.40; P < 0.001; I2 = 0.0%). Also, there was a significant prognostic role for PA on patients' survival (HR 0.77; 95% CI, 0.74-0.81; P < 0.001; I2 = 0.0%). In other words, patients with low values of PA were 23% less likely to survive than patients with high values of PA. CONCLUSIONS Given that predicting survival in advanced cancer patients remains a challenge, the findings of this systematic review and meta-analysis suggest that phase angle may be an important prognostic factor of survival in this population.
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Affiliation(s)
- Arman Arab
- Department of Community Nutrition, School of Nutrition and Food Science, Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Elham Karimi
- Department of Clinical Nutrition, School of Nutrition and Food Science, Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran; Research Development Center, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Kristina Vingrys
- Institute for Health and Sport, Victoria University, PO Box 14428, Melbourne, Victoria 8001, Australia.
| | - Fatemeh Shirani
- Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
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Zhou X, Li X, Wang Z. Impact of individualized intervention on the psychological status of patients with localized small cell lung cancer complicated with pleural effusion. PSYCHOL HEALTH MED 2021; 27:1326-1333. [PMID: 33455419 DOI: 10.1080/13548506.2021.1874435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
To explore the intervention effects of individualized measures on the psychological status of patients with localized small cell lung cancer complicated with pleural effusion (LSCLC-PE). A total of 79 LSCLC patients were selected for comparing the source of psychological control and psychological distress between the patients with combined (group LSCLC-PE, n = 38) and non-combined pleural effusion (group LSCLC, n = 41). LSCLC-PE patients were randomly sub-divided into the control group (CON, for conventional intervention) and the observation group (OBS, for individualized intervention) for evaluating the intervention effects between these two subgroups using the SCL-90 scale. The PHLC score, psychological pain score, and sources of psychological pain (proportion of dyspnea, etc.) in group LSCLC-PE were higher than group LSCLC, but the IHLC and CHLC scores were lower; after intervention, the somatization, obsessive-compulsive symptoms, and total average score in subgroup OBS were statistically lower than subgroup CON. LSCLC-PE patients have poor psychological status, and intervention can improve their psychological status.
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Affiliation(s)
- Xia Zhou
- Department of Oncology, The First People's Hospital of Lianyungang (the First Affiliated Hospital of Kangda College, Nanjing Medical University), Lianyungang, Jiangsu Province, China
| | - Xiang Li
- Department of Oncology, The First People's Hospital of Lianyungang (the First Affiliated Hospital of Kangda College, Nanjing Medical University), Lianyungang, Jiangsu Province, China
| | - Zongsheng Wang
- Department of Radiology, the First People's Hospital of Lianyungang (the First Affiliated Hospital of Kangda College, Nanjing Medical University), Lianyungang, Jiangsu Province, China
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Derry HM, Epstein AS, Lichtenthal WG, Prigerson HG. Emotions in the room: common emotional reactions to discussions of poor prognosis and tools to address them. Expert Rev Anticancer Ther 2019; 19:689-696. [PMID: 31382794 DOI: 10.1080/14737140.2019.1651648] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Advanced cancer patients often want prognostic information, and discussions of prognosis have been shown to enhance patient understanding of their illness. Such discussions can lead to high-quality, value-consistent care at the end of life, yet they are also often emotionally challenging. Despite how common and normal it is for patients to experience transient emotional distress when receiving 'bad news' about prognosis, emotional responses have been under-addressed in existing literature on prognostic discussions. Areas covered: Drawing upon psychology research, principles of skilled clinical communication, and published approaches to discussions of serious illness, we summarize patients' common emotional reactions and coping strategies. We then provide suggestions for how to respond to them in clinic. Expert opinion: Ultimately, effective management of emotional reactions to bad news may lead to earlier, more frequent, and more transparent discussions of prognosis, thus promoting cancer patients' understanding of, and adjustment to, their illness and improving the quality of their end-of-life care.
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Affiliation(s)
| | - Andrew S Epstein
- Weill Cornell Medicine , New York , NY , USA.,Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Wendy G Lichtenthal
- Weill Cornell Medicine , New York , NY , USA.,Memorial Sloan Kettering Cancer Center , New York , NY , USA
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Derry HM, Reid MC, Prigerson HG. Advanced cancer patients' understanding of prognostic information: Applying insights from psychological research. Cancer Med 2019; 8:4081-4088. [PMID: 31199597 PMCID: PMC6675734 DOI: 10.1002/cam4.2331] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/06/2019] [Accepted: 05/22/2019] [Indexed: 11/29/2022] Open
Abstract
Purpose Informed medical decision‐making at the end of life often requires engaging in highly emotional, potentially upsetting discussions about prognosis, while ensuring that patients grasp its personal meaning. Behavioral science offers insights into ways to promote prognostic understanding among patients with advanced cancer. Summary In this literature review, we synthesize complementary findings from basic behavioral science and applied clinical research, which suggest that psychological factors can significantly influence both patients’ clinical interactions and their prognostic understanding. For example, stress and emotion can affect cognition, which may shape how patients process complex medical information. Additionally, clinicians may be less likely to share prognostic information with distressed patients who, in turn, may be hesitant to ask about their prognosis for fear of the answer. Although traditional approaches for increasing advanced cancer patients’ understanding focus on improving information delivery, these efforts may not be sufficient without corresponding interventions that assist patients in managing distress. Conclusions Psychological barriers may limit opportunities for patients to fully understand their prognosis and to receive high quality of end‐of‐life care that is linked with an accurate understanding of their disease and treatment options. Failure to attend to patients’ emotional distress may undermine efforts to improve medical communication. This underscores the importance of increased attention to the psychological factors that impede patients’ comprehension of material shared in cancer clinic visits, in order to inform interventions that address patient distress both before and after receiving “bad news." Integrating findings from psychological research into prognostic discussions may not only improve advanced cancer patients’ mental health, but may also promote their ability to make informed, value‐consistent medical decisions.
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Prognostication in advanced cancer: update and directions for future research. Support Care Cancer 2019; 27:1973-1984. [PMID: 30863893 DOI: 10.1007/s00520-019-04727-y] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/01/2019] [Indexed: 01/07/2023]
Abstract
The objective of this review is to provide an update on prognostication in patients with advanced cancer and to discuss future directions for research in this field. Accurate prognostication of survival for patients with advanced cancer is vital, as patient life expectancy informs many important personal and clinical decisions. The most common prognostic approach is clinician prediction of survival (CPS) using temporal, surprise, or probabilistic questions. The surprise and probabilistic questions may be more accurate than the temporal approach, partly by limiting the time frame of prediction. Prognostic models such as the Glasgow Prognostic Score (GPS), Palliative Performance Scale (PPS), Palliative Prognostic Score (PaP), Palliative Prognostic Index (PPI), or Prognosis in Palliative Care Study (PiPS) predictor model may augment CPS. However, care must be taken to select the appropriate tool since prognostic accuracy varies by patient population, setting, and time frame of prediction. In addition to life expectancy, patients and caregivers often desire that expected treatment outcomes and bodily changes be communicated to them in a sensible manner at an appropriate time. We propose the following 10 major themes for future prognostication research: (1) enhancing prognostic accuracy, (2) improving reliability and reproducibility of prognosis, (3) identifying the appropriate prognostic tool for a given setting, (4) predicting the risks and benefits of cancer therapies, (5) predicting survival for pediatric populations, (6) translating prognostic knowledge into practice, (7) understanding the impact of prognostic uncertainty, (8) communicating prognosis, (9) clarifying outcomes associated with delivery of prognostic information, and (10) standardizing prognostic terminology.
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The complexity of physicians' understanding and management of prognostic uncertainty in neonatal hypoxic-ischemic encephalopathy. J Perinatol 2019; 39:278-285. [PMID: 30568164 DOI: 10.1038/s41372-018-0296-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Prognosis of Hypoxic-Ischemic Encephalopathy (HIE) remains challenging and uncertain. This paper investigates how physicians understand and address the ethical challenges of prognostic uncertainty in the case of neonatal HIE, contextualized within the social science literature. STUDY DESIGN Semi-structured interviews were conducted with 12 Canadian neurologists and neonatologists, addressing their perspectives and clinical experiences concerning neonatal HIE prognostication. Interviews were analyzed using thematic content analysis. RESULTS Participants unanimously recognized uncertainty in their prognostication. They identified several sources contributing to uncertainty in HIE prognostication, including etiology and underlying pathophysiologic mechanisms, statistical limitations, variable clinical data, the dynamic process of neurodevelopment, or the impact of hypothermia treatment. Unlike in some other literature, some physicians in this study talked about ways to render uncertainty explicit rather than hide it. CONCLUSION Results from this study support the call for recognition of the ubiquitous uncertainty surrounding this act in medical education and training.
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Henselmans I, Smets EMA, Han PKJ, de Haes HCJC, Laarhoven HWMV. How long do I have? Observational study on communication about life expectancy with advanced cancer patients. PATIENT EDUCATION AND COUNSELING 2017; 100:1820-1827. [PMID: 28511804 DOI: 10.1016/j.pec.2017.05.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/01/2017] [Accepted: 05/05/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To examine how communication about life expectancy is initiated in consultations about palliative chemotherapy, and what prognostic information is presented. METHODS Patients with advanced cancer (n=41) with a median life expectancy <1year and oncologists (n=6) and oncologists-in-training (n=7) meeting with them in consultations (n=62) to discuss palliative chemotherapy were included. Verbatim transcripts of audio-recorded consultations were analyzed using MAXqda10. RESULTS Life expectancy was addressed in 19 of 62 of the consultations. In all cases, patients took the initiative, most often through direct questions. Estimates were provided in 12 consultations in various formats: the likelihood of experiencing a significant event, point estimates or general time scales of "months to years", often with an emphasis on the "years". The indeterminacy of estimates was consistently stressed. Also their potential inadequacy was regularly addressed, often by describing beneficial prognostic predictors for the specific patient. Oncologists did not address the reliability or precision of estimates. CONCLUSION Oncologists did not initiate talk about life expectancy, they used different formats, emphasized the positive and stressed unpredictability, yet not ambiguity of estimates. PRACTICE IMPLICATIONS Prognostic communication should be part of the medical curriculum. Further research should address the effect of different formats of information provision.
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Affiliation(s)
- I Henselmans
- Academic Medical Center, Department of Medical Psychology, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam, The Netherlands.
| | - E M A Smets
- Academic Medical Center, Department of Medical Psychology, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - P K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME, USA; Tufts University Clinical and Translational Sciences Institute, Boston, MA, USA
| | - H C J C de Haes
- Academic Medical Center, Department of Medical Psychology, Amsterdam, The Netherlands
| | - H W M van Laarhoven
- Cancer Center Amsterdam, Amsterdam, The Netherlands; Academic Medical Center, Department of Medical Oncology, Amsterdam, The Netherlands
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