Managing awareness: negotiating and coping with a terminal prognosis

To be aware or not to be aware of the prognosis in the terminal stage of cancer? A systematic review of the associations between prognostic awareness with anxiety, depression, and quality of life according to cancer stage

Prognostic awareness (PA) has an important role in promoting informed care planning in cancer patients. However, studies in the literature showed discordant results regarding the impact of PA on psychological and quality of life outcomes. The present systematic review aimed to investigate the associations between PA with anxiety, depression, and quality of life in oncological patients according to early, advanced, and terminal cancer stages. The review adhered to PRISMA guidelines and was registered on PROSPERO. The research identified 42.357 studies, of which 54 were included. The main result showed that the associations of PA with anxiety, depression, and quality of life varied according to the cancer stage. In studies with early and advanced cancer patients, 0 % and 9 %, respectively, showed favourable associations, while in those with terminal cancer patients, 53 % showed favourable associations. In terminal stage cancer, the associations were favourable when patients were enrolled in hospice, had a mean survival time shorter than 60 days, and a mean age older than 65 years. These findings suggest that it could be important within psychological interventions for patients to consider the impact of PA at different stages of cancer. While in the early and advanced stages of cancer, patients might benefit most from interventions focused on implementing psychological resources to face the illness and maintaining a hopeful outlook, in the terminal stage of cancer, it could be important to promote the process of becoming aware of their prognosis.

Life beyond Loss: A Retrospective Analysis of the Impact of Meaning of Life Therapy on the Grieving Process of Cancer Patients' Family Caregivers

Oncological disease in the palliative stage is a huge challenge for patients and their family caregivers (FCs) due to the fact that it confronts them with death, as well as physical, psychological, and existential suffering. Meaning of Life Therapy (MLT) is a brief structured psycho-existential intervention aiming to help patients in a meaning-making life review process, promoting end-of-life adaptation. The Life Letter (LL) resulting from MLT is an element that facilitates communication between the patient and their caregivers. The goal of this study was to understand the impact of MLT on the grieving processes of eight FCs and to study their perceptions of the role of the LL on grief through semi-structured interviews. The results of our qualitative analysis indicate that MLT was perceived by the FCs as a positive experience despite the conspiracy of silence being identified as a drawback. The LL was interpreted as a communicational element, promoting emotional closeness with the cancer patients and serving as a valuable tool in the FCs' adaptation to loss. Our research findings show that the needs of FCs, especially after experiencing the loss of their relative, are dynamic and specific. This is why it is urgent to develop interventions that consider the idiosyncrasies of end-of-life cancer patients and their FCs in order to avoid frustrated farewells, lonely deaths, and maladaptive grieving processes. This is the direction in which MLT should evolve.

Adult-Child Caregivers' Family Communication Experiences after an Older Parent's Blood Cancer Diagnosis: A Survey Exploring Their Openness, Avoidance, and Social Support

Adult-child caregivers of an aging parent living with a blood cancer describe struggling to communicate with one another and within the family system. They may avoid critical care conversations, which may impede care and their ability to receive social support. We examined what approaches adult-child caregivers of a parent diagnosed with a blood cancer use to enhance their family communication, the topics they find most challenging to discuss, and the roles of openness and support. We used qualitative and quantitative approaches to analyze data from a larger online survey study. In partnership with the Leukemia & Lymphoma Society, we recruited 121 adult-child caregivers. Responses to one open-ended item were analyzed to capture strategies used to enhance communication with their parent and family. They reported utilizing digital communication modalities, prioritizing frequent communication, engaging in openness, establishing boundaries, kinkeeping, and enacting support. Within the quantitative data, we further explored two of these themes (openness and support) and their relationships to other variables using t-tests and regression analysis. Adult-child caregivers and diagnosed parents avoid talking about mortality and negative feelings. Openness in the family about cancer was linked to caregivers' perceptions of receiving social support. Findings demonstrate that cultivating openness between midlife adult children and diagnosed parents may enhance opportunities to receive support.

Awareness of Disease Status Among Patients With Cancer: An Integrative Review

BACKGROUND

As the quality of cancer care improves, oncology patients face a rapidly increasing number of treatment options. Thus, it is vital that they are full and active partners in the treatment decision-making process. Awareness of disease status has been investigated in the literature; it has been inconsistently conceptualized and operationalized.

OBJECTIVE

The aim of this integrative review was to develop a conceptual definition and model of the awareness of disease status among patients with cancer.

METHODS

Whittemore and Knafl's integrative review methodology guided this article. We obtained data through a systematic search of 8 databases. Key terms utilized were awareness, perception, truth disclosure, diagnosis, prognosis, terminal illness, status, neoplasm, and metastasis. Dates through January 2020 were searched to capture all relevant articles. Sixty-nine articles met inclusion criteria.

RESULTS

The integrative review methodology guided the development of a conceptual definition and model. The concept of "awareness of disease status" was defined as the individual patient's understanding of being diagnosed and treated for cancer based on the multifactorial components of individual patient characteristics and contextually driven communication practices of healthcare providers. This understanding is dynamic and changes throughout the disease trajectory.

CONCLUSION

These findings will inform consistency in the literature. Such consistency may improve person-centered clinical communication, care planning practices, and, ultimately, cancer-related outcomes.

IMPLICATIONS FOR PRACTICE

With a greater understanding of the complexity of patients' awareness of disease status, nurses will be able to guide their patients to make informed decisions throughout their disease trajectory.

Characteristics of patients with advanced cancer preferring not to know prognosis: a multicenter survey study

Background

For some patients with advanced cancer not knowing prognosis is essential. Yet, in an era of informed decision-making, the potential protective function of unawareness is easily overlooked. We aimed to investigate 1) the proportion of advanced cancer patients preferring not to know prognosis; 2) the reasons underlying patients’ prognostic information preference; 3) the characteristics associated with patients’ prognostic information preference; and 4) the concordance between physicians’ perceived and patients’ actual prognostic information preference.

Methods

This is a cross-sectional study with structured surveys (PROSPECT). Medical and thoracic oncologists included patients (n = 524), from seven Dutch hospitals, with metastatic/inoperable cancer and an expected median overall survival of ≤ 12 months. For analysis, descriptive statistics and logistic regression models were used.

Results

Twenty-five to 31% of patients preferred not to know a general life expectancy estimate or the 5/2/1-year mortality risk. Compared to patients preferring to know prognosis, patients preferring unawareness more often reported optimism, avoidance and inability to comprehend information as reasons for wanting limited information; and less often reported expectations of others, anxiety, autonomy and a sense of control as reasons for wanting complete information. Females (p < .05), patients receiving a further line of systemic treatment (p < .01) and patients with strong fighting spirit (p < .001) were more likely to prefer not to know prognosis. Concordance between physicians’ perceived and patients’ actual prognostic information preference was poor (kappa = 0.07).

Conclusions

We encourage physicians to explore patients’ prognostic information preferences and the underlying reasons explicitly, enabling individually tailored communication. Future studies may investigate changes in patients’ prognostic information preferences over time and examine the impact of prognostic disclosure on patients who prefer unawareness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09911-8.

Beliefs About Advanced Cancer Curability in Older Patients, Their Caregivers, and Oncologists

BACKGROUND

Ensuring older patients with advanced cancer and their oncologists have similar beliefs about curability is important. We investigated discordance in beliefs about curability in patient-oncologist and caregiver-oncologist dyads.

MATERIALS AND METHODS

We used baseline data from a cluster randomized trial assessing whether geriatric assessment improves communication and quality of life in older patients with advanced cancer and their caregivers. Patients were aged ≥70 years with incurable cancer from community oncology practices. Patients, caregivers, and oncologists were asked: "What do you believe are the chances the cancer will go away and never come back with treatment?" Options were 100%, >50%, 50/50, <50%, and 0% (5-point scale). Discordance in beliefs about curability was defined as any difference in scale scores (≥3 points were severe). We used multivariate logistic regressions to describe correlates of discordance.

RESULTS

Discordance was present in 60% (15% severe) of the 336 patient-oncologist dyads and 52% (16% severe) of the 245 caregiver-oncologist dyads. Discordance was less common in patient-oncologist dyads when oncologists practiced longer (adjusted odds ratio [AOR] 0.90, 95% confidence interval [CI] 0.84-0.97) and more common in non-Hispanic white patients (AOR 5.77, CI 1.90-17.50) and when patients had lung (AOR 1.95, CI 1.29-2.94) or gastrointestinal (AOR 1.55, CI 1.09-2.21) compared with breast cancer. Severe discordance was more common when patients were non-Hispanic white, had lower income, and had impaired social support. Caregiver-oncologist discordance was more common when caregivers were non-Hispanic white (AOR 3.32, CI 1.01-10.94) and reported lower physical health (AOR 0.88, CI 0.78-1.00). Severe discordance was more common when caregivers had lower income and lower anxiety level.

CONCLUSION

Discordance in beliefs about curability is common, occasionally severe, and correlated with patient, caregiver, and oncologist characteristics.

IMPLICATIONS FOR PRACTICE

Ensuring older patients with advanced cancer and their caregivers have similar beliefs about curability as the oncologist is important. This study investigated discordance in beliefs about curability in patient-oncologist (PO) and caregiver-oncologist (CO) dyads. It found that discordance was present in 60% (15% severe) of PO dyads and 52% (16% severe) of CO dyads, raising serious questions about the process by which patients consent to treatment. This study supports the need for interventions targeted at the oncologist, patient, caregiver, and societal levels to improve the delivery of prognostic information and patients'/caregivers' understanding and acceptance of prognosis.

The Experience of Being Aware of Disease Status in Women with Recurrent Ovarian Cancer: A Phenomenological Study

BACKGROUND

Awareness of disease status has been identified as a factor in the treatment decision-making process. Women with recurrent ovarian cancer are facing the challenge of making treatment decisions throughout the disease trajectory. It is not understood how women with ovarian cancer perceive their disease and subsequently make treatment decisions.

PURPOSE

The purpose of this phenomenological study was to understand the lived experience of women with recurrent ovarian cancer, how they understood their disease and made their treatment decisions.

METHODS

A qualitative design with a descriptive phenomenological method was used to conduct 2 in-depth interviews with 12 women (n = 24 interviews). Each interview was ∼60 minutes and was digitally recorded and professionally transcribed. Data collection focused on patients' understanding of their disease and how patients participated in treatment decisions. A modified version of Colaizzi's method of phenomenological reduction guided data analysis.

RESULTS

Three themes emerged to describe the phenomenon of being aware of disease status: (1) perceiving recurrent ovarian cancer as a chronic illness, (2) perceived inability to make treatment decisions, and (3) enduring emotional distress.

CONCLUSIONS AND IMPLICATIONS

This study revealed how 12 women conceptualized recurrent ovarian cancer as a chronic disease and their perceived inability to make treatment decisions because of lack of information and professional qualifications, resulting in enduring emotional distress. Future research should replicate the study to confirm the persistence of the themes for racially, ethnically, and religiously diverse patient samples and to improve understanding of awareness of disease status and decision-making processes of patients.

Communication about the impending death of patients with cancer to the family: a nationwide survey

Objectives

Explanation about the impending death of imminently dying patients with cancer is important for their families. However, little is known about how clinicians explain impending death and how families perceive the explanation. We aimed to clarify bereaved families’ perception of the need for improvements in the explanation about impending death and to explore the factors contributing to the need.

Methods

In a nationwide survey of 818 bereaved families of patients with cancer admitted to inpatient hospices in Japan, we evaluated family-perceived need for improvements in the explanation about impending death and families’ experiences of the explanation.

Results

Among all the participants (n=516, 63%), 35 (6.8%), 123 (24%) and 297 (58%) families felt that much/considerable, some and no improvements were needed, respectively. Independent determinants of the need were a younger patient age (OR=0.97; 95% CI 0.95 to 0.99; P=0.009); not receiving an ‘explicit explanation about physical signs of impending death’ (OR=0.67; 95% CI 0.51 to 0.88; P=0.004); not receiving an ‘explanation of how long the patient and family could talk’ (OR=0.67; 95% CI 0.51 to 0.88; P<0.001); receiving an ‘excessive warning of impending death’ (OR=1.45; 95% CI 1.03 to 2.03; P=0.033) and having a feeling of ‘uncertainty caused by vague explanations about future changes’ (OR=1.77; 95% CI 1.38 to 2.27; P<0.001).

Conclusions

Nearly a third of the bereaved families perceived some need to improve the explanation about impending death. To better help patients/families prepare for their end-of-life, clinicians should recognise and explain various impending death signs; find a balance between detailed explanation and excessive warning and address how long they could talk in the remaining time.

Patient characteristics associated with prognostic awareness: a study of a Canadian palliative care population using the InterRAI palliative care instrument

CONTEXT

Awareness of their medical prognosis enables terminally ill patients to make decisions on treatments and end-of-life care/planning, and to reach acceptance. Yet, many patients receiving palliative care (PC) are unaware of their prognosis, even when death is imminent and has been discussed with health care providers. A better understanding of patient characteristics associated with prognostic awareness (PA) is needed to develop interventions aimed at improving it.

OBJECTIVES

To identify patient characteristics associated with PA in a PC population.

METHODS

The sample comprised 2090 palliative home care patients in Ontario, Canada, assessed using the interRAI Palliative Care Assessment. Independent variables included sociodemographic, cognitive/physical functioning, mood, psychological well-being, and social support. Using cross-sectional data, an adjusted logistic regression model was developed to identify key patient characteristics associated with PA. A multifaceted definition of PA was assumed and represented dichotomously in the model. Multiple imputation was used to address missing data, generating results similar to the complete case analysis.

RESULTS

The PA was higher in patients with: a shorter prognosis (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.93-4.33), increased hours of informal care (OR 1.71, 95% CI 1.15-2.52), less cognitive impairment (OR 1.61, 95% CI 1.14-2.28), and in patients at peace with life (OR 1.79, 95% CI 1.27-2.53). Site differences were observed but do not reflect differences in age, gender, prognosis, or diagnosis.

CONCLUSION

Some patient characteristics are amenable to clinical intervention to raise PA, such as being at peace, cognitive impairment, and depression. Prognostic communications vary in timing and quality and may underlie our site differences, but further research is required to confirm this.

Conceptualizing prognostic awareness in advanced cancer: a systematic review

This systematic review synthesizes the complex literature on prognostic awareness in cancer. A total of 37 studies examining cancer patients' understanding of their prognosis were included. Prognostic awareness definitions and assessment methods were inconsistent across studies. A surprisingly high percentage of patients (up to 75%) were unaware of their poor prognosis, and in several studies, even their cancer diagnosis (up to 96%), particularly in studies conducted outside of North America. This review highlights surprisingly low rates of prognostic awareness in patients with advanced cancer as well as discrepancies in prognostic awareness assessment, suggesting the need for empirically validated measures of prognostic awareness.

When cure is no option: how explicit and hopeful can information be given? A qualitative study in breast cancer

OBJECTIVE

To investigate how oncologists can balance explicit with general and realistic with hopeful information when discussing various topics at the transition from curative to palliative care in breast cancer.

METHODS

Qualitative analysis of focus groups consisting of female breast cancer survivors and healthy women.

RESULTS

Perceptions of survivors and healthy women largely overlapped. Participants thought that oncologists can help patients regain a future perspective during this consultation. To achieve this, four themes seemed important: honest medical information, availability of continued support, hope has many faces, and space to choose. Moreover, participants stressed they would need time to let the message sink in before any further information was provided.

CONCLUSION

Participants thought that when confronted with this type of consultation they would need - more or less explicit - medical information and information regarding support. In order to maintain hope, knowledge about (treatment) possibilities is important, but also the certainty not to be abandoned by the hospital at a later stage of the disease and the confidence to remain able to make one's own decisions.

PRACTICE IMPLICATIONS

A life-limiting diagnosis may shatter patients' future perspective; however, this study provides suggestions for oncologists to create a new perspective.

Information of Imminent Death or Not: Does It Make a Difference?

Purpose

This study examines whether end-of-life care for patients with cancer who were informed about imminent death differs from care for those patients with cancer who were not informed.

Patients and Methods

This study included all cancer deaths between 2006 and 2008 for which the patient did not lose his or her decision-making capacities until hours or days before death (N=13,818). These patients were taken from a national quality register for end-of-life care. The majority of the patients—91% (n=12,609) —had been given information about imminent death; 9% (n=1,209) had not been informed. Because of the difference in sample size, a matching procedure was performed to minimize bias. This resulted in a comparison of 1,191 informed and 1,191 uniformed patients. Nonparametric methods were used for statistical analyses.

Results

Informed patients significantly more often had parenteral drugs prescribed as needed (ie, PRN), had his or her family informed, died in his or her preferred place, and had family who were offered bereavement support. There was no difference in symptom control (ie, pain, anxiety, confusion, nausea, and respiratory tract secretions) between the groups.

Conclusion

Providing information of imminent death to a patient with cancer at the end of life does not seem to increase pain or anxiety, but it does seem to be associated with improved care and to increase the likelihood of fulfilling the principles of a good death.

Hope against hope in cancer at the end of life

Hope has many facets to it in the context of cancer. This article outlines an instrumental case study for a patient with aggressive lymphoma who rapidly deteriorated to the point of dying. How her and her family's hope was managed is outlined here from various perspectives. Interviews were carried out with the patient's family, medical consultant-in-charge (attending physician) and nurses caring for her at the end of life. The findings outline the transition from hope for cure to hope for a good death and the role that the patient and family's Christian hope played in this. Religiosity and spirituality of hope in terms of Christian hope is explored from the theological perspective. Practical aspects of care in the face of changing hope are discussed. Conclusions are drawn about reframing hope in a changing clinical situation with reference to theories of hope. The importance of acknowledging hope, coping, spirituality and religiosity, especially at end of life, is emphasised.

Direct communication, the unquestionable ideal? Oncologists' accounts of communication of bleak prognoses

OBJECTIVE

To explore the factors that influence the clinical practice of oncologists concerning disclosure of prognostic information.

METHODS

Focus group interviews with oncologists in three Norwegian university hospitals. Interview guide consisting of three patient cases where challenging aspects of prognostic information delivery were presented to the participants. Each group consisted of six participants, all groups with a mix of men and women, and ranging from very experienced consultants to relatively inexperienced residents in oncology. Transcribed interviews were qualitatively analyzed through categorization and condensation.

RESULTS

The importance of openness when dealing with prognostic information towards the end of life was strongly advocated by all participants. However, there was a reluctance to give tangible information regarding survival, and a feeling that this part of clinical practice was a challenge. Skills in how to communicate negative prognostic information were attained primarily by observing colleagues, but also from personal experience. Existing guidelines for communication were not perceived as useful.

CONCLUSION

Primarily focusing on open communication regarding bleak prospects of life expectancy entails a risk of overrunning the information needs of individual patients. Oncologists still see communication skills primarily as personal, and are at risk of not exploring and responding to the individual patient's wish for information.

The importance of hope as a mediator of psychological distress and life satisfaction in a community sample of cancer patients

BACKGROUND

Although hope is an important resource for cancer patients, few studies include it as an independent or dependent variable in quality-of-life research.

OBJECTIVE

The purposes of this study, in a community-based sample of cancer patients, were to evaluate the relationships between demographic and clinical characteristics, health status, hope, psychological distress, and life satisfaction and evaluate whether hope mediated the relationship between psychological distress and life satisfaction.

METHODS

Participants (n = 194) completed a demographic and clinical questionnaire, a single item of self-assessed health, the Herth Hope Index, Impact of Event Scale, and a single-item rating of satisfaction with life. Structural regression models were examined to evaluate the interrelationships among these variables, with life satisfaction as the primary outcome.

RESULTS

Participants were primarily women with breast cancer. In the final structural regression model that explained 60% of the variance in life satisfaction, poorer health status, lower hope, and higher psychological distress were significantly related to lower satisfaction with life. Hope was found to mediate the relationship between psychological distress and health status, such that the direct association between distress and health status was no longer significant with hope in the model. Finally, hope partially mediated the association between psychological distress and life satisfaction.

CONCLUSIONS

These data suggest that hope is an important resource for oncology patients that impacts their quality of life.

IMPLICATIONS FOR PRACTICE

Hope may be an important coping mechanism that clinicians need to consider when they try to help patients reduce the psychological distress associated with cancer and its treatment.

The transition experience of rural older persons with advanced cancer and their families: a grounded theory study

BACKGROUND

Transitions often occur suddenly and can be traumatic to both patients with advanced disease and their families. The purpose of this study was to explore the transition experience of older rural persons with advanced cancer and their families from the perspective of palliative home care patients, bereaved family caregivers, and health care professionals. The specific aims were to: (1) describe the experience of significant transitions experienced by older rural persons who were receiving palliative home care and their families and (2) develop a substantive theory of transitions in this population.

METHODS

Using a grounded theory approach, 27 open-ended individual audio-taped interviews were conducted with six older rural persons with advanced cancer and 10 bereaved family caregivers. Four focus group interviews were conducted with 12 palliative care health care professionals. All interviews were transcribed verbatim, coded, and analyzed using Charmaz's constructivist grounded theory approach.

RESULTS

Within a rural context of isolation, lack of information and limited accessibility to services, and values of individuality and community connectedness, older rural palliative patients and their families experienced multiple complex transitions in environment, roles/relationships, activities of daily living, and physical and mental health. Transitions disrupted the lives of palliative patients and their caregivers, resulting in distress and uncertainty. Rural palliative patients and their families adapted to transitions through the processes of "Navigating Unknown Waters". This tentative theory includes processes of coming to terms with their situation, connecting, and redefining normal. Timely communication, provision of information and support networks facilitated the processes.

CONCLUSION

The emerging theory provides a foundation for future research. Significant transitions identified in this study may serve as a focus for improving delivery of palliative and end of life care in rural areas. Improved understanding of the transitions experienced by advanced cancer palliative care patients and their families, as well as the psychological processes involved in adapting to the transitions, will help health care providers address the unique needs of this vulnerable population.

Advanced cancer patients' prognostic information preferences: a review

Open communication in cancer care has gained increasing importance in recent years and diagnostic disclosure is now common place. However, there is a significant variability in the sharing of prognostic information. Information needs may vary significantly over the disease trajectory, and there has been relatively little work done focussing on late illness. Using systematic review procedures, 13 studies were identified that addressed this issue. The evidence shows that all patients wanted honesty from their professional team and the vast majority wanted some broad indication of their prognosis, but that preferences for quantitative information were more varied. Benefits associated with realistic awareness included enhanced control and end-of-life planning, which was seen to engender hope. However, for a proportion of patients, hope and realism were irreconcilable when presented with detailed or unequivocal information. Professionals have a responsibility to provide information to patients, but also to respect the need to maintain some ambiguity about the future, if that is a patient's wish. Therefore, prognostic discussions necessitate careful, individualised assessment, a process which can facilitate enhanced palliative care for patients with advanced cancer.

Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review

Many health professionals (HPs) express discomfort at having to broach the topic of prognosis, including limited life expectancy, and may withhold information or not disclose prognosis. A systematic review was conducted of 46 studies relating to truth-telling in discussing prognosis with patients with progressive, advanced life-limiting illnesses and their caregivers. Relevant studies meeting the inclusion criteria were identified by searching computerized databases (MEDLINE, EMBASE, CINAHL, PsychINFO and Cochrane Register of Controlled Trials) up to November 2004, with handsearching of studies, as well as inclusion of studies satisfying selection criteria reported in 2005 by the authors. The reference lists of identified studies were hand-searched for further relevant studies. Inclusion criteria were studies of any design evaluating communication of prognostic information that included adult patients with an advanced, life-limiting illness; their caregivers; and qualified HPs. Results showed that although the majority of HPs believed that patients and caregivers should be told the truth about the prognosis, in practice, many either avoid discussing the topic or withhold information. Reasons include perceived lack of training, stress, no time to attend to the patient's emotional needs, fear of a negative impact on the patient, uncertainty about prognostication, requests from family members to withhold information and a feeling of inadequacy or hopelessness regarding the unavailability of further curative treatment. Studies suggest that patients can discuss the topic without it having a negative impact on them. Differences and similarities in findings from different cultures are explored.

A systematic review of prognostic/end-of-life communication with adults in the advanced stages of a life-limiting illness: patient/caregiver preferences for the content, style, and timing of information

Evidence-based recommendations concerning how to discuss dying, life expectancy, and likely future symptoms with patients with a limited life expectancy and their families are lacking. The aim of this systematic review was to review studies regarding prognostic/end-of-life communication with adult patients in the advanced stages of a life-limiting illness and their caregivers. Relevant studies meeting the inclusion criteria were identified by searching computerized databases up to November 2004. One hundred twenty-three studies met the criteria for the full review, and 46 articles reported on patient/caregiver preferences for content, style, and timing of information. The majority of the research was descriptive. Although there were individual differences, patients/caregivers in general had high levels of information need at all stages of the disease process regarding the illness itself, likely future symptoms and their management, and life expectancy and information about clinical treatment options. Patient and caregiver information needs showed a tendency to diverge as the illness progressed, with caregivers needing more and patients wanting less information. Patients and caregivers preferred a trusted health professional who showed empathy and honesty, encouraged questions, and clarified each individual's information needs and level of understanding. In general, most patients/caregivers wanted at least some discussion of these topics at the time of diagnosis of an advanced, progressive, life-limiting illness, or shortly after. However, they wanted to negotiate the content and extent of this information.

Communicating prognosis in cancer care: a systematic review of the literature

Prognosis is an issue that most doctors and patients describe as difficult to discuss and the best way of presenting prognostic information to optimise patient understanding, psychological adjustment and decision-making is uncertain. A systematic review of the literature was conducted with the aim of clarifying the current available knowledge of patient preferences, clinician views and current practice regarding the communication of prognosis. Eleven primary research questions guided organisation of the review findings, which were: patient preferences for prognostic information and preferred style of communicating prognosis; disclosure of prognosis to family members; physicians' views on communication of prognosis; current practice of delivering prognostic information; patient understanding and awareness of prognostic information; cultural differences in preferences and understanding; impact of prognostic information on patient outcomes; and interventions to facilitate prognostic discussion. Predictors of patient preferences for and understanding of prognostic information were also summarised. Studies are summarised under the subcategories according to the participants' disease stage. It was found that the majority of the published research has been conducted in the early stage cancer setting providing mostly descriptive evidence, and there is little evidence of the best method of communicating prognosis or of the impact of prognostic information on patient outcomes.

Fostering coping and nurturing hope when discussing the future with terminally ill cancer patients and their caregivers

BACKGROUND

It is challenging for clinicians to foster coping and allow hope when discussing prognosis and end-of-life (EOL) issues with terminally ill cancer patients and their caregivers. To the authors' knowledge, little research evidence is currently available to guide clinical practice.

METHODS

The authors conducted focus groups and individual interviews with 19 patients with far advanced cancer and 24 caregivers from 3 palliative care (PC) services in Sydney, and 22 PC health professionals (HPs) from around Australia. The focus groups and individual interviews were audiotaped and fully transcribed. Additional focus groups or individual interviews were conducted until no additional topics were raised. The participants' narratives were analyzed using qualitative methodology.

RESULTS

All participant groups believed there were ways of fostering coping and nurturing hope when discussing prognosis and EOL issues. Themes identified from the transcripts regarding ways of helping patients with a limited life expectancy to cope were: 1) emphasize what can be done (namely: a) control of physical symptoms; b) emotional support, care, and dignity; and c) practical support), 2) explore realistic goals, and 3) discuss day-to-day living. Two additional themes were identified regarding ways of fostering hope: the balance between truth telling and nurturing hope, and the spectrum of hope. All these themes were raised by the patients, caregivers, and HPs. However, there were some differences of opinion within the three participant groups.

CONCLUSIONS

The results of the current study demonstrated that most participants believed there were ways of fostering coping and maintaining hope and that HPs have a role in facilitating this with terminally ill cancer patients and their caregivers.

Identity loss and maintenance: commonality of experience in cancer and dementia

This paper examines parallel thematic findings from two qualitative studies exploring the experience of disease as it relates to cancer and dementia. The original studies examined the experiences of 16 individuals with cancer and 20 with dementia, and the impact of these first hand experiences and those of their principal family carers. The paper presents findings linked to the common or shared concepts of identity loss and maintenance as expressed by both the affected individual and the family carer.

Entrevista semi-estructurada para la evaluación de la conciencia de enfermedad oncológica E-CEO. Estudio de fiabilidad sobre una muestra de pacientes con enfermedad avanzada

Objetivo: La comunicación entre pacientes oncológicos y profesionales de la salud se considera uno de los aspectos más importantes del cuidado, especialmente en fases avanzadas de la enfermedad. La conciencia de enfermedad consistiría en un proceso dinámico y cambiante en el tiempo, influenciado por la cantidad y calidad de la información y el significado que cada sujeto le asigna. En el presente trabajo se describe el proceso de diseño, validación y cálculo de la fiabilidad de una entrevista semiestructurada (Entrevista sobre la Conciencia de Enfermedad Oncológica E-CEO). Este instrumento, escasamente invasivo y no revelador de información, permite situar a los sujetos a lo largo de un continuum en base a su percepción de severidad de la enfermedad. Método: En una primera fase se realizó una entrevista abierta sobre 15 pacientes y se elaboró un listado de expresiones clave, que fueron agrupadas en cinco categorías. En una segunda fase se aplicó un modelo de entrevista semiestructurada a 42 pacientes ingresados con diagnóstico de enfermedad oncológica avanzada (estadio clínico IV) en la Unidad de Hospitalización de Oncología del Hospital de A Coruña. Resultados: La fiabilidad obtenida entre diferentes observadores muestra que se trata de un instrumento de elevada calidad (Kappa=0,70). Los datos reflejan una discrepancia amplia entre el estado de salud de los pacientes y su propia consideración. Más del 50% consideraron su enfermedad “controlada”. Conclusiones: Se trata de un instrumento de sencilla aplicación que permitirá en futuras investigaciones profundizar en el estudio de los procesos de integración de información en este tipo de pacientes.