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Shayya A, Young Y. End-of-Life Medical Decisions: The Link Between Sociodemographic Characteristics and Treatment Preferences. Am J Hosp Palliat Care 2023:10499091231218988. [PMID: 38008990 DOI: 10.1177/10499091231218988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023] Open
Abstract
INTRODUCTION Advance directives (ADs) promote patient autonomy in end-of-life (EOL) care, including an individual's EOL medical treatment preferences. This study aims to better understand preferences regarding EOL medical treatment among community-dwelling adults (18 and older) residing in the United States and examine the association between sociodemographic characteristics and EOL medical treatment preferences. METHODS Utilizing a cross-sectional study and snowball sampling methodology, community-dwelling adults completed a survey containing two different ADs and a questionnaire with sociodemographic information. Univariate analyses were used to summarize EOL medical treatment preferences among the sample, and bivariate analyses (Chi-square and Fisher's Exact tests) were performed to examine the association between sociodemographic characteristics (age, gender, and race/ethnicity) and EOL medical treatment preferences. RESULTS The mean age of the 166 participants was 50 (SD: 21.65, range: 18-93), with 58.4% being White and 61.4% being female. Generally, when EOL scenarios involved brain damage or a coma, more participants indicated that they did not want life-support treatment. Age and race were both associated with EOL medical treatment preferences, but no significant differences were observed in the bivariate results by gender. Largely, young and middle-aged adults, along with Black participants, were more likely to prefer more aggressive EOL medical treatments than older adults and White participants. CONCLUSION Overall, EOL medical treatment preferences varied among participants. The study findings indicate that adults develop different preferences for EOL medical treatment, with some of the variation attributable to sociodemographic characteristics such as age and race.
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Affiliation(s)
- Ashley Shayya
- Department of Health Policy, Management, and Behavior, School of Public Health, State University of New York at Albany, Rensselaer, NY, USA
| | - Yuchi Young
- Department of Health Policy, Management, and Behavior, School of Public Health, State University of New York at Albany, Rensselaer, NY, USA
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Kim J, Heo S, Yang J, Kim M, Park S, Cho K, Kang J, Yi H, An M. The moderating effect of attitudes in the relationship between knowledge and self-efficacy in palliative care among nurses: A cross-sectional, correlational study. PLoS One 2023; 18:e0292135. [PMID: 37796889 PMCID: PMC10553266 DOI: 10.1371/journal.pone.0292135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/13/2023] [Indexed: 10/07/2023] Open
Abstract
Provision of palliative care to patients with advanced chronic diseases or old populations is suboptimal, which results in unnecessary suffering of and burden to patients, caregivers, and society. Low self-efficacy in palliative care among nurses is a factor affecting suboptimal utilization of palliative care. Poor knowledge is a factor affecting low self-efficacy in palliative care of nurses. Attitudes may contribute to the relationship between knowledge and self-efficacy in palliative care, but these relationships have been rarely examined in nurses. This study aimed to determine whether nurses' attitudes moderate the relationship between knowledge and self-efficacy in palliative care. In a cross-sectional, correlational study, online or offline survey on self-efficacy, knowledge, attitudes, and covariates was conducted from 282 nurses in South Korea. PROCESS v4.1 for SPSS was used to address the study aim. Higher levels of knowledge (p = .048) and attitudes (p < .001), and the interaction term of knowledge and attitudes (p = .025) were significantly associated with higher levels of self-efficacy (F = 6.12, p < .001, R2 = .152), indicating the moderating effects of attitudes. The relationships between higher levels of knowledge and self-efficacy were significant only in nurses with highly and moderately positive attitudes (R2 change = .016, F = 5.11, p = .025), but not nurses with lack of positive attitudes. Our results supported the moderating role of nurses' attitudes in the relationship between knowledge and self-efficacy. To improve self-efficacy in palliative care in nurses, improvement in knowledge and facilitation of positive attitudes are needed.
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Affiliation(s)
- JinShil Kim
- College of Nursing, Gachon University, Incheon, South Korea
| | - Seongkum Heo
- Georgia Baptist College of Nursing, Mercer University, Atlanta, GA, United States of America
| | - Jisun Yang
- College of Nursing, Gachon University, Incheon, South Korea
| | - Miyeong Kim
- Department of Nursing, Gachon University Gil Medical Center, Incheon, Korea
| | - SeongHu Park
- College of Nursing Sciences, Sungshin Women’s University, Seoul, South Korea
| | - KyungAh Cho
- College of Nursing, Gachon University, Incheon, South Korea
| | - JungHee Kang
- College of Nursing, University of Kentucky, Lexington, Kentucky, United States of America
| | - Hani Yi
- Department of Nursing, Asan Medical Center, Seoul, South Korea
| | - Minjeong An
- College of Nursing, Chonnam National University, Gwangju, South Korea
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3
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Ngo J, Le J, Gandhi CH, Mariano JD, Viveros LA, Wang SE. Evolving Advance Care Planning in a Health Ecosystem: The Kaiser Permanente Experience. J Pain Symptom Manage 2023; 66:e245-e253. [PMID: 37054957 DOI: 10.1016/j.jpainsymman.2023.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/14/2023] [Accepted: 03/18/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Advance care planning is an integral part of supporting patients through serious illness and end-of-life care. PROBLEM Several components of advance care planning may be too inflexible to account for patients' changing disease and evolving goals as serious illness progresses. Health systems are starting to implement processes to address these barriers, though implementation has varied. PROPOSED SOLUTION In 2017, Kaiser Permanente introduced Life Care Planning (LCP), incorporating advance care planning dynamically into concurrent disease management. LCP provides a framework for identifying surrogates, documenting goals, and eliciting patient values across disease progression. LCP provides standardized training to facilitate communication and utilizes a centralized section within the electronic health record for longitudinal documentation of goals. OUTCOMES More than 6000 physicians, nurses, and social workers have been trained in LCP. Over one million patients have engaged in LCP since its inception, with over 52% of patients age 55+ having a surrogate designated. There is evidence of high treatment concordance with patients' desired wishes (88.9%), with high rates of advance directive completion as well (84.1%).
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Affiliation(s)
- Jason Ngo
- Department of Geriatrics, Palliative, and Continuing Care (J.N., C.H.G.), Kaiser Permanente Southern California, Fontana Medical Center, Fontana, California, USA.
| | - John Le
- Department of Internal Medicine (J.L.), Kaiser Permanente Southern California, Fontana Medical Center, Fontana, California, USA
| | - Chirag H Gandhi
- Department of Geriatrics, Palliative, and Continuing Care (J.N., C.H.G.), Kaiser Permanente Southern California, Fontana Medical Center, Fontana, California, USA
| | - Jeffrey D Mariano
- Department of Geriatrics, Palliative, and Continuing Care (J.D.M., S.E.W.), Kaiser Permanente Southern California, West Los Angeles Medical Center, Los Angeles, California, USA
| | - Lori A Viveros
- Kaiser Permanente Southern California (L.A.V.), Pasadena, California, USA
| | - Susan E Wang
- Department of Geriatrics, Palliative, and Continuing Care (J.D.M., S.E.W.), Kaiser Permanente Southern California, West Los Angeles Medical Center, Los Angeles, California, USA
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Ahmad SR, Tarabochia AD, Budahn L, LeMahieu AM, Karnatovskaia LV, Turnbull AE, Gajic O. Determining Goal Concordant Care in the Intensive Care Unit Using Electronic Health Records. J Pain Symptom Manage 2023; 65:e199-e205. [PMID: 36400406 PMCID: PMC10557174 DOI: 10.1016/j.jpainsymman.2022.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Goal concordant care (GCC) is the alignment of care to patient values and preferences. GCC is a major outcome of communication with patients and families in serious/critical illness. Using the electronic health record (EHR) to study the provision of GCC would be pragmatic and cost-effective for research and quality improvement efforts. RESEARCH QUESTION Do EHRs contain information to identify GCC? METHODS This is a feasibility retrospective chart review performed by two independent reviewers. An existing framework containing four questions for identifying GCC was adopted. Two clinicians reviewed multi-disciplinary notes and extracted pertinent information. The primary outcomes were whether the four key questions for determining goal concordance could be answered using information in the EHR. The secondary outcome was the type of goals identified. Cohen's kappa was used to measure agreement between two reviewers. RESULTS Patient care was considered goal concordant in 35 (85%) of 41 patients in a random sample comprising of 36 survivors and five who died in hospital. Inter-rater agreement on identifying data to determine GCC was excellent (Kappa 0.70). Patient goals were identified in 80% of charts reviewed. Note sources informative of patient preferences, included social work (39%), hospital progress notes (29%), palliative care (20%), and physical/occupational therapy (15%). "Returning home" and "getting better/ stronger" were among the most common patient goals captured in EHR. CONCLUSION The EHR can be used to understand patient goals, but the information is scattered across the multi-disciplinary notes. Improving EHR and external validation will facilitate ascertainment of goal concordance as an important outcome measure.
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Affiliation(s)
- Sumera R Ahmad
- Division of Pulmonary and Critical Care Medicine (S.R.A., L.k., O.G.), Mayo Clinic, Rochester, Minnesota.
| | - Alex D Tarabochia
- Department of Internal Medicine (A.D.T.), Mayo Clinic, Rochester, Minnesota
| | - LuAnn Budahn
- Anesthesia and Critical Care Research Unit (L.B.), Mayo Clinic, Rochester, Minnesota
| | - Allison M LeMahieu
- Department of Quantitative Health Sciences (A.M.L.), Mayo Clinic, Rochester, Minnesota
| | - Lioudmila V Karnatovskaia
- Division of Pulmonary and Critical Care Medicine (S.R.A., L.k., O.G.), Mayo Clinic, Rochester, Minnesota
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine (A.E.T.), Johns Hopkins University, Baltimore, Maryland; Department of Epidemiology, Bloomberg School of Public Health (A.E.T.), Johns Hopkins University, Baltimore, Maryland; Outcomes After Critical Illness and Surgery Research group (A.E.T.), Johns Hopkins University, Baltimore, Maryland
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine (S.R.A., L.k., O.G.), Mayo Clinic, Rochester, Minnesota
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Kunzler BR, Smith TJ, Levi BH, Green MJ, Badzek L, Katsaros MG, Van Scoy LJ. The Value of Advance Care Planning for Spokespersons of Patients With Advanced Illness. J Pain Symptom Manage 2023; 65:471-478.e4. [PMID: 36690164 DOI: 10.1016/j.jpainsymman.2022.12.143] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/21/2023]
Abstract
CONTEXT Advance Care Planning (ACP) has fallen under scrutiny primarily because research has not consistently demonstrated patient-focused benefits. OBJECTIVES To better understand how spokespersons regard, engage with, and find value in ACP during decision-making for their loved ones. METHODS This qualitative analysis was part of a randomized controlled trial involving spokespersons of patients with advanced illness who had completed ACP. After making a medical decision on behalf of their loved one (or that loved one's death), semi-structured interviews explored spokespersons' experience of decision-making and if (and how) ACP played a role. Thematic analysis was conducted on interview transcripts. RESULTS From 120 interviews, five themes emerged: 1) Written advance directives (ADs) helped increase spokespersons' confidence that decisions were aligned with patient wishes (serving as a physical reminder of previous discussions and increasing clarity during decision-making and family conflict); 2) Iterative discussions involving ACP facilitated "In the moment" decision-making; 3) ADs and ACP conversations helped spokespersons feel more prepared for future decisions; 4) Spokespersons sometimes felt there was "no choice" regarding their loved one's medical care; and 5) Regrets and second-guessing were the most common negative emotions experienced by spokespersons. CONCLUSION Considering the recent debate about the utility of ACP and ADs, this analysis highlights the value of ACP for spokespersons involved in surrogate decision-making. Reframing the goals of ACP in terms of their benefit for spokespersons (and identifying appropriate outcome measures) may provide additional perspective on the utility of ACP.
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Affiliation(s)
| | - Theresa J Smith
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA; Department of Pediatrics, Penn State College of Medicine (B.H.L.), Hershey, PA, USA
| | - Michael J Green
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA; Department of Medicine, Penn State College of Medicine (M.J.G, L.J.V.S.), Hershey, PA, USA
| | - Laurie Badzek
- Penn State Ross and Carol Nese College of Nursing (L.B.), University Park, PA, USA
| | - Maria G Katsaros
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA
| | - Lauren J Van Scoy
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA; Department of Medicine, Penn State College of Medicine (M.J.G, L.J.V.S.), Hershey, PA, USA; Department of Public Health Sciences, Penn State College of Medicine (L.J.V.S.), Hershey, PA, USA.
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Zhu Y, Olchanski N, Cohen JT, Freund KM, Faul JD, Fillit HM, Neumann PJ, Lin PJ. Life-Sustaining Treatments Among Medicare Beneficiaries with and without Dementia at the End of Life. J Alzheimers Dis 2023; 96:1183-1193. [PMID: 37955089 PMCID: PMC10777481 DOI: 10.3233/jad-230692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND Older adults with dementia including Alzheimer's disease may have difficulty communicating their treatment preferences and thus may receive intensive end-of-life (EOL) care that confers limited benefits. OBJECTIVE This study compared the use of life-sustaining interventions during the last 90 days of life among Medicare beneficiaries with and without dementia. METHODS This cohort study utilized population-based national survey data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Our sample included Medicare fee-for-service beneficiaries aged 65 years or older deceased between 2000 and 2016. The main outcome was receipt of any life-sustaining interventions during the last 90 days of life, including mechanical ventilation, tracheostomy, tube feeding, and cardiopulmonary resuscitation. We used logistic regression, stratified by nursing home use, to examine dementia status (no dementia, non-advanced dementia, advanced dementia) and patient characteristics associated with receiving those interventions. RESULTS Community dwellers with dementia were more likely than those without dementia to receive life-sustaining treatments in their last 90 days of life (advanced dementia: OR = 1.83 [1.42-2.35]; non-advanced dementia: OR = 1.16 [1.01-1.32]). Advance care planning was associated with lower odds of receiving life-sustaining treatments in the community (OR = 0.84 [0.74-0.96]) and in nursing homes (OR = 0.68 [0.53-0.86]). More beneficiaries with advanced dementia received interventions discordant with their EOL treatment preferences. CONCLUSIONS Community dwellers with advanced dementia were more likely to receive life-sustaining treatments at the end of life and such treatments may be discordant with their EOL wishes. Enhancing advance care planning and patient-physician communication may improve EOL care quality for persons with dementia.
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Affiliation(s)
- Yingying Zhu
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Natalia Olchanski
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Joshua T. Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Karen M. Freund
- Center for Health Equity Research, Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Jessica D. Faul
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | | | - Peter J. Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Pei-Jung Lin
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
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Dupont C, Smets T, Monnet F, Eneslätt M, Tishelman C, Van den Block L. The cultural adaptation of the go wish card game for use in Flanders, Belgium: a public health tool to identify and discuss end-of-life preferences. BMC Public Health 2022; 22:2110. [PMID: 36397020 PMCID: PMC9672613 DOI: 10.1186/s12889-022-14523-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/02/2022] [Indexed: 11/19/2022] Open
Abstract
Background Public health tools like the Go Wish card game from the US, have been found useful to support people in reflecting on their end-of-life preferences, but a cultural adaptation is essential for their success. In the present study, we explore the necessary cultural adaptations to the Go Wish cards by applying an extensive, systematic, and community-engaging negotiating procedure to facilitate the use of the cards in the general population of Flanders, Belgium. Methods We used an iterative cultural adaptation process with repeated discussions with various community organizations and representatives of minority and religious groups. After that, the cards were evaluated by 12 healthcare professionals in relation to: linguistic equivalence to the original version, applicability, comprehensibility, and relevance per card. Additional testing with potential users preceded final adjustments. Results We found that stakeholders were keen to engage throughout the process of cultural adaptation and we were able to make a range of cultural adaptations for the use of the cards in Flanders. All original statements were rephrased from passive to more active statements. Sixteen out of 36 cards were adjusted to make them more culturally appropriate for use in Flanders, e.g., “to meet with clergy or a chaplain” to “having a spiritual counselor as support.” Three new cards were added: two with statements appropriate to the Belgian patient rights and euthanasia legislation and one extra Wild Card. Potential users (n = 33) felt that the cards supported conversations about end-of-life preferences. Conclusion By making community engagement a cornerstone of our adaption process, we developed a card set that potential end-users considered a supportive public health tool for reflecting and discussing end-of-life values and preferences. The described process is particularly valuable for culturally adapt interventions, especially given that community engagement in adapting interventions is essential to creating grounded interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14523-9.
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Li J, Braun RT, Kakarala S, Prigerson HG. How Should Cost-Informed Goals of Care Decisions Be Facilitated at Life's End? AMA J Ethics 2022; 24:E1040-E1048. [PMID: 36342486 PMCID: PMC9811733 DOI: 10.1001/amajethics.2022.1040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Interventions near patients' deaths in the United States are often expensive, burdensome, and inconsistent with patients' goals and preferences. For patients and their loved ones to make informed care decisions, physicians must share adequate information about prognoses, prospective benefits and harms of specific interventions, and costs. This commentary on a case discusses strategies for sharing such information and suggests that properly designed advance care planning incentives can help improve communication and decision sharing.
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Affiliation(s)
- Jing Li
- Assistant professor in the Comparative Health Outcomes, Policy, and Economics Institute and in the Department of Pharmacy in the School of Pharmacy at the University of Washington in Seattle
| | - Robert Tyler Braun
- Assistant professor in the Division of Health Policy and Economics in the Department of Population Health Sciences at Weill Cornell Medical College in New York City
| | - Sophia Kakarala
- Research assistant at the Center for Research on End-of-Life Care at Weill Cornell Medicine in New York City
| | - Holly G Prigerson
- Irving Sherwood Wright Professor of Geriatrics at Weill Cornell Medicine in New York City
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Andersen SK, Vincent G, Butler RA, Brown EHP, Maloney D, Khalid S, Oanesa R, Yun J, Pidro C, Davis VN, Resick J, Richardson A, Rak K, Barnes J, Bezak KB, Thurston A, Reitschuler-Cross E, King LA, Barbash I, Al-Khafaji A, Brant E, Bishop J, McComb J, Chang CCH, Seaman J, Temel JS, Angus DC, Arnold R, Schenker Y, White DB. ProPACC: Protocol for a Trial of Integrated Specialty Palliative Care for Critically Ill Older Adults. J Pain Symptom Manage 2022; 63:e601-e610. [PMID: 35595373 PMCID: PMC9299559 DOI: 10.1016/j.jpainsymman.2022.02.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Each year, approximately one million older adults die in American intensive care units (ICUs) or survive with significant functional impairment. Inadequate symptom management, surrogates' psychological distress and inappropriate healthcare use are major concerns. Pioneering work by Dr. J. Randall Curtis paved the way for integrating palliative care (PC) specialists to address these needs, but convincing proof of efficacy has not yet been demonstrated. DESIGN We will conduct a multicenter patient-randomized efficacy trial of integrated specialty PC (SPC) vs. usual care for 500 high-risk ICU patients over age 60 and their surrogate decision-makers from five hospitals in Pennsylvania. INTERVENTION The intervention will follow recommended best practices for inpatient PC consultation. Patients will receive care from a multidisciplinary SPC team within 24 hours of enrollment that continues until hospital discharge or death. SPC clinicians will meet with patients, families, and the ICU team every weekday. SPC and ICU clinicians will jointly participate in proactive family meetings according to a predefined schedule. Patients in the control arm will receive routine ICU care. OUTCOMES Our primary outcome is patient-centeredness of care, measured using the modified Patient Perceived Patient-Centeredness of Care scale. Secondary outcomes include surrogates' psychological symptom burden and health resource utilization. Other outcomes include patient survival, as well as interprofessional collaboration. We will also conduct prespecified subgroup analyses using variables such as PC needs, measured by the Needs of Social Nature, Existential Concerns, Symptoms, and Therapeutic Interaction scale. CONCLUSIONS This trial will provide robust evidence about the impact of integrating SPC with critical care on patient, family, and health system outcomes.
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Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Grace Vincent
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rachel A Butler
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elke H P Brown
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dave Maloney
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sana Khalid
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rae Oanesa
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - James Yun
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carrie Pidro
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Valerie N Davis
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Judith Resick
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Aaron Richardson
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kimberly Rak
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jackie Barnes
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Karl B Bezak
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Andrew Thurston
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eva Reitschuler-Cross
- Department of Medicine, Division of General Internal Medicine (E.R.-C., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Linda A King
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ian Barbash
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of Pulmonary, Allergy and Critical Care (I.B., J.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Emily Brant
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jonathan Bishop
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer McComb
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care (I.B., J.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chung-Chou H Chang
- Department of Medicine, Division of General Internal Medicine (E.R.-C., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer Seaman
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Acute and Tertiary Care (J.S.), University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Jennifer S Temel
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston (J.S.T.), Massachusetts, USA
| | - Derek C Angus
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Robert Arnold
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Douglas B White
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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10
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Baker JN, Friebert S, Needle J, Jiang J, Wang J, Lyon ME. An Intervention in Congruence for End-of-Life Treatment Preference: A Randomized Trial. Pediatrics 2022; 149:e2021054796. [PMID: 35425986 PMCID: PMC9648108 DOI: 10.1542/peds.2021-054796] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There is a gap in family knowledge of their adolescents' end-of-life (EOL) treatment preferences. We tested the efficacy of Family Centered Advance Care Planning for Teens with Cancer (FACE-TC) pediatric advance care planning (to increase congruence in EOL treatment preferences. METHODS Adolescents with cancer/family dyads were randomized into a clinical trial from July 2016 to April 2019 at a 2:1 ratio: intervention (n = 83); control (n = 43) to either 3 weekly sessions of FACE-TC (Lyon Advance Care Planning Survey; Next Steps: Respecting Choices Interview; Five Wishes, advance directive) or treatment as usual (TAU). Statement of Treatment Preferences measured congruence. RESULTS Adolescents' (n = 126) mean age was 16.9 years; 57% were female and 79% were White. FACE-TC dyads had greater overall agreement than TAU: high 34% vs 2%, moderate 52% vs 45%, low 14% vs 52%, and P < .0001. Significantly greater odds of congruence were found for FACE-TC dyads than TAU for 3 of 4 disease-specific scenarios: for example, "a long hospitalization with low chance of survival," 78% (57 of 73) vs 45% (19 of 42); odds ratio, 4.31 (95% confidence interval, 1.89-9.82). FACE-TC families were more likely to agree to stop some treatments. Intervention adolescents, 67% (48 of 73), wanted their families to do what is best at the time, whereas fewer TAU adolescents, 43% (18 of 42), gave families this leeway (P = .01). CONCLUSIONS High-quality pediatric advance care planning enabled families to know their adolescents' EOL treatment preferences.
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Affiliation(s)
- Justin N. Baker
- Division of Quality of Life and Palliative Care, St. Jude
Children’s Research Hospital, Memphis, Tennessee
| | - Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center
- Rebecca D. Considine Research Institute, Akron
Children’s Hospital, Akron, Ohio
| | - Jennifer Needle
- Department of Pediatrics and Center for Bioethics,
University of Minnesota, Minneapolis, Minnesota
| | - JiJi Jiang
- Henry M. Jackson Foundation for the Advancement of
Military Medicine, Bethesda, Maryland
| | - Jichuan Wang
- Divisions of Biostatistics and Study Methodology
- Center for Translational Research/Children’s
National Research Institute, Children’s National Hospital, Washington,
DC
| | - Maureen E. Lyon
- Adolescent and Young Adult Medicine
- Center for Translational Research/Children’s
National Research Institute, Children’s National Hospital, Washington,
DC
- Department of Pediatrics, George Washington University
School of Medicine and Health Sciences, Washington, DC
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11
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Yeoh LY, Seow YY, Tan HC. Identifying high-risk hospitalised chronic kidney disease patient using electronic health records for serious illness conversation. Ann Acad Med Singap 2022; 51:161-169. [PMID: 35373239 DOI: 10.47102/annals-acadmedsg.2021427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION This study aimed to identify risk factors that are associated with increased mortality that could prompt a serious illness conversation (SIC) among patients with chronic kidney disease (CKD). METHODS The electronic health records of adult CKD patients admitted between August 2018 and February 2020 were retrospectively reviewed to identify CKD patients with >1 hospitalisation and length of hospital stay ≥4 days. Outcome measures were mortality and the duration of hospitalisation. We also assessed the utility of the Cohen's model to predict 6-month mortality among CKD patients. RESULTS A total of 442 patients (mean age 68.6 years) with median follow-up of 15.3 months were identified. The mean (standard deviation) Charlson Comorbidity Index [CCI] was 6.8±2.0 with 48.4% on chronic dialysis. The overall mortality rate until August 2020 was 36.7%. Mortality was associated with age (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.29-1.77), CCI≥7 (1.58, 1.08-2.30), lower serum albumin (1.09, 1.06-1.11), readmission within 30-day (1.96, 1.43-2.68) and CKD non-dialysis (1.52, 1.04-2.17). Subgroup analysis of the patients within first 6-month from index admission revealed longer hospitalisation stay for those who died (CKD-non dialysis: 5.5; CKD-dialysis: 8.0 versus 4 days for those survived, P<0.001). The Cohen's model demonstrated reasonable predictive ability to discriminate 6-month mortality (area under the curve 0.81, 95% CI 0.75-0.87). Only 24 (5.4%) CKD patients completed advanced care planning. CONCLUSION CCI, serum albumin and recent hospital readmission could identify CKD patients at higher risk of mortality who could benefit from a serious illness conversation.
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Affiliation(s)
- Lee Ying Yeoh
- Department of General Medicine, Sengkang General Hospital, Singapore
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12
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Dillon EC, Chopra V, Mesghina E, Milki A, Chan A, Reddy R, Kapp DS, Silver BA, Chan JK. The Healthcare Journey of Women With Advanced Gynecological Cancer From Diagnosis Through Terminal Illness: Qualitative Analysis of Progress Note Data. Am J Hosp Palliat Care 2021; 39:1090-1097. [PMID: 34951820 DOI: 10.1177/10499091211064242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To examine women's journeys with gynecologic cancer from before diagnosis through death and identify elements of their healthcare experience that warrant improvement. METHODS This exploratory study used longitudinal progress notes data from a multispecialty practice in Northern California. The sample included women with stage IV gynecological cancer diagnosed after 2011 and who died before 2018. Available progress notes from prior to diagnosis to death were qualitatively analyzed. RESULTS We identified 32 women, (median age 61 years) with mostly uterine (n=17) and ovarian (n=9) cancers and median survival of 9.2 months (min:2.9 and max:47.5). Sixteen (50%) received outpatient palliative care and 18 (56%) received hospice care. The analysis found wide variation in documentation about communication about diagnosis, prognosis, goals of care, stopping treatment, and starting hospice care. Challenges included escalating/severe symptoms, repeated urgent care/emergency department/hospital encounters, and lack of or late access to palliative and hospice care. Notes also illustrated how patient background and goals influenced care trajectory and communication. Documentation styles varied substantially, with palliative care notes more consistently documenting conversations about goals of care and psychosocial needs. CONCLUSION This analysis of longitudinal illness experience of women with advanced gynecological cancer suggests that clinicians may want to (1) prioritize earlier discussion about goals of care; (2) provide supplemental support to patients with higher needs, possibly through palliative care or navigation; and (3) write notes to enhance patient understanding now that patients may access all notes.
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Affiliation(s)
- Ellis C Dillon
- Center for Health Systems Research, 33314Sutter Health and Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Vidita Chopra
- Center for Health Systems Research, 33314Sutter Health and Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Elizabeth Mesghina
- Center for Health Systems Research, 7024Sutter Health, Palo Alto, CA, USA
| | - Anthony Milki
- 43989The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ava Chan
- Division of Gynecologic Oncology, Sutter Research Institute, 204799California Pacific-Palo Alto Medical Foundation, San Francisco, CA, USA
| | - Ravali Reddy
- Department of Obstetrics and Gynecology, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Daniel S Kapp
- Department of Radiation Oncology, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Barbara A Silver
- The Ovarian and Reproductive Cancer Recovery Program at The Women's Health Resource Center, 7153California Pacific Medical Center, San Francisco, CA, USA
| | - John K Chan
- Division of Gynecologic Oncology, Sutter Research Institute, 204799California Pacific-Palo Alto Medical Foundation, San Francisco, CA, USA
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13
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Molloy MJ, Ruhnke GW. Goal-Concordant Care After Hospitalization for Serious Acute Illness: A Key Opportunity for Hospitalists in Patient-Centered Outcomes. J Hosp Med 2021; 16:703. [PMID: 34752215 DOI: 10.12788/jhm.3723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Matthew J Molloy
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
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14
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Calvache JA, Moreno S, Prue G, Reid J, Ahmedzai SH, Arango-Gutierrez A, Ardila L, Arroyo LI, de Vries E. Knowledge of end-of-life wishes by physicians and family caregivers in cancer patients. BMC Palliat Care 2021; 20:140. [PMID: 34507567 PMCID: PMC8434705 DOI: 10.1186/s12904-021-00823-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/15/2021] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES To describe communication regarding cancer patient's end-of-life (EoL) wishes by physicians and family caregivers. METHODS An online questionnaire and telephone-based surveys were performed with physicians and family caregivers respectively in three teaching hospitals in Colombia which had been involved in the EoL care of cancer patients. RESULTS For 138 deceased patients we obtained responses from physicians and family caregivers. In 32 % physicians reported they spoke to the caregiver and in 17 % with the patient regarding EoL decisions. In most cases lacking a conversation, physicians indicated the treatment option was "clearly the best for the patient" or that it was "not necessary to discuss treatment with the patient". Twenty-six percent of the caregivers indicated that someone from the medical team spoke with the patient about treatment, and in 67% who had a conversation, caregivers felt that the provided information was unclear or incomplete. Physicians and family caregivers were aware if the patient had any advance care directive in 6% and 26% of cases, respectively, with low absolute agreement (34%). CONCLUSIONS There is a lack of open conversation regarding EoL in patients with advanced cancer with their physicians and family caregivers in Colombia. Communication strategies are urgently needed.
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Affiliation(s)
- Jose A Calvache
- Department of Anesthesiology, Universidad del Cauca, Popayán, Colombia
- Department of Anesthesiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Socorro Moreno
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Gillian Prue
- Reader in Chronic Illness, School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Joanne Reid
- Professor of Cancer and Palliative Care, School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK.
| | - Sam H Ahmedzai
- Academic Unit of Supportive Care, Section of Oncology, School of Medicine and Biomedical Sciences, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
| | | | | | - Lucia I Arroyo
- Departamento de Fonoaudiología, Universidad del Cauca, Popayan, Colombia
- MPH programme Public Health, Pontificia Universidad Javeriana Cali, Cali, Colombia
| | - Esther de Vries
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogotá, Colombia
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Affiliation(s)
- Ayah Nayfeh
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Maneesha Kamra
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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