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Kaye EC, Smith J, Zhou Y, Bagatell R, Baker JN, Cohn SL, Diller LR, Glade Bender JL, Granger MM, Marachelian A, Park JR, Rosenberg AR, Shusterman S, Twist CJ, Mack JW. Factors influencing parents' choice of palliative treatment goals for children with relapsed or refractory neuroblastoma: A multi-site longitudinal survey study. Cancer 2024; 130:1101-1111. [PMID: 38100619 PMCID: PMC10939929 DOI: 10.1002/cncr.35149] [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] [Received: 07/07/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Many parents of children with advanced cancer report curative goals and continue intensive therapies that can compound symptoms and suffering. Factors that influence parents to choose palliation as the primary treatment goal are not well understood. The objective of this study was to examine experiences impacting parents' report of palliative goals adjusted for time. The authors hypothesized that awareness of poor prognosis, recall of oncologists' prognostic disclosure, intensive treatments, and burdensome symptoms and suffering would influence palliative goal-setting. METHODS The authors collected prospective, longitudinal surveys from parents of children with relapsed/refractory neuroblastoma at nine pediatric cancer centers across the United States, beginning at relapse and continuing every 3 months for 18 months or until death. Hypothesized covariates were examined for possible associations with parental report of palliative goals. Generalized linear mixed models were used to evaluate factors associated with parents' report of palliative goals at different time points. RESULTS A total of 96 parents completed surveys. Parents were more likely to report a primary goal of palliation when they recalled communication about prognosis by their child's oncologist (odds ratio [OR], 52.48; p = .010). Treatment intensity and previous ineffective therapeutic regimens were not associated with parents' report of palliative goals adjusted for time. A parent who reported new suffering for their child was less likely to report palliative goals (OR, 0.13; p = .008). CONCLUSIONS Parents of children with poor prognosis cancer may not report palliative goals spontaneously in the setting of treatment-related suffering. Prognostic communication, however, does influence palliative goal-setting. Evidence-based interventions are needed to encourage timely, person-centered prognostic disclosure in the setting of advanced pediatric cancer. PLAIN LANGUAGE SUMMARY Many parents of children with poor-prognosis cancer continue to pursue curative treatments that may worsen symptoms and suffering. Little is known about which factors influence parents to choose palliative care as their child's main treatment goal. To explore this question, we asked parents of children with advanced neuroblastoma across the United States to complete multiple surveys over time. We found that the intensity of treatment, number of treatments, and suffering from treatment did not influence parents to choose palliative goals. However, when parents remembered their child's oncologist talking about prognosis, they were more likely to choose palliative goals of care.
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Affiliation(s)
- Erica C. Kaye
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
| | - Jesse Smith
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, TN
| | - Yiwang Zhou
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, TN
| | - Rochelle Bagatell
- Division of Oncology, Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Justin N. Baker
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
| | - Susan L. Cohn
- Department of Pediatrics, Comer Children’s Hospital, University of Chicago, Chicago, IL
| | - Lisa R. Diller
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Pediatric Hematology-Oncology, Boston Children’s Hospital, Boston, MA
| | - Julia L. Glade Bender
- Department of Pediatric Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - M. Meaghan Granger
- Hematology and Oncology Center, Cook Children’s Hospital, Fort Worth, TX
| | - Araz Marachelian
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Julie R. Park
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
- Department of Pediatric Hematology/Oncology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Abby R. Rosenberg
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
- Department of Pediatric Hematology/Oncology, Seattle Children’s Hospital, Seattle, WA, USA
- Department of Psychosocial Oncology and Palliative Care, Division of Pediatric Palliative Care; Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Suzanne Shusterman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Pediatric Hematology-Oncology, Boston Children’s Hospital, Boston, MA
| | - Clare J. Twist
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Jennifer W. Mack
- Department of Pediatrics, Comer Children’s Hospital, University of Chicago, Chicago, IL
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Population Sciences’ Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, MA, USA
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Zhuang Q, Zhou S, Ho S, Neo PSH, Cheung YB, Yang GM. Can an Integrated Palliative and Oncology Co-rounding Model Reduce Aggressive Care at the End of Life? Secondary Analysis of an Open-label Stepped-wedge Cluster-randomized Trial. Am J Hosp Palliat Care 2024; 41:442-451. [PMID: 37246153 DOI: 10.1177/10499091231180460] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Clinical trial evidence on the effect of palliative care models in reducing aggressive end-of-life care is inconclusive. We previously reported on an integrated inpatient palliative care and medical oncology co-rounding model that significantly reduced hospital bed-days and postulate additional effect on reducing care aggressiveness. OBJECTIVES To compare the effect of a co-rounding model vs usual care in reducing receipt of aggressive treatment at end-of-life. METHODS Secondary analysis of an open-label stepped-wedge cluster-randomized trial comparing two integrated palliative care models within the inpatient oncology setting. The co-rounding model involved pooling specialist palliative care and oncology into one team with daily review of admission issues, while usual care constituted discretionary specialist palliative care referrals by the oncology team. We compared odds of receiving aggressive care at end-of-life: acute healthcare utilization in last 30 days of life, death in hospital, and cancer treatment in last 14 days of life between patients in two trial arms. RESULTS 2145 patients were included in the analysis, and 1803 patients died by 4th April 2021. Median overall survival was 4.90 (4.07 - 5.72) months in co-rounding and 3.75 (3.22 - 4.21) months in usual care, with no difference in survival (P = .12). We found no significant differences between both models with respect to receipt of aggressive care at end-of-life. (Odds Ratio .67 - 1.27; all P > .05). CONCLUSION The co-rounding model within an inpatient setting did not reduce aggressiveness of care at end-of-life. This could be due in part to the overall focus on resolving episodic admission issues.
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Affiliation(s)
- Qingyuan Zhuang
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Siqin Zhou
- Division of Clinical Trials and Epidemiological Sciences, National Cancer Centre Singapore, Singapore
| | - Shirlynn Ho
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Patricia Soek Hui Neo
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Yin Bun Cheung
- Program in Health Services and Systems Research and Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Grace Meijuan Yang
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
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Wen FH, Hsieh CH, Su PJ, Shen WC, Hou MM, Chou WC, Chen JS, Chang WC, Tang ST. Factors Associated With Family Surrogate Decisional-Regret Trajectories. J Pain Symptom Manage 2024; 67:223-232.e2. [PMID: 38036113 DOI: 10.1016/j.jpainsymman.2023.11.013] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/09/2023] [Accepted: 11/17/2023] [Indexed: 12/02/2023]
Abstract
CONTEXT/OBJECTIVES The scarce research on factors associated with surrogate decisional regret overlooks longitudinal, heterogenous decisional-regret experiences and fractionally examines factors from the three decision-process framework stages: decision antecedents, decision-making process, and decision outcomes. This study aimed to fill these knowledge gaps by focusing on factors modifiable by high-quality end-of-life (EOL) care. METHODS This observational study used a prior cohort of 377 family surrogates of terminal-cancer patients to examine factors associated with their membership in the four preidentified distinct decisional-regret trajectories: resilient, delayed-recovery, late-emerging, and increasing-prolonged trajectories from EOL-care decision making through the first two bereavement years by multinomial logistic regression modeling using the resilient trajectory as reference. RESULTS Decision antecedent factors: Financial sufficiency and heavier caregiving burden increased odds for the delayed-recovery trajectory. Spousal loss, higher perceived social support during an EOL-care decision, and more postloss depressive symptoms increased odds for the late-emerging trajectory. More pre- and postloss depressive symptoms increased odds for the increasing-prolonged trajectory. Decision-making process factors: Making an anticancer treatment decision and higher decision conflict increased odds for the delayed-recovery and increasing-prolonged trajectories. Making a life-sustaining-treatment decision increased membership in the three more profound trajectories. Decision outcome factors: Greater surrogate appraisal of quality of dying and death lowered odds for the three more profound trajectories. Patient receipt of anticancer or life-sustaining treatments increased odds for the late-emerging trajectory. CONCLUSION Surrogate membership in decisional-regret trajectories was associated with decision antecedent, decision-making process, and decision outcome factors. Effective interventions should target identified modifiable factors to address surrogate decisional regret.
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Affiliation(s)
- Fur-Hsing Wen
- Department of International Business (F.H.W.), Soochow University, Taipei, Taiwan
| | - Chia-Hsun Hsieh
- College of Medicine (C.H.H., W.C.C., J.S.C., W.C.C.), Chang Gung University, Tao-Yuan, Taiwan; Division of Hematology-Oncology (C.H.H.), Department of Internal Medicine, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Po-Jung Su
- Division of Hematology-Oncology (P.J.S., W.C.S., M.M.H., W.C.C., J.S.C., W.C.C., S.T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
| | - Wen-Chi Shen
- Division of Hematology-Oncology (P.J.S., W.C.S., M.M.H., W.C.C., J.S.C., W.C.C., S.T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
| | - Ming-Mo Hou
- Division of Hematology-Oncology (P.J.S., W.C.S., M.M.H., W.C.C., J.S.C., W.C.C., S.T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
| | - Wen-Chi Chou
- College of Medicine (C.H.H., W.C.C., J.S.C., W.C.C.), Chang Gung University, Tao-Yuan, Taiwan; Division of Hematology-Oncology (P.J.S., W.C.S., M.M.H., W.C.C., J.S.C., W.C.C., S.T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
| | - Jen-Shi Chen
- College of Medicine (C.H.H., W.C.C., J.S.C., W.C.C.), Chang Gung University, Tao-Yuan, Taiwan; Division of Hematology-Oncology (P.J.S., W.C.S., M.M.H., W.C.C., J.S.C., W.C.C., S.T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
| | - Wen-Cheng Chang
- College of Medicine (C.H.H., W.C.C., J.S.C., W.C.C.), Chang Gung University, Tao-Yuan, Taiwan; Division of Hematology-Oncology (P.J.S., W.C.S., M.M.H., W.C.C., J.S.C., W.C.C., S.T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
| | - Siew Tzuh Tang
- Division of Hematology-Oncology (P.J.S., W.C.S., M.M.H., W.C.C., J.S.C., W.C.C., S.T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan; School of Nursing, Medical College (S.T.T.), Chang Gung University, Tao-Yuan, Taiwan; Department of Nursing (S.T.T.), Chang Gung Memorial Hospital at Kaohsiung, Taiwan; Department of Nursing (S.T.T.), Chang Gung University of Science and Technology, Tao-Yuan, Taiwan.
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SenthilKumar G, Madhusudhana S, Flitcroft M, Sheriff S, Thalji S, Merrill J, Clarke CN, Maduekwe UN, Tsai S, Christians KK, Gamblin TC, Kothari AN. Automated machine learning (AutoML) can predict 90-day mortality after gastrectomy for cancer. Sci Rep 2023; 13:11051. [PMID: 37422500 PMCID: PMC10329647 DOI: 10.1038/s41598-023-37396-3] [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] [Received: 12/30/2022] [Accepted: 06/21/2023] [Indexed: 07/10/2023] Open
Abstract
Early postoperative mortality risk prediction is crucial for clinical management of gastric cancer. This study aims to predict 90-day mortality in gastric cancer patients undergoing gastrectomy using automated machine learning (AutoML), optimize models for preoperative prediction, and identify factors influential in prediction. National Cancer Database was used to identify stage I-III gastric cancer patients undergoing gastrectomy between 2004 and 2016. 26 features were used to train predictive models using H2O.ai AutoML. Performance on validation cohort was measured. In 39,108 patients, 90-day mortality rate was 8.8%. The highest performing model was an ensemble (AUC = 0.77); older age, nodal ratio, and length of inpatient stay (LOS) following surgery were most influential for prediction. Removing the latter two parameters decreased model performance (AUC 0.71). For optimizing models for preoperative use, models were developed to first predict node ratio or LOS, and these predicted values were inputted for 90-day mortality prediction (AUC of 0.73-0.74). AutoML performed well in predicting 90-day mortality in a larger cohort of gastric cancer patients that underwent gastrectomy. These models can be implemented preoperatively to inform prognostication and patient selection for surgery. Our study supports broader evaluation and application of AutoML to guide surgical oncologic care.
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Affiliation(s)
- Gopika SenthilKumar
- Medical Scientist Training Program, Medical College of Wisconsin, Milwaukee, USA
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Sharadhi Madhusudhana
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Madelyn Flitcroft
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Salma Sheriff
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Samih Thalji
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Jennifer Merrill
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Callisia N Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Ugwuji N Maduekwe
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Susan Tsai
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Kathleen K Christians
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - T Clark Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Anai N Kothari
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
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Wen FH, Hsieh CH, Hou MM, Su PJ, Shen WC, Chou WC, Chen JS, Chang WC, Tang ST. Decisional-Regret Trajectories From End-of-Life Decision Making Through Bereavement. J Pain Symptom Manage 2023; 66:44-53.e1. [PMID: 36889452 DOI: 10.1016/j.jpainsymman.2023.02.321] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/21/2023] [Accepted: 02/24/2023] [Indexed: 03/08/2023]
Abstract
CONTEXT Regret plays a central role in surrogate decision making. Research on decisional regret in family surrogates is scarce and lacks longitudinal studies to illustrate the heterogenous, dynamic evolution of decisional regret. OBJECTIVES To identify distinct decisional-regret trajectories from end-of-life (EOL) decision making through the first two bereavement years among surrogates of cancer patients. METHODS A prospective, longitudinal, observational study was conducted on a convenience sample of 377 surrogates of terminally ill cancer patients. Decisional regret was measured by the five-item Decision Regret Scale monthly during the patient's last six months and 1, 3, 6, 13, 18, and 24 months post loss. Decisional-regret trajectories were identified using latent-class growth analysis. RESULTS Surrogates reported substantially high decisional regret (pre- and postloss mean [SD] as 32.20 [11.47] and 29.90 [12.47], respectively). Four decisional-regret trajectories were identified. The resilient trajectory (prevalence: 25.6%) showed a general low decisional-regret level with mild and transient perturbations around the time of patient death only. Decisional regret for the delayed-recovery trajectory (56.3%) accelerated before the patient's death and decreased slowly throughout bereavement. Surrogates in the late-emerging (10.2%) trajectory reported a low decisional-regret level before loss but their decisional regret increased gradually thereafter. The increasing-prolonged trajectory (6.9%) rapidly increased in decisional-regret levels during EOL decision making, peaked one-month post loss, then declined steadily but without a complete resolution. CONCLUSION Surrogates heterogeneously suffered decisional regret from EOL decision making through bereavement as evident by four identified distinct decisional-regret trajectories. Early identification and prevention of increasing/prolonged decisional-regret trajectories is warranted.
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Affiliation(s)
- Fur-Hsing Wen
- Department of International Business (F-H.W.), Soochow University, Taipei, Taiwan, R.O.C
| | - Chia-Hsun Hsieh
- College of Medicine (C-H.H., W-C.C., J-S.C., W-C.C.), Chang Gung University, Tao-Yuan, Taiwan, R.O.C.; Division of Hematology-Oncology (C-H.H.), Department of Internal Medicine, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan, R.O.C
| | - Ming-Mo Hou
- Division of Hematology-Oncology (M-M.H., P-J.S., W-C.S., W-C.C., J-S.C., W-C.C., S-T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, ROC
| | - Po-Jung Su
- Division of Hematology-Oncology (M-M.H., P-J.S., W-C.S., W-C.C., J-S.C., W-C.C., S-T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, ROC
| | - Wen-Chi Shen
- Division of Hematology-Oncology (M-M.H., P-J.S., W-C.S., W-C.C., J-S.C., W-C.C., S-T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, ROC
| | - Wen-Chi Chou
- College of Medicine (C-H.H., W-C.C., J-S.C., W-C.C.), Chang Gung University, Tao-Yuan, Taiwan, R.O.C.; Division of Hematology-Oncology (M-M.H., P-J.S., W-C.S., W-C.C., J-S.C., W-C.C., S-T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, ROC
| | - Jen-Shi Chen
- College of Medicine (C-H.H., W-C.C., J-S.C., W-C.C.), Chang Gung University, Tao-Yuan, Taiwan, R.O.C.; Division of Hematology-Oncology (M-M.H., P-J.S., W-C.S., W-C.C., J-S.C., W-C.C., S-T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, ROC
| | - Wen-Cheng Chang
- College of Medicine (C-H.H., W-C.C., J-S.C., W-C.C.), Chang Gung University, Tao-Yuan, Taiwan, R.O.C.; Division of Hematology-Oncology (M-M.H., P-J.S., W-C.S., W-C.C., J-S.C., W-C.C., S-T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, ROC
| | - Siew Tzuh Tang
- Division of Hematology-Oncology (M-M.H., P-J.S., W-C.S., W-C.C., J-S.C., W-C.C., S-T.T.), Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, ROC; School of Nursing (S.T.T.), Medical College, Chang Gung University, Tao-Yuan, Taiwan, R.O.C.; Department of Nursing (S.T.T.), Chang Gung Memorial Hospital at Kaohsiung, Taiwan, R.O.C.; Department of Nursing (S.T.T.), Chang Gung University of Science and Technology, Tao-Yuan, Taiwan, R.O.C..
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Silva CMD, Germano JN, Costa AKDA, Gennari GA, Caruso P, Nassar AP. Association of appropriateness for ICU admission with resource use, organ support and long-term survival in critically ill cancer patients. Intern Emerg Med 2023; 18:1191-1201. [PMID: 36800071 DOI: 10.1007/s11739-023-03216-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 08/02/2022] [Accepted: 02/02/2023] [Indexed: 02/18/2023]
Abstract
We aimed to evaluate the characteristics, resource use and outcomes of critically ill patients with cancer according to appropriateness of ICU admission. This was a retrospective cohort study of patients with cancer admitted to ICU from January 2017 to December 2018. Patients were classified as appropriate, potentially inappropriate, or inappropriate for ICU admission according to the Society of Critical Care Medicine guidelines. The primary outcome was ICU length of stay (LOS). Secondary outcomes were one-year, ICU, and hospital mortality, hospital LOS and utilization of ICU organ support. We used logistic regression and competing risk models accounting for relevant confounders in primary outcome analyses. From 6700 admitted patients, 5803 (86.6%) were classified as appropriate, 683 (10.2%) as potentially inappropriate and 214 (3.2%) as inappropriate for ICU admission. Potentially inappropriate and inappropriate ICU admissions had lower likelihood of being discharged from the ICU than patients with appropriate ICU admission (sHR 0.55, 95% CI 0.49-0.61 and sHR 0.65, 95% CI 0.53-0.81, respectively), and were associated with higher 1-year mortality (OR 6.39, 95% CI 5.60-7.29 and OR 11.12, 95% CI 8.33-14.83, respectively). Among patients with appropriate, potentially inappropriate, and inappropriate ICU admissions, ICU mortality was 4.8%, 32.6% and 35.0%, and in-hospital mortality was 12.2%, 71.6% and 81.3%, respectively (p < 0.01). Use of organ support was more common and longer among patients with potentially inappropriate ICU admission. The findings of our study suggest that inappropriateness for ICU admission among patients with cancer was associated with higher resource use in ICU and higher one-year mortality among ICU survivors.
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Affiliation(s)
- Carla Marchini Dias Silva
- Intensive Care Unit, A.C.Camargo Cancer Center, São Paulo, Brazil.
- Intensive Care Unit, Hospital Vila Nova Star, São Paulo, Brazil.
| | | | | | - Giovanna Alves Gennari
- A.C.Camargo Cancer Center, São Paulo, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Pedro Caruso
- Intensive Care Unit, A.C.Camargo Cancer Center, São Paulo, Brazil
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Haun MW, Wildenauer A, Hartmann M, Bleyel C, Becker N, Jäger D, Friederich HC, Tönnies J. Negotiating decisions on aggressive cancer care at end-of-life between patients, family members, and physicians – A qualitative interview study. Front Oncol 2022; 12:870431. [PMID: 36212451 PMCID: PMC9539079 DOI: 10.3389/fonc.2022.870431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background Patients with advanced cancer do receive increasingly aggressive end-of-life care, despite it does often not prolong survival time but entails decreased quality of life for patients. This qualitative study explores the unfolding of aggressive end-of-life care in clinical practice focusing on the decision-making process and the quality of end-of-life care from family members’ perspective. Materials and methods We conducted semi-structured interviews with 16 family members (six of cancer patients with and ten without aggressive end-of-life care) at the National Center for Tumor Diseases Heidelberg, Germany. We conducted a content analysis applying a theoretical framework to differentiate between ‘decision-making’ (process of deciding for one choice among many options) and ‘decision-taking’ (acting upon this choice). Results While patients of the aggressive care group tended to make and take decisions with their family members and physicians, patients of the other group took the decision against more aggressive treatment alone. Main reason for the decision in favor of aggressive care was the wish to spend more time with loved ones. Patients took decisions against aggressive care given the rapid decline in physical health and to spare relatives difficult decisions and arising feelings of guilt and self-reproach. Conclusion Treatment decisions at end-of-life are always individual. Nevertheless, treatment courses with aggressive end-of-life care and those without differ markedly. To account for a longitudinal perspective on the interplay between patients, family members, and physicians, cohort studies are needed. Meanwhile, clinicians should validate patients and family members considering refraining from aggressive end-of-life care and explore their motives. Clinical trial registration https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022837, identifier DRKS00022837.
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Affiliation(s)
- Markus W. Haun
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
- *Correspondence: Markus W. Haun,
| | - Alina Wildenauer
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Mechthild Hartmann
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Caroline Bleyel
- Department of Child and Adolescent Psychiatry, Heidelberg University, Heidelberg, Germany
| | - Nikolaus Becker
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Dirk Jäger
- Department of Medical Oncology, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Hans-Christoph Friederich
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Justus Tönnies
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
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Schakowski A, Tönnies J, Friederich HC, Hartmann M, Haun MW. The Inventory of Complicated Grief-A Systematic Psychometric Review and Conceptual Replication Study of the Structural Validity. Assessment 2022:10731911221100980. [PMID: 35723204 DOI: 10.1177/10731911221100980] [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]
Abstract
The Inventory of Complicated Grief (ICG) is a commonly used self-report measure in psycho-oncology, best supportive care, and palliative medicine. However, existing validation studies yielded conflicting results regarding the structural validity. This study provides a psychometric review and conceptual replication of the ICG latent structure to test the hypothesis that existing studies overfit unreliable sources of variance, which overshadow the unidimensionality of the ICG. All proposed latent models identified in the psychometric review were tested in a series of confirmatory and exploratory structural equation models. Specifically, at least five to six latent intercorrelated factors were necessary to reach acceptable model fit. However, a general CG factor accounted for most variance and ICG sum scores showed predictable associations with anxiety and depressive symptoms, which suggests that the ICG is essentially unidimensional. There are indications that other measures of pathological grief show similar inconsistencies. Overall, potentially emerging subfacets of the ICG should not be interpreted as distinct "symptom clusters." If time constraints are an issue as is often the case in clinical research, complicated grief may just be measured by a reduced item set without a significant loss of information or complexity.
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Malhotra C, Bundoc F, Chaudhry I, Teo I, Ozdemir S, Finkelstein E, Dent RA, Kumarakulasinghe NB, Cheung YB, Malhotra R, Kanesvaran R, Yee ACP, Chan N, Wu HY, Chin SM, Allyn HYM, Yang GM, Neo PSH, Harding R, Heng LL. A prospective cohort study assessing aggressive interventions at the end-of-life among patients with solid metastatic cancer. Palliat Care 2022; 21:73. [PMID: 35578270 PMCID: PMC9109395 DOI: 10.1186/s12904-022-00970-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 04/12/2022] [Indexed: 01/08/2023] Open
Abstract
Background Many patients with a solid metastatic cancer are treated aggressively during their last month of life. Using data from a large prospective cohort study of patients with an advanced cancer, we aimed to assess the number and predictors of aggressive interventions during last month of life among patients with solid metastatic cancer and its association with bereaved caregivers’ outcomes. Methods We used data of 345 deceased patients from a prospective cohort study of 600 patients. We surveyed patients every 3 months until death for their physical, psychological and functional health, end-of-life care preference and palliative care use. We surveyed their bereaved caregivers 8 weeks after patients’ death regarding their preparedness about patient’s death, regret about patient’s end-of-life care and mood over the last week. Patient data was merged with medical records to assess aggressive interventions received including hospital death and use of anti-cancer treatment, more than 14 days in hospital, more than one hospital admission, more than one emergency room visit and at least one intensive care unit admission, all within the last month of life. Results 69% of patients received at least one aggressive intervention during last month of life. Patients hospitalized during the last 2–12 months of life, male patients, Buddhist or Taoist, and with breast or respiratory cancer received more aggressive interventions in last month of life. Patients with worse functional health prior to their last month of life received fewer aggressive interventions in last month of life. Bereaved caregivers of patients receiving more aggressive interventions reported feeling less prepared for patients’ death. Conclusion Findings suggest that intervening early in the sub-group of patients with history of hospitalization prior to their last month may reduce number of aggressive interventions during last month of life and ultimately positively influence caregivers’ preparedness for death during the bereavement phase. Trial registration NCT02850640. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00970-z.
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Lu SC, Xu C, Nguyen CH, Geng Y, Pfob A, Sidey-Gibbons C. Machine Learning-based Short-term Mortality Prediction Models for Cancer Patients Using Electronic Health Record Data: A Systematic Review and Critical Appraisal (Preprint). JMIR Med Inform 2021; 10:e33182. [PMID: 35285816 PMCID: PMC8961346 DOI: 10.2196/33182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/23/2022] [Accepted: 01/31/2022] [Indexed: 01/17/2023] Open
Abstract
Background Objective Methods Results Conclusions
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Affiliation(s)
- Sheng-Chieh Lu
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Cai Xu
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Chandler H Nguyen
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, United States
| | - Yimin Geng
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - André Pfob
- Department of Obstetrics and Gynecology, Heidelberg University Hospital, Heidelberg, Germany
| | - Chris Sidey-Gibbons
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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