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Schwartz R, Blanch-Hartigan D, Valbuena G, Weil A, Dubey M, Catzen HZ, Hall JA, Sanders JJ. Reply to "Empathic communication: The premise of inclusive care for historically excluded populations". Cancer 2022; 128:2838-2839. [PMID: 35471702 DOI: 10.1002/cncr.34236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/16/2022] [Accepted: 03/29/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Rachel Schwartz
- Stanford University School of Medicine, Stanford, California
| | | | | | - Amy Weil
- Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Manisha Dubey
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | | | - Judith A Hall
- Department of Psychology, Northeastern University, Boston, Massachusetts
| | - Justin J Sanders
- Division of Palliative Care, Department of Family Medicine, McGill University, Montreal, Quebec, Canada
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Durieux BN, Berrier A, Catzen HZ, Gray TF, Lakin JR, Cunningham R, Morris SE, Tulsky JA, Sanders JJ. " I think that she would have wanted. . .": Qualitative interviews with bereaved caregivers reveal complexity in measuring goal-concordant care at the end of life. Palliat Med 2022; 36:742-750. [PMID: 35164612 DOI: 10.1177/02692163221078472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Experts consider goal-concordant care an important healthcare outcome for individuals with serious illness. Despite their relationship to the patient and knowledge about the patient's wishes and values, little is known about bereaved family caregivers' perceptions of how end-of-life care aligns with patient goals and preferences. AIM To understand caregivers' perceptions about patients' care experiences, the extent to which care was perceived as goal-concordant, and the factors that contextualized the end-of-life care experience. DESIGN Qualitative interview study employing a semi-structured interview guide based on the National Health and Aging Trends Survey end-of-life planning module. Template analysis was used to identify themes. SETTING/PARTICIPANTS Nineteen recently bereaved family caregivers of people with serious illness in two academic medical centers in the Northeastern United States. RESULTS Most caregivers reported goal-concordant care, though many also recalled experiences of goal discordance. Three themes characterized care perceptions and related to perceived quality: communication, relationships and humanistic care, and care transitions. Within communication, caregivers described the importance of clear communication, inadequate prognostic communication, and information gaps that undermined caregiver confidence in decision making. Patient-clinician relationships enriched care and were considered higher-quality when felt to be humanistic. Finally, care transitions impacted goal discordance when marked by logistical barriers, a need to establish relationships with new providers, inadequate information transfer, and poor care coordination. CONCLUSIONS Bereaved caregivers commonly rated care as goal-concordant while also identifying areas of disappointing and low-quality care. Communication, relationships and humanistic care, and care transitions are modifiable quality improvement targets for patients with advanced cancer.
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Affiliation(s)
| | - Anna Berrier
- Dana-Farber Cancer Institute, Boston, MA, USA.,Gillings School of Global Public Health at The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Tamryn F Gray
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Joshua R Lakin
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Rebecca Cunningham
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sue E Morris
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - James A Tulsky
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Justin J Sanders
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Durieux BN, Berrier A, Catzen HZ, Gray T, Tulsky JA, Sanders JJ. “I think that she would have wanted...”: Caregiver reflections on goal-concordant care for patients with cancer at the end of life. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
163 Background: Experts recognize goal-concordant care (GCC) as among the most important outcomes for those with advanced cancer. Despite a conceptual understanding about ways to measure goal-concordant care, we know little about what patient experiences align perceptions of goal concordance. Caregivers’ close proximity to patients give them a unique perspective on what factors contribute to perceived goal concordance. Methods: We conducted semi-structured interviews with 19 recently bereaved family caregivers of those with cancer to understand their experience of care, the extent to which they felt it was goal-concordant, and the factors of care which contextualized their experience. Caregivers were interviewed using a semi-structured guide based on the end-of-life planning module in Round 2 of the National Health and Aging Trends Survey (NHATS). We used template analysis to identify themes across the 19 interviews. Results: Most caregivers reported goal-concordant care when prompted, though many also recalled moments of goal discordance. Three high-level themes characterized their care perceptions: communication, relationships and humanistic care, and care transitions. Sub-themes of communication included clinician communication quality, prognostic communication, and information gaps. First, clear and transparent clinician communication facilitated GCC and high-quality care. Prognostic communication that did not align to patient preferences or consider patient hope was seen as harmful. Information gaps inhibited high-quality care as well as caregivers’ confidence that decisions were goal concordant. Second, relationships between patients and their clinicians enriched care, and humanistic care was seen as higher-quality. Lastly, logistical barriers, the need for relationship rebuilding, uncertain information communication, and a general lack of coordination characterized perceptions around care transitions and goal discordance. In particular, several caregivers noted issues and inter-specialty tensions around transitions specifically involving hospice. Conclusions: Caregivers consistently rated care as goal-concordant while also identifying areas of disappointing and low-quality care. Measures that capture goal-concordant care may be subject to psychological bias and may not clearly align with or predict other measures of care quality. Communication, relationships and humanistic care, and care transitions are all modifiable targets for quality improvement and deserve clear attention for patients with advanced cancer.
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Sanders JJ, Dubey M, Hall JA, Catzen HZ, Blanch-Hartigan D, Schwartz R. What is empathy? Oncology patient perspectives on empathic clinician behaviors. Cancer 2021; 127:4258-4265. [PMID: 34351620 DOI: 10.1002/cncr.33834] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/04/2021] [Accepted: 02/11/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Oncology patients and physicians value empathy because of its association with improved health outcomes. Common measures of empathy lack consistency and were developed without direct input from patients. Because of their intense engagement with health care systems, oncology patients may have unique perspectives on what behaviors signal empathy in a clinical setting. METHODS As part of a cross-sectional study of patient perspectives on clinician empathy at an academic cancer center in the northeastern United States, the authors solicited up to 10 free-text responses to an open-ended question about what clinician behaviors define empathy. RESULTS The authors categorized open-ended responses from 89 oncology patients into 5 categories representing 14 themes. These categories were relationship sensitivity, focus on the whole person, communication, clinician attributes, and institutional resources and care processes. Frequently represented themes, including listening, understanding, and attention to emotions and what matters most, aligned with existing measures of empathy; behaviors that were not well represented among existing measures included qualities of information sharing and other communication elements. Patients also associated clinician demeanor, accessibility, and competence with empathy. CONCLUSIONS Oncology patients' perspectives on empathy highlight clinician behaviors and attributes that may help to refine patient experience measures and may be adopted by clinicians and cancer centers to enhance patient care and outcomes. High-quality communication skills training can promote active listening and paying attention to the whole person. A system-level focus on delivering empathic care may improve patients' experiences and outcomes. LAY SUMMARY Oncology patients' responses to an open-ended question about empathic clinician behavior have revealed insights into a variety of behaviors that are perceived as demonstrative of empathy. These include behaviors that imply sensitivity to the clinician-patient relationship, such as listening and understanding and attention to the whole person. Participants valued caring communication and demeanor and clinician accessibility. Perspective taking was not common among answers. Many existing measures of clinical care quality do not include the behaviors cited by patients as empathic. These results can inform efforts to refine quality measures of empathy-associated behaviors in clinical practice. Cancer centers can use skills training to improve elements of communication.
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Affiliation(s)
- Justin J Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Manisha Dubey
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Judith A Hall
- Department of Psychology, Northeastern University, Boston, Massachusetts
| | - Hannah Z Catzen
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,University of Michigan School of Medicine, Ann Arbor, Michigan
| | | | - Rachel Schwartz
- WellMD and WellPhD Center, Stanford University School of Medicine, Palo Alto, California
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Lakin JR, Arnold CG, Catzen HZ, Rangarajan A, Berger RS, Brannen EN, Cunningham RJ, Schaffer AC, Lamey J, Baker O, Bernacki RE. Early serious illness communication in hospitalized patients: A study of the implementation of the Speaking About Goals and Expectations (SAGE) program. Healthc (Amst) 2021; 9:100510. [PMID: 33517037 DOI: 10.1016/j.hjdsi.2020.100510] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 11/23/2020] [Accepted: 12/11/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Early conversations about patients' goals and values in advancing serious illness (serious illness conversations) can drive better healthcare. However, these conversations frequently happen during acute illness, often near death, without time to realize benefits of early communication. METHODS The Speaking About Goals and Expectations (SAGE) Program, adapted from the Serious Illness Care Program, is a multicomponent intervention designed to foster earlier and more comprehensive serious illness conversations for patients admitted to the hospital. We present a quality improvement study of the SAGE Program assessing older adults admitted to a general medicine service at the Brigham & Women's Hospital in Boston, Massachusetts. Our primary outcomes included the proportion of patients with at least one documented conversation, the timing between first conversation documented and death, the quality of conversations, and their interprofessional nature. Secondary outcomes assessed evaluations of the training and hospital utilization. RESULTS We trained 37 clinicians and studied 133 patients split between the SAGE intervention and a comparison population. Intervention patients were more likely to have documented serious illness conversations (89.1% vs. 26.1%, p < 0.001); these conversations occurred earlier (mean of 598.9 vs. 180.8 days before death, p < 0.001) and included more key elements of conversation (mean of 6.56 vs. 1.78, p < 0.001). CONCLUSIONS This study demonstrated significant differences in the frequency and quality of serious illness conversations completed earlier in the illness course for hospitalized patients. IMPLICATIONS Programs designed to drive serious illness conversations earlier in the hospital may be an effective way to improve care for patients not reached in the ambulatory setting. LEVEL OF EVIDENCE Prospectively designed trial, non-randomized sample.
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Affiliation(s)
- Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | | | | | | | - Rebecca S Berger
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Elise N Brannen
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rebecca J Cunningham
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Brigham & Women's Physician Organization, Boston, MA, USA
| | - Adam C Schaffer
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jan Lamey
- Brigham & Women's Physician Organization, Boston, MA, USA
| | - Olesya Baker
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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