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Binkley MS, Flerlage JE, Savage KJ, Akhtar S, Steiner R, Zhang XY, Dickinson M, Prica A, Major A, Hendrickson PG, Hopkins D, Ng A, Casulo C, Baron J, Roberts KB, Al Kendi J, Balogh A, Ricardi U, Torka P, Specht L, De Silva R, Pickard K, Blazin LJ, Henry M, Smith CM, Halperin D, Brady J, Brennan B, Senchenko MA, Reeves M, Hoppe BS, Terezakis S, Talaulikar D, Picardi M, Kirova Y, Fergusson P, Hawkes EA, Lee D, Doo NW, Barraclough A, Cheah CY, Ku M, Hamad N, Mutsando H, Gilbertson M, Marconi T, Viiala N, Maurer MJ, Eichenauer DA, Hoppe RT. International Prognostic Score for Nodular Lymphocyte-Predominant Hodgkin Lymphoma. J Clin Oncol 2024:JCO2301655. [PMID: 38531001 DOI: 10.1200/jco.23.01655] [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] [Received: 08/02/2023] [Revised: 09/20/2023] [Accepted: 01/11/2024] [Indexed: 03/28/2024] Open
Abstract
PURPOSE Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is a rare cancer, and large international cooperative efforts are needed to evaluate the significance of clinical risk factors and immunoarchitectural patterns (IAPs) for all stages of pediatric and adult patients with NLPHL. METHODS Thirty-eight institutions participated in the Global nLPHL One Working Group retrospective study of NLPHL cases from 1992 to 2021. We measured progression-free survival (PFS), overall survival (OS), transformation rate, and lymphoma-specific death rate. We performed uni- and multivariable (MVA) Cox regression stratified by management to select factors for the lymphocyte-predominant international prognostic score (LP-IPS) validated by five-fold cross-validation. RESULTS We identified 2,243 patients with a median age of 37 years (IQR, 23-51). The median follow-up was 6.3 years (IQR, 3.4-10.8). Most had stage I to II (72.9%) and few B symptoms (9.9%) or splenic involvement (5.4%). IAP was scored for 916 (40.8%). Frontline management included chemotherapy alone (32.4%), combined modality therapy (30.5%), radiotherapy alone (24.0%), observation after excision (4.6%), rituximab alone (4.0%), active surveillance (3.4%), and rituximab and radiotherapy (1.1%). The PFS, OS, transformation, and lymphoma-specific death rates at 10 years were 70.8%, 91.6%, 4.8%, and 3.3%, respectively. On MVA, IAPs were not associated with PFS or OS, but IAP E had higher risk of transformation (hazard ratio [HR], 1.81; P < .05). We developed the LP-IPS with 1 point each for age ≥45 years, stage III-IV, hemoglobin <10.5 g/dL, and splenic involvement. Increasing LP-IPS was significantly associated with worse PFS (HR, 1.52) and OS (HR, 2.31) and increased risk of lymphoma-specific death (HR, 2.63) and transformation (HR, 1.41). CONCLUSION In this comprehensive study of all ages of patients with NLPHL, we develop the LP-IPS to identify high-risk patients and inform upcoming prospective clinical trials evaluating de-escalation of therapy for patients with low LP-IPS scores (<2).
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Affiliation(s)
- Michael Sargent Binkley
- Department of Radiation Oncology, Stanford School of Medicine, Stanford University, Stanford, CA
| | - Jamie E Flerlage
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | | | - Saad Akhtar
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Raphael Steiner
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Anca Prica
- Princess Margaret Cancer Centre, Toronto, Canada
| | | | | | - David Hopkins
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Andrea Ng
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | | | - Pallawi Torka
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Lena Specht
- Copenhagen University Hospital, Copenhagen, Denmark
| | - Ravindu De Silva
- Norfolk and Norwich University Hospital, Norfolk, United Kingdom
| | - Keir Pickard
- Newcastle upon Tyne Hospitals, Newcastle upon Tyne, United Kingdom
| | - Lindsay J Blazin
- Division of Hematology/Oncology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | | | | | - Daniel Halperin
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Jessica Brady
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Maria Anatolevna Senchenko
- Oncology and Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Moscow, Russian Federation
| | - Marie Reeves
- Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Bradford S Hoppe
- University of Florida, Gainesville, FL
- Mayo Clinic, Jacksonville, FL
| | | | - Dipti Talaulikar
- Canberra Health Services, Canberra, Australia
- College of Health and Medicine, Australian National University, Canberra, Australia
| | - Marco Picardi
- Department of Clinical Medicine and Surgery, AOU Federico II, Naples, Italy
| | | | | | - Eliza A Hawkes
- Olivia Newton-John Cancer Research Centre at Austin Health, Melbourne, Australia
- Lymphoma and Related Diseases Registry, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise Lee
- Austin Hospital, Eastern Health, Melbourne, Australia
| | - Nicole Wong Doo
- Lymphoma and Related Diseases Registry, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Haematology, Concord Hospital, Concord Clinical School, University of Sydney, Sydney, Australia
| | | | - Chan Y Cheah
- Department of Haematology, Sir Charles Gairdner Hospital, Perth, Australia
- Medical School, University of Western Australia, Perth, Australia
| | - Matthew Ku
- Department of Haematology, St Vincent's Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Nada Hamad
- Department of Haematology, St Vincent's Hospital Sydney, Sydney, Australia
- Faculty of Medicine and Health, School of Clinical Medicine, UNSW Sydney, Sydney, Australia
- School of Medicine, University of Notre Dame, Sydney, Australia
| | - Howard Mutsando
- Faculty of Medicine and Health, School of Clinical Medicine, UNSW Sydney, Sydney, Australia
- University of Queensland Rural Clinical School, Toowoomba, Australia
| | | | | | - Nicholas Viiala
- Department of Haematology, Liverpool Hospital, Liverpool, Australia
- South West Sydney Clinical School, UNSW Medicine, Liverpool, Australia
| | - Matthew J Maurer
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Dennis A Eichenauer
- Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University Hospital Cologne, German Hodgkin Study Group, Cologne, Germany
| | - Richard T Hoppe
- Department of Radiation Oncology, Stanford School of Medicine, Stanford University, Stanford, CA
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2
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Blazin LJ, Cuviello A, Spraker-Perlman H, Kaye EC. Approaches for Discussing Clinical Trials with Pediatric Oncology Patients and Their Families. Curr Oncol Rep 2022; 24:723-732. [PMID: 35258760 DOI: 10.1007/s11912-022-01239-7] [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] [Accepted: 11/30/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW This manuscript aims to describe evidence-based best practices to guide clinicians in communicating with pediatric patients and their families about clinical trial enrollment. RECENT FINDINGS The standard paradigm for discussing clinical trial enrollment with pediatric oncology patients and their families inconsistently enables or facilitates true informed consent. Evidence exists to suggest that adopting a shared decision-making approach may improve patient and family understanding. When navigating communication about clinical trials, clinicians should integrate the following evidence-based communication approaches: (1) extend dialogue about clinical trial enrollment across multiple conversations, allowing families space and time to process information independently; (2) use core communication skills such as avoiding jargon, checking for understanding, and responding to emotion. Clinicians should consider factors at the individual, team, organizational, community, and policy levels that may impact clinical trial communication with pediatric cancer patients and their families. This article reviews learnable skills that clinicians can master to optimize communication about clinical trial enrollment with pediatric cancer patients and their families.
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Affiliation(s)
- Lindsay J Blazin
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Indiana University, 705 Riley Hospital Dr., Suite 4340, Indianapolis, IN, 46202, USA.
| | - Andrea Cuviello
- Department of Oncology, Division of Quality of Life & Palliative Care, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS 260, Memphis, TN, 38105, USA
| | - Holly Spraker-Perlman
- Department of Oncology, Division of Quality of Life & Palliative Care, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS 260, Memphis, TN, 38105, USA
| | - Erica C Kaye
- Department of Oncology, Division of Quality of Life & Palliative Care, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS 260, Memphis, TN, 38105, USA
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3
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Dunn TJ, Terao MA, Blazin LJ, Spraker-Perlman H, Baker JN, Mandrell B, Sellers J, Crabtree VM, Hoffman JM, Burlison JD. Associations of job demands and patient safety event involvement on burnout among a multidisciplinary group of pediatric hematology/oncology clinicians. Pediatr Blood Cancer 2021; 68:e29214. [PMID: 34227729 DOI: 10.1002/pbc.29214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 04/05/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Workplace burnout can result in negative consequences for clinicians and patients. We assessed burnout prevalence and sources among pediatric hematology/oncology inpatient nurses, ambulatory nurses, physicians (MDs), and advanced practice providers (APPs) by evaluating effects of job demands and involvement in patient safety events (PSEs). METHODS A cross-sectional survey (Maslach Burnout Inventory) measured emotional exhaustion, depersonalization, and reduced personal accomplishment. The National Aeronautics and Space Administration Task Load Index measured mental demand, physical demand, temporal demand, effort, and frustration. Relative weights analyses estimated the unique contributions of tasks and PSEs on burnout. Post hoc analyses evaluated open-response comments for burnout factors. RESULTS Burnout prevalence was 33%, 20%, 34%, and 33% in inpatient nurses, ambulatory nurses, and MD, and APPs, respectively (N = 481, response rate 69%). Reduced personal accomplishment was significantly higher in inpatient nurses than MDs and APPs. Job frustration was the most significant predictor of burnout across all four cohorts. Other significant predictors of burnout included temporal demand (nursing groups and MDs), effort (inpatient nurses and MDs), and PSE involvement (ambulatory nurses). Open-response comments identified time constraints, lack of administrator support, insufficient institutional support for self-care, and inadequate staffing and/or turnover as sources of frustration. CONCLUSIONS All four clinician groups reported substantial levels of burnout, and job demands predicted burnout. The body of knowledge on job stress and workplace burnout supports targeting organizational-level sources versus individual-level factors as the most effective prevention and reduction strategy. This study elaborates on this evidence by identifying structural drivers of burnout within a multidisciplinary context of pediatric hematology/oncology clinicians.
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Affiliation(s)
- Tyler J Dunn
- Department of Pharmacy Administration, University of Mississippi, Oxford, Mississippi, USA
| | - Michael A Terao
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Pediatrics, Division of Pediatric Hematology and Oncology, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Lindsay J Blazin
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Pediatrics, Division of Pediatric Hematology and Oncology, Indiana University, Indianapolis, Indiana, USA
| | - Holly Spraker-Perlman
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Justin N Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Belinda Mandrell
- Department of Pediatric Medicine, Division of Nursing Research, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Janet Sellers
- Department of Psychosocial Services, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Valerie McLaughlin Crabtree
- Department of Psychosocial Services, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Psychology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - James M Hoffman
- Office of Quality and Patient Care, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jonathan D Burlison
- Office of Quality and Patient Care, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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4
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Sisk BA, Schulz GL, Blazin LJ, Baker JN, Mack JW, DuBois JM. Parental views on communication between children and clinicians in pediatric oncology: a qualitative study. Support Care Cancer 2021; 29:4957-4968. [PMID: 33569673 PMCID: PMC8295182 DOI: 10.1007/s00520-021-06047-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 11/28/2020] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Communication is essential to providing family-centered care in pediatric oncology. Previously, we developed a functional model of communication between parents and clinicians. Prior research has not examined the domains and purposes of communication between children and clinicians. We explored parental perspectives to begin understanding this communication. METHODS Secondary analysis of semi-structured interviews with 80 parents of children with cancer across 3 academic medical centers during treatment, survivorship, or bereavement. We employed semantic content analysis, using the functional model of parental communication as an a priori framework. RESULTS We identified 6 distinct functions of communication in child-clinician interactions: building relationships, promoting patient engagement, addressing emotions, exchanging information, managing uncertainty, and fostering hope. These communication functions were identified by parents of older (> 13 years old) and younger (< 12 years old) children, although the specific manifestations sometimes differed by age. Notably, age was not always an indicator of the child's communication needs. For example, some parents noted older children who did not want to discuss difficult topics, whereas other parent described younger children who wanted to know every detail. Two functions from the previous parental model of communication were absent from this analysis: supporting family self-management and making decisions. CONCLUSION Interviews with 80 parents provided evidence for 6 distinct functions of communication between children and clinicians. These functions apply to older and younger children, although specific manifestations might vary by age. This functional model provides a framework to guide clinicians' communication efforts and future communication research.
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Affiliation(s)
- Bryan A Sisk
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8005, St. Louis, MO, 63110, USA.
| | - Ginny L Schulz
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8005, St. Louis, MO, 63110, USA
| | - Lindsay J Blazin
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Justin N Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jennifer W Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, MA, USA
| | - James M DuBois
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
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5
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Sisk BA, Keenan MA, Blazin LJ, Kaye E, Baker JN, Mack JW, DuBois JM. "Don't be afraid to speak up": Communication advice from parents and clinicians of children with cancer. Pediatr Blood Cancer 2021; 68:e29052. [PMID: 33861026 PMCID: PMC8286806 DOI: 10.1002/pbc.29052] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/02/2021] [Accepted: 03/25/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Parents and clinicians of children with cancer can provide advice to improve communication that reflects lessons learned through experience. We aimed to identify categories of communication advice offered to parents of children with cancer from clinicians and other parents. PROCEDURE (1) Semi-structured interviews with 80 parents of children with cancer at three sites; (2) single-item, open-ended survey administered following 10 focus groups with 58 pediatric oncology clinicians at two sites. We asked participants for communication advice to parents, and analyzed responses using semantic content analysis. RESULTS Parents provided five categories of communication advice to other parents. Advocacy involved asking questions, communicating concerns, and speaking up for the child. Support involved pursuing self-care, seeking and accepting help, and identifying supportive communities. Managing information involved taking and organizing notes, remaining open to difficult truths, and avoiding inaccurate information. Partnership involved establishing open lines of communication with clinicians, making the family's values and priorities known, and trusting the clinical team. Engaging and supporting the child involved, understanding and incorporating the child's preferences and values, and creating a loving environment. Clinicians' advice addressed similar categories, although only one clinician described engaging and supporting the child. Furthermore, parental advice expanded beyond interactions with the clinical team, whereas clinician advice focused more on the role of clinicians. CONCLUSIONS Parents and clinicians of children with cancer provided five categories of communication advice. With these data, clinicians, health care organizations, support groups, and patient advocates could offer experience-informed advice to parents who are seeking information and support.
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Affiliation(s)
- Bryan A Sisk
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Megan A Keenan
- Bioethics Research Center, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lindsay J Blazin
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Erica Kaye
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Justin N Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jennifer W Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - James M DuBois
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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6
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Blazin LJ, Terao MA, Spraker-Perlman H, Baker JN, McLaughlin Crabtree V, Mandrell BN, Gattuso J, Sellers J, Dunn TJ, Lu Z, Hoffman JM, Burlison JD. Never Enough Time: Mixed Methods Study Identifies Drivers of Temporal Demand That Contribute to Burnout Among Physicians Who Care for Pediatric Hematology-Oncology Patients. JCO Oncol Pract 2021; 17:e958-e971. [PMID: 33720755 PMCID: PMC8462670 DOI: 10.1200/op.20.00754] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/12/2020] [Accepted: 01/27/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment because of chronic occupational stress. Approximately one third of pediatric hematology-oncology physicians experience burnout. The goal of this mixed methods study was to determine the prevalence and drivers of burnout among physicians caring for pediatric hematology-oncology patients at our institution. MATERIALS AND METHODS This mixed methods, cross-sectional study was conducted at a large academic cancer center. Validated survey instruments were used to measure burnout, job demands, experience with patient safety events, and workplace culture. Quantitative data informed development of a semistructured interview guide, and physicians were randomly selected to participate in individual interviews. Interviews were transcribed and analyzed via content analysis based on a priori codes. RESULTS The survey was distributed to 132 physicians, and 53 complete responses were received (response rate 40%). Of the 53 respondents, 15 (28%) met criteria for burnout. Experiencing burnout was associated with increased temporal demand. Twenty-six interviews were conducted. Qualitative themes revealed that frequent meetings, insufficient support staff, and workflow interruptions were key drivers of temporal demand and that temporal demand contributed to burnout through emotional exhaustion and reduced personal accomplishment. CONCLUSION Nearly one-third of participating physicians met criteria for burnout, and burnout was associated with increased temporal demand. Qualitative interviews identified specific drivers of temporal demand and burnout, which can be targeted for intervention. This methodology can be easily adapted for broad use and may represent an effective strategy for identifying and mitigating institution-specific drivers of burnout.
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Affiliation(s)
- Lindsay J. Blazin
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Indiana University, Indianapolis, IN
| | - Michael A. Terao
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Pediatrics, Division of Pediatric Adolescent and Young Adult Hematology and Oncology, Medstar Georgetown University Hospital, Washington, DC
| | - Holly Spraker-Perlman
- Department of Oncology, Division of Quality of Life and Palliative Care, St Jude Children's Research Hospital, Memphis, TN
| | - Justin N. Baker
- Department of Oncology, Division of Quality of Life and Palliative Care, St Jude Children's Research Hospital, Memphis, TN
| | | | - Belinda N. Mandrell
- Department of Pediatric Medicine, Division of Nursing Research, St Jude Children's Research Hospital, Memphis, TN
| | - Jami Gattuso
- Department of Pediatric Medicine, Division of Nursing Research, St Jude Children's Research Hospital, Memphis, TN
| | - Janet Sellers
- Department of Psychosocial Services, St Jude Children's Research Hospital, Memphis, TN
| | - Tyler J. Dunn
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN
- Department of Pharmacy Administration, University of Mississippi, Oxford, MS
| | - Zhaohua Lu
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - James M. Hoffman
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN
- Office of Quality and Patient Care, St Jude Children's Research Hospital, Memphis, TN
| | - Jonathan D. Burlison
- Office of Quality and Patient Care, St Jude Children's Research Hospital, Memphis, TN
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7
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Sisk BA, Zavadil JA, Blazin LJ, Baker JN, Mack JW, DuBois JM. Assume It Will Break: Parental Perspectives on Negative Communication Experiences in Pediatric Oncology. JCO Oncol Pract 2021; 17:e859-e871. [PMID: 33848191 DOI: 10.1200/op.20.01038] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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
PURPOSE Communication breakdowns in pediatric oncology can have negative consequences for patients and families. A detailed analysis of these negative encounters will support clinicians in anticipating and responding to communication breakdowns. METHODS Semistructured interviews with 80 parents of children with cancer across three academic medical centers during treatment, survivorship, or bereavement. We analyzed transcripts using semantic content analysis. RESULTS Nearly all parents identified negative communication experiences (n = 76). We identified four categories of contributors to negative experiences: individual (n = 68), team (n = 26), organization (n = 46), and greater health care system (n = 8). These experiences involved a variety of health care professionals across multiple specialties. Parents reported 12 personal consequences of communication breakdowns: emotional distress (n = 65), insufficient understanding (n = 48), decreased trust or confidence (n = 37), inconvenience (n = 36), medical harm (n = 23), decreased self-confidence (n = 17), decreased emotional support (n = 13), decreased engagement (n = 9), false hope (n = 9), decreased hope (n = 7), financial insult (n = 7), and decreased access to resources (n = 3). We identified five categories of supportive responses from clinicians: exploring (n = 8), acknowledging (n = 17), informing (n = 27), adapting (n = 27), and advocating (n = 18). Parents often increased their own advocacy on behalf of their child (n = 47). Parents also identified the need for parental engagement in finding solutions (n = 12). Finally, one parent suggested that clinicians should assume that communication will fail and develop contingency plans in advance. CONCLUSION Communication breakdowns in pediatric oncology negatively affect parents and children. Clinicians should plan for communication breakdowns and respond by exploring, acknowledging, informing, adapting, advocating, and engaging parents in finding solutions.
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Affiliation(s)
- Bryan A Sisk
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St Louis, MO
| | - Jessica A Zavadil
- Department of Pediatrics, St Louis Children's Hospital, St Louis, MO
| | - Lindsay J Blazin
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Justin N Baker
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN.,Division of Quality of Life and Palliative Care, St Jude Children's Research Hospital, Memphis, TN
| | - Jennifer W Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, MA
| | - James M DuBois
- Department of Medicine, Washington University School of Medicine, St Louis, MO
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8
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Abstract
BACKGROUND When children are seriously ill, parents rely on communication with their clinicians. However, in previous research, researchers have not defined how this communication should function in pediatric oncology. We aimed to identify these communication functions from parental perspectives. METHODS Semistructured interviews with 78 parents of children with cancer from 3 academic medical centers at 1 of 3 time points: treatment, survivorship, or bereavement. We analyzed interview transcripts using inductive and deductive coding. RESULTS We identified 8 distinct functions of communication in pediatric oncology. Six of these functions are similar to previous findings from adult oncology: (1) building relationships, (2) exchanging information, (3) enabling family self-management, (4) making decisions, (5) managing uncertainty, and (6) responding to emotions. We also identified 2 functions not previously described in the adult literature: (7) providing validation and (8) supporting hope. Supporting hope manifested as emphasizing the positives, avoiding false hopes, demonstrating the intent to cure, and redirecting toward hope beyond survival. Validation manifested as reinforcing "good parenting" beliefs, empowering parents as partners and advocates, and validating concerns. Although all functions seemed to interact, building relationships appeared to provide a relational context in which all other interpersonal communication occurred. CONCLUSIONS Parent interviews provided evidence for 8 distinct communication functions in pediatric oncology. Clinicians can use this framework to better understand and fulfill the communication needs of parents whose children have serious illness. Future work should be focused on measuring whether clinical teams are fulfilling these functions in various settings and developing interventions targeting these functions.
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Affiliation(s)
- Bryan A. Sisk
- Division of Hematology and Oncology, Department of
Pediatrics and
| | - Annie Friedrich
- Albert Gnaegi Center for Health Care Ethics, Saint
Louis University, St Louis, Missouri
| | - Lindsay J. Blazin
- Department of Oncology, St. Jude Children’s
Research Hospital, Memphis, Tennessee
| | - Justin N. Baker
- Division of Quality of Life and Palliative Care
and,Department of Oncology, St. Jude Children’s
Research Hospital, Memphis, Tennessee
| | - Jennifer W. Mack
- Division of Population Sciences, McGraw Patterson
Center for Population Sciences and Department of Pediatric Oncology, Dana-Farber
Cancer Institute, Boston, Massachusetts; and,Division of Hematology/Oncology, Boston
Children’s Hospital, Boston, Massachusetts
| | - James DuBois
- Division of General Medical Sciences, Department of
Medicine, School of Medicine, Washington University in St Louis, St Louis,
Missouri
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9
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Blazin LJ, Sitthi-Amorn J, Hoffman JM, Burlison JD. Improving Patient Handoffs and Transitions through Adaptation and Implementation of I-PASS Across Multiple Handoff Settings. Pediatr Qual Saf 2020; 5:e323. [PMID: 32766496 PMCID: PMC7382547 DOI: 10.1097/pq9.0000000000000323] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/09/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Communication failures are common root causes of serious medical errors. Standardized, structured handoffs improve communication and patient safety. I-PASS is a handoff program that decreases medical errors and preventable patient harm. The I-PASS mnemonic is defined as illness severity, patient information, action list, situational awareness and contingency plans, and synthesis by receiver. I-PASS was validated for physician handoffs, yet has the potential for broader application. The objectives of this quality improvement initiative were to adapt and implement I-PASS to handoff contexts throughout a pediatric hospital, including those with little or no known evidence of using I-PASS. METHODS We adapted and implemented I-PASS for inpatient nursing bedside report, physician handoff, and imaging/procedures handoff. Throughout the initiative, end-user stakeholders participated as team members and informed the adaptation of the I-PASS mnemonic, handoff processes, written handoff documents, and performance evaluation methods. Peers observed handoffs, scored performance, and provided formative feedback. Adherence to I-PASS was the primary outcome. We also evaluated changes in handoff-related error frequency and clinician attitudes about the effects of I-PASS on personal and overall handoff performance. RESULTS All 5 elements of the I-PASS mnemonic were used in 87% of inpatient nursing, 76% of physician, and 89% of imaging/procedures handoffs. Inpatient nurses reported reductions in handoff-related errors following I-PASS implementation. Clinicians across most handoff settings reported that using I-PASS improved both general and personal handoff performance. CONCLUSIONS I-PASS is adaptable to many handoff settings, which expands its potential to improve patient safety. Clinicians reported reductions in errors and improvements in handoff performance. We identified broad institutional support, customized written handoff documents, and peer observations with feedback as crucial factors in sustaining I-PASS usage.
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Affiliation(s)
- Lindsay J Blazin
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Jitsuda Sitthi-Amorn
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
- Hospitalist Program, St. Jude Children's Research Hospital, Memphis, TN
| | - James M Hoffman
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
- Office of Quality and Patient Care, St. Jude Children's Research Hospital, Memphis TN
| | - Jonathan D Burlison
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
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Kaye EC, DeMarsh S, Gushue CA, Jerkins J, Sykes A, Lu Z, Snaman JM, Blazin LJ, Johnson LM, Levine DR, Morrison RR, Baker JN. Predictors of Location of Death for Children with Cancer Enrolled on a Palliative Care Service. Oncologist 2018; 23:1525-1532. [PMID: 29728467 DOI: 10.1634/theoncologist.2017-0650] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 12/09/2017] [Accepted: 04/03/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In the U.S., more children die from cancer than from any other disease, and more than one third die in the hospital setting. These data have been replicated even in subpopulations of children with cancer enrolled on a palliative care service. Children with cancer who die in high-acuity inpatient settings often experience suffering at the end of life, with increased psychosocial morbidities seen in their bereaved parents. Strategies to preemptively identify children with cancer who are more likely to die in high-acuity inpatient settings have not been explored. MATERIALS AND METHODS A standardized tool was used to gather demographic, disease, treatment, and end-of-life variables for 321 pediatric palliative oncology (PPO) patients treated at an academic pediatric cancer center who died between 2011 and 2015. Multinomial logistic regression was used to predict patient subgroups at increased risk for pediatric intensive care unit (PICU) death. RESULTS Higher odds of dying in the PICU were found in patients with Hispanic ethnicity (odds ratio [OR], 4.02; p = .002), hematologic malignancy (OR, 7.42; p < .0001), history of hematopoietic stem cell transplant (OR, 4.52; p < .0001), total number of PICU hospitalizations (OR, 1.98; p < .0001), receipt of cancer-directed therapy during the last month of life (OR, 2.96; p = .002), and palliative care involvement occurring less than 30 days before death (OR, 4.7; p < .0001). Conversely, lower odds of dying in the PICU were found in patients with hospice involvement (OR, 0.02; p < .0001) and documentation of advance directives at the time of death (OR, 0.37; p = .033). CONCLUSION Certain variables may predict PICU death for PPO patients, including delayed palliative care involvement. Preemptive identification of patients at risk for PICU death affords opportunities to study the effects of earlier palliative care integration and increased discussions around preferred location of death on end-of-life outcomes for children with cancer and their families. IMPLICATIONS FOR PRACTICE Children with cancer who die in high-acuity inpatient settings often experience a high burden of intensive therapy at the end of life. Strategies to identify patients at higher risk of dying in the pediatric intensive care unit (PICU) have not been explored previously. This study finds that certain variables may predict PICU death for pediatric palliative oncology patients, including delayed palliative care involvement. Preemptive identification of patients at risk for PICU death affords opportunities to study the effects of earlier palliative care integration and increased discussions around preferred location of death on end-of-life outcomes for children with cancer and their families.
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Affiliation(s)
- Erica C Kaye
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Samantha DeMarsh
- Ohio University Heritage College of Osteopathic Medicine, Cleveland, Ohio, USA
| | - Courtney A Gushue
- Le Bonheur Children's Hospital, Memphis, Tennessee, USA
- University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jonathan Jerkins
- Le Bonheur Children's Hospital, Memphis, Tennessee, USA
- University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - April Sykes
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Zhaohua Lu
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jennifer M Snaman
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Boston Children's Hospital, Boston, Massachusetts, USA
| | | | | | - Deena R Levine
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - R Ray Morrison
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Justin N Baker
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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11
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Abstract
Effective communication is essential to the practice of pediatric oncology. Clear and empathic delivery of diagnostic and prognostic information positively impacts the ways in which patients and families cope. Honest, compassionate discussions regarding goals of care and hopes for patients approaching end of life can provide healing when other therapies have failed. Effective communication and the positive relationships it fosters also can provide comfort to families grieving the loss of a child. A robust body of evidence demonstrates the benefits of optimal communication for patients, families, and healthcare providers. This review aims to identify key communication skills that healthcare providers can employ throughout the illness journey to provide information, encourage shared decision-making, promote therapeutic alliance, and empathically address end-of-life concerns. By reviewing the relevant evidence and providing practical tips for skill development, we strive to help healthcare providers understand the value of effective communication and master these critical skills.
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Affiliation(s)
- Lindsay J. Blazin
- Department of Oncology, Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (L.J.B.); (E.C.K.)
| | - Cherilyn Cecchini
- Department of Pediatrics, Children’s National Medical Center, Washington, DC 20010, USA; (C.C); (C.H.)
| | - Catherine Habashy
- Department of Pediatrics, Children’s National Medical Center, Washington, DC 20010, USA; (C.C); (C.H.)
| | - Erica C. Kaye
- Department of Oncology, Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (L.J.B.); (E.C.K.)
| | - Justin N. Baker
- Department of Oncology, Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (L.J.B.); (E.C.K.)
- Correspondence: ; Tel.: +1-901-595-4446
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