1
|
Sadang KG, Centracchio JA, Turk Y, Park E, Feliciano JL, Chua IS, Blackhall L, Silveira MJ, Fischer SM, Rabow M, Zachariah F, Grey C, Campbell TC, Strand J, Temel JS, Greer JA. Clinician Perceptions of Barriers and Facilitators for Delivering Early Integrated Palliative Care via Telehealth. Cancers (Basel) 2023; 15:5340. [PMID: 38001600 PMCID: PMC10670662 DOI: 10.3390/cancers15225340] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Early integrated palliative care (EIPC) significantly improves clinical outcomes for patients with advanced cancer. Telehealth may be a useful tool to deliver EIPC sustainably and equitably. Palliative care clinicians completed a survey regarding their perceptions of the barriers, facilitators, and benefits of using telehealth video visits for delivering EIPC for patients with advanced lung cancer. Forty-eight clinicians across 22 cancer centers completed the survey between May and July 2022. Most (91.7%) agreed that telehealth increases access to EIPC and simplifies the process for patients to receive EIPC (79.2%). Clinicians noted that the elderly, those in rural areas, and those with less-resourced backgrounds have greater difficulty using telehealth. Perceived barriers were largely patient-based factors, including technological literacy, internet and device availability, and patient preferences. Clinicians agreed that several organizational factors facilitated telehealth EIPC delivery, including technological infrastructure (85.4%), training (83.3%), and support from study coordinators (81.3%). Other barriers included systems-based factors, such as insurance reimbursement and out-of-state coverage restrictions. Patient-, organization-, and systems-based factors are all important to providing and improving access to telehealth EIPC services. Further research is needed to investigate the efficacy of telehealth EIPC and how policies and interventions may improve access to and dissemination of this care modality.
Collapse
Affiliation(s)
- Katrina Grace Sadang
- Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA;
- Lifelong Medical Care Family Medicine Residency, Richmond, CA 94801, USA
| | - Joely A. Centracchio
- Massachusetts General Hospital, Boston, MA 02114, USA; (J.A.C.); (Y.T.); (E.P.); (J.S.T.)
| | - Yael Turk
- Massachusetts General Hospital, Boston, MA 02114, USA; (J.A.C.); (Y.T.); (E.P.); (J.S.T.)
| | - Elyse Park
- Massachusetts General Hospital, Boston, MA 02114, USA; (J.A.C.); (Y.T.); (E.P.); (J.S.T.)
| | | | - Isaac S. Chua
- Brigham and Women’s Hospital & Dana-Farber Cancer Institute, Boston, MA 02215, USA;
| | - Leslie Blackhall
- Department of Palliative Care, University of Virginia, Charlottesville, VA 22903, USA;
| | - Maria J. Silveira
- Department of Geriatrics and Palliative Medicine, Ann Arbor Veterans Affairs (VA) Medical Center, University of Michigan, Ann Arbor, MI 48104, USA;
| | | | - Michael Rabow
- University of California San Francisco Medical Center, San Francisco, CA 94143, USA;
| | | | - Carl Grey
- Wake Forest Baptist Health, Winston-Salem, NC 27157, USA;
| | - Toby C. Campbell
- Department of Hematology/Oncology and Palliative Care, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA;
| | | | - Jennifer S. Temel
- Massachusetts General Hospital, Boston, MA 02114, USA; (J.A.C.); (Y.T.); (E.P.); (J.S.T.)
| | - Joseph A. Greer
- Massachusetts General Hospital, Boston, MA 02114, USA; (J.A.C.); (Y.T.); (E.P.); (J.S.T.)
| |
Collapse
|
2
|
Chwistek M, Sherry D, Kinczewski L, Silveira MJ, Davis M. Should Buprenorphine Be Considered a First-Line Opioid for the Treatment of Moderate to Severe Cancer Pain? J Pain Symptom Manage 2023; 66:e638-e643. [PMID: 37343903 DOI: 10.1016/j.jpainsymman.2023.06.022] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/02/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023]
Abstract
Cancer pain remains a significant problem worldwide, affecting more than half of patients receiving anti-cancer treatment and most patients with advanced disease. Opioids remain the cornerstone of therapy, and morphine, given its availability, multiple formulations, price, and evidence base, is typically considered the first-line treatment for moderate to severe cancer pain. Buprenorphine has emerged in recent decades as an alternative opioid for treating chronic pain and substance use disorder (SUD). However, it remains controversial whether buprenorphine should be considered a first-line opioid for moderate to severe cancer pain. In this "Controversies in Palliative Care" article, three expert clinicians independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought process, share practical advice on their clinical approach, and highlight the opportunities for future research. All three groups agree that there is a place for the use of buprenorphine as a first-line opioid in cancer pain. Specifically, they mention populations of elderly patients, patients with renal failure, and those with (SUD). They also underscore many unique and favorable characteristics of buprenorphine, such as the low risk for respiratory depression, lack of adverse effects on testosterone levels in men, no risk of serotonin syndrome when combined with antidepressants, and ease of use given its transdermal, transmucosal, and sublingual formulations. However, further studies are needed to guide the use of buprenorphine for cancer pain-primarily randomized clinical trials (RCTs) comparing buprenorphine with other opioids in various pain syndromes.
Collapse
Affiliation(s)
- Marcin Chwistek
- Department of Hematology and Oncology (M.C., D.S., L.K.), Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, USA.
| | - Dylan Sherry
- Department of Hematology and Oncology (M.C., D.S., L.K.), Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, USA
| | - Leigh Kinczewski
- Department of Hematology and Oncology (M.C., D.S., L.K.), Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, USA
| | - Maria J Silveira
- Division of Geriatric and Palliative Medicine (M.J.S.), University of Michigan & Geriatric Research Education and Clinical Center, Ann Arbor Veteran Administration Medical Center, Ann Arbor, MI, USA
| | - Mellar Davis
- Department of Palliative Care, Geisinger Medical Center, Geisinger Health Geisinger Commonwealth School of Medicine (M.D.), Danville, PA, USA
| |
Collapse
|
3
|
Shore S, O'Leary M, Kamdar N, Harrod M, Silveira MJ, Hummel SL, Nallamothu BK. Do Not Attempt Resuscitation Order Rates in Hospitalized Patients With Heart Failure, Acute Myocardial Infarction, Chronic Obstructive Pulmonary Disease, and Pneumonia. J Am Heart Assoc 2022; 11:e025730. [PMID: 36382963 PMCID: PMC9851455 DOI: 10.1161/jaha.122.025730] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Descriptions of do not attempt resuscitation (DNAR) orders in heart failure (HF) are limited. We describe use of DNAR orders in HF hospitalizations relative to other common conditions, focusing on race. Methods and Results This was a retrospective study of all adult hospitalizations for HF, acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), and pneumonia from 2010 to 2016 using the California State Inpatient Dataset. Using a hierarchical multivariable logistic regression model with random effects for the hospital, we identified factors associated with DNAR orders for each condition. For racial variation, hospitals were divided into quintiles based on proportion of Black patients cared for. Our cohort comprised 399 816 HF, 190 802 AMI, 192 640 COPD, and 269 262 pneumonia hospitalizations. DNAR orders were most prevalent in HF (11.9%), followed by pneumonia (11.1%), COPD (7.9%), and AMI (7.1%). Prevalence of DNAR orders did not change from 2010 to 2016 for each condition. For all conditions, DNAR orders were more common in elderly people, women, and White people with significant site-level variation across 472 hospitals. For HF and COPD, hospitalizations at sites that cared for a higher proportion of Black patients were less likely associated with DNAR orders. For AMI and pneumonia, conditions such as dementia and malignancy were strongly associated with DNAR orders. Conclusions DNAR orders were present in 12% of HF hospitalizations, similar to pneumonia but higher than AMI and COPD. For HF, we noted significant variability across sites when stratified by proportion of Black patients cared for, suggesting geographic and racial differences in end-of-life care.
Collapse
Affiliation(s)
- Supriya Shore
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI
| | - Michael O'Leary
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI
| | - Neil Kamdar
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI
| | - Molly Harrod
- Veterans Affairs Ann Arbor Center for Clinical Management ResearchAnn ArborMI
| | - Maria J. Silveira
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Veterans Affairs Geriatric Research Education and Clinical CenterAnn ArborMI
| | - Scott L. Hummel
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI,Veterans Affairs Ann Arbor Center for Clinical Management ResearchAnn ArborMI
| | - Brahmajee K. Nallamothu
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI,Veterans Affairs Ann Arbor Center for Clinical Management ResearchAnn ArborMI
| |
Collapse
|
4
|
Lenko R, Voepel-Lewis T, Robinson-Lane SG, Silveira MJ, Hoffman GJ. Racial and Ethnic Differences in Informal and Formal Advance Care Planning Among U.S. Older Adults. J Aging Health 2022; 34:1281-1290. [PMID: 35621163 PMCID: PMC9633341 DOI: 10.1177/08982643221104926] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine advance care planning (ACP) trends among an increasingly diverse aging population, we compared informal and formal ACP use by race/ethnicity among U.S. older adults (≤65 years). METHODS We used Health and Retirement Study data (2012-2018) to assess relationships between race/ethnicity and ACP type (i.e., no ACP, informal ACP only, formal ACP only, or both ACP types). We reported adjusted risk ratios with 95% confidence intervals. RESULTS Non-Hispanic Black and Hispanic respondents were 1.77 (1.60, 1.96) and 1.76 (1.55, 1.99) times as likely, respectively, to report no ACP compared to non-Hispanic White respondents. Non-Hispanic Black and Hispanic respondents were 0.74 (0.71, 0.78) and 0.74 (0.69, 0.80) times as likely, respectively, to report using both ACP types as non-Hispanic White respondents. DISCUSSION Racial/ethnic differences in ACP persist after controlling for a variety of barriers to and facilitators of ACP which may contribute to disparities in end-of-life care.
Collapse
Affiliation(s)
- Rachel Lenko
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing
| | - Terri Voepel-Lewis
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing
| | - Sheria G. Robinson-Lane
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing
| | - Maria J. Silveira
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan
| | - Geoffrey J. Hoffman
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing
| |
Collapse
|
5
|
Powell VD, Kumar N, Galecki AT, Kabeto M, Clauw DJ, Williams DA, Hassett A, Silveira MJ. Bad company: Loneliness longitudinally predicts the symptom cluster of pain, fatigue, and depression in older adults. J Am Geriatr Soc 2022; 70:2225-2234. [PMID: 35415848 PMCID: PMC9378441 DOI: 10.1111/jgs.17796] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 02/10/2022] [Accepted: 03/11/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Pain, fatigue, and depression frequently co-occur as a symptom cluster. While commonly occurring in those with cancer and autoimmune disease, the cluster is also found in the absence of systemic illness or inflammation. Loneliness is a common psychosocial stressor associated with the cluster cross-sectionally. We investigated whether loneliness predicted the development of pain, fatigue, depression, and the symptom cluster over time. METHODS Data from the Health and Retirement Study were used. We included self-respondents ≥50 year-old who had at least two measurements of loneliness and the symptom cluster from 2006-2016 (n = 5974). Time-varying loneliness was used to predict pain, fatigue, depression, and the symptom cluster in the subsequent wave(s) using generalized estimating equations (GEE) and adjusting for sociodemographic covariates, living arrangement, and the presence of the symptom(s) at baseline. RESULTS Loneliness increased the odds of subsequently reporting pain (aOR 1.22, 95% CI 1.08, 1.37), fatigue (aOR 1.47, 95% CI 1.32, 1.65), depression (aOR 2.33, 95% CI 2.02, 2.68), as well as the symptom cluster (aOR 2.15, 95% CI 1.74, 2.67). The median time between the baseline and final follow-up measurement was 7.6 years (IQR 4.1, 8.2). CONCLUSIONS Loneliness strongly predicts the development of pain, fatigue, and depression as well as the cluster of all three symptoms several years later in a large, nonclinical sample of older American adults. Future studies should examine the multiple pathways through which loneliness may produce this cluster, as well as examine whether other psychosocial stressors also increase risk. It is possible that interventions which address loneliness in older adults may prevent or mitigate the cluster of pain, fatigue, and depression.
Collapse
Affiliation(s)
- Victoria D. Powell
- Division of Geriatric and Palliative MedicineUniversity of MichiganAnn ArborMichiganUSA
- Geriatric Research, Education, and Clinical CenterLTC Charles S. Kettles VA Medical CenterAnn ArborMichiganUSA
| | - Navasuja Kumar
- Division of Geriatric and Palliative MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Andrzej T. Galecki
- Division of Geriatric and Palliative MedicineUniversity of MichiganAnn ArborMichiganUSA
- Department of Biostatistics, School of Public HealthUniversity of MichiganAnn ArborMichiganUSA
| | - Mohammed Kabeto
- Division of Geriatric and Palliative MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Daniel J. Clauw
- Department of AnesthesiologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - David A. Williams
- Department of AnesthesiologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Afton Hassett
- Department of AnesthesiologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Maria J. Silveira
- Division of Geriatric and Palliative MedicineUniversity of MichiganAnn ArborMichiganUSA
- Geriatric Research, Education, and Clinical CenterLTC Charles S. Kettles VA Medical CenterAnn ArborMichiganUSA
| |
Collapse
|
6
|
Abstract
OBJECTIVE The aim of this study was to determine whether older adults are at higher risk of lasting functional and cognitive decline after surgery, and the impact of decline on survival and healthcare use. SUMMARY BACKGROUND DATA Patient-centered outcomes after surgery are poorly characterized. METHODS Using data from the Health and Retirement Study linked with Medicare, we matched older adults (≥65 years) who underwent one of 163 high-risk elective operations (ie, inpatient mortality of ≥1%) with nonsurgical controls between 1992 and 2012. Functional decline was defined as an increase in the number of activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs) requiring assistance from baseline. Cognitive decline was defined by worse response to a test of memory and mental processing from baseline. Using logistic regression, we examined whether surgery was associated with functional and cognitive decline, and whether declines were associated with poorer survival and increased healthcare use. RESULTS The matched cohort of patients who did not undergo surgery consisted of 3591 (75%) participants compared to 1197 (25%) who underwent surgery. Patients who underwent surgery were at higher risk of functional and cognitive declines [adjusted odds ratio (aOR) 1.52, 95% confidence interval (CI): 1.23-1.87 and aOR 1.32, 95% CI: 1.03-1.71]. Declines were associated with poorer long-term survival [hazard ratio (HR) 1.67, 95% CI: 1.43-1.94 and HR 1.35, 95% CI: 1.15-1.58], and were significantly associated with nearly all measures of increased healthcare utilization (P < 0.001). CONCLUSION Older adults undergoing high-risk surgery are at increased risk of developing lasting functional and cognitive declines.
Collapse
Affiliation(s)
| | - Yun Li
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Paul Abrahamse
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | | | | | - Maria J. Silveira
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan
- Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan
- Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System
| | | |
Collapse
|
7
|
Powell VD, Rosenberg JM, Yaganti A, Garpestad C, Lagisetty P, Shannon C, Silveira MJ. Evaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic Pain: A Systematic Review. JAMA Netw Open 2021; 4:e2124152. [PMID: 34495339 PMCID: PMC8427372 DOI: 10.1001/jamanetworkopen.2021.24152] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Individuals with chronic pain who use long-term opioid therapy (LTOT) are at risk of opioid use disorder and other harmful outcomes. Rotation to buprenorphine may be considered, but the outcomes of such rotation in this population have not been systematically reviewed. OBJECTIVE To synthesize the evidence on rotation to buprenorphine from full μ-opioid receptor agonists among individuals with chronic pain who were receiving LTOT, including the outcomes of precipitated opioid withdrawal, pain intensity, pain interference, treatment success, adverse events or adverse effects, mental health condition, and health care use. EVIDENCE REVIEW PubMed, CINAHL, Embase, and PsycInfo were searched from inception through November 3, 2020, for peer-reviewed original English-language research that reported the prespecified outcomes of rotation from prescribed long-term opioids to buprenorphine among individuals with chronic pain. Two independent reviewers extracted data as well as assessed risk of bias and study quality according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Quality of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. FINDINGS A total of 22 studies were analyzed, of which 5 (22.7%) were randomized clinical trials, 7 (31.8%) were case-control or cohort studies, and 10 (45.5%) were uncontrolled pre-post studies, which involved 1616 unique participants (675 female [41.8%] and 941 male [58.2%] individuals). Six of the 22 studies (27.3%) were primary or secondary analyses of a large randomized clinical trial. Participants had diverse pain and opioid use histories. Rationale for buprenorphine rotation included inadequate analgesia, intolerable adverse effects, risky opioid regimens (eg, high dose and/or sedative coprescriptions), and aberrant opioid use. Most protocols were adapted from protocols for initiating treatment in patients with opioid use disorder and used buccal or sublingual buprenorphine. Very low-quality evidence suggested that buprenorphine rotation was associated with maintained or improved analgesia, with a low risk of precipitating opioid withdrawal. Steady-dose buprenorphine was better tolerated than tapered-dose buprenorphine. Adverse effects were manageable, and severe adverse events were rare. Only 2 studies evaluated mental health outcomes, but none evaluated health care use. Limitations included a high risk of bias in most studies. CONCLUSIONS AND RELEVANCE In this systematic review, buprenorphine was associated with reduced chronic pain intensity without precipitating opioid withdrawal in individuals with chronic pain who were receiving LTOT. Future studies are necessary to ascertain the ideal starting dose, formulation, and administration frequency of buprenorphine as well as the best approach to buprenorphine rotation.
Collapse
Affiliation(s)
- Victoria D. Powell
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor
- Geriatrics Research, Education, and Clinical Center, LTC Charles S. Kettles Veterans Affairs (VA) Medical Center, Ann Arbor, Michigan
| | - Jack M. Rosenberg
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor
- Department of Anesthesiology, University of Michigan, Ann Arbor
- Department of Physical Medicine and Rehabilitation, LTC Charles S. Kettles VA Medical Center, Ann Arbor, Michigan
- Department of Anesthesiology, LTC Charles S. Kettles VA Medical Center, Ann Arbor, Michigan
| | - Avani Yaganti
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | | | - Pooja Lagisetty
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Center for Clinical Management and Research, Ann Arbor VA, Ann Arbor, Michigan
| | - Carol Shannon
- Taubman Health Sciences Library, University of Michigan, Ann Arbor
| | - Maria J. Silveira
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor
- Geriatrics Research, Education, and Clinical Center, LTC Charles S. Kettles Veterans Affairs (VA) Medical Center, Ann Arbor, Michigan
| |
Collapse
|
8
|
Giannitrapani KF, Silveira MJ, Azarfar A, Glassman PA, Singer SJ, Asch SM, Midboe AM, Zenoni MA, Gamboa RC, Becker WC, Lorenz KA. Cross Disciplinary Role Agreement is Needed When Coordinating Long-Term Opioid Prescribing for Cancer: a Qualitative Study. J Gen Intern Med 2021; 36:1867-1874. [PMID: 33948790 PMCID: PMC8298631 DOI: 10.1007/s11606-021-06747-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/24/2020] [Accepted: 03/18/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers. OBJECTIVES To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer-related pain in a large integrated healthcare system. DESIGN Qualitative research. PARTICIPANTS We conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs). APPROACH We deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus. RESULTS Theme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines. CONCLUSIONS Our findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of cross-disciplinary role agreement may result in delays in clinically appropriate cancer pain management.
Collapse
Affiliation(s)
- K F Giannitrapani
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA. .,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA.
| | - M J Silveira
- Geriatric Research Education Clinical Center (GRECC), Ann Arbor VA Health Care System, University of Michigan, Ann Arbor, MI, USA.,Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - A Azarfar
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,University of Central Florida, Orlando, FL, USA
| | - P A Glassman
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington, DC, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - S J Singer
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - S M Asch
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - A M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - M A Zenoni
- Pain Research Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Health Care System, West Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - R C Gamboa
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - W C Becker
- Pain Research Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Health Care System, West Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - K A Lorenz
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
9
|
Affiliation(s)
- Maria J Silveira
- Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor.,Veterans Affairs Ann Arbor Healthcare System, Michigan
| | - Kevin F Boehnke
- Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor
| | - Dan Clauw
- Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor
| |
Collapse
|
10
|
Powell VD, Abedini NC, Galecki AT, Kabeto M, Kumar N, Silveira MJ. Unwelcome Companions: Loneliness Associates with the Cluster of Pain, Fatigue, and Depression in Older Adults. Gerontol Geriatr Med 2021; 7:2333721421997620. [PMID: 33709010 PMCID: PMC7907946 DOI: 10.1177/2333721421997620] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 11/29/2022] Open
Abstract
Objective: Pain, fatigue, and depression commonly co-occur as a
symptom cluster in pathological inflammatory states. Psychosocial stressors such
as loneliness may lead to similar states through shared mechanisms. We
investigated the association of loneliness with pain, fatigue, and depression in
older adults. Methods: Using Health and Retirement Study data
(N = 11,766), we measured cross-sectional prevalence of
frequent, moderate to severe pain; severe fatigue; depressive symptoms; and
co-occurrence of symptoms surpassing threshold levels (i.e., symptom cluster).
Logistic regression models evaluated associations with loneliness.
Results: Pain, fatigue, and depression were reported in 19.2%,
20.0%, and 15.3% of the total sample, respectively. The symptom cluster was seen
in 4.9% overall; prevalence in lonely individuals was significantly increased
(11.6% vs. 2.3%, p < .0001). After adjusting for demographic
variables, loneliness associated with the symptom cluster (adjusted OR = 3.39,
95% CI = 2.91, 3.95) and each symptom (pain adjusted OR = 1.61, 95% CI = 1.48,
1.76; fatigue adjusted OR = 2.02, 95% CI = 1.85, 2.20; depression adjusted
OR = 4.34, 95% CI = 3.93, 4.79). Discussion: Loneliness strongly
associates with the symptom cluster of pain, fatigue, and depression. Further
research should examine causal relationships and investigate whether
interventions targeting loneliness mitigate pain, fatigue, and depression.
Collapse
Affiliation(s)
- Victoria D Powell
- Veterans Affairs Ann Arbor Geriatric Research, Education, and Clinical Center, MI, USA.,University of Michigan, Ann Arbor, USA
| | | | | | | | | | - Maria J Silveira
- Veterans Affairs Ann Arbor Geriatric Research, Education, and Clinical Center, MI, USA.,University of Michigan, Ann Arbor, USA
| |
Collapse
|
11
|
Giannitrapani KF, Fereydooni S, Silveira MJ, Azarfar A, Glassman PA, Midboe A, Zenoni M, Becker WC, Lorenz KA. How Patients and Providers Weigh the Risks and Benefits of Long-Term Opioid Therapy for Cancer Pain. JCO Oncol Pract 2021; 17:e1038-e1047. [PMID: 33534632 DOI: 10.1200/op.20.00679] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
PURPOSE To understand how patients and providers weigh the risks and benefits of long-term opioid therapy (LTOT) for cancer pain. METHODS Researchers used VA approved audio-recording devices to record interviews. ATLAS t.i., a qualitative analysis software, was used for analysis of transcribed interview data. Participants included 20 Veteran patients and 20 interdisciplinary providers from primary care- and oncology-based practice settings. We conducted semistructured interviews and analyzed transcripts used thematic qualitative methods. Interviews explored factors that affect decision making about appropriateness of LTOT for cancer related pain. We saturated themes for providers and patients separately. RESULTS Factors affecting patient decision-making included influence from various information sources, persuasion from trusted providers, and sometimes deferral of the decision to their provider. Relative prioritization of pain management as the focal patient concern varied with some patients describing comparatively more fear of chemotherapy than opioid analgesics, comparatively more knowledge of opioids in relation to other drugs;patients expressed a preference to spend the limited time they have with their oncologist discussing cancer treatment rather than opioid use. Factors affecting provider decision making included prognosis, patient goals, patient characteristics, and provider experience and biases. Providers differed in how they weigh the relative importance of alleviating pain or avoiding opioids in the face of treating patients with cancer and histories of substance abuse. CONCLUSION Divergent perspectives on factors need to be considered when weighing risks and benefits. Policies and interventions should be designed to reduce variation in practice to promote equal access to adequate pain management. Improved shared decision-making initiatives will take advantage of patient decision-making factors and priorities.
Collapse
Affiliation(s)
- Karleen F Giannitrapani
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA.,Stanford University School of Medicine, Stanford, CA
| | - Soraya Fereydooni
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA.,Stanford University School of Medicine, Stanford, CA
| | - Maria J Silveira
- Geriatric Research Education Clinical Center (GRECC), Ann Arbor VA Health Care System, Ann Arbor, MI.,University of Michigan, Michigan, MI
| | - Azin Azarfar
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA.,University of Central Florida, Orlando, FL
| | - Peter A Glassman
- VA Pharmacy Benefits Management Services, Washington, DC.,David Geffen School of Medicine at University of California Los Angles, Los Angeles, CA
| | - Amanda Midboe
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA.,Stanford University School of Medicine, Stanford, CA
| | - Maria Zenoni
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Health Care System, West Haven, CT
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Health Care System, West Haven, CT.,Yale School of Medicine, New Haven, CT
| | - Karl A Lorenz
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA.,Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
12
|
Abstract
Older adults with multimorbidity face difficulty accessing healthcare in the COVID era. Palliative care referral may be appropriate to provide additional support for symptoms, advance care planning, or caregiver distress. Since COVID, many palliative care providers have become more accessible through telehealth; however, older adults may have challenges with technology and require caregiver involvement to use. In the inpatient setting, palliative consult teams have assumed a greater role in daily communication with families who cannot visit the patient and in providing emotional support to front-line colleagues. Busy primary clinicians have embraced these efforts, but challenges remain to sustaining these changes.
Collapse
Affiliation(s)
- Victoria D Powell
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA.,Geriatric Research Education and Clinical Center, Ann Arbor Veterans Administration Medical Center, Ann Arbor, Michigan, USA
| | - Maria J Silveira
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA.,Geriatric Research Education and Clinical Center, Ann Arbor Veterans Administration Medical Center, Ann Arbor, Michigan, USA
| |
Collapse
|
13
|
Affiliation(s)
- Victoria D Powell
- Veterans Affairs Ann Arbor Geriatric Research Education and Clinical Center, Ann Arbor, Michigan, USA; Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| | - Maria J Silveira
- Veterans Affairs Ann Arbor Geriatric Research Education and Clinical Center, Ann Arbor, Michigan, USA; Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
14
|
Suwanabol PA, Vitous CA, Perumalswami CR, Li SH, Raja N, Dillon BR, Lee CW, Forman J, Silveira MJ. Surgery Residents' Experiences With Seriously-Ill and Dying Patients: An Opportunity to Improve Palliative and End-of-Life Care. J Surg Educ 2020; 77:582-597. [PMID: 32063510 DOI: 10.1016/j.jsurg.2019.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 03/04/2019] [Revised: 04/25/2019] [Accepted: 12/21/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To describe how and when surgery residents provided primary palliative care and engaged specialty palliative care services. DESIGN Phase I consisted of a previously validated survey instrument supplemented with additional questions. We then conducted semistructured interviews with a subset of the survey respondents (Phase II). Using thematic analysis, we characterized surgery residents' perceptions of palliative care delivery among surgical patients. SETTING General surgery residency programs across the state of Michigan. PARTICIPANTS General surgery residents across the state of Michigan. All residents in participating programs were invited to complete the survey in Phase I. Phase II consisted of a subset of the survey respondents who underwent semistructured interviews. Interview respondents were sampled to reflect the overall surveyed group. RESULTS Among 119 survey respondents (response rate 70%), all had encountered a palliative care specialist but only 58.8% had been taught when to consult or to refer to palliative care. Survey respondents reported on a multitude of barriers within the clinician, patient and family, and systemic domains. Interviews expanded on survey findings and 4 influential factors of palliative care delivery emerged: (1) Resident Education and Training; (2) Resident Attitudes Toward Palliative Care; (3) Knowledge of Palliative Care; and (4) Training within a Surgical Culture. CONCLUSIONS This study reveals how surgery resident training and experiences impact palliative and end-of-life care for surgical patients at teaching institutions. Knowledge of how and when residents are providing primary palliative care and engaging with palliative care services will inform future knowledge and behavioral interventions for trainees who often provide care for patients nearing the end of life.
Collapse
Affiliation(s)
- Pasithorn A Suwanabol
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - C Ann Vitous
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Chithra R Perumalswami
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan; University of Michigan Medical School, Ann Arbor, Michigan
| | - Sylvia H Li
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Nicholas Raja
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Christina W Lee
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Jane Forman
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Center for Clinical Management, Ann Arbor Veterans Affairs Health, Ann Arbor, Michigan
| | - Maria J Silveira
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
15
|
Giannitrapani KF, Fereydooni S, Azarfar A, Silveira MJ, Glassman PA, Midboe AM, Bohnert ABS, Zenoni MA, Kerns RD, Pearlman RA, Asch SM, Becker WC, Lorenz KA. Signature Informed Consent for Long-Term Opioid Therapy in Patients With Cancer: Perspectives of Patients and Providers. J Pain Symptom Manage 2020; 59:49-57. [PMID: 31476361 DOI: 10.1016/j.jpainsymman.2019.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 05/30/2019] [Revised: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 01/07/2023]
Abstract
CONTEXT Signature informed consent (SIC) is a part of a Veterans Health Administration ethics initiative for patient education and shared decision making with long-term opioid therapy (LTOT). Historically, patients with cancer-related pain receiving LTOT are exempt from this process. OBJECTIVES Our objective is to understand patients' and providers' perspectives on using SIC for LTOT in patients with cancer-related pain. METHODS Semistructured interviews with 20 opioid prescribers and 20 patients who were prescribed opioids at two large academically affiliated Veterans Health Administration Medical Centers. We used a combination of deductive and inductive approaches in content analysis to produce emergent themes. RESULTS Potential advantages of SIC are that it can clarify and help patients comprehend LTOT risks and benefits, provide clear upfront boundaries and expectations, and involve the patient in shared decision making. Potential disadvantages of SIC include time delay to treatment, discouragement from recommended opioid use, and impaired trust in the patient-provider relationship. Providers and patients have misconceptions about the definition of SIC. Providers and patients question if SIC for LTOT is really informed consent. Providers and patients advocate for strategies to improve comprehension of SIC content. Providers had divergent perspectives on exemptions from SIC. Oncologists want SIC for LTOT to be tailored for patients with cancer. CONCLUSION Provider and patient interviews highlight various aspects about the advantages and disadvantages of requiring SIC for LTOT in cancer-related pain. Tailoring SIC for LTOT to be specific to cancer-related concerns and to have an appropriate literacy level are important considerations.
Collapse
Affiliation(s)
- Karleen F Giannitrapani
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University School of Medicine, Palo Alto, California, USA.
| | - Soraya Fereydooni
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University, Palo Alto, California, USA
| | - Azin Azarfar
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, University of Central Florida, Orlando, Florida, USA
| | - Maria J Silveira
- Geriatric Research Education Clinical Center (GRECC), Ann Arbor VA Health Care System, University of Michigan, Michigan, USA
| | - Peter A Glassman
- Center for the Study of Health Care Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles HCS, David Geffen School of Medicine at University of California Los Angles, Los Angeles, California, USA
| | - Amanda M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Amy B S Bohnert
- Center for Clinical Management Research (CCMR), VA Ann Arbor Health Care System, University of Michigan, Michigan, USA
| | - Maria A Zenoni
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Health Care System, New Haven, Connecticut, USA
| | - Robert D Kerns
- Yale University Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Health Care System, West Haven, Connecticut, USA
| | - Robert A Pearlman
- National Center for Ethics in Health Care (NCEHC), Seattle VA Puget Sound Health Care System, University of Washington, School of Medicine and Public Health, Seattle, Washington, USA
| | - Steven M Asch
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University School of Medicine, Palo Alto, California, USA
| | - William C Becker
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Health Care System, Yale School of Medicine, New Haven, Connecticut, USA
| | - Karl A Lorenz
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University School of Medicine, Palo Alto, California, USA
| |
Collapse
|
16
|
Smith MA, Quirk KC, Saul DC, Rodgers PE, Silveira MJ. Comparing Methadone Rotation to Consensus Opinion. J Pain Symptom Manage 2020; 59:116-120. [PMID: 31560968 DOI: 10.1016/j.jpainsymman.2019.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/05/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Methadone is a complex but useful medication for pain management in palliative care. Recent expert opinions have been published on the safe and effective use of methadone. OBJECTIVES To determine the success of methadone rotations and evaluate concordance with consensus recommendations by a palliative care consult service. METHODS A retrospective study of methadone rotation practice by a palliative care consult service and outcomes for patients hospitalized between January 1, 2012 and December 31, 2018 at a single academic medical center. A successful rotation was defined as a 30% reduction in pain or as-needed medication use sustained for at least three consecutive days. Patient outcomes were compared with expert consensus recommendations. RESULTS About 59 patients met the inclusion criteria. The study population was mostly Caucasian men and women of equal proportions who were started on methadone for inadequate pain control. Sixty-eight percent of patients were successfully rotated. Subjects who were rotated using a standardized protocol were six times more likely to have a successful rotation (odds ratio 6.28 [1.25-30.92]; P = 0.0238). CONCLUSION The utilization of a standardized protocol was associated with better patient outcomes.
Collapse
Affiliation(s)
- Michael A Smith
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA; University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA.
| | - Kyle C Quirk
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA; University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - D'Anna C Saul
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA; Department of Pediatrics, Ann Arbor, Michigan, USA
| | - Phillip E Rodgers
- Department of Family Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Maria J Silveira
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| |
Collapse
|
17
|
Silveira MJ, Giannitrapani KF, Fereydooni S, Azarfar A, Glassman P, Becker W, Lorenz K. Shared decision making about opioid therapy for cancer patients: Do patients and providers take the same factors into consideration? J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.31_suppl.32] [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
32 Background: Many patients with cancerpain are appropriately managed on long-term opioid therapy (LTOT), but are at similar risk of overdose and addiction as are patients with non-cancer pain. Whether to commence opioids for cancer pain is often a shared decision between patient and provider. Little is known about this process. Methods: Semi-structured interviews with 20 cancer patients on LTOT and 20 interdisciplinary providers who prescribe LTOT from two VA medical centers. Transcripts were coded and analyzed using constant comparison to find common themes. Results: Providers and patients largely weighed the risks and benefits of LTOT similarly, except in the case of cancer patients with past/present substance use disorder (SUD). In those cases, providers felt the risks outweighed the benefits, while patients felt the benefits outweighed the risks. Generally, patients considered pain relief their overarching concern. Other factors that impacted their risk/benefit calculus included: personal/family experience with opioids and the opinions of trusted providers. Only rarely did patients defer decision making to providers. Factors that impacted the risk/benefit calculus of providers included: disease status, patient goals, patient characteristics, and providers' past experiences/biases. Of note, patients with past opioid exposure generally viewed their experience with opioids as positive, and usually anchored their risk assessment for opioids relative to those of chemotherapy. Patients also expressed that they would prefer to spend less physician time discussing LTOT and more time discussing cancer treatment instead. Conclusions: Patients and providers often agree on when it is appropriate to use LTOT for cancer pain. In cases where they disagree, providers are well advised to explore and address patients’ fears about the adequacy of pain management without opioids, as well as their lived experience with opioids. Patients are comfortable having such discussions with physician extenders in order to reserve face-to-face physician time to discuss cancer treatment instead.
Collapse
Affiliation(s)
| | - Karleen F Giannitrapani
- Center for Innovation to Implementation, VA Palo Alto Health Care System & Stanford University School of Medicine, Palo Alto, CA
| | - Soraya Fereydooni
- Center for Innovation to Implementation, VA Palo Alto and Stanford University, Palo Alto, CA
| | - Azin Azarfar
- Center for Innovation to Implementation, VA Palo Alto and Stanford University, Palo Alto, CA
| | - Peter Glassman
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles and UCLA, Los Angeles, CA
| | - William Becker
- Pain Research, Informatics, Multi-morbidities and Education Center, VA Connecticut & Yale, New Haven, CA
| | - Karl Lorenz
- Center for Innovation to Implementation, VA Palo Alto and Stanford University, Stanford, CA
| |
Collapse
|
18
|
Lee CW, Vitous CA, Silveira MJ, Forman J, Dossett LA, Mody L, Dimick JB, Suwanabol PA. Delays in Palliative Care Referral Among Surgical Patients: Perspectives of Surgical Residents Across the State of Michigan. J Pain Symptom Manage 2019; 57:1080-1088.e1. [PMID: 30742891 PMCID: PMC9077765 DOI: 10.1016/j.jpainsymman.2019.01.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
CONTEXT Palliative care services (PCS) are underutilized and frequently delayed among surgical patients. Surgical residents often serve at the forefront for patient issues, including conducting conversations regarding prognosis and goals of care. OBJECTIVES This qualitative study identifies critical barriers to palliative care referral among seriously ill surgical patients from the perspective of surgical residents. METHODS We conducted semistructured interviews with surgical residents (n = 18) across the state of Michigan, which focused on experiences with seriously ill surgical patients and PCS. Inductive thematic analysis was used to establish themes based on the research objectives and data collected. RESULTS Four dominant themes of resident-perceived barriers to palliative care referral were identified: 1) challenges with prognostication, 2) communication barriers, 3) respect for the surgical hierarchy, and 4) surgeon mentality. Residents consistently expressed challenges in predicting patient outcomes, and verbalizing this to both attendings and families augmented this uncertainty in seeking PCS. Communicative challenges included managing discordant provider opinions and the stigma associated with PCS. Finally, residents perceived that an attending surgeon's decisive authority and mentality negatively influenced the delivery of PCS. CONCLUSIONS Among resident trainees, unpredictable patient outcomes led to uncertainty in the timing and appropriateness of palliative care referral and further complicated communicating plans of care. Residents perceived and relied on the attending surgeon as the ultimate decision maker, wherein the surgeon's sense of responsibility to the patient was identified as a significant barrier to PCS referral. Further studies are needed to test surgeon-specific interventions to improve access to and delivery of PCS.
Collapse
Affiliation(s)
- Christina W Lee
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - C Ann Vitous
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Maria J Silveira
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Geriatric Research, Education and Clinical Center (GRECC), Veterans Affairs Health Affairs, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
| | - Jane Forman
- Center for Clinical Management Research, Veterans Affairs Health Services Research & Development, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
| | - Lesly A Dossett
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA; Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Geriatric Research, Education and Clinical Center (GRECC), Veterans Affairs Health Affairs, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA; Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Pasithorn A Suwanabol
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA; Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.
| |
Collapse
|
19
|
Dillon BR, Healy MA, Lee CW, Reichstein AC, Silveira MJ, Morris AM, Suwanabol PA. Surgeon Perspectives Regarding Death and Dying. J Palliat Med 2019; 22:132-137. [DOI: 10.1089/jpm.2018.0197] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
| | - Mark A. Healy
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Christina W. Lee
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Ari C. Reichstein
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Maria J. Silveira
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Arden M. Morris
- S-SPIRE Center, Department of Surgery, Stanford University, Stanford, California
| | | |
Collapse
|
20
|
Suwanabol PA, Kanters AE, Reichstein AC, Wancata LM, Dossett LA, Rivet EB, Silveira MJ, Morris AM. Characterizing the Role of U.S. Surgeons in the Provision of Palliative Care: A Systematic Review and Mixed-Methods Meta-Synthesis. J Pain Symptom Manage 2018; 55:1196-1215.e5. [PMID: 29221845 DOI: 10.1016/j.jpainsymman.2017.11.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [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: 08/07/2017] [Revised: 11/27/2017] [Accepted: 11/28/2017] [Indexed: 12/25/2022]
Abstract
CONTEXT The provision of palliative care varies appropriately by clinical factors such as patient age and severity of disease and also varies by provider practice and specialty. Surgical patients are persistently less likely to receive palliative care than their medical counterparts for reasons that are not clear. OBJECTIVES We sought to characterize surgeon-specific determinants of palliative care in seriously ill and dying patients. METHODS We performed a systematic review of the literature focused on surgery and palliative care within PubMed, CINAHL, EMBASE, Scopus, and Ovid Medline databases from January 1, 2000 through December 31, 2016 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quantitative and qualitative studies with primary data evaluating surgeons' attitudes, knowledge, and behaviors or experiences in care for seriously ill and dying patients were selected for full review by at least two study team members based on predefined inclusion criteria. Data were extracted based on a predetermined instrument and compared across studies using thematic analysis in a meta-synthesis of qualitative and quantitative findings. RESULTS A total of 2589 abstracts were identified and screened, and 35 articles (26 quantitative and nine qualitative) fulfilled criteria for full review. Among these, 17 articles explored practice and attitudes of surgeons regarding palliative and end-of-life care, 11 articles assessed training in palliative care, five characterized surgical decision making, one described behaviors of surgeons caring for seriously ill and dying patients, and one explicitly identified barriers to use of palliative care. Four major themes across studies affected receipt of palliative care for surgical patients: 1) surgeons' experience and knowledge, 2) surgeons' attitudes, 3) surgeons' preferences and decision making for treatment, and 4) perceived barriers. CONCLUSIONS Among the articles reviewed, surgeons overall demonstrated insight into the benefits of palliative care but reported limited knowledge and comfort as well as a multitude of challenges to introducing palliative care to their patients. These findings indicate a need for wider implementation of strategies that allow optimal integration of palliative care with surgical decision making.
Collapse
Affiliation(s)
| | - Arielle E Kanters
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ari C Reichstein
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Lauren M Wancata
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily B Rivet
- Department of Surgery and Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Maria J Silveira
- Department of Surgery, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Arden M Morris
- S-SPIRE Center and Department of Surgery, Stanford University, Stanford, California, USA
| |
Collapse
|
21
|
Suwanabol PA, Reichstein AC, Suzer-Gurtekin ZT, Forman J, Silveira MJ, Mody L, Morris AM. Surgeons' Perceived Barriers to Palliative and End-of-Life Care: A Mixed Methods Study of a Surgical Society. J Palliat Med 2018; 21:780-788. [PMID: 29649396 DOI: 10.1089/jpm.2017.0470] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [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: 12/19/2022] Open
Abstract
BACKGROUND Nearly 20% of colorectal cancer (CRC) patients present with potentially incurable (Stage IV) disease, yet their physicians do not integrate cancer treatment with palliative care. Compared with patients treated by primary providers, surgical patients with terminal diseases are significantly less likely to receive palliative or end-of-life care. OBJECTIVE To describe surgeon perspectives on palliative and end-of-life care for patients with Stage IV CRCs. DESIGN This is a convergent mixed methods study using a validated survey instrument from the Critical Care Peer Workgroup of the Robert Wood Johnson Foundation's Promoting Excellence in End-of-Life Care Project with additional qualitative questions. SETTINGS Participants were all current, nonretired members of the American Society of Colon and Rectal Surgeons. MAIN OUTCOME MEASURES Surgeon-perceived barriers to palliative and end-of-life care for patients with Stage IV CRCs were identified. RESULTS Among 131 Internet survey respondents (response rate 16.5%), 76.1% reported no formal education in palliative care, and specifically noted inadequate training in techniques to forgo life-sustaining measures (37.9%) and communication (42.7%). Over half (61.8%) of surgeons cited unrealistic expectations among patients and families as a barrier to care, which also limited discussion of palliation. At the system level, absence of documentation, appropriate processes, and culture hindered the initiation of palliative care. Thematic analysis of open-ended questions confirmed and extended these findings through the following major barriers to palliative and end-of-life care: (1) surgeon knowledge and training; (2) communication challenges; (3) difficulty with prognostication; (4) patient and family factors encompassing unrealistic expectations and discordant preferences; and (5) systemic issues including culture and lack of documentation and appropriate resources. LIMITATIONS Generalizability is limited by the small sample size inherent to Internet surveys, which may contribute to selection bias. CONCLUSIONS Surgeons valued palliative and end-of-life care but reported multilevel barriers to its provision. These data will inform strategies to reduce these perceived barriers.
Collapse
Affiliation(s)
- Pasithorn A Suwanabol
- 1 Division of Colorectal Surgery, Department of Surgery, University of Michigan , Ann Arbor, Michigan
| | - Ari C Reichstein
- 2 Division of Colorectal Surgery, Department of Surgery, Allegheny Health Network , Pittsburgh, Pennsylvania
| | | | - Jane Forman
- 4 Center for Clinical Management Research , Veterans Affairs Health Services Research & Development, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Maria J Silveira
- 5 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan , Ann Arbor, Michigan.,6 Geriatric Research, Education and Clinical Center (GRECC) , Veterans Affairs Health Affairs, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Lona Mody
- 5 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan , Ann Arbor, Michigan.,6 Geriatric Research, Education and Clinical Center (GRECC) , Veterans Affairs Health Affairs, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Arden M Morris
- 7 Department of Surgery, S-SPIRE Center, Stanford University , Stanford, California
| |
Collapse
|
22
|
Bluhm M, Connell CM, De Vries RG, Janz NK, Bickel KE, Silveira MJ. Paradox of Prescribing Late Chemotherapy: Oncologists Explain. J Oncol Pract 2016; 12:e1006-e1015. [DOI: 10.1200/jop.2016.013995] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Purpose: The value of chemotherapy for patients with cancer in the last weeks of life warrants examination. Late chemotherapy may not improve survival or quality of life but typically precludes hospice enrollment and may result in additional symptoms, increased use of other aggressive treatments, and worsening quality of life. Few studies have explored oncologists’ rationales for administering chemotherapy near death. This study examines the self-reported factors that influence oncologists’ decisions about late chemotherapy. Methods: In-depth individual interviews were conducted with 17 oncologists through a semistructured interview guide. Interviews were audio recorded and transcribed verbatim. Transcripts were coded and analyzed using conventional content analysis, a qualitative method that allows the detection and analysis of patterns in the data. Results: Clinical factors take priority in determining late chemotherapy decisions when clear treatment choices exist. When clinical factors are ambiguous, emotion becomes a highly salient influence. Oncologists view late chemotherapy to be patient driven and use it to palliate emotional distress and maintain patient hope even when physical benefit is unexpected. Oncologists experience unique and difficult challenges when caring for dying patients, including emotionally draining communication, overwhelming responsibility for life/death, limitations of oncology to heal, and prognostic uncertainty. These challenges are also eased by offering late chemotherapy. Conclusion: The findings reveal a nuanced understanding of why oncologists find it difficult to refuse chemotherapy treatment for patients near death. Optimal end-of-life treatment decisions require supportive interventions and system change, both of which must take into account the challenges oncologists face.
Collapse
Affiliation(s)
- Minnie Bluhm
- Eastern Michigan University, Ypsilanti; University of Michigan, Ann Arbor, MI; and Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Cathleen M. Connell
- Eastern Michigan University, Ypsilanti; University of Michigan, Ann Arbor, MI; and Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Raymond G. De Vries
- Eastern Michigan University, Ypsilanti; University of Michigan, Ann Arbor, MI; and Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Nancy K. Janz
- Eastern Michigan University, Ypsilanti; University of Michigan, Ann Arbor, MI; and Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Kathleen E. Bickel
- Eastern Michigan University, Ypsilanti; University of Michigan, Ann Arbor, MI; and Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Maria J. Silveira
- Eastern Michigan University, Ypsilanti; University of Michigan, Ann Arbor, MI; and Geisel School of Medicine at Dartmouth, Hanover, NH
| |
Collapse
|
23
|
Silveira MJ. Advance directives: Better than nothing at all. Rev Clin Esp 2014; 214:311-2. [PMID: 24954291 DOI: 10.1016/j.rce.2014.05.008] [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: 05/03/2014] [Accepted: 05/06/2014] [Indexed: 11/16/2022]
Affiliation(s)
- M J Silveira
- Research Scientist Center for Clinical Management Research, Ann Arbor Veterans Administration Medical Center, Michigan, United States; Department of Internal Medicine, University of Michigan, United States.
| |
Collapse
|
24
|
Kelley AS, Langa KM, Smith AK, Cagle J, Ornstein K, Silveira MJ, Nicholas L, Covinsky KE, Ritchie CS. Leveraging the health and retirement study to advance palliative care research. J Palliat Med 2014; 17:506-11. [PMID: 24694096 DOI: 10.1089/jpm.2013.0648] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The critical need to expand and develop the palliative care evidence base was recently highlighted by the Journal of Palliative Medicine's series of articles describing the Research Priorities in Geriatric Palliative Care. The Health and Retirement Study (HRS) is uniquely positioned to address many priority areas of palliative care research. This nationally representative, ongoing, longitudinal study collects detailed survey data every 2 years, including demographics, health and functional characteristics, information on family and caregivers, and personal finances, and also conducts a proxy interview after each subject's death. The HRS can also be linked with Medicare claims data and many other data sources, e.g., U.S. Census, Dartmouth Atlas of Health Care. SETTING While the HRS offers innumerable research opportunities, these data are complex and limitations do exist. Therefore, we assembled an interdisciplinary group of investigators using the HRS for palliative care research to identify the key palliative care research gaps that may be amenable to study within the HRS and the strengths and weaknesses of the HRS for each of these topic areas. CONCLUSION In this article we present the work of this group as a potential roadmap for investigators contemplating the use of HRS data for palliative care research.
Collapse
Affiliation(s)
- Amy S Kelley
- 1 Brookdale Depratment of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Affiliation(s)
- Maria J. Silveira
- Center for Clinical Management Research; Ann Arbor Veterans Affairs Medical Center; Ann Arbor Michigan
- Division of General Medicine; Department of Internal Medicine; University of Michigan; Ann Arbor Michigan
| | - Wyndy Wiitala
- Center for Clinical Management Research; Ann Arbor Veterans Affairs Medical Center; Ann Arbor Michigan
| | - John Piette
- Center for Clinical Management Research; Ann Arbor Veterans Affairs Medical Center; Ann Arbor Michigan
- Division of General Medicine; Department of Internal Medicine; University of Michigan; Ann Arbor Michigan
| |
Collapse
|
26
|
Piette JD, Sussman JB, Pfeiffer PN, Silveira MJ, Singh S, Lavieri MS. Maximizing the value of mobile health monitoring by avoiding redundant patient reports: prediction of depression-related symptoms and adherence problems in automated health assessment services. J Med Internet Res 2013; 15:e118. [PMID: 23832021 PMCID: PMC3713922 DOI: 10.2196/jmir.2582] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 04/23/2013] [Accepted: 04/23/2013] [Indexed: 11/13/2022] Open
Abstract
Background Interactive voice response (IVR) calls enhance health systems’ ability to identify health risk factors, thereby enabling targeted clinical follow-up. However, redundant assessments may increase patient dropout and represent a lost opportunity to collect more clinically useful data. Objective We determined the extent to which previous IVR assessments predicted subsequent responses among patients with depression diagnoses, potentially obviating the need to repeatedly collect the same information. We also evaluated whether frequent (ie, weekly) IVR assessment attempts were significantly more predictive of patients’ subsequent reports than information collected biweekly or monthly. Methods Using data from 1050 IVR assessments for 208 patients with depression diagnoses, we examined the predictability of four IVR-reported outcomes: moderate/severe depressive symptoms (score ≥10 on the PHQ-9), fair/poor general health, poor antidepressant adherence, and days in bed due to poor mental health. We used logistic models with training and test samples to predict patients’ IVR responses based on their five most recent weekly, biweekly, and monthly assessment attempts. The marginal benefit of more frequent assessments was evaluated based on Receiver Operator Characteristic (ROC) curves and statistical comparisons of the area under the curves (AUC). Results Patients’ reports about their depressive symptoms and perceived health status were highly predictable based on prior assessment responses. For models predicting moderate/severe depression, the AUC was 0.91 (95% CI 0.89-0.93) when assuming weekly assessment attempts and only slightly less when assuming biweekly assessments (AUC: 0.89; CI 0.87-0.91) or monthly attempts (AUC: 0.89; CI 0.86-0.91). The AUC for models predicting reports of fair/poor health status was similar when weekly assessments were compared with those occurring biweekly (P value for the difference=.11) or monthly (P=.81). Reports of medication adherence problems and days in bed were somewhat less predictable but also showed small differences between assessments attempted weekly, biweekly, and monthly. Conclusions The technical feasibility of gathering high frequency health data via IVR may in some instances exceed the clinical benefit of doing so. Predictive analytics could make data gathering more efficient with negligible loss in effectiveness. In particular, weekly or biweekly depressive symptom reports may provide little marginal information regarding how the person is doing relative to collecting that information monthly. The next generation of automated health assessment services should use data mining techniques to avoid redundant assessments and should gather data at the frequency that maximizes the value of the information collected.
Collapse
Affiliation(s)
- John D Piette
- VA Center for Clinical Management Research and Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48113-0170, United States.
| | | | | | | | | | | |
Collapse
|
27
|
Zaros MC, Curtis JR, Silveira MJ, Elmore JG. Opportunity lost: end-of-life discussions in cancer patients who die in the hospital. J Hosp Med 2013; 8:334-40. [PMID: 23169553 PMCID: PMC4146526 DOI: 10.1002/jhm.1989] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 08/24/2012] [Accepted: 09/19/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND End-of-life discussions are associated with decreased use of life-sustaining treatments in patients dying of cancer in the outpatient setting, but little is known about discussions that take place during terminal hospitalizations. OBJECTIVES To determine the proportion of patients assessed by the clinical team to have decisional capacity on admission, how many of these patients participated or had a surrogate participate in a discussion about end-of-life care, and whether patient participation was associated with treatments received. DESIGN Retrospective review. SETTING Inpatient. PATIENTS Adult patients with advanced cancer who died in the hospital between January 1, 2004 and December 31, 2007. RESULTS Of the 145 inpatients meeting inclusion criteria, 115 patients (79%) were documented to have decisional capacity on admission. Among these patients, 46 (40%) were documented to lose decisional capacity prior to an end-of-life discussion and had the discussion held instead by a surrogate. Patients who had surrogate participation in the end-of-life discussions were more likely to receive mechanical ventilation (56.5% vs 23.2%, P < 0.01), artificial nutrition (45.7% vs 25.0%, P = 0.03), chemotherapy (39.1% vs 5.4%, P <0.01), and intensive care unit (ICU) treatment (56.5% vs 23.2%, P <0.01) compared to patients who participated in discussions. There was no difference between palliative treatments received. CONCLUSION The majority of patients with advanced cancer are considered to have decisional capacity at the time of their terminal hospitalization. Many lose decisional capacity before having an end-of-life discussion and have surrogate decision-makers participate in these discussions. These patients received more aggressive life-sustaining treatments prior to death and represent a missed opportunity to improve end-of-life care.
Collapse
Affiliation(s)
- Mark C Zaros
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, Washington, USA.
| | | | | | | |
Collapse
|
28
|
Piette JD, Marinec N, Gallegos-Cabriales EC, Gutierrez-Valverde JM, Rodriguez-Saldaña J, Mendoz-Alevares M, Silveira MJ. Spanish-speaking patients' engagement in interactive voice response (IVR) support calls for chronic disease self-management: data from three countries. J Telemed Telecare 2013; 19:89-94. [PMID: 23532005 DOI: 10.1177/1357633x13476234] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We measured Spanish-speaking patients' engagement in Interactive Voice Response (IVR) calls using data from self-management support studies in Honduras, Mexico and the US. A total of 268 patients with diabetes or hypertension participated in 6-12 weeks of weekly IVR follow-up. Participants had an average of 6.1 years of education, and 73% of them were women. After 2443 person-weeks of follow-up, patients had completed 1494 IVR assessments. The call completion rates were higher in the US (75%) than in Honduras (59%) or Mexico (61%; P < 0.001). Patients participating with an informal caregiver were more likely to complete calls (adjusted odds ratio 1.5; P = 0.03) while patients reporting fair or poor health at enrolment were less likely (adjusted odds ratio 0.59; P = 0.02). Satisfaction rates were high, with 98% of patients reporting that the system was easy to use, and 86% reporting that the calls helped them a great deal in managing their health problems. IVR self-management support is feasible among Spanish-speaking patients with chronic disease, including those living in less-developed countries. Involving informal caregivers may increase patient engagement.
Collapse
Affiliation(s)
- John D Piette
- Department of Veterans Affairs, Ann Arbor, Michigan 48113-0170, USA.
| | | | | | | | | | | | | |
Collapse
|
29
|
Abstract
PURPOSE To explore the factors influencing primary care providers' ability to care for their dying patients in Michigan. METHODS We conducted 16 focus groups to explore the provision of end-of-life care by 7 diverse primary care practices in southeast Michigan. Twenty-eight primary care providers and 22 clinical support staff participated in the study. Interviews were analyzed using thematic analysis. RESULTS Primary care providers (PCPs) wanted to care for their dying patients and felt largely competent to provide end-of-life care. They and their staff reported the presence of five structural factors that influenced their ability to do so: (1) continuity of care to help patients make treatment decisions and plan for the end of life; (2) scheduling flexibility and time with patients to address emergent needs, provide emotional support, and conduct meaningful end-of-life discussions; (3) information-sharing with outside providers and within the primary care practice; (4) coordination of care to address patients' needs quickly; and (5) authority to act on behalf of their patients. CONCLUSIONS In order to provide end-of-life care, PCPs need structural supports within primary care for continuity of care, flexible scheduling, information-sharing, coordination of primary care, and protection of their authority.
Collapse
Affiliation(s)
- Maria J Silveira
- Veterans Administration, Health Services Research and Development Center of Excellence, 300 North Ingalls Building, Room 7C27, Box 5429, Ann Arbor, MI USA.
| | | |
Collapse
|
30
|
Thompson AJ, Silveira MJ, Vitale CA, Malani PN. Antimicrobial use at the end of life among hospitalized patients with advanced cancer. Am J Hosp Palliat Care 2012; 29:599-603. [PMID: 22218916 DOI: 10.1177/1049909111432625] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We sought to evaluate antimicrobial use among patients with advanced cancer. METHODS Retrospective review of patients experiencing cancer-related death while hospitalized. RESULTS Among 145 patients, 126 (86.9%) received antimicrobials for a mean of 12.5 ± 12.9 days. 88 (69.8%) of 126 had clinical findings suggestive of infection. Sixty-one patients (48.4%) had positive cultures, the remaining were treated empirically. "Comfort care" was ultimately pursued in 99 (78.5%) of 126; 35 (35.4%) of 99 continued to receive antimicrobials after a transition to comfort care for an average of 1.6 ± 1.1 days. On average, antimicrobials were discontinued <1day prior to death. CONCLUSION Antimicrobial use was common among patients with advanced cancer. Even after transition to comfort care, more than one third of patients remained on antimicrobials. The risks and burdens of antimicrobials should be carefully examined when comfort is the stated goal.
Collapse
Affiliation(s)
- Andrew J Thompson
- Department of Internal Medicine Divisions of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | | |
Collapse
|
31
|
Silveira MJ, Given CW, Cease KB, Sikorskii A, Given B, Northouse LL, Piette JD. Cancer Carepartners: Improving patients' symptom management by engaging informal caregivers. BMC Palliat Care 2011; 10:21. [PMID: 22117890 PMCID: PMC3295676 DOI: 10.1186/1472-684x-10-21] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 11/25/2011] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Previous studies have found that cancer patients undergoing chemotherapy can effectively manage their own symptoms when given tailored advice. This approach, however, may challenge patients with poor performance status and/or emotional distress. Our goal is to test an automated intervention that engages a friend or family member to support a patient through chemotherapy. METHODS/DESIGN We describe the design and rationale of a randomized, controlled trial to assess the efficacy of 10 weeks of web-based caregiver alerts and tailored advice for helping a patient manage symptoms related to chemotherapy. The study aims to test the primary hypothesis that patients whose caregivers receive alerts and tailored advice will report less frequent and less severe symptoms at 10 and 14 weeks when compared to patients in the control arm; similarly, they will report better physical function, fewer outpatient visits and hospitalizations related to symptoms, and greater adherence to chemotherapy. 300 patients with solid tumors undergoing chemotherapy at two Veteran Administration oncology clinics reporting any symptom at a severity of ≥4 and a willing informal caregiver will be assigned to either 10 weeks of automated telephonic symptom assessment (ATSA) alone, or 10 weeks of ATSA plus web-based notification of symptom severity and problem solving advice to their chosen caregiver. Patients and caregivers will be surveyed at intake, 10 weeks and 14 weeks. Both groups will receive standard oncology, hospice, and palliative care. DISCUSSION Patients undergoing chemotherapy experience many symptoms that they may be able to manage with the support of an activated caregiver. This intervention uses readily available technology to improve patient caregiver communication about symptoms and caregiver knowledge of symptom management. If successful, it could substantially improve the quality of life of veterans and their families during the stresses of chemotherapy without substantially increasing the cost of care. TRIAL REGISTRATION NCT00983892.
Collapse
Affiliation(s)
- Maria J Silveira
- Center for Clinical Management Research, Veteran Affairs Medical Center, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Charles W Given
- Center for Family Care, Michigan State University, East Lansing, MI, USA
| | - Kemp B Cease
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Division of Hematology & Oncology, Veteran Affairs Medical Center, Ann Arbor, MI, USA
| | - Alla Sikorskii
- Department of Statistics and Probability, Michigan State University, East Lansing, MI, USA
| | - Barbara Given
- Center for Family Care, Michigan State University, East Lansing, MI, USA
| | | | - John D Piette
- Center for Clinical Management Research, Veteran Affairs Medical Center, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
32
|
Silveira MJ, Connor SR, Goold SD, McMahon LF, Feudtner C. Community supply of hospice: does wealth play a role? J Pain Symptom Manage 2011; 42:76-82. [PMID: 21429702 DOI: 10.1016/j.jpainsymman.2010.09.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 09/20/2010] [Accepted: 09/25/2010] [Indexed: 10/18/2022]
Abstract
CONTEXT Hospice is underused by older, rural, and minority populations. OBJECTIVE Because local availability of hospice is an important predictor of use, we aimed to identify geographic variation in hospice supply and examine its community-level determinants, including wealth. METHODS This was an observational geographic study using the 2008 National Hospice and Palliative Care Organization's National Data Set and the 2,000 U.S. census data for 3,140 U.S. counties. Our outcome of interest was hospice supply defined according to the number of hospice programs (regardless of level of care) servicing each county. We used binomial multivariable regression to test the relationship between supply and log-transformed counts of population, African Americans, Hispanics, residents aged 65, and high school educated residents as well as area, median household income, and certificate of need status. RESULTS Hospice availability varied greatly across the United States, with an unadjusted mean of 24.3 hospice programs servicing each county (standard deviation 19.7, range 0-160). After adjusting for all covariates, median household income (incidence rate ratio [IRR] 1.03, P < 0.001), population count (IRR 17.9, P < 0.001), count of African Americans (IRR 1.26, P < 0.001) and elderly adults (IRR 2.81, P < 0.001) positively predicted supply, whereas area (IRR 0.84, P < 0.001), certificate of need status (IRR 0.89, P < 0.001), count of Hispanics (IRR 0.86, P < 0.01), and high school educated (IRR 0.03, P < 0.001) negatively predicted supply. CONCLUSION There is gross variation in hospice supply that can be explained by community wealth, population density, age, ethnicity, and race. To address disparate utilization of hospice, the relationship between wealth and availability will need to be better understood.
Collapse
Affiliation(s)
- Maria J Silveira
- VA Health Services Research and Development Center of Excellence, University of Michigan, Ann Arbor, Michigan, USA.
| | | | | | | | | |
Collapse
|
33
|
Piette JD, Rosland AM, Silveira MJ, Hayward R, McHorney CA. Medication cost problems among chronically ill adults in the US: did the financial crisis make a bad situation even worse? Patient Prefer Adherence 2011; 5:187-94. [PMID: 21573050 PMCID: PMC3090380 DOI: 10.2147/ppa.s17363] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Indexed: 11/26/2022] Open
Abstract
A national internet survey was conducted between March and April 2009 among 27,302 US participants in the Harris Interactive Chronic Illness Panel. Respondents reported behaviors related to cost-related medication non-adherence (CRN) and the impacts of medication costs on other aspects of their daily lives. Among respondents aged 40-64 and looking for work, 66% reported CRN in 2008, and 41% did not fill a prescription due to cost pressures. More than half of respondents aged 40-64 and nearly two-thirds of those in this group who were looking for work or disabled reported other impacts of medication costs, such as cutting back on basic needs or increasing credit card debt. More than one-third of respondents aged 65+ who were working or looking for work reported CRN. Regardless of age or employment status, roughly half of respondents reporting medication cost hardship said that these problems had become more frequent in 2008 than before the economic recession. These data show that many chronically ill patients, particularly those looking for work or disabled, reported greater medication cost problems since the economic crisis began. Given links between CRN and worse health, the financial downturn may have had significant health consequences for adults with chronic illness.
Collapse
Affiliation(s)
- John D Piette
- Ann Arbor VA Healthcare System, Ann Arbor, MI, USA
- Correspondence: John D Piette, Department of Internal Medicine, University of Michigan, 300 N Ingalls Building, Room 7E10, Ann Arbor, MI 48109-5429, USA, Tel +1 734 936 4787, Fax +1 734 936 8944, Email
| | | | | | | | | |
Collapse
|
34
|
Affiliation(s)
- David I Shalowitz
- Bioethics Program, University of Michigan Medical School, Ann Arbor, MI 48109-5429, USA.
| | | |
Collapse
|
35
|
Abstract
BACKGROUND Recent discussions about health care reform have raised questions regarding the value of advance directives. METHODS We used data from survey proxies in the Health and Retirement Study involving adults 60 years of age or older who had died between 2000 and 2006 to determine the prevalence of the need for decision making and lost decision-making capacity and to test the association between preferences documented in advance directives and outcomes of surrogate decision making. RESULTS Of 3746 subjects, 42.5% required decision making, of whom 70.3% lacked decision-making capacity and 67.6% of those subjects, in turn, had advance directives. Subjects who had living wills were more likely to want limited care (92.7%) or comfort care (96.2%) than all care possible (1.9%); 83.2% of subjects who requested limited care and 97.1% of subjects who requested comfort care received care consistent with their preferences. Among the 10 subjects who requested all care possible, only 5 received it; however, subjects who requested all care possible were far more likely to receive aggressive care as compared with those who did not request it (adjusted odds ratio, 22.62; 95% confidence interval [CI], 4.45 to 115.00). Subjects with living wills were less likely to receive all care possible (adjusted odds ratio, 0.33; 95% CI, 0.19 to 0.56) than were subjects without living wills. Subjects who had assigned a durable power of attorney for health care were less likely to die in a hospital (adjusted odds ratio, 0.72; 95% CI, 0.55 to 0.93) or receive all care possible (adjusted odds ratio, 0.54; 95% CI, 0.34 to 0.86) than were subjects who had not assigned a durable power of attorney for health care. CONCLUSIONS Between 2000 and 2006, many elderly Americans needed decision making near the end of life at a time when most lacked the capacity to make decisions. Patients who had prepared advance directives received care that was strongly associated with their preferences. These findings support the continued use of advance directives.
Collapse
Affiliation(s)
- Maria J Silveira
- Veterans Affairs Center for Clinical Management Research, and Division of General Medicine, University of Michigan, Ann Arbor, USA.
| | | | | |
Collapse
|
36
|
Silveira MJ, Given CW, Given B, Rosland AM, Piette JD. Patient-caregiver concordance in symptom assessment and improvement in outcomes for patients undergoing cancer chemotherapy. Chronic Illn 2010; 6:46-56. [PMID: 20308350 DOI: 10.1177/1742395309359208] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To measure the agreement between cancer patients' and family caregivers' perceptions of the patients' symptom severity, and the association between changes in caregiver accuracy and changes in outcomes. METHODS Secondary analysis of baseline and 10-week follow-up data from 142 cancer patient/caregiver dyads. Patient/caregiver agreement about symptom burden was measured for the 8 most prevalent symptoms and overall. Bivariate analyses examined the patient and caregiver characteristics associated with caregivers who were overestimators, underestimators or accurate at baseline. We tested the relationship between change in caregiver accuracy and both caregiver behaviour (e.g. use of information, hours spent caregiving) and patient outcomes (e.g. total symptom severity and frequency). RESULTS At baseline, caregivers overestimated the severity of 17 out of 18 symptoms; 50% predicted mean symptom severity accurately. Accuracy worsened over time for 51%, stayed the same for 36%, and improved for 13%. While not statistically significant, caregivers whose accuracy improved over time had patients who reported greater declines in: symptom severity, number of symptoms, symptom interference, total symptom frequency and depression. In addition, these caregivers experienced greater reductions in their use of information and hours helping the patient. DISCUSSION Caregivers typically over-estimate cancer patients' symptom burden and accuracy does not improve over time. Improving caregiver accuracy may boost the positive effects of cognitive behavioural interventions designed to improve cancer patients' quality of life.
Collapse
Affiliation(s)
- Maria J Silveira
- VA Center for Clinical Management Research, PO Box 130170, Ann Arbor, MI 48113, USA.
| | | | | | | | | |
Collapse
|
37
|
Rosland AM, Heisler M, Choi HJ, Silveira MJ, Piette JD. Family influences on self-management among functionally independent adults with diabetes or heart failure: do family members hinder as much as they help? Chronic Illn 2010; 6:22-33. [PMID: 20308348 PMCID: PMC3712767 DOI: 10.1177/1742395309354608] [Citation(s) in RCA: 166] [Impact Index Per Article: 11.9] [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
OBJECTIVES Among functionally independent patients with diabetes or heart failure, we examined family member support and family-related barriers to self-care. We then identified patient characteristics associated with family support and family barriers and how each was associated with self-management adherence. METHODS Cross-sectional survey of 439 patients with diabetes or heart failure (74% response rate). RESULTS 75% of respondents reported supportive family involvement in self-care; however, 25% reported frequent family-related barriers to self-care. Women reported family support less often (64% v. 77%) and family barriers to self-care more often (30% v. 21%) than men. 78% of respondents reported involved family members nagged or criticized them about illness care. In multivariate models, low health literacy, partnered status and higher family function were associated with higher family support levels, while female gender, older age, higher education, and more depression symptoms were associated with family barriers to self-care. Family barriers were associated with lower disease care self-efficacy (p<0.01), and both barriers and family support were associated with patients' self-management adherence (both p<0.05). DISCUSSION Family members are highly involved in the self-care of these higher functioning patients. Interventions should help patients with chronic illness overcome family barriers to self-care and help families use positive and effective support techniques.
Collapse
Affiliation(s)
- Ann-Marie Rosland
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | | | | | | | | |
Collapse
|
38
|
Silveira MJ, Kazanis AS, Shevrin MP. Statins in the last six months of life: a recognizable, life-limiting condition does not decrease their use. J Palliat Med 2008; 11:685-93. [PMID: 18588398 DOI: 10.1089/jpm.2007.0215] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Some have advocated discontinuing statins in patients with life-limiting conditions. However, the extent of statin use at the end of life has yet to be described and whether statin prescribing may already be influenced by the presence of a recognizable, life-limiting condition is unknown. OBJECTIVE To measure the prevalence of statin use during the last 6 months of life and determine if statin prescribing varies according to the presence of a recognizable, life-limiting condition. DESIGN Matched, case-control trial nested within a retrospective, cohort study. SETTING/SUBJECTS From 3031 VISN 11 patients who died in FY2004, we identified 1584 (52%) receiving statins at least 6 months before death. Of those, we identified 337 cases with a recognizable, life-limiting condition and 1247 controls matched on number of comorbidities, age, and socioeconomic status. ANALYSES We used survival analysis to test the relationship between days without statins and the presence of a life limiting condition, while controlling for pills supplied and comorbidity score. RESULTS There was no significant difference in the time off statins between cases and controls even though the study was sufficiently powered to detect one. CONCLUSIONS These findings underscore a missed opportunity to reduce the therapeutic burden upon dying patients and limit health care spending.
Collapse
Affiliation(s)
- Maria J Silveira
- Veterans Health Administration, Health Services Research and Development Center of Excellence, Ann Arbor, Michigan, USA.
| | | | | |
Collapse
|
39
|
|
40
|
Silveira MJ. Should cost be a consideration in palliative care? AMA J Ethics 2006; 8:599-601. [PMID: 23234712 DOI: 10.1001/virtualmentor.2006.8.9.pfor1-0609] [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] [Indexed: 06/01/2023]
|
41
|
Silveira MJ, Copeland LA, Feudtner C. Likelihood of home death associated with local rates of home birth: influence of local area healthcare preferences on site of death. Am J Public Health 2006; 96:1243-8. [PMID: 16735639 PMCID: PMC1483880 DOI: 10.2105/ajph.2005.063057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We tested whether local cultural and social values regarding the use of health care are associated with the likelihood of home death, using variation in local rates of home births as a proxy for geographic variation in these values. METHODS For each of 351110 adult decedents in Washington state who died from 1989 through 1998, we calculated the home birth rate in each zip code during the year of death and then used multivariate regression modeling to estimate the relation between the likelihood of home death and the local rate of home births. RESULTS Individuals residing in local areas with higher home birth rates had greater adjusted likelihood of dying at home (odds ratio [OR]=1.04 for each percentage point increase in home birth rate; 95% confidence interval [CI] = 1.03, 1.05). Moreover, the likelihood of dying at home increased with local wealth (OR=1.04 per $10000; 95% CI=1.02, 1.06) but decreased with local hospital bed availability (OR=0.96 per 1000 beds; 95% CI=0.95, 0.97). CONCLUSIONS The likelihood of home death is associated with local rates of home births, suggesting the influence of health care use preferences.
Collapse
Affiliation(s)
- Maria J Silveira
- VA Health Services Research and Development Center of Excellence, VA Ann Arbor Healthcare System, Ann Arbor, USA.
| | | | | |
Collapse
|
42
|
Abstract
OBJECTIVE For patients who die in hospitals, the regionalization of tertiary health care services may be increasing the home-to-hospital distance, particularly for younger patients whose care is especially regionalized and for whom access to and use of home hospice services remains limited. The objective of this study was to test the hypotheses that the distance from home at the time of death in a hospital has increased over time and is inversely related to the age of the dying patient. METHODS A population-based case series was conducted in Washington State of all deaths of state residents from 1989 to 2002. The main outcome measure was driving distance between home residence and location at the time of death. RESULTS The overall mean distance from home to the hospital where death occurred has increased by 1% annually. Children who died in hospitals were much farther from home than their adult counterparts: the mean distance was 37.4 km for neonates and 50.9 km for children who were aged 1 to 9 years, compared with 19.9 km for adults who were aged 60 to 79 years and 14.0 km for patients who were older than 79 years. Disparities of distance were even greater among patients who were at the 90th percentile for distance (85.6 km for neonates compared with 30.8 for patient who were older than 79 years). CONCLUSIONS The distance between home residence and the hospital where death occurs is greatest for children and has increased over time. Both of these findings have implications for the design of local and regional pediatric end-of-life supportive care services.
Collapse
Affiliation(s)
- Chris Feudtner
- Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | | | | | | |
Collapse
|
43
|
Abstract
OBJECTIVES To explore the predictors of symptom burden at the end of life. DESIGN Observational, secondary analysis of Health and Retirement Study (HRS) data. SETTING USA. PARTICIPANTS Two thousand six hundred four deceased, older adults. METHODS Multivariate Poisson and logistic regression to explore the relationship between sociodemographic and clinical factors with symptoms. RESULTS Fatigue, pain, dyspnea, depression, and anorexia were common and severe; 58% of participants experienced more than 3 of these during their last year of life. Sociodemographic and clinical factors were associated with the number of symptoms as well as the presence of pain, depression, and dyspnea alone. Decedents in the highest quartile of net worth had fewer symptoms (incident rate ratio [IRR] 0.90, confidence interval [CI] 0.85-0.96) and less pain (odds ratio [OR] 0.66, CI 0.51-0.85) than comparisons did. Patients with cancer experienced more pain (OR 2.02, CI 1.62-2.53) and depression (OR 1.31, CI 1.07-1.61). Patients experienced more depression (OR 2.37, CI 1.85-3.03) and dyspnea (OR 1.40, CI 1.09-1.78). LIMITATION Use of proxy reports for primary data. CONCLUSION Older Americans experience a large symptom burden in the last year of life, largely with treatable symptoms such as pain, dyspnea, and depression. The adequacy of symptom control relates to clinical factors as well as net worth. This association between symptoms and wealth suggests that access to health care and other social services beyond those covered by Medicare may be important in decreasing symptom burden at the end of life.
Collapse
Affiliation(s)
- Maria J Silveira
- VA Health Services Research & Development Center of Excellence, VA Ann Arbor Healthcare System, 300 North Ingalls Building, Ann Arbor, MI 48109-0429, USA.
| | | | | |
Collapse
|
44
|
Abstract
Must health care professionals provide treatments or interventions that they consider futile? Although much of the past and current debate about futility has centered on how to best define futility, it is the application of the concept in clinical decision making that is of central concern. Most physicians feel confident that they know futile treatment when they see it, but despite years of debate in scholarly journals, professional meetings, and popular media, consensus on a precise definition eludes us still. This article reviews numerous definitions of futility to illustrate the general lack of consensus over this concept. It also provides a flexible definition of futility that is patient centered and reliant on goals of care as the morally preferable definition. In short, the concept of futility as a means to resolve disputes over treatment decisions may, itself, be futile.
Collapse
Affiliation(s)
- Kathryn L Moseley
- Bioethics Program, University of Michigan Medical School, 300 North Ingalls Street, 7D20, Ann Arbor, MI 48109-0429, USA
| | | | | |
Collapse
|
45
|
|
46
|
Silveira MJ, Rhodes L, Feudtner C. Deciding How to Decide: What Processes Do Patients Use When Making Medical Decisions? The Journal of Clinical Ethics 2004. [DOI: 10.1086/jce200415308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
47
|
Silveira MJ, Rhodes L, Feudtner C. Deciding how to decide: what processes do patients use when making medical decisions? J Clin Ethics 2004; 15:269-81. [PMID: 15630870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
|
48
|
Abstract
OBJECTIVES To assess whether physicians know of Washington State's prehospital do-not-resuscitate (DNR) policy, 6 years after its implementation. DESIGN Cross-sectional survey. SETTING Washington State, April 2001. PARTICIPANTS Four hundred seventy-one practicing physicians. MEASUREMENTS Multivariate logistic regression was used to determine relationships between physician and practice characteristics with knowledge of policies governing advance care planning. RESULTS Among respondents, 60% did not know that Washington State requires an emergency medical service (EMS)-specific DNR order authored by a physician. Seventy-nine percent did not know that patient-authored advance directives apply only in hospitals and medical offices. CONCLUSION The findings in this study suggest that most physicians in Washington State lack knowledge about the documentation needed for EMS personnel to forgo pre-hospital attempts at cardiopulmonary resuscitation. Further study is needed to determine whether physician education or legislative change is necessary.
Collapse
Affiliation(s)
- Maria J Silveira
- General Medicine, Bioethics Program, University of Michigan, Ann Arbor, Michigan, USA.
| | | | | |
Collapse
|
49
|
Abstract
To understand the factors associated with interest in assisted suicide among terminally ill patients, we surveyed 50 caregivers of decedent amyotrophic lateral sclerosis (ALS) patients from Oregon and Washington regarding perceptions of patients' interest in assisted suicide and their physical and emotional state in the last month of life. For 38 caregivers, we had baseline information from the patients themselves, gathered a median of 11 months before death, regarding depression, hopelessness, sense of burden, social support, quality of life, pain, and suffering. According to our respondents, one-third of ALS patients discussed wanting assisted suicide in the last month of life. Hopelessness and interest in assisted suicide at baseline predicted desire for assisted suicide later on. ALS patients who were interested in assisted suicide, compared to those who were not, had greater distress at being a burden to others and more insomnia, pain, and discomfort other than pain.
Collapse
Affiliation(s)
- Linda Ganzini
- Mental Health Division, Oregon Health and Science University, Portland, USA
| | | | | |
Collapse
|
50
|
Abstract
OBJECTIVE To study the health care experiences and palliative care needs of patients with ALS in their final month of life. METHODS Caregivers of decedent patients with ALS completed a single survey focused on the final month of life. They reported the patients' physical and emotional symptoms, preferences for end-of-life care, completion of advance directives, and preparation for death. The caregiver reported which life-sustaining treatments were administered, withheld, or withdrawn; whether the patient was enrolled in hospice; and their own satisfaction with the patient's medical care. RESULTS Fifty caregivers completed the survey. Caregivers reported that the most common symptoms in the last month of life included difficulty communicating (62%), dyspnea (56%), insomnia (42%), and discomfort other than pain (48%). Pain was both frequent and severe. One-third of caregivers were dissatisfied with some aspect of symptom management. Caregivers reported an advance directive was completed by 88% of patients and the patients' goals of care were honored by 88% of health care practitioners. Two-thirds of patients were enrolled in hospice. Compared to nonhospice patients, hospice patients were significantly more likely to: 1) die in their preferred location; 2) die outside the hospital; and 3) receive morphine. Most caregivers reported that their loved one was at peace, and prepared for and was accepting of death. CONCLUSIONS Caregivers report that many patients with ALS still experience distressing physical symptoms in the last month of life, despite enrollment in hospice. Most patients with ALS, however, anticipate and plan for their deaths and have their wishes respected.
Collapse
Affiliation(s)
- Linda Ganzini
- Behavior Health and Clinical Neurosciences Division, Portland VA Medical Center, PO Box 1034, Portland, OR 97207, USA. ganzinil@.ohsu.edu
| | | | | |
Collapse
|