Experience of Time and Subjective Age When Facing a Limited Lifetime: The Case of Older Adults with Advanced Cancer

Objectives

We addressed two questions: (1) Does advanced cancer in later life affect a person’s awareness of time and their subjective age? (2) Are awareness of time and subjective age associated with distress, perceived quality of life, and depression?

Methods

We assessed patients suffering terminal cancer (OAC, n = 91) and older adults free of any life-threatening disease (OA, n = 89), all subjects being aged 50 years or older.

Results

Older adults with advanced cancer perceived time more strongly as being a finite resource and felt significantly older than OA controls. Feeling younger was meaningfully related with better quality of life and less distress. In the OA group, feeling younger was also associated to reduced depression. Perceiving time as a finite resource was related to higher quality of life in the OA group.

Discussion

Major indicators of an older person’s awareness of time and subjective aging differ between those being confronted with advanced cancer versus controls.

Distress in hospitalized cancer patients: Associations with personality traits, clinical and psychosocial characteristics

OBJECTIVE

To improve allocation of psychosocial care and to provide patient-oriented support offers, identification of determinants of elevated distress is needed. So far, there is a lack of evidence investigating the interplay between individual disposition and current clinical and psychosocial determinants of distress in the inpatient setting.

METHODS

In this cross-sectional study, we investigated 879 inpatients with different cancer sites treated in a German Comprehensive Cancer Center. Assessment of determinants of elevated distress included sociodemographic, clinical and psychosocial characteristics as well as dimensions of personality. Multiple linear regression was applied to identify determinants of psychosocial distress.

RESULTS

Mean age of the patients was M = 61.9 (SD = 11.8), 48.1% were women. In the multiple linear regression model younger age (β = -0.061, p = 0.033), higher neuroticism (β = 0.178, p = <0.001), having metastases (β = 0.091, p = 0.002), being in a worse physical condition (β = 0.380, p = <0.001), depressive symptoms (β = 0.270, p = <0.001), not feeling well informed about psychological support (β = 0.054, p = 0.046) and previous uptake of psychological treatment (β = 0.067, p = 0.020) showed significant associations with higher psychosocial distress. The adjusted R² of the overall model was 0.464.

CONCLUSION

Controlling for sociodemographic characteristics and dispositional vulnerability, that is neuroticism, current clinical and psychosocial characteristics were still associated with hospitalized patients' psychosocial distress. Psycho-oncologists should address both, the more transient emotional responses, such as depressive symptoms, as well as more enduring patient characteristics, like neuroticism.

"Often Relatives are the Key […]" -Family Involvement in Treatment Decision Making in Patients with Advanced Cancer Near the End of Life

Background

Family communication has been increasingly recognized as an important factor in decision making near the end of life. However, the role of the family in decision making is less studied in oncology settings, where most patients are conscious and able to communicate almost until dying. The aim of this study was to explore oncologists’ and nurses’ perceptions of family involvement in decision making about forgoing cancer‐specific treatment in patients with advanced cancer.

Materials and Methods

Qualitative semistructured interviews with 22 oncologists and 7 oncology nurses were analyzed according to the grounded theory approach. The results were discussed against the background of the clinical and ethical debate on family role near the end of life.

Results

We could identify two approaches shared by both oncologists and nurses toward family involvement. These approaches could be partly explained by different perception and definition of the concept of patients' autonomy: (a) a patient‐focused approach in which a patient's independence in decision making was the highest priority for oncologists and (b) a mediator approach with a family focus in which oncologists and nurses assigned an active role to patients' family in decision making and strived for building consensus and resolving conflicts.

Conclusion

The main challenge was to involve family, increasing their positive influences on the patient and avoiding a negative one. Thereby, the task of both oncologists and oncology nurses is to support a patient's family in understanding of a patient's incurable condition and to identify a patient's preference for therapy.

Implications for Practice

This study focused on oncologists’ and oncology nurses’ perceptions of family involvement in decision making about treatment limitation in patients with advanced cancer who are able to communicate in a hospital setting. Oncologists and oncology nurses should be aware of both positive aspects and challenges of family involvement. Positive aspects are patients’ emotional support and support in understanding and managing the information regarding treatment decisions. Challenges are diverging family preferences with regard to treatment goals that might become a barrier to advanced care planning, a possible increased psychological burden for the family. Especially challenging is involving the family of a young patient because increased attention, more time investment, and detailed discussions are needed.

The role of family communication is recognized as an important factor in decision making for cancer patients near the end of life. This article discusses the value and role of family in end‐of‐life discussions and the challenges encountered by oncologist and oncology nurses when involving family in decision making.

Factors associated with the decline of psychological support in hospitalized patients with cancer

OBJECTIVE

Many distressed cancer patients do not want or, finally, do not use psychological support. This study aimed at identifying factors associated with the decline of psychological support during hospital stay.

METHODS

This cross-sectional study included inpatients with different cancer diagnoses. Distress was assessed using the short form of the Questionnaire on Stress in Cancer Patients-Revised (QSC-R10) and the Distress Thermometer (DT). Multivariable logistic regression was used to identify factors associated with decline.

RESULTS

Of 925 patients, 71.6% (n = 662) declined psychological support. Male sex (OR = 2.54, 95% CI = 1.69-3.80), low psychosocial distress (OR = 3.76, CI = 2.50-5.67), not feeling depressed (OR = 1.93, CI = 1.24-2.99), perceived overload (OR = 3.37, CI = 2.19-5.20), no previous psychological treatment (OR = 1.88, CI = 1.25-2.83), and feeling well informed about psychological support (OR = 1.66, CI = 1.11-2.46) were associated with decline. Among the patients who indicated clinical distress (46.2%), 53.9% declined psychological support. Male sex (OR = 2.96, CI = 1.71-5.12), not feeling depressed (OR = 1.87, CI = 1.12-3.14), perceived overload (OR = 5.37, CI = 3.07-9.37), agreeableness (OR = 0.70, CI = 0.51-0.95), and feeling well informed about psychological support (OR = 1.81, CI = 1.07-3.07) were uniquely associated with decline in this subgroup.

CONCLUSIONS

Decline of psychological support is primarily due to psychological factors. Feeling well informed about support emerged as a relevant factor associated with decline. Thus, design of informational material and education about available psychological services seem crucial.

Development and Evaluation of an Ethical Guideline for Decisions to Limit Life-Prolonging Treatment in Advanced Cancer: Protocol for a Monocentric Mixed-Method Interventional Study

BACKGROUND

Many patients with advanced cancer receive chemotherapy close to death and are referred too late to palliative or hospice care, and therefore die under therapy or in intensive care units. Oncologists still have difficulties in involving patients appropriately in decisions about limiting tumor-specific or life-prolonging treatment.

OBJECTIVE

The aim of this Ethics Policy for Advanced Care Planning and Limiting Treatment Study is to develop an ethical guideline for end-of-life decisions and to evaluate the impact of this guideline on clinical practice regarding the following target goals: reduction of decisional conflicts, improvement of documentation transparency and traceability, reduction of distress of the caregiver team, and better knowledge and consideration of patients' preferences.

METHODS

This is a protocol for a pre-post interventional study that analyzes the clinical practice on treatment limitation before and after the guideline implementation. An embedded researcher design with a mixed-method approach encompassing both qualitative and quantitative methods is used. The study consists of three stages: (1) the preinterventional phase, (2) the intervention (development and implementation of the guideline), and 3) the postinterventional phase (evaluation of the guideline's impact on clinical practice). We evaluate the process of decision-making related to limiting treatment from different perspectives of oncologists, nurses, and patients; comparing them to each other will allow us to develop the guideline based on the interests of all parties.

RESULTS

The first preintervention data of the project have already been published, which detailed a qualitative study with oncologists and oncology nurses (n=29), where different approaches to initiation of end-of-life discussions were ethically weighted. A framework for oncologists was elaborated, and the study favored an anticipatory approach of preparing patients for forgoing therapy throughout the course of disease. Another preimplementational study of current decision-making practice (n=567 patients documented) demonstrated that decisions to limit treatment preceded the death of many cancer patients (62/76, 82% of deceased patients). However, such decisions were usually made in the last week of life, which was relatively late.

CONCLUSIONS

The intervention will be evaluated with respect to the following endpoints: better knowledge and consideration of patients' treatment wishes; reduction of decisional conflicts; improvement of documentation transparency and traceability; and reduction of the psychological and moral distress of a caregiver team.

REGISTERED REPORT IDENTIFIER

RR1-10.2196/9698.

"Rather one more chemo than one less…": Oncologists and Oncology Nurses' Reasons for Aggressive Treatment of Young Adults with Advanced Cancer

BACKGROUND

Empirical research demonstrates that there is a tendency to administer tumor-directed therapy to patients with advanced cancer close to death, especially if they are young. The aim of this qualitative study was to understand oncologists' treatment decisions and oncology nurses' perception of these decisions in young adult patients and to investigate the extent to which young age was a factor in cancer treatment decisions.

MATERIALS AND METHODS

We conducted 29 face-to-face interviews with oncologists and oncology nurses at the Department of Hematology and Oncology at the University Hospital in Munich, Germany. The interviews were analyzed according to the grounded theory approach.

RESULTS

Oncologists and nurses reported that decisions about limiting cancer treatment with young adult patients are the most challenging and stressful in clinical practice. Apart from using young age as a proxy for patient's medical fitness, oncologists' decisions in favor of more aggressive treatment of younger patients were mainly guided by ethical reasons such as patient preferences and the perceptions of injustice associated with dying at a young age, as well as by psychological reasons, such as identification and emotional entanglement.

CONCLUSION

"Struggling" together with the patient against the injustice of dying young for a longer lifetime is an important factor driving aggressive treatment in young adult patients. However, oncologists might run a risk of neglecting other ethical aspects, such as a principle of nonmaleficence, that might even result in life-shortening adverse events.

IMPLICATIONS FOR PRACTICE

This study identifies two ethical and one psychological reasons for patients' overtreatment: 1) patients' preference for further treatment; 2) oncologists' perception of un-fairness of dying young; and 3) identification and emotional entanglement with patient. These findings emphasize the need for oncologists' awareness of the reasons guiding their treatment decisions - a sole focus on patients' preferences and on the fighting against the unfairness of dying young might lead to neglecting obligations of non-maleficence. Self-reflection, the balance of empathy and professional distance as well as timely end of life discussions and involvement of psycho-oncologists are needed in the care of young cancer patients.

Häufigkeit und Zeitpunkt von Entscheidungen gegen intensivmedizinische Maßnahmen und tumorspezifische Therapien in einer universitären Hämatologie und Onkologie

Hintergrund und Fragestellung Entscheidungen zur Therapiebegrenzung (TBE) sind wichtig, um Übertherapie am Lebensende zu verhindern. Sie werden jedoch nicht immer vorher mit dem Patienten besprochen oder ausreichend dokumentiert. Im Rahmen einer Studie zur Verbesserung von TBE bei Patienten mit fortgeschrittener hämatologischer/onkologischer Erkrankung wurde untersucht, wie häufig TBE einem Todesfall vorausgehen und wie frühzeitig diese festgelegt werden.

Methodik In die Querschnittsstudie wurden 567 stationäre Patienten mit fortgeschrittenen hämatologischen/ onkologischen Neoplasien an der Medizinischen Klinik und Poliklinik III am LMU-Klinikum München eingeschlossen. Mithilfe eines standardisierten Erfassungsbogens wurde dokumentiert, ob und welche Entscheidungen zur Therapiebegrenzung festgelegt waren und bis zum Tod umgesetzt wurden.

Ergebnisse Bei 26 % (n = 147) der 567 Patienten wurde eine TBE festgelegt. Meist waren diese TBE von Beginn an schriftlich dokumentiert (90 %; n = 132), 20 % (n = 30) wurden im Verlauf geändert. Der Anteil der Verstorbenen mit TBE betrug 82 % (n = 62 von 76 Verstorbenen). Die Erstfestlegung einer TBE erfolgte auf Normalstation im Median 6 Tage vor dem Tod der Patienten, auf der Palliativstation im Median 10,5 Tage vor dem Tod. Im Vergleich zu den hämatologischen Patienten wurde bei jenen mit onkologischen Erkrankungen häufiger eine TBE festgelegt (64 vs. 36 %) und die Entscheidung wurde etwas früher getroffen (7 vs. 5 Tage vor dem Tod).

Folgerung Die Ergebnisse zeigen, dass TBE heute dem Tod vieler hämatologisch-onkologischer Patienten vorausgehen, jedoch in der Regel erst in der letzten Lebenswoche erfolgen. Dies birgt die Gefahr, dass die Zeit bis zum Tod für Gespräche mit allen Beteiligten nicht ausreicht. Diese Ergebnisse sind in eine Ethikleitlinie zur Therapiebegrenzung für stationäre Patienten mit einer fortgeschrittenen hämatologischen/ onkologischen Erkrankung eingeflossen, die eine vorausschauende Behandlungsplanung unterstützen soll.

[Advance Care Planning and Decisions to limit treatment at the end of life - the view from medical ethics and psychooncology]

Decisions to limit treatment are important in order to avoid overtreatment at the end of life. They proceed more than half of expected deaths in Europe and the US, but are not always communicated with the patient in advance. One reason for non-involvement is that conversations that prepare patients for end-of-life decisions and work out their preferences do not take place on a regular basis. At the same time there is growing evidence that such communication improves patients' quality of life, reduces anxiety and depression and allows patients to develop a realistic understanding of their situation - which in turn is a prerequisite for shared decision making about limiting treatment. In this paper we define "treatment limitation" and explain the medical ethics perspective. The main focus, however, is on the causes that hinder advanced care planning and conversations about limiting treatment in the care of patients with advanced disease. Finally the evidence for approaches to improve the situation is presented with concrete suggestions for solutions.

ComOn Coaching: Study protocol of a randomized controlled trial to assess the effect of a varied number of coaching sessions on transfer into clinical practice following communication skills training

Background

Communication skills training has proven to be an effective means to enhance communication of health care professionals in oncology. These effects are well studied in standardized settings. The question of transferring these skills into clinical consultations remains open. We build up on a previous developed training concept consisting of a workshop and coaching. This training achieved a medium effect size in two studies with standardized patients. In the current study, we expanded and manualized the coaching concept, and we will evaluate effects of a varied number of coaching sessions on real clinical consultations. Our aim is to determine how much coaching oncologists need to transfer communication skills into clinical practice.

Methods/design

Physicians of two German medical centers will participate in a workshop for communication skills and will be randomized to either a group with one coaching session or a group with four coaching sessions following the workshop. The participation is voluntary and the physicians will receive medical education points. Consultations held by the participating physicians with actual patients who gave their informed consent will be filmed at three time points. These consultations will be evaluated by blinded raters using a checklist based on the training content (primary outcome). Secondary outcomes will be the self-evaluated communication competence by physicians and an evaluation of the consultations by both physicians and patients.

Discussion

We will evaluate our communication training concept on three levels – rater, physician and patient – and concentrate on the transfer of communication skills into real life situations.

As we emphasize the external validity in this study design, limitations will be expected due to heterogeneity of data. With this study we aim to gain data on how to improve communication skills training that will result in better patient outcomes.

Trial registration

German Clinical Trials Register DRKS00004385.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1454-z) contains supplementary material, which is available to authorized users.

Framework for timing of the discussion about forgoing cancer-specific treatment based on a qualitative study with oncologists

BACKGROUND

Many patients with advanced cancer receive aggressive chemotherapy close to death and are referred too late to palliative or hospice care.

AIM

The aim of this study was to investigate oncologists' and oncology nurses' perceptions of the optimal timing for discussions about forgoing cancer-specific therapy at the End-of-Life (EOL) and the reasons that might hinder them.

DESIGN

Qualitative in-depth interviews with oncologists and oncology nurses were carried out. The empirical data were evaluated from a normative perspective.

SETTING/PARTICIPANTS

Twenty-nine physicians and nurses working at the Department of Hematology and Oncology of a German university hospital were interviewed.

RESULTS

Health-care professionals differed considerably in their understanding of when to initiate discussions about forgoing cancer-specific therapy at the EOL. However, their views could be consolidated into three approaches: (1) preparing patients gradually throughout the course of disease (anticipatory approach) which is best suited to empower patient self-determination in decision-making, (2) waiting until the patient him/herself starts the discussion about forgoing cancer-specific treatment, and (3) waiting until all tumor-specific therapeutic options are exhausted.

CONCLUSION

The empirically informed ethical analysis clearly favors an approach that prepares patients for forgoing cancer-specific therapy throughout the course of disease. Since the last two approaches often preclude advance care planning, these approaches may be less ethically acceptable. The proposed framework could serve as a starting point for the development of concrete recommendations on the optimal timing for EOL discussions.

Cancer patients' preferences for quantity or quality of life: German translation and validation of the quality and quantity questionnaire

BACKGROUND

Decision-making with patients with incurable cancer often requires trade-offs between quality and length of life. The 'Quality and Quantity Questionnaire' (QQ) is an English-language measure of patients' preference for length or quality of life. The aim of this study was to translate and validate this questionnaire.

MATERIALS AND METHODS

1 new item was formulated to improve the 'Quality of life' scale. Construct validity including exploratory factor analysis, convergent and discriminant validity, and reliability was determined in n = 194 patients.

RESULTS

The acceptability of the questionnaire among patients was high. The item-non-response rate was very low (2.5-4%). The 2 QQ scales 'Quality of life' (QL) and 'Length of life' (LL) had good and acceptable internal consistency (Cronbach's = 0.71 for LL and 0.59 for QL). Convergent validity was shown by significant correlation of the QL subscale with the CCAT (Cancer Communication Assessment Tool) subscale 'Limitation of treatment' (r = 0.37, p < 0.01) and the LL scale with the CCAT subscale 'Continuing treatment' (r = 0.24, p = 0.00).

CONCLUSION

The German version of 'QQ' has satisfactory psychometric properties for measuring patients' preferences for LL or QL. It can be used in all research fields that should be informed by patients' preferences: shared decision-making, palliative care, and health services.

Cognitive functioning in allogeneic hematopoietic stem cell transplantation recipients and its medical correlates: a prospective multicenter study

BACKGROUND

Owing to its neurotoxicity, allogeneic hematopoietic stem cell transplantation (HSCT) carries risks for cognitive impairment. In this multicenter study, we prospectively evaluated cognitive functioning and its medical and demographic correlates in patients undergoing allogeneic HSCT.

METHODS

A total of 102 patients were consecutively assessed prior to (T0 ), 100 ± 20 days (T1 ) after, and 12 ± 1 months (T2 ) after HSCT (61% men, 41% acute myeloid leukemia). A comprehensive neuropsychological test battery was applied to evaluate attention, memory, executive function, and fine motor function, summing up into 14 test scores.

RESULTS

Before and after HSCT, patients performed below test norms in up to 50% of the test scores. Patients were mostly impaired on word fluency (24%, T0 ), fine motor function, and verbal delayed recall (19% each, T2 ). Impairment on ≥ 1/5 cognitive domains occurred in 47% (T0 ) and 41% (T2 ) of the patients. Performance (mean z-scores) partially improved over time (i.e., visual span forward, verbal learning, and word fluency). However, from baseline to T2 , 16% of the patients showed reliable decline on ≥ 3/14 test scores (reliable change index method). For the majority of neuropsychological subtests, no associations with conditioning intensity, total body irradiation, graft-versus-host disease, cyclosporine treatment, and length of hospital stay were found. Age and premorbid intelligence level were consistently associated with cognition.

CONCLUSIONS

Below average cognitive performance is common in this patient group. In addition, a subgroup shows reliable cognitive decline after allogeneic HSCT. Healthcare professionals should be aware of these treatment-related cognitive side effects.