EMPOWER: A Multi-Site Pilot Trial to Reduce Distress in Surrogate Decision-Makers in the ICU

CONTEXT

Efforts to reduce the psychological distress of surrogate decision-makers of critically ill patients have had limited success, and some have even exacerbated distress.

OBJECTIVES

The aim of this study was to determine the feasibility, acceptability, and preliminary efficacy of EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), an ultra-brief (∼2-hour), 6-module manualized psychological intervention for surrogates.

METHODS

Surrogates who reported significant anxiety and/or an emotionally close relationship with the patient (n=60) were randomized to receive EMPOWER or enhanced usual care (EUC) at one of three metropolitan hospitals. Participants completed evaluations of EMPOWER's acceptability and measures of psychological distress pre-intervention, immediately post-intervention, and at 1- and 3-month follow-up assessments.

RESULTS

Delivery of EMPOWER appeared feasible, with 89% of participants completing all 6 modules, and acceptable, with high ratings of satisfaction (mean=4.5/5, SD = .90). Compared to EUC, intent-to-treat analyses showed EMPOWER was superior at reducing peritraumatic distress (Cohen's d = -0.21, small effect) immediately post-intervention and grief intensity (d = -0.70, medium-large effect), posttraumatic stress (d = -0.74, medium-large effect), experiential avoidance (d = -0.46, medium effect), and depression (d = -0.34, small effect) 3 months post-intervention. Surrogate satisfaction with overall critical care (d = 0.27, small effect) was higher among surrogates randomized to EMPOWER.

CONCLUSIONS

EMPOWER appeared feasible and acceptable, increased surrogates' satisfaction with critical care, and prevented escalation of posttraumatic stress, grief, and depression 3 months later.

Patient-Caregiver Dyads & End-of-Life Care: Caregiver Personality Disrupts Gender-Based Norms

CONTEXT

Gender and personality may individually impact end-of-life care. Men often receive more aggressive treatments than women near death, and personality - particularly openness - may be associated with increased care utilization when it diverges from traditional treatment norms. However, research has not examined the interaction of these variables in a dyadic context.

OBJECTIVES

This study examined the dyadic effects of patient gender and caregiver personality on end-of-life care.

METHODS

Using data from the VOICE randomized clinical trial, the present sample consisted of patient-caregiver dyads receiving outpatient care for advanced cancer in Sacramento and Western New York. Analyses assessed whether caregiver personality was associated with gender-based differences in patient chemotherapy or emergency department/inpatient visits in the 30 days before death. Logistic regression examined the interaction between caregivers' Big Five personality dimensions and patient gender while accounting for patient and caregiver demographic and health characteristics.

RESULTS

Of a total of 134 patient-caregiver dyads, 19.4% (n = 26) of patients received chemotherapy and 47.8% (n = 64) had an emergency department/inpatient visit in the 30 days before death. Results demonstrated a significant interaction between caregiver openness and patient gender on receipt of chemotherapy (odds ratio = 0.07, p = 0.006). When caregivers were less open, men were more likely to receive chemotherapy near death, whereas when caregivers were more open, women were more likely to receive chemotherapy near death.

CONCLUSION

Results suggest caregiver personality characteristics, particularly openness, might disrupt gender-based treatment norms at end-of-life. Findings demonstrate that patient and caregiver factors can interact to explain patient healthcare utilization.

A communication intervention to improve prognostic understanding and engagement in advance care planning among diverse advanced cancer patient-caregiver dyads: A pilot study

OBJECTIVES

Accurate prognostic understanding among patients with advanced cancer and their caregivers is associated with greater engagement in advance care planning (ACP) and receipt of goal-concordant care. Poor prognostic understanding is more prevalent among racial and ethnic minority patients. The purpose of this study was to examine the feasibility, acceptability, and impact of a patient-caregiver communication-based intervention to improve prognostic understanding, engagement in ACP, and completion of advance directives among a racially and ethnically diverse, urban sample of patients and their caregivers.

METHODS

Patients with advanced cancer and their caregivers (n = 22 dyads) completed assessments of prognostic understanding, engagement in ACP, and completion of advance directives at baseline and post-intervention, Talking About Cancer (TAC). TAC is a 7-session intervention delivered remotely by licensed social workers that includes distress management and communication skills, review of prognosis, and information on ACP.

RESULTS

TAC met a priori benchmarks for feasibility, acceptability, and fidelity. Prognostic understanding and engagement in ACP did not change over time. However, patients showed increases in completion of advance directives.

SIGNIFICANCE OF RESULTS

TAC was feasible, acceptable, and delivered with high fidelity. Involvement of caregivers in TAC may provide added layers of support to patients facing advanced cancer diagnoses, especially among racial and ethnic minorities. Trends indicated greater completion of advance directives but not in prognostic understanding or engagement in ACP. Future research is needed to optimize the intervention to improve acceptability, tailor to diverse patient populations, and examine the efficacy of TAC in a randomized controlled trial.

Human Connection: Oncologist Characteristics and Behaviors Associated With Therapeutic Bonding With Latino Patients With Advanced Cancer

PURPOSE

Therapeutic alliances (TAs) between oncologists and patients are bonds characterized by mutual caring, trust, and respect. We here relate oncologist characteristics and behaviors to TA among Latino and non-Latino patients with advanced cancer.

METHODS

Participants included non-Latino oncologists (n = 41) and their Latino (n = 67) and non-Latino White (n = 90) patients with advanced cancer who participated in Coping with Cancer III, a multisite, US-based prospective cohort study of Latino/non-Latino disparities in end-of-life cancer care, conducted 2015-2019. Oncologist characteristics included age, sex, race, institution type, Spanish language proficiency, familismo practice style (emphasis on family) and clinical etiquette behaviors. Patient-reported TA was assessed using the average score of six items from The Human Connection scale. Hierarchical linear modeling (HLM) estimated effects of oncologist characteristics on TA.

RESULTS

Of 157 patients, a majority were female (n = 92, 58.6%) and age younger than 65 years (n = 95, 60.5%). Most oncologists were male (n = 24, 58.5%), non-Latino White (n = 25, 61%), and age 40 years and older (n = 25, 61%). An adjusted HLM in the full sample showed that Latino patient ethnicity was associated with significantly lower TA (β = -.25; P < .001). In an adjusted stratified HLM for TA, among Latino patients, oncologist familismo practice style (β = .19; P = .012), preference using first names (β = .25; P = .023), and greater Spanish fluency (β = .11; P < .001) were positively associated with TA. In contrast, familismo practice style had no impact on TA for non-Latino White patients.

CONCLUSION

Latino patients with advanced cancer had worse TAs with their oncologists versus non-Latino patients. Modifiable oncologist behaviors may be targeted in an intervention designed to improve the patient-physician relationship between oncologists and their Latino patients with advanced cancer.

Giving information strategically and transparently: A pilot trial of the Oncolo-GIST intervention to promote patients' prognostic understanding

PURPOSE

Most patients with cancer lack the prognostic understanding necessary to make informed decisions. We tested the feasibility and acceptability of the Oncolo-GIST ("Giving Information Strategically and Transparently, GIST") intervention and explored its associations with patients' improved prognostic understanding.

METHODS

The Oncolo-GIST intervention distills prognostic discussions into easy-to-understand talking points. Patients with metastatic cancers that progressed on ≥1 line of chemotherapy and not expected to survive 12 months (n = 31) were recruited from October 2020 through November 2022. We compared patients who discussed their progressive scans with an oncologist trained in the GIST technique or not (i.e., usual care). A primary outcome was prognostic understanding (e.g., patients reporting a life-expectancy of months) assessed within a week of the scan discussion visit.

RESULTS

Oncologists (n = 4) appeared receptive to the Oncolo-GIST intervention and scored nearly perfectly on post-training tests of material mastery after a < 2-h tutorial. Post-scan discussion visit, 100% of patients who met with an Oncolo-GIST-trained clinician understood that their cancer was considered incurable (a 31% improvement from pre-visit) compared with 91% of patients meeting with usual care oncologists (an 18% improvement); 33% of patients who met with an Oncolo-GIST-trained oncologist understood that they likely had months, not years, compared to 18% in the usual care group. No statistically significant differences emerged for these changes, nor for therapeutic alliance, anxiety, or depression scores between groups.

CONCLUSION

Oncolo-GIST appears to be an easily learned approach to improve prognostic understanding that neither undermines therapeutic alliances nor increases patients' anxiety or depressive symptoms. Efficacy testing in a larger trial is warranted.

Planning for Your Advance Care Needs (PLAN): A Communication Intervention to Improve Advance Care Planning among Latino Patients with Advanced Cancer

BACKGROUND

The goal of this study was to develop and optimize an intervention designed to address barriers to engagement in advance care planning (ACP) among Latino patients with advanced cancer. The resulting intervention, titled Planning Your Advance Care Needs (PLAN), is grounded in theoretical models of communication competence and sociocultural theory.

MATERIALS AND METHODS

An initial version of the PLAN manual was developed based on a prior intervention, Ca-HELP, that was designed to improve communication around pain among cancer patients. PLAN uses this framework to coach patients on how to plan for and communicate their end-of-life care needs through ACP. In the present study, feedback was obtained from key stakeholders (n = 11 patients, n = 11 caregivers, n = 10 experts) on this preliminary version of the PLAN manual. Participants provided ratings of acceptability and feedback around the intervention content, format, design, modality, and delivery through quantitative survey questions and semi-structured qualitative interviews.

RESULTS

Results indicated that the PLAN manual was perceived to be helpful and easy to understand. All stakeholder groups liked the inclusion of explicit communication scripts and guidance for having conversations about ACP with loved ones and doctors. Specific feedback was given to modify PLAN to ensure it was optimized and tailored for Latino patients. Some patients noted reviewing the manual motivated engagement in ACP.

CONCLUSIONS

Feedback from stakeholders resulted in an optimized, user-centered version of PLAN tailored to Latino patients. Future research will examine the acceptability, feasibility, and potential efficacy of this intervention to improve engagement in ACP.

Associations between Latino ethnicity and the use of emotional support and completion of advance directives

OBJECTIVES

Latino patients have been shown to engage in advance care planning (ACP) at much lower rates than non-Latino White patients. Coping strategies, such as the use of emotional support, may differentially relate to engagement in ACP among Latino and non-Latino patients. The present study sought to examine the moderating effect of ethnicity on the relationship between the use of emotional support as a coping strategy and completion of advance directives.

METHODS

The present study employed a weighted sample (Nw = 185) of Latino and non-Latino White patient participants in Coping with Cancer III, an National Institutes of Health-sponsored, multisite, longitudinal, observational cohort study of patients with advanced cancer and their informal caregivers and oncology providers designed to evaluate Latino/non-Latino disparities in ACP and end-of-life cancer care. Main and interaction effects of Latino ethnicity and use of emotional support on patient use of advance directives were estimated as odds ratios.

RESULTS

Use of emotional support was associated with dramatically lower do-not-resuscitate (DNR) order completion to a greater extent among Latino as compared to non-Latino patients (interaction AOR = 0.33, p = 0.005). Interaction effects were not statistically significant for living will or health-care proxy form completion.

SIGNIFICANCE OF RESULTS

Use of emotional support is associated with lower odds of completing DNRs among Latino than among non-Latino patients. Seeking and/or receiving emotional support may deter Latino patients from completing DNR orders. Research is needed to address both emotional needs and practicalities to ensure high quality end-of-life care among Latino patients with cancer.

Advance care planning (ACP) to promote receipt of value-concordant care: Results vary according to patient priorities

BACKGROUND

Benefits of advance care planning (ACP) have recently been questioned by experts, but ACP is comprised of discrete activities. Little is known about which, if any, ACP activities are associated with patients' greater likelihood of receiving value-concordant end-of-life (EoL) care.

OBJECTIVES

To determine which ACP activities [Do-Not-Resuscitate (DNR) order completion, designation of a healthcare proxy (HCP), and/or EoL discussions with physicians], individually and in combination, are associated with the greatest likelihood of receiving value-concordant care, and how results may vary based on patient-reported EoL care priorities.

METHODS

Data from 2 federally-funded, multisite, prospective cohort studies of EoL cancer care from 2002-2019 were analyzed. Cancer patients (N = 278) with metastatic disease refractory to chemotherapy were interviewed for a baseline assessment and followed prospectively until death. Interviews regarding patient priorities occurred a median of 111 days prior to death; data regarding EoL medical care were collected post-mortem from caregiver interviews and medical record abstraction. Patients who 1) prioritized life-extending care, and then received life-extending care (or avoided hospice care), or 2) prioritized comfort-focused care, and then avoided life-extending care (or received hospice care) in the last week of life, were coded as receiving value-concordant care.

RESULTS

After inverse propensity score weighting, the ACP combination associated with the largest proportion of patients receiving value-concordant care was DNR, HCP, and EoL discussions (87% vs. 64% for no ACP activities; OR = 3.91, p = 0.006). In weighted analyses examining each ACP activity individually, DNR orders were associated with decreased likelihood of life-extending care (89% vs. 75%; p = 0.005) and EoL discussions were associated with increased likelihood of hospice care (77% vs. 55%; p = 0.002) among patients prioritizing comfort. ACP activities were not significantly associated with increased likelihood of receiving value-concordant care among patients prioritizing life-extension.

CONCLUSIONS AND RELEVANCE

For patients who prioritize comfort, EoL discussions with physicians and completion of DNR orders may improve odds of receiving value-concordant EoL care. For patients who prioritize life-extension, ACP does not appear to improve odds of receiving value-concordant EoL care.

Grief and Bereavement in the Latino/a Community: A Literature Synthesis and Directions for Future Research

Introduction

Bereavement and grief are social phenomena influenced by a multitude of cultural factors. Prior studies of bereavement adjustment have primarily focused on bereaved survivors who identify racially as white; knowledge of the experience of grief and bereavement among racial/ethnic and other minority groups, particularly among Latino/a groups, in the United States is limited.

Objective

The purpose of this review is to synthesize the literature documenting the bereavement experiences of the Latino/a community, evaluate the strength of the current evidence, and provide recommendations to guide future research.

Method

A narrative review of research on grief and bereavement in the Latino/a community published between 1990 and 2021. Two authors used a thematic, deductive approach to categorize emergent prevalent themes from the literature and used The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and The Oxford Center for Evidence-Based Medicine-Evidence Quality Rating Scale (OCEBM) approaches to evaluate the strength of the qualitative and quantitative reports reviewed.

Results

Searches revealed 26 reports that were categorized into six themes: cultural values, mourning rituals, immigration, spirituality, disparities related to the COVID-19 pandemic, and the effects of COVID-19 on Latino/a communities. Our evaluation concludes that the evidence in this area is weak, with limited methodologically rigorous research examining the influence of culture on bereavement among Latino/a groups.

Conclusion

Research is needed to identify Latino/a groups' mental health, cultural, social, and family needs and how fulfillment of mourning rituals and other cultural factors may promote or impede bereavement adjustment. Investigation into factors that may protect bereaved survivors against adverse mental health outcomes is also needed. A better understanding of Latino/a grief and bereavement is a step toward the development of culturally competent interventions designed to promote the mental health and psychosocial adjustment of Latino/a mourners.

Association between immigrant status and advanced cancer patients' location and quality of death

Background

Cancer patients often prefer to die at home, a location associated with better quality of death (QoD). Several studies demonstrate disparities in end‐of‐life care among immigrant populations in the United States. This study aimed to evaluate how immigrant status affects location and quality of death among patients with advanced cancer in the United States.

Methods

Data were derived from Coping with Cancer, a federally funded multi‐site prospective study of advanced cancer patients and caregivers. The sample of patients who died during the study period was weighted (N_w = 308) to reduce statistically significant differences between immigrant (N_w = 49) and nonimmigrant (N_w = 259) study participants. Primary outcomes were location of death, death at preferred location, and poor QoD.

Results

Analyses adjusted for covariates indicated that patients who were immigrants were more likely to die in a hospital than home (adjusted odds ratio [AOR], 3.33; 95% confidence interval [CI], 1.65–6.71) and less likely to die where they preferred (AOR, 0.42; 95% CI, 0.20–0.90). Furthermore, immigrants were more likely to have poor QoD (AOR, 5.47; 95% CI, 2.70–11.08).

Conclusions

Immigrants, as compared to nonimmigrants, are more likely to die in hospital settings, less likely to die at their preferred location, and more likely to have poor QoD.

Lay summary

Cancer patients typically prefer to die in their own homes, which is associated with improved quality of death.

However, disparities in end‐of‐life care among immigrant populations in the United States remain significant.

Our study found that immigrants are less likely to die in their preferred locations and more likely to die in hospital settings, resulting in poorer quality of death.

Disparities in end‐of‐life care and quality of death are prevalent among immigrants. The findings of this study illustrate that immigrants in the United States are more likely to die in hospital settings and less likely to die at their preferred location.

Associations of financial hardship with suicidal ideation among bereaved cancer caregivers

PURPOSE

To examine associations between financial hardship and suicidal ideation among bereaved informal caregivers of cancer patients.

DESIGN

Longitudinal cohort study.

SAMPLE

173 informal caregivers of advanced cancer patients.

METHODS

Caregivers were interviewed a median 3.1 months before and 6.5 months after the death of the patient they cared for. Logistic regression models estimated associations between caregiver-perceived pre-loss and post-loss financial hardship due to the patient's illness and post-loss suicidal ideation.

FINDINGS

Suicidal ideation was identified in 12% (n = 21) of the sample pre-loss, rising to 20% (n = 34) post-loss (p=.049). Pre-loss financial hardship (OR = 3.4, 95% CI = 1.5-7.4, p=.002) and post-loss financial hardship (OR = 3.7, 95% CI = 1.7-8.2, p=.001) were each bivariately associated with post-loss suicidal ideation. In multivariable models adjusting for pre-loss suicidal ideation, psychiatric diagnosis, and spousal relationship to the patient, post-loss financial hardship remained significantly associated with post-loss suicidal ideation (AOR = 3.6, 95% CI = 1.4-8.8, p=.006).

CONCLUSION

Among a cohort of cancer caregivers followed from active caregiving into bereavement, post-loss financial hardship was associated with suicidal ideation in bereavement.

IMPLICATIONS

Economic policies that financially benefit caregivers may represent promising strategies for preventing suicidal thoughts and behaviors.

A micro-sociological theory of adjustment to loss

Although grief is a reaction to a social loss, it has been viewed almost exclusively through the lens of individual psychology and not sociology. In this article, we suggest that more attention to sociological aspects of grief is warranted. We propose a micro-sociological theory of bereavement and grief to complement, not replace, psychological perspectives. We assert that bereavement represents a state of loss-associated social deprivations (e.g. social disconnection). Furthermore, we postulate that addressing social deprivations (e.g. enhancing social connection) will lessen severity of distressing, disabling grief and, thereby, promote adjustment to loss. Future research is needed to test our theory and the hypotheses that follow from it in the service of promoting adaptation to bereavement.

Associations between beta-blocker use and psychological distress in bereaved adults with cardiovascular conditions

The death of a close other is a major life stressor that disrupts mental and physical health. Beta-blocker medications are indicated treatments for cardiovascular conditions that may also mitigate psychological distress in the context of stressors by reducing adrenergic activity. We sought to examine observational links between beta-blocker medication use and psychological distress during bereavement. Using publicly available data from the Midlife in the United States Refresher study, we examined associations between beta-blocker use and general distress, depressive symptoms, and anxiety symptoms (as measured by the Mood and Anxiety Symptom Questionnaire) among bereaved adults with cardiovascular conditions (n = 161) using t-tests and regression models. Beta-blocker users reported lower levels of anxiety-related general distress (b = -2.49, SE = 0.88, p = 0.005) and depression-related general distress than non-users (b = -2.39, SE = 1.14, p = 0.039) in multivariate linear regression models adjusting for demographic characteristics, mental health treatments, time since loss and comorbid health conditions. These observed links between beta-blockers and lower psychological distress in bereavement warrant further investigation in prospective and randomized studies, as beta-blockers could be a scalable intervention for mitigating distress following loss.

Development of the Oncolo-GIST ("Giving Information Strategically & Transparently") Intervention Manual for Oncologist Skills Training in Advanced Cancer Prognostic Information Communication

CONTEXT

Patient prognostic understanding is improved by oncologists' discussions of life expectancy. Most patients deem it important to discuss prognosis with their oncologists, but a minority of cancer patients within months of death report that they had such a discussion with their oncologist.

OBJECTIVES

To query stakeholders about their perspectives on the clinical approach and utility of an Oncolo-GIST manualized communication intervention, designed to enhance oncologists' ability to convey the gist of prognostic information simply, clearly, and effectively in the setting of progressing solid tumors and limited life expectancy.

METHODS

We obtained and analyzed feedback on the intervention from solid tumor oncology clinicians and bereaved family caregivers, soliciting opinions on the clinical approach taken in the videos, acceptability and likely impact of the instructions, and specific phrases recommended in the manual.

RESULTS

Twenty stakeholders (9 clinicians, 11 caregivers) participated. All agreed that oncologists should broach prognosis with patients, balancing honesty and sensitivity. Participants also advocated for oncologists to involve interprofessional team members (e.g., nurses, social workers) when serious mental health concerns arose. After the research team's discussion of the stakeholder feedback, the manual was modified to include or exclude preferred language and approaches.

CONCLUSION

The Oncolo-GIST intervention was characterized as simple and potentially effective at conveying prognoses to advanced cancer patients. Future research should determine if this approach to medical communication, which distills the essence of prognostic messages clearly and simply, is associated with improvements in patients' prognostic understanding.

Inequity in location and quality of death of advanced cancer patients by immigrant status

12036

Background: Most cancer patients prefer to die at home, a location associated with better quality of death (QoD) and caregiver outcomes. A number of studies demonstrate disparities in end-of-life (EoL) care among immigrant vs non-immigrant populations in the U.S. This study aims to evaluate how immigrant status affects location and QoD among patients with advanced cancer in the U.S. Methods: Data were derived from Coping with Cancer, a federally funded multi-site prospective study of advanced cancer patients and caregivers. The analytic sample of patients who died during the study observation period was weighted (Nw=308) to reduce statistically significant sociodemographic differences between immigrant (Nw=49) and non-immigrant (Nw=259) groups. Immigrant status was determined by patient self-report. Primary outcomes were location of death (intensive care unit, hospital, nursing home, inpatient hospice, home), death at preferred location (yes/no, as per caregiver report in post-mortem interview), and poor QoD (composite score of post-mortem caregiver ratings for patient psychological distress, physical distress, and quality of life in the last week of life). Results: As compared to non-immigrants, immigrants were more likely to die in a hospital as opposed to home [AOR 3.33; 95% CI (1.65-6.71); p=0.001] and less likely to die where they preferred [AOR 0.42, 95% CI (0.20-0.90); p=0.026]. As shown in Table, values-inconsistent aggressive EoL care mediated the effect of immigrant status on death at the patient s preferred location. Further, immigrants were more likely to have poor QoD [AOR 5.47; 95% CI (2.70-11.08); p<0.001]. In particular, among patients who preferred symptom-directed, comfort EoL care, immigrants as opposed to non-immigrants were more likely to have poor QoD [AOR 9.53, 95%CI (4.05-22.40); p<0.001]. Conclusions: Immigrants, as compared to non-immigrants, are more likely to die in hospital settings, less likely to die at their preferred location, and more likely to have poor QoD. These findings are consistent with previously described inequities in EoL care of immigrants and highlight the importance of determining the potential causes and solutions to ensure immigrants receive values-congruent care.[Table: see text]

Associations Between Hospice Care and Scary Family Caregiver Experiences

CONTEXT

Hospice deaths in the U.S. are increasing. Dying hospice patients may have rapidly emerging needs the hospice team cannot immediately meet, exposing family caregivers to fright-inducing (i.e., scary) situations.

OBJECTIVES

To examine relationships between hospice care and family caregiver exposures and psychological responses to witnessing common and distressing patient symptoms near the end of life.

METHODS

Secondary analysis of prospective cohort study of 169 patients with advanced cancer and their family caregivers was analyzed. Multivariable regression analyses modeled associations between hospice use and caregiver exposures and psychological responses (fear and helplessness) to witnessing distressing symptoms common near death, adjusting for potential confounding influences (e.g., home death, patient characteristics, and suffering). Caregiver self-reported exposures and responses to observing patient symptoms during the last month of life were assessed using the validated Stressful Caregiving Response to Experiences of Dying (SCARED) scale.

RESULTS

Hospice care was significantly positively associated with more exposures and negative psychological responses to distressing patient symptoms, adjusting for home death, patient characteristics, and physical and mental suffering. On average, hospice patients' caregivers scored 1.6 points higher on the SCARED exposure scale and 6.2 points higher on the SCARED psychological response scale than caregivers of patients without hospice (exposure: 10.53 vs. 8.96; psychological responses: 29.85 vs. 23.67). Patient pain/discomfort, delirium, and difficulty swallowing/choking were reported by three-fourths of caregivers and associated with the most fear and helplessness among caregivers.

CONCLUSION

Hospice care is associated with more exposures to and caregiver fear and helplessness in response to scary patient experiences. Research is needed to understand how better to support family caregivers of hospice patients to enable them to cope with common distressing symptoms of dying cancer patients. Hospice clinicians providing additional education and training about these symptoms might enable caregivers to better care for dying loved ones and reduce the stresses of end-of-life caregiving.

The Role of Advance Care Planning in Cancer Patient and Caregiver Grief Resolution: Helpful or Harmful?

Simple Summary

Grief is a common emotion felt by advanced cancer patients and their family caregivers, yet little is known of the relationship between grief in patients and caregivers, how grief in patients and caregivers changes as patients get closer to death, and the way advance care planning (ACP) relates to grief in both members of this “care pair.” In a sample of advanced cancer patients and caregivers, we found their grief tended to be synchronized and that, on average, patients’ grief remained stable whereas caregivers’ grief declined. Further, results revealed that completion of a living will (LW) for the patient increased levels of patient grief, while completion of a do-not-resuscitate (DNR) order decreased levels of caregiver grief. Results suggest that grieving may be synchronized between patients and caregivers and that while ACP may promote grief resolution for family caregivers, it is evocative of grief for patients.

Abstract

Cancer patients and their family caregivers experience various losses when patients become terminally ill, yet little is known about the grief experienced by patients and caregivers and factors that influence grief as patients approach death. Additionally, few, if any, studies have explored associations between advance care planning (ACP) and grief resolution among cancer patients and caregivers. To fill this knowledge gap, the current study examined changes in grief over time in patients and their family caregivers and whether changes in patient grief are associated with changes in caregiver grief. We also sought to determine how grief changed following the completion of advance directives. The sample included advanced cancer patients and caregivers (n = 98 dyads) from Coping with Cancer III, a federally funded, multi-site prospective longitudinal study of end-stage cancer care. Participants were interviewed at baseline and at follow-up roughly 2 months later. Results suggest synchrony, whereby changes in patient grief were associated with changes in caregiver grief. We also found that patients who completed a living will (LW) experienced increases in grief, while caregivers of patients who completed a do-not-resuscitate (DNR) order experienced reductions in grief, suggesting that ACP may prompt “grief work” in patients while promoting grief resolution in caregivers.

Suffering and Symptoms At the End of Life in ICU Patients Undergoing Renal Replacement Therapy

BACKGROUND

We know little about the end-of-life suffering and symptoms of intensive care unit (ICU) decedents in general and those who undergo renal replacement therapy (RRT) in particular.

OBJECTIVES

To examine differences in end-of-life suffering and various symptoms' contribution to suffering between ICU decedents who did not undergo RRT, those who underwent RRT for end-stage kidney disease (ESKD), and those who underwent RRT for acute kidney injury (AKI).

METHODS

This is a cross-sectional study conducted at a quaternary-level referral hospital September 2015-March 2017. Nurses completed interviews about ICU patients' suffering and symptoms in their final week. We dichotomized overall suffering into elevated and non-elevated and each symptom as contributing or not to a patient's suffering.

RESULTS

Sixty-four nurses completed interviews on 165 patients. Median patient age was 67 years (interquartile range 57, 78); 41% were female. In a multivariable model, undergoing RRT for AKI (odds ratio [OR] 2.95, 95% confidence interval [CI] 1.34-6.49) was significantly associated with elevated suffering compared to no RRT; undergoing RRT for ESKD was not. Adjusting for length of stay, AKI-RRT patients were more likely than non-RRT patients to have fecal incontinence (OR 2.21, 95% CI 1.00-4.93), painful broken skin (OR 2.41, 95% CI 1.14-5.12), and rashes (OR 3.61, 95% CI 1.35-9.67) contributing to their suffering.

CONCLUSIONS

Undergoing RRT for AKI was associated with elevated suffering in the last week of life in ICU decedents. Painful broken skin, rashes, and fecal incontinence were more likely to contribute to suffering in AKI-RRT patients than in non-RRT patients. How to reduce suffering associated with AKI-RRT in ICU patients merits further study.

Validation of the new DSM-5-TR criteria for prolonged grief disorder and the PG-13-Revised (PG-13-R) scale

Although the concept of pathological grief dates back at least as far as Freud's "Mourning and Melancholia", there has been opposition to its recognition as a distinct mental disorder. Resistance has been overcome by evidence demonstrating that distinctive symptoms of prolonged grief disorder (PGD) - an attachment disturbance featuring yearning for the deceased, loss of meaning and identity disruption - can endure, prove distressing and disabling, and require targeted treatment. In acknowledgement of this evidence, the American Psychiatric Association Assembly has recently voted to include PGD as a new mental disorder in the DSM-5-TR. We tested the validity of the new DSM criteria for PGD and of an adapted version of our PG-13 scale, the PG-13-Revised (PG-13-R), designed to map onto these criteria, using data from investigations conducted at Yale University (N=270), Utrecht University (N=163) and Oxford University (N=239). Baseline assessments were performed at 12-24 months post-loss; follow-up assessments took place 5.3-12.0 months later. Results indicated that the PG-13-R grief symptoms represent a unidimensional construct, with high degrees of internal consistency (Cronbach's alpha = 0.83, 0.90 and 0.93, for Yale, Utrecht and Oxford, respectively). The DSM PGD diagnosis was distinct from post-traumatic stress disorder (phi=0.12), major depressive disorder (phi=0.25) and generalized anxiety disorder (phi=0.26) at baseline. Temporal stability was remarkable for this diagnosis (r=0.86, p<0.001). Kappa agreement between a PG-13-R threshold symptom summary score of 30 and the DSM symptom criterion for PGD was 0.70-0.89 across the datasets. Both the DSM PGD diagnosis and the PG-13-R symptom summary score at baseline were significantly associated (p<0.05) with symptoms and diagnoses of major depressive disorder, post-traumatic stress disorder and/or generalized anxiety disorder, suicidal ideation, worse quality of life and functional impairments at baseline and at follow-up, in the Yale, Utrecht and Oxford datasets. Overall, the DSM-5-TR criteria for PGD and the PG-13-R both proved reliable and valid measures for the classification of bereaved individuals with maladaptive grief responses.

Naltrexone treatment for prolonged grief disorder: study protocol for a randomized, triple-blinded, placebo-controlled trial

BACKGROUND

There is a lack of effective pharmacotherapy for prolonged grief disorder (PGD). Evidence suggests that the neurobiology of PGD involves the same circuitry as the reward pathway. Based upon this evidence, we hypothesize that PGD can be conceptualized as a disorder of addiction and therefore could benefit from being treated with medications that are currently used to treat such disorders. One such medication is naltrexone, which is currently used to treat alcohol and opioid dependence. Oral naltrexone was chosen for its mechanism of action, safety, and convenience. The primary aim of this study is to establish the efficacy of using oral naltrexone as a pharmacological treatment for PGD. Specifically, we hypothesize that participants receiving naltrexone will demonstrate reduced PGD symptoms when compared to placebo.

METHODS/DESIGN

This is a randomized, placebo-controlled, triple-blinded (to healthcare professionals/study staff, participants, and data analysts) study in which we propose to enroll 48 participants who meet criteria for Prolonged Grief Disorder (PGD). Participants will be randomly assigned to the naltrexone 50 mg oral arm or placebo arm; medications will be over-encapsulated to appear identical. Participants will take their assigned medication for 8 weeks, with clinic visits every 4 weeks to assess symptom severity, social closeness, and adverse reactions. Weekly surveys of Prolonged Grief-13-Revised (PG-13-R) will be used to relate naltrexone use to changes in PGD symptom severity. Follow-up 4 weeks after their last visit will assess the longevity of treatment, as well as any lingering adverse reactions.

DISCUSSION

This study is the first to investigate the use of oral naltrexone as pharmacological treatment for PGD. The acute and debilitating nature of the disorder, in addition to the increased risk of comorbidities, highlights the need for pharmacological treatment like naltrexone that can act more rapidly, may help those for whom psychotherapy may not be effective, and/or may augment psychotherapy to promote PGD symptom grief resolution.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04547985 . Registered on 8/31/2020.

History and Status of Prolonged Grief Disorder as a Psychiatric Diagnosis

Prolonged grief disorder (PGD) is a diagnostic entity now included in the International Classification of Diseases 11th Revision (ICD-11) and soon to appear in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR). A characteristic feature of PGD is distressing, disabling yearning that persists a year or more after the loss. Other characteristic symptoms include disbelief and lack of acceptance of the loss, emotional detachment from others since the loss, loneliness, identity disturbance, and sense of meaninglessness. In this review, we detail psychiatric views on grief and their evolution over the twentieth century. We then discuss the development of diagnostic formulations for disordered grief, which culminated in PGD's status as a mental disorder in the DSM. After summarizing recent evidence that may suggest that PGD is linked to the neural reward system, we suggest further areas of research. In particular, we note the need for studies that extend the evidence base concerning PGD across cultural and sociodemographic boundaries and that investigate novel treatments.

The neurobiological reward system in Prolonged Grief Disorder (PGD): A systematic review

Prolonged Grief Disorder (PGD) is a debilitating condition affecting between 7% and 10% of bereaved individuals. Past imaging and psychological studies have proposed links between PGD's characteristic symptoms - in particular, profound yearning - and the neural reward system. We conducted a systematic review to investigate this connection. On December 19, 2019, we searched six bibliographic databases for data on the neurobiology of grief and disordered grief. We excluded studies of the hypothalamic-pituitary-adrenal (HPA) axis, animal studies, and reviews. After abstract and full-text screening, twenty-four studies were included in the final review. We found diverse evidence for the activation of several reward-related regions of the brain in PGD. The data reviewed suggest that compared to normative grief, PGD involves a differential pattern of activity in the amygdala and orbitofrontal cortex (OFC); likely differential activity in the posterior cingulate cortex (PCC), rostral or subgenual anterior cingulate cortex (ACC), and basal ganglia overall, including the nucleus accumbens (NAc); and possible differential activity in the insula. It also appears that oxytocin signaling is altered in PGD, though the exact mechanism is unclear. Our findings appear to be consistent with, though not confirmative of, conceptualizing PGD as a disorder of reward, and identify directions for future research.

Advanced Cancer Patients' Changes in Accurate Prognostic Understanding and Their Psychological Well-Being

CONTEXT

Clinicians often worry that patients' recognition of the terminal nature of their illness may impair psychological well-being.

OBJECTIVES

To determine if such recognition was associated with decrements to psychological well-being that persisted over time.

METHODS

About 87 patients with advanced cancer, with an oncologist-expected life expectancy of less than six months, were assessed before and after an oncology visit to discuss cancer restaging scan results and again at follow-up (median time between assessments, approximately six weeks). Prognostic understanding (PU) was assessed at previsit and postvisit, and a change score was computed. Psychological well-being was assessed at pre, post, and follow-up, and two change scores were computed (post minus pre; follow-up minus post).

RESULTS

Changes toward more accurate PU was associated with a corresponding initial decline in psychological well-being (r = -0.33; P < 0.01) but thereafter was associated with subsequent improvements (r = 0.40; P < 0.001). This pattern remained controlling for potential confounds. Patients showed different patterns of psychological well-being change (F = 3.07, P = 0.05; F = 6.54, P < 0.01): among patients with improved PU accuracy, well-being initially decreased but subsequently recovered; by contrast, among patients with stable PU accuracy, well-being remained relatively unchanged, and among patients with decrements in PU accuracy, well-being initially improved but subsequently declined.

CONCLUSION

Improved PU may be associated with initial decrements in psychological well-being, followed by patients rebounding to baseline levels. Concerns about lasting psychological harm may not need to be a deterrent to having prognostic discussions with patients.

Validation of the prolonged grief scale (PG-13) and investigation of the prevalence and risk factors of prolonged grief disorder in Turkish bereaved samples

The aim of this study was to validate the Turkish version of the Prolonged Grief Scale (PG-13) and to determine the prevalence and predictors of prolonged grief disorder (PGD). Data were gathered from two independent samples of 306 (Study 1) and 271 (Study 2) bereaved adults to determine if findings in one sample could be replicated in the other. The results supported the one-factor structure of PG-13. PGD prevalence rates were 11.4% in Study 1 and 10% in Study 2. Lower level meaning reconstruction and unnatural cause of death were found as risk factors for the PGD diagnosis in both studies.

Underdetection and Undertreatment of Dyspnea in Critically Ill Patients

Rationale: Dyspnea is a common and distressing physical symptom among patients in the ICU and may be underdetected and undertreated. Objectives: To determine the frequency of dyspnea relative to pain, the accuracy of nurses and personal caregiver dyspnea ratings relative to patient-reported dyspnea, and the relationship between nurse-detected dyspnea and treatment. Methods: This was an observational study of patients (n = 138) hospitalized in a medical ICU (MICU). Nurses and patients' personal caregivers at the bedside reported on their perception of patients' symptoms. Measurements and Main Results: Dyspnea was assessed by patients, caregivers, and nurses with a numerical rating scale. Across all three raters, the frequency of moderate to severe dyspnea was similar or greater than that of pain (P < 0.05 for caregiver and nurse ratings). Personal caregivers' ratings of dyspnea had substantial agreement with patient ratings (κ = 0.65, P < 0.001), but nurses' ratings were not significantly related to patient ratings (κ = 0.19, P = 0.39). Nurse detection of moderate to severe pain was significantly associated with opioid treatment (odds ratio, 2.70; 95% confidence interval, 1.10-6.60; P = 0.03); however, nurse detection of moderate to severe dyspnea was not significantly associated with any assessed treatment. Conclusions: Dyspnea was reported at least as frequently as pain among the sampled MICU patients. Personal caregivers had good agreement with patient reports of moderate to severe dyspnea. However, even when detected by nurses, dyspnea appeared to be undertreated. These findings suggest the need for improved detection and treatment of dyspnea in the MICU.

Timing is everything: Early do-not-resuscitate orders in the intensive care unit and patient outcomes

Background

The use of Do-Not-Resuscitate (DNR) orders has increased but many are placed late in the dying process. This study is to determine the association between the timing of DNR order placement in the intensive care unit (ICU) and nurses’ perceptions of patients’ distress and quality of death.

Methods

200 ICU patients and the nurses (n = 83) who took care of them during their last week of life were enrolled from the medical ICU and cardiac care unit of New York Presbyterian Hospital/Weill Cornell Medicine in Manhattan and the surgical ICU at the Brigham and Women’s Hospital in Boston. Nurses were interviewed about their perceptions of the patients’ quality of death using validated measures. Patients were divided into 3 groups—no DNR, early DNR, late DNR placement during the patient’s final ICU stay. Logistic regression analyses modeled perceived patient quality of life as a function of timing of DNR order placement. Patient’s comorbidities, length of ICU stay, and procedures were also included in the model.

Results

59 patients (29.5%) had a DNR placed within 48 hours of ICU admission (early DNR), 110 (55%) placed after 48 hours of ICU admission (late DNR), and 31 (15.5%) had no DNR order placed. Compared to patients without DNR orders, those with an early but not late DNR order placement had significantly fewer non-beneficial procedures and lower odds of being rated by nurses as not being at peace (Adjusted Odds Ratio namely AOR = 0.30; [CI = 0.09–0.94]), and experiencing worst possible death (AOR = 0.31; [CI = 0.1–0.94]) before controlling for procedures; and consistent significance in severe suffering (AOR = 0.34; [CI = 0.12–0.96]), and experiencing a severe loss of dignity (AOR = 0.33; [CI = 0.12–0.94]), controlling for non-beneficial procedures.

Conclusions

Placement of DNR orders within the first 48 hours of the terminal ICU admission was associated with fewer non-beneficial procedures and less perceived suffering and loss of dignity, lower odds of being not at peace and of having the worst possible death.

"My doctor says the cancer is worse, but I believe in miracles"-When religious belief in miracles diminishes the impact of news of cancer progression on change in prognostic understanding

BACKGROUND

News of cancer progression is critical to setting accurate prognostic understanding, which guides patients' treatment decision making. This study examines whether religious belief in miracles modifies the effect of receiving news of cancer progression on change in prognostic understanding.

METHODS

In a multisite, prospective cohort study, 158 patients with advanced cancer, whom oncologists expected to die within 6 months, were assessed before and after the visit at which scan results were discussed. Before the visit, religious belief in miracles was assessed; after the visit, patients indicated what scan results they had received (cancer was worse vs cancer was stable, better, or other). Before and after the visit, prognostic understanding was assessed, and a change score was computed.

RESULTS

Approximately 78% of the participants (n = 123) reported at least some belief in miracles, with almost half (n = 73) endorsing the strongest possible belief. A significant interaction effect emerged between receiving news of cancer progression and belief in miracles in predicting change in prognostic understanding (b = -0.18, P = .04). Receiving news of cancer progression was associated with improvement in the accuracy of prognostic understanding among patients with weak belief in miracles (b = 0.67, P = .007); however, among patients with moderate to strong belief in miracles, news of cancer progression was unrelated to change in prognostic understanding (b = 0.08, P = .64).

CONCLUSIONS

Religious belief in miracles was highly prevalent and diminished the impact of receiving news of cancer progression on prognostic understanding. Assessing patients' beliefs in miracles may help to optimize the effectiveness of "bad news" scan result discussions.

Palliative Chemotherapy or Radiation and Prognostic Understanding among Advanced Cancer Patients: The Role of Perceived Treatment Intent

Background: As patients' accurate understanding of their prognosis is essential for informed end-of-life planning, identifying associated factors is important. Objective: We examine if receiving palliative chemotherapy or radiation, and the perception of those treatments as curative or noncurative, is associated with prognostic understanding. Design: Cross-sectional analyses from a multisite, observational study. Setting/Subjects: Patients with advanced cancers refractory to at least one chemotherapy regimen (N = 334). Measurements: In structured interviews, patients reported whether they were receiving chemotherapy or radiation, and whether its intent was curative or not. Their responses were categorized into three groups: patients not receiving chemotherapy/radiation (no cancer treatment group); patients receiving chemotherapy/radiation and misperceiving it as curative (treatment misperception group); and patients receiving chemotherapy/radiation and accurately perceiving it as noncurative (accurate treatment perception group). Patients also reported on various aspects of their prognostic understanding (e.g., life expectancy). Results: Eighty-six percent of the sample was receiving chemotherapy or radiation; of those, 16.7% reported the purpose of treatment to be curative. The no-treatment group had higher prognostic understanding scores compared with the treatment misperception group (adjusted odds ratio [AOR] = 5.00, p < 0.001). However, the accurate treatment perception group had the highest prognostic understanding scores in comparison to the no-treatment group (AOR = 2.04, p < 0.05) and the treatment misperception group (AOR = 10.19, p < 0.001). Conclusions: Depending on patient perceptions of curative intent, receipt of palliative chemotherapy or radiation is associated with better or worse prognostic understanding. Research should examine if enhancing patients' understanding of treatment intent can improve accurate prognostic expectations.

Latino Ethnicity, Immigrant Status, and Preference for End-of-Life Cancer Care

Background: Little is known about how immigration status influences preference for life-extending care (LEC) at the end of life (EoL). Objective: The purpose was to determine how preference for LEC at the EoL for advanced cancer patients varied by Latino ethnicity and immigrant status, and over time between two large cohorts. Methods: Data were derived from two sequential multi-institutional, longitudinal cohort studies of advanced cancer patients, recruited from 2002 to 2008 (coping with cancer I [CwC-1]) and 2010 to 2015 (coping with cancer II [CwC-2]). Self-reported U.S.-born whites (whites) (N = 253), U.S.-born Latinos (US-L) (N = 34), and Latino immigrants (LI) (N = 65) with a poor-prognosis cancer were included. The primary independent variables were immigrant status, Latino ethnicity, and CwC cohort. The primary dependent variable was preference for LEC. Results: Within CwC-2, LI were 9.4 times more likely to prefer LEC over comfort care versus US-L (adjusted odds ratio [AOR] = 9.4; 95% confidence interval [CI]: 1.2-72.4), and US-L were 0.3 times less likely to prefer LEC versus whites (AOR = 0.3; 95% CI: 0.1-1.0). LI from CwC-2 were 11.4 times more likely to prefer LEC versus LI from CwC-1 (AOR = 11.4; 95% CI: 2.7-48.4). Within CwC-1, there was no difference in LEC preference between LI and US-L, nor between US-L and whites. Conclusions: Immigrant status had a strong effect on preference for LEC at the EoL among the more recent cohort of Latino cancer patients. Preference for LEC appears to have increased significantly over time for LI but remained unchanged for US-L. LI may increasingly want LEC near death.

Effects of the Values and Options in Cancer Care Communication Intervention on Personal Caregiver Experiences of Cancer Care and Bereavement Outcomes

Background: Care teams are increasingly expected to attend to the needs of patient's personal caregivers (e.g., family members). Improving communication among oncologists, patients with advanced cancer, and their personal caregivers might enhance caregivers' experiences of end-of-life (EoL) cancer care and bereavement outcomes. Objective: To explore the effects of the Values and Options in Cancer Care intervention on caregivers' experiences of EoL care and bereavement outcomes. Design: We developed a brief behavioral intervention to improve communication among oncologists, patients with advanced cancer, and their personal caregivers. The intervention was designed to help patients/caregivers ask questions, express concerns, and help oncologists respond effectively. We randomly assigned oncologists (and their patients/caregivers) to the intervention or usual care. Setting/Subjects: Medical oncologists in NY and CA; patients/personal caregivers with advanced cancer. Measurements: Two months after the patient's death, caregivers completed three instruments assessing their experiences of EoL care. Seven months after the patient's death, caregivers completed the Prolonged Grief Disorder-13 (PG-13; primary prespecified outcome), the Purpose-in-Life scale, and scales assessing mental health function, depression, and anxiety. Results: The intervention did not significantly improve caregivers' scores on the PG-13 (p = 0.21), mental health function, depression, or anxiety, but it did improve purpose-in-life scores (p = 0.018). Cohen's d (95% confidence interval) for all three experiences of EoL care outcomes were promising, ranging from 0.22 (-0.19 to 0.63) to 0.39 (-0.07 to 0.86) although none was statistically significant. Conclusion: Preliminary findings show promise that scalable interventions in cancer care settings may improve caregiver experiences with cancer care and some bereavement outcomes.

The Stability of Treatment Preferences Among Patients With Advanced Cancer

CONTEXT

Stability of patients' treatment preferences has important implications for decisions about concurrent and future treatment.

OBJECTIVES

To examine the stability of treatment preferences and correlates among patients with advanced cancer.

METHODS

In this cohort, 104 patients with metastatic cancer, progression after at least one chemotherapy regimen, and an oncologist-estimated life expectancy of six or fewer months participated in structured interviews after clinical visits in which patients' recent scan results were discussed. Interviews were repeated in three monthly follow-ups. At baseline, patients' age, education, sex, race, marital status, insurance status, and type of cancer were documented. At each assessment, patients reported their treatment preferences (i.e., prioritizing life-prolonging vs. comfort), quality of life, and current health status.

RESULTS

At baseline (n = 104), 55 (53%) patients preferred life-prolonging care and 49 (47%) preferred comfort care. Patients were followed up for one (n = 104), two (n = 74), or three months (n = 44). Between baseline and Month 1, 84 patients (81%) had stable preferences. During follow-up, preferences of 71 patients (68%) remained stable (equally divided between a consistent preference for life-prolonging and comfort care). Treatment preferences of 33 (32%) patients changed at least once during follow-up. Direction of change was inconsistent. Patients' preferences at baseline strongly predicted preferences at Month 1 (odds ratio = 17.8; confidence interval = 6.7-47.3; P < .001). Description of the current health status at baseline was the only variable significantly associated with stability of preferences at Month 1.

CONCLUSION

Two-thirds of patients with advanced cancer had stable preferences. Changes of preferences were often inconsistent and unpredictable. Our findings suggest potential benefits of ongoing communication about preferences.

Advanced cancer patients’ changes in terminal illness understanding (TIU) and their psychological well-being

11617

Background: Although accurate TIU is necessary for informed treatment decision-making, clinicians worry that patients’ recognition of the terminal nature of their illness may lower psychological well-being. This study examines if such recognition is associated with lowered psychological well-being, that persists over time. Methods: Data came from 87 advanced cancer patients, with a life expectancy of less than 6 months. Patients were assessed pre and post an oncology visit to discuss cancer restaging scan results, and again one month later (follow-up). TIU was assessed at pre and post as the sum of four indicator variables — understanding of terminal nature of illness, curability, stage, and life-expectancy — and a TIU change score was computed (post minus pre). Psychological well-being (psychological symptoms subscale, McGill questionnaire) was assessed at pre, post, and follow-up, and two change scores were computed (post minus pre; follow-up minus post). Results: Changes toward more accurate TIU was associated with a corresponding decline in psychological well-being ( r = -0.33, p < .01), but thereafter was associated with subsequent improvements in psychological well-being ( r = .40, p < .001). This pattern persisted even after adjustment for relevant demographic factors, prognostic discussion, scan results, and physical well-being change. TIU change scores ranged from positive to negative, with some participants showing improvements in TIU ( n = 19), some showing decrements in TIU ( n = 14), and others showing stable TIU ( n = 54). Among patients with improved TIU, psychological well-being initially decreased, but subsequently recovered [7.03 (2.23) to 6.30 (1.80), to 7.63 (2.08)]; the stable TIU group showed relatively unchanged well-being [7.34 (2.37) to 7.45 (2.32), to 7.36 (2.66)], and the less accurate TIU group showed an initial improvement followed by a subsequent decline [6.30 (2.62) to 7.36 (2.04), to 5.63 (3.40)]. Conclusions: Improved TIU may be associated with initial decrements in psychological well-being, followed by patients rebounding to baseline levels. Concerns about psychological harm may not need to be a deterrent to having prognostic discussions with patients.

A scale to assess religious beliefs in end-of-life medical care

BACKGROUND

Studies postulate that certain religious beliefs related to medical care influence the end-of-life (EOL) medical decision making and care of patients with advanced cancer. Because to the best of the authors' knowledge no current measure explicitly assesses such beliefs, in the current study the authors introduced and evaluated the Religious Beliefs in EOL Medical Care (RBEC) scale, a new measure designed to assess religious beliefs within the context of EOL cancer care.

METHODS

The RBEC scale consists of 7 items designed to reflect religious beliefs in EOL medical care. Its psychometric properties were evaluated in a sample of 275 patients with advanced cancer from the Coping With Cancer II study, a National Cancer Institute-funded, multisite, longitudinal, observational study of communication processes and outcomes in EOL cancer care.

RESULTS

The RBEC scale proved to be internally consistent (Cronbach α, .81), unidimensional, positively associated with other indicators of patients' religiousness and spirituality (establishing its convergent validity), and inversely associated with patients' terminal illness understanding and acceptance (establishing its criterion validity), suggesting its potential clinical usefulness in promoting informed EOL decision making. The majority of patients (87%) reported some ("somewhat," "quite a bit," or "a great deal") endorsement of at least 1 RBEC item and a majority (62%) endorsed ≥3 RBEC items.

CONCLUSIONS

The RBEC scale is a reliable and valid tool with which to assess religious beliefs within the context of EOL medical care, beliefs that frequently are endorsed and inversely associated with terminal illness understanding.

Associations between Anxiety, Poor Prognosis, and Accurate Understanding of Scan Results among Advanced Cancer Patients

Background: Routine imaging ("scan") results contain key prognostic information for advanced cancer patients. Yet, little is known about how accurately patients understand this information, and whether psychological states relate to accurate understanding. Objective: To determine if patients' sadness and anxiety, as well as results showing poorer prognosis, are associated with patients' understanding of scan results. Design: Archival contrasts performed on multi-institutional cohort study data. Subjects: Advanced cancer patients whose disease progressed after at least one chemotherapy regimen (N = 94) and their clinicians (N = 28) were recruited before an oncology appointment to discuss routine scan results. Measurements: In preappointment structured interviews, patients rated sadness and anxiety about their cancer. Following the appointment, patients and clinicians reported whether the imaging results discussed showed progressive, improved, or stable disease. Results: Overall, 68% of patients reported their imaging results accurately, as indicated by concordance with their clinician's rating. Accuracy was higher among patients whose results indicated improved (adjusted odds ratio [AOR] = 4.12, p = 0.02) or stable (AOR = 2.59, p = 0.04) disease compared with progressive disease. Patients with greater anxiety were less likely to report their imaging results accurately than those with less anxiety (AOR = 0.09, p = 0.003); in contrast, those with greater sadness were more likely to report their results accurately than those with less sadness (AOR = 5.23, p = 0.03). Conclusions: Advanced cancer patients with higher anxiety and those with disease progression may need more help understanding or accepting their scan results than others.

Perceiving hope from oncologists and prognostic understanding and treatment planning

21

Background: Offering hope during prognostic discussions is widely considered essential to the delivery of humane medical care. However, clinicians always offering hope may undermine realism in patients' prognostic understanding and preparation for what lies ahead. We examine how patients’ perceptions of their oncologists as always offering hope, compared to a more tempered sense of hope, relate to prognostic understanding and treatment planning. Methods: Data came from post-scan baseline assessments of an NCI funded multi-site study on prognostic communication among metastatic cancer patients’ refractory to at least one chemotherapy regimen. The analytic sample consisted of 235 participants, who during structured interviews, rated the question, “how often does your oncologist offer hope,” as “always,” “most of the time” or “sometimes.” A binary variable was created comparing participants endorsing “always” to participants endorsing “most of the time” or “sometimes.” Patients also reported on elements of prognostic understanding, DNR order completion, and preference for either life-extending or comfort care. Results: Patients who rated their oncologists as “always” offering hope (62.1%), compared to those who rated “most of the time” or “sometimes” (37.9%), were more likely to have inaccurate prognostic understanding regarding life-expectancy ( OR = 0.40; 95% CI, 0.16, 0.97), and marginally more likely to have a treatment preference that favored life-extending care over comfort care ( OR = 0.61; 95% CI, 0.35, 1.07). A significant moderation effect was seen ( b = -1.43, p = .04) such that accurate understanding of the incurability of their cancer was associated with DNR completion only among patients who perceived more tempered hope from oncologists ( OR = 5.53; 95% CI, 1.80, 17.02), and not among patients who always perceived hope ( OR = 1.32; 95% CI, 0.63, 2.78). Conclusions: Results suggest that the tempering of hope may have benefits, as perceiving oncologists as always offering hope was associated with worse prognostic understanding and lower advance care planning. Future research examining in a more nuanced way the nature of hope offered (e.g., hope for cure vs. symptom management) in longitudinal designs is needed.

How much time is left? Associations between estimations of patient life expectancy and quality of life in patients and caregivers

PURPOSE

It is unclear whether life-expectancy estimates of patients with advanced cancer and their caregivers are associated with patient existential, social, or emotional quality of life (QOL) or caregiver emotional QOL.

METHODS

Patients with advanced cancer and their caregivers (n = 162 dyads) reported estimates of the chance the patient would live for 2 years or more from 0% (most pessimistic) to 100% (most optimistic). They also completed self-report measures of QOL.

RESULTS

Adjusting for sociodemographic confounds and multiple comparisons, more pessimistic caregiver and patient life-expectancy estimates were associated with worse caregiver emotional QOL and worse patient existential QOL. Discrepancies between patient and caregiver estimates were not associated with patient or caregiver QOL.

CONCLUSIONS

Pessimistic life-expectancy estimates are associated with worse existential QOL in patients and worse emotional QOL in caregivers. Prospective research to establish causal relationships is needed, and interventions to address the relationship between beliefs about life expectancy and existential and emotional QOL should be considered. Providing these interventions to patients and caregivers receiving information on life expectancy may mitigate the negative impact of life-expectancy information on patient existential quality of life.

Impact of Immigrant Status on Aggressive Medical Care Counter to Patients' Values Near Death among Advanced Cancer Patients

BACKGROUND

Little is known about disparities in end-of-life (EoL) care between U.S. immigrants and nonimmigrants.

OBJECTIVE

To determine immigrant/nonimmigrant advanced cancer patient differences in receipt of values-inconsistent aggressive medical care near the EoL.

DESIGN

Analysis of data from Coping with Cancer, a federally funded, prospective, multi-institutional cohort study of advanced cancer patients with limited life expectancies recruited from 2002 to 2008.

SETTING/SUBJECTS

U.S. academic medical center and community-based clinics. Self-reported immigrant (n = 41) and nonimmigrant (n = 261) advanced cancer patients with poor prognoses who died within the study observation period.

MEASUREMENTS

The primary independent/predictor variable was patient immigrant status. Primary outcome variables: (1) aggressive medical care near death, operationalized as the use of mechanical ventilation, resuscitation, feeding tube, and/or antibiotics in the last week of life and (2) receipt of values inconsistent aggressive care, operationalized as receiving aggressive care inconsistent with stated preferences for comfort-focused EoL care.

RESULTS

In a propensity-weighted sample (N = 302), in which immigrant and nonimmigrant groups were weighted to be demographically similar, immigrants were significantly more likely than nonimmigrants to receive aggressive medical care [OR 1.9; 95% CI (1.0-3.6); p = 0.042] and values-inconsistent aggressive medical care [OR 2.1; 95% CI (1.1-4.2); p = 0.032] near death.

CONCLUSIONS

Immigrant, as compared with nonimmigrant, advanced cancer patients are not only more likely to receive aggressive EoL care, but also more likely to receive care counter to their wishes. These findings indicate potential disparities in, rather than differences in preference for, aggressive care and a need for further investigation into potential causes of these disparities.

Beyond Pain: Nurses' Assessment of Patient Suffering, Dignity, and Dying in the Intensive Care Unit

CONTEXT

Deaths in the intensive care unit (ICU) are increasingly common in the U.S., yet little is known about patients' experiences at the end of life in the ICU.

OBJECTIVES

The objective of this study was to determine nurse assessment of symptoms experienced, and care received by ICU patients in their final week, and their associations with nurse-perceived suffering and dignity.

METHODS

From September 2015 to March 2017, nurses who cared for 200 ICU patients who died were interviewed about physical and psychosocial dimensions of patients' experiences. Medical chart abstraction was used to document baseline patient characteristics and care.

RESULTS

The patient sample was 61% males, 70.2% whites, and on average 66.9 (SD 15.1) years old. Nurses reported that 40.9% of patients suffered severely and 33.1% experienced severe loss of dignity. The most common symptoms perceived to contribute to suffering and loss of dignity included trouble breathing (44.0%), edema (41.9%), and loss of control of limbs (36.1%). Most (n = 9) remained significantly (P < 0.05) associated with suffering, after adjusting for physical pain, including fever/chills, fatigue, and edema. Most patients received vasopressors and mechanical ventilation. Renal replacement therapy was significantly (<0.05) associated with severe suffering (adjusted odds ratio [AOR] 2.53) and loss of dignity (AOR 3.15). Use of feeding tube was associated with severe loss of dignity (AOR 3.12).

CONCLUSION

Dying ICU patients are perceived by nurses to experience extreme indignities and suffer beyond physical pain. Attention to symptoms such as dyspnea and edema may improve the quality of death in the ICU.

Being present: oncologists' role in promoting advanced cancer patients' illness understanding

Realistic illness understanding is essential to an advanced cancer patient's ability to make informed medical decisions at the end of life. This study sought to determine whether advanced cancer patients better understood the late stage of their cancer if an oncologist, compared to other members of the care team, was present to discuss their scan results. Data were derived from a multi-institutional, longitudinal cohort study of patients recruited between 2010 and 2015. Patients (n = 209) with late-stage cancers (metastatic cancers that progressed after at least one chemotherapy regimen) were interviewed before and after clinic visits in which scan results were discussed. Patients reported pre- and postvisit if their cancer was at a late stage. Postvisit, patients reported if they discussed scan results with an oncologist or another oncology provider (i.e., oncology fellow, oncology resident, nurse practitioner, nurse, physician's assistant, or other). Logistic regression analysis was used to determine if the presence of an oncologist during scan results discussions differentially predicted the patients' likelihood of postvisit late-stage illness understanding (LSIU). Propensity weighting was used to correct for sociodemographic imbalances between groups, and previsit LSIU and the presence of multiple providers were controlled for in the logistic regression analyses. After propensity-weighted adjustment and controlling for previsit LSIU and the presence of multiple providers, patients were 2.6 times more likely (AOR = 2.6; 95% CI = 1.2, 6.0; P = 0.021) to report that their disease was late stage if an oncologist was present for the scan results discussion compared to if an oncologist was absent. The presence of an oncologist during scan results discussions was associated with a higher likelihood of patients acknowledging being in a late stage of their disease. These results suggest that oncologist involvement in scan results discussions is associated with advanced cancer patients having better prognostic understanding.

Chemotherapy Use, End-of-Life Care, and Costs of Care Among Patients Diagnosed With Stage IV Pancreatic Cancer

CONTEXT

For patients with metastatic cancer and limited life expectancy, potential benefits of chemotherapy must be balanced against harms to quality of life near death and increased out-of-pocket costs of care.

OBJECTIVES

To evaluate the association between chemotherapy use by patients with Stage IV pancreatic cancer and health care use and Medicare and out-of-pocket costs in the last 30 days of life.

METHODS

We conducted a retrospective cohort study of 3825 patients aged 66 years or older when diagnosed with Stage IV pancreatic cancer in 2006-2011, using the linked Surveillance, Epidemiology, and End Results-Medicare data. Using a propensity score matched sample, we examined associations between initiation of chemotherapy shortly after the metastatic diagnosis (and secondarily, continued chemotherapy use in the last 30 days of life) and health care use and costs (both Medicare payment and patient out-of-pocket costs) in the last 30 days of life.

RESULTS

Chemotherapy use was associated with increased rates of hospital admissions (45.0% vs. 29.2%, P < 0.001), emergency department visits (41.3% vs. 27.2%, P < 0.001), and death in a hospital (14.2% vs. 9.1%, P < 0.001); fewer days in hospice care (11.5 days vs. 15.7 days, P < 0.001); and more than 50% increase in patient out-of-pocket costs for care ($1311.5 vs. $841.0, P < 0.001) in the last 30 days of life. Among patients who initiated chemotherapy, more stark differences in these outcomes were found by whether patients received chemotherapy in the last 30 days of life.

CONCLUSION

Chemotherapy use among older patients diagnosed with metastatic pancreatic cancer was associated with substantially increased use of health care and higher patient out-of-pocket costs near death.

Bereavement Challenges and Their Relationship to Physical and Psychological Adjustment to Loss

OBJECTIVE

The psychosocial challenges confronted by bereaved survivors may contribute to poor bereavement adjustment. Measures of the challenges of bereavement are limited. This study is a preliminary examination of the factor structure of a new measure of bereavement challenges and their relationships to quality of life and mental illness in bereaved cancer caregivers. This measure was designed to identify intervention targets to reduce the likelihood of prolonged grief.

METHODS

Caregivers of advanced cancer patients were administered measures of bereavement challenges (Bereavement Challenges Scale, BCS), quality of life (Medical Outcomes Study Short Form-36), prolonged grief (PG-13), and mental disorders (Structured Clinical Interview for the DSM-IV). Principal component factor analyses identified the underlying factor structure of the BCS. We examined associations between the factors and caregiver quality of life, prolonged grief, and rates of mental disorders.

RESULTS

A factor analysis identified five factors: "Challenges with Connecting with Others," "Challenges with Change," "Challenges Imagining a Hopeful Future," "Challenges with Accepting the Loss," and "Challenges with Guilt." Greater endorsement of bereavement challenges was associated with worse quality of life, more severe symptoms of prolonged grief, and greater likelihood of meeting criteria for a mental disorder.

CONCLUSIONS

Assessing the challenges associated with bereavement is important to understanding barriers to bereaved individuals' adjustment. The five factors of the BCS point to potential targets for clinical intervention. Additional research on the BCS is needed, including validation in larger more diverse samples, and confirmation that reduction of these challenges is associated with less psychiatric morbidity and, specifically, symptoms of prolonged grief.

Prolonged, but not complicated, grief is a mental disorder

The DSM and ICD have taken steps to introduce a grief disorder as a new diagnostic entity. Evidence justifies the inclusion of prolonged grief disorder, but not complicated grief, as a new mental disorder.

Practice Patterns, Attitudes, and Barriers to Palliative Care Consultation by Gynecologic Oncologists

PURPOSE

We sought to describe practice patterns, attitudes, and barriers to the integration of palliative care services by gynecologic oncologists.

METHODS

Members of the Society of Gynecologic Oncology were electronically surveyed regarding their practice of incorporating palliative care services and to identify barriers for consultation. Descriptive statistics were used, and two-sample z-tests of proportions were performed to compare responses to related questions.

RESULTS

Of the 145 respondents, 71% were attending physicians and 58% worked at an academic medical center. The vast majority (92%) had palliative care services available for consultation at their hospital; 48% thought that palliative care services were appropriately used, 51% thought they were underused, and 1% thought they were overused. Thirty percent of respondents thought that palliative care services should be incorporated at first recurrence, whereas 42% thought palliative care should be incorporated when prognosis for life expectancy is ≤ 6 months. Most participants (75%) responded that palliative care consultation is reasonable for symptom control at any stage of disease. Respondents were most likely to consult palliative care services for pain control (53%) and other symptoms (63%). Eighty-three percent of respondents thought that communicating prognosis is the primary team's responsibility, whereas the responsibilities for pain and symptom control, resuscitation status, and goals of care discussions were split between the primary team only and both teams. The main barrier for consulting palliative care services was the concern that patients and families would feel abandoned by the primary oncologist (73%). Ninety-seven percent of respondents answered that palliative care services are useful to improve patient care.

CONCLUSION

The majority of gynecologic oncologists perceived palliative care as a useful collaboration that is underused. Fear of perceived abandonment by the patient and family members was identified as a significant barrier to palliative care consult.