bluuebunny/crossref_metadata_2025 huggingface dataset:
Diagnostic and prognostic awareness among patients with metastatic solid cancer in a public cancer center in Mexico.
Authors: Alcalde Castro Mirza , Chavarri Guerra Yanin , Ramos-Lopez Wendy Alicia , Covarrubias-Gómez Alfredo , Sanchez Sofia , Quiroz Paulina , Navarro-Lara Africa , Medina-Campos Andrea , Moreno-García María Luisa , Contreras-Garduño Sergio , Pérez-Montessoro Viridiana , Goss Paul E. , Soto Perez De Celis Enrique
Published: November 2018

42

Background: Patient awareness regarding diagnosis and prognosis may lead to improved treatment shared decision making and improve satisfaction with treatment choices. We assessed the diagnostic and prognostic awareness among newly diagnosed patients with metastatic solid tumors in a public cancer center in Mexico City. Methods: Patients with metastatic cancer enrolled in a randomized clinical trial of patient navigation to improve access to supportive care in a public cancer center in Mexico City (NCT03293849) were included. At baseline, demographic, social, and clinical characteristics were collected. Patients answered open-ended questions regarding knowledge about their diagnosis and prognosis, as well as on patient-physician communication. We analyzed prognostic and diagnostic awareness using descriptive statistics, and explored if patients reporting worse patient-physician communication were less aware of their diagnosis and prognosis. Results: 125 patients were included between 08/17 and 04/18. Median age was 61 years (range 23-93; 52% male); 88.8% lived in urban areas; 41.6% had less than high school education; and 57.6% were married or partnered. 61% had gastrointestinal, 14% genitourinary, and 25% other tumors. Although all patients had had at least one consultation with an oncologist, 3% did not know what their diagnosis was. 77% of patients considered they had prognostic awareness; however, only 14% considered that their disease had a bad prognosis, and 2% considered they could be cured. 6.5% of the patients believed the information given by their oncologist was insufficient, and 8% felt they had trouble getting information about their disease. We found no statistically significant relationship between perceived barriers to patient-physician communication and diagnostic (p = 0.28) or prognostic (p = 0.18) awareness. Conclusions: Although most patients understood their oncologic diagnosis, a significant proportion were unaware of their prognosis. Communication strategies, tailored to the specific characteristics of each patient population and aimed at improving prognostic awareness, are fundamental for optimal shared decision making.
Relationship between perceptions of treatment goals and psychological distress in patients with advanced cancer.
Authors: El-Jawahri Areej , Greer Joseph , Forst Deborah Anne , Nipp Ryan David , Waldman Lauren , Sereno Isabella , Temel Jennifer S.
Published: November 2018

44

Background: Several studies have demonstrated discordance between how patients perceive their goal of treatment versus how they perceive their oncologist’s goal. Studies evaluating the extent and risk factors of this discordance are lacking. Methods: We conducted a cross-sectional study of 559 patients with incurable lung, gastrointestinal, breast, and brain cancers. We used the Perception of Treatment and Prognosis Questionnaire to assess patients’ perceptions of both their treatment goal and their oncologist’s goal and categorized responses: 1) patients who reported that both their goal and their oncologist’s goal was concordant (either to cure or not to cure); and 2) patients who reported discordant perceptions of their goal versus their oncologist’s goal. We assessed patients’ psychological distress using the Hospital-Anxiety-and-Depression-Scale and used linear regression to assess the relationship between patients’ perceptions of their treatment goal and psychological outcomes. Results: 61.7% of patients reported that both their goal and their oncologist’s goal was non-curative; 19.3% reported that both their goal and their oncologist’s goal was to cure their cancer; and 19.0% reported discordance between their goal and their perception of the oncologist’s goal. Older age (OR = 0.98, P = 0.01), non-Hispanic ethnicity (OR = 0.31, P = 0.049), and higher education (OR = 0.62, P = 0.042) were associated with lower likelihood of reporting discordant goals. Patients with discordant perceptions of their goal and their oncologist’s goal reported higher anxiety (B = 1.56, P = 0.003) compared to those who reported that both their goal and their oncologist’s goal was curative. Patients who reported both their goal and the oncologist’s goal was non-curative had higher depression symptoms (B = 1.06, P = 0.013) compared to those who reported that both their goal and the oncologists’ goal was curative. Conclusions: One-fifth of patients with advanced cancer report discrepancies between their perceptions of their own and their oncologists’ treatment goal which is associated with psychological distress. Tools are needed to identify patients at risk of cognitive dissonance about their prognosis.
A randomized clinical trial of TrialTALK, a communication tool to facilitate treatment-related shared decision making.
Authors: Campbell Toby Christopher , Jasicki Mallory , Kwekkeboom Kristine L , Schwarze Margaret L , Zelenski Amy , Mast Kimberly
Published: November 2018

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Background: Cancer treatment decision making involves timely, high-risk, life altering shared decision-making conversations between patients, their families, and their oncologists. As such, these conversations are a prime target for a carefully designed, easy to interpret approach to facilitate preference-sensitive decision making. Patients need several important pieces of information delivered in a way that is easy to interpret. The TrialTALK approach has two core elements: a verbal approach and a pen and paper (P&P) diagram. The P&P diagram includes the diagnosis with prognostic implications, all available treatment options including best supportive care alone, estimates for efficacy, and anticipated impact on daily life. The verbal conversation corresponds to the diagram and includes a phrase to encourage deliberation, and empathic responses. Our trial is evaluating the effectiveness of TrialTALK to influence decision making, in particular clinical trial participation. Here, we report the results of the initial oncologist training. Methods: 28 oncologists volunteered to participate and were randomly assigned to control (Group A, n=13) or intervention (Group B, n=15). Oncologists in the intervention group each received two hours of training, including simulated conversations with feedback and optional 1:1 follow up for troubleshooting. At the conclusion of training, oncologists completed a video-recorded simulated encounter with an actor. Trainers reviewed P&P diagrams in real time and provided feedback. Results: We used a fidelity checklist to assess effectiveness of the training. We considered ≥ 14 points out of a possible 20 as an acceptable use of TrialTALK. The average score was 14.8 ± 2. Scores ranged 10-18. 12 of 15 intervention oncologists demonstrated adoption of the tool after 2 hours of training. Conclusions: Oncologist can effectively learn to use TrialTALK. The ongoing study will estimate preliminary efficacy of the TrialTALK intervention in regards to patient decision making and participation in clinical trials.
Improving communication about prognosis on an academic inpatient solid tumor oncology consult service.
Authors: Landry Chrystal Ann , Kessler Alaina J , Bhardwaj Aarti Sonia , Smith Cardinale B.
Published: November 2018

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Background: As the number of patients living with cancer increases, a growing proportion of hospital inpatients will have an advanced cancer diagnosis. Data suggests that an unscheduled hospitalization for a patient with advanced cancer strongly predicts a median survival of less than 6 months. As hospitalists more frequently become the primary team taking care of admitted cancer patients, communication between a patient's oncologic care team and inpatient primary providers is crucial. We sought to implement and assess the impact of improved oncology consult documentation of patient prognosis on outcomes of advanced cancer patients admitted to our hospitalist medicine teaching services. Methods: We implemented an EMR-based oncology consult note template which required documentation of prognosis, potential future treatment options (if available), and advance care planning. We reviewed all patients with stage IV solid tumors admitted to the hospitalist teaching service for 8 weeks prior and 8 weeks post-template implementation for comparison. We utilized descriptive statistics and chi-squared testing as appropriate for analysis. Results: We evaluated 51 patients in the pre- and 36 patients in the post-intervention groups. Post-intervention, there was an improvement in documentation of prognosis (29.4% vs. 52.8%, p = 0.03), advanced care planning (37.2% vs. 83.3%, p < 0.0001), and in number of palliative care consults (58.8% vs. 83.3%, p = 0.02). On average, goals of care conversations occurred 2 days earlier in the post-intervention group (11 vs 9 days). Similarly, there was a decrease in inpatient chemotherapy administration (3 cases vs. 0), unit codes (2 vs. 0) and in-hospital death (23.5% vs. 11.1%). Conclusions: Creation of an oncology consult note template which incorporates current oncologic prognostic information improved documentation of prognosis and advance care planning as well as outcomes for advanced solid tumor oncology patients and enhanced inter-service communication. Based on these results, continued and targeted interventions are planned to further improve interservice communication.
Cancer patients’ perception of usefulness with wearable exercise tracker.
Authors: Ng Amy , Gupta Ekta , Bansal Swati , Fontillas Rhodora C. , Williams Janet L. , Dibaj Seyedeh , Bruera Eduardo
Published: November 2018

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Background: Wearable trackers (WT) are known for its popular use in healthy, active persons but limited studies have been conducted in cancer survivors. Methods: Participants were asked to wear the WT and synchronize data. Patients were asked to fill out questionnaire regarding their patient reported perceptions of the WT and their perception of usefulness of the WT. Results: 110 cancer patients were enrolled with 100 evaluable surveys. Median age of patients was 62 years old, females (60, 55%), white (79,73%), married/with significant other (77, 71%), with college education and above (51, 47%). There was no statistically significant association between demographic factors of age, gender, ethnicity, marital status, or education and the perception of usefulness of the WT. Eighty-four percent of outpatient (OP) and 67% of inpatient (IP) cancer patients perceived WT as useful, 96% OP and 94% IP reported wearing WT daily, 64% OP and 55% IP perceived WT as helping to increase physical activity and 76% OP and 59% IP would continue to wear WT after this study. For inpatients, ESAS score of pain (p value <0.001), shortness of breath (p value <0.0002) and feeling of well-being (p value <0.001) improved over the course of rehabilitation. Improvement in FIM scores for transfers to wheelchair, walk assistance, walk distance, walking, stairs assistance, and stairs is significantly improved in rehabilitation (p value<0.05). The average resting heart rate was 77 beats per minute and average number of steps per day was 1,863. For outpatients, the average resting heart rate was 77 beats per minute and average number of steps per day was 3,423. Patients who reported the WT as useful had significantly lower fatigue severity (3.3 vs. 6, p value<0.05). Conclusions: Cancer patients perceived the WT as useful in both the inpatient and outpatient rehabilitation setting. No specific sub-group(s) of patients who expressed a higher level of agreement for usefulness of a wearable exercise tracker. There was an association between lower ESAS fatigue score and patient agreement of usefulness of the WT. These findings justify more research in WT and cancer rehabilitation. Clinical trial information: NCT03042884.
Emergency department visits among patients with advanced solid tumors at a cancer center in Mexico City.
Authors: Araujo Miguel , Alcalde Castro Mirza , Soto Perez De Celis Enrique , De la O Andrea , Reyes Rafael , Chavarri Guerra Yanin
Published: November 2018

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Background: Emergency department (ED) visits are a distressing event for patients with advanced cancer, and identifying planned, unplanned and avoidable ED visits is important for providing better cancer care. We studied the causes for ED visits, as well as potentially avoidable ED visits during palliative chemotherapy, among patients with advanced cancer treated at a public cancer center in Mexico City. Methods: Consecutive patients with newly diagnosed advanced solid tumors treated at Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán from 10/2015 to 03/2016 were screened. Patients who visited the ED during that period were included, and their demographic and clinical characteristics recorded. Number and reasons for ED visits were obtained from medical records. Among patients who received chemotherapy within the previous 30 days, the following reasons for ED visits were classified as avoidable: anemia, nausea, dehydration, neutropenia, diarrhea, pain, emesis, pneumonia, fever or sepsis (according to Centers for Medicare and Medicare Services Hospital Outpatient Quality Reporting Program). Results: 77 patients were diagnosed with advanced solid tumors during the study period, of which 53 (69%) had at least one ED visit. Median age was 63 years (range, 19-88), and 47% were men (n = 25). 51% had gastrointestinal, 21% genitourinary and 28% other tumors. Median follow-up was 360 days. 95 ED visits were identified; with a median number of ED visits per patient of 1 (range 1-5). The most common causes of ED visits were: infections (n = 20; 21%), gastrointestinal disorders (n = 18; 19%), pain (n = 15; 16%), ascites (n = 14; 15%), anemia (n = 4; 4%), catheter dysfunction (n = 4; 4%), and other causes (n = 20; 21%). 57% of ED visits among patients who received chemotherapy within the previous 30 days were classified as potentially avoidable. Conclusions: Over two thirds of patients with newly diagnosed metastatic cancer had ED visits in the first year after diagnosis. Furthermore, more than a half of ED visits among patients receiving palliative chemotherapy were potentially avoidable. Strategies aimed at reducing ED visits are needed to improve quality of care for patients with advanced cancer.
Pediatric cancer care professionals’ experiences with an interprofessional communication intervention.
Authors: Feraco Angela Marie , McCarthy Sarah R. , Das P. Jeet , Revette Anna , Tulsky James A. , Wolfe Joanne
Published: November 2018

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Background: The National Academy of Medicine recommends interprofessional collaboration to promote optimal patient- and family-centered care. We sought to understand whether medical and psychosocial professionals who participated in an interprofessional communication intervention perceived it as distinct from usual clinical care. Methods: Our intervention targeted “medical” (physicians, nurse practitioners) and “psychosocial” (social workers, psychologists) professionals. It consisted of an interprofessional family conference, using a structured conversation guide, conducted during the first 6 months of a child’s cancer care. Conferences aimed to enable families to share hopes and worries and ask questions about their child’s care. Clinicians received a 60-minute training focused on communication skills, such as eliciting families’ hopes and worries, and suggested approaches to collaborating during conferences. Clinicians participated in debriefing interviews after each conference (range 1-3). Three of us conducted thematic analysis of interview data. Results: Twenty-two professionals (6 attending MDs, 4 fellow MDs, 8 NPs, and 8 psychosocial clinicians) gave 34 interviews. Medical and psychosocial professionals described interprofessional family conferences as distinct from usual practice patterns, largely due to their interprofessional colleagues’ presence. This co-presence contributed to “being on the same page.” Conferences sometimes bred a new understanding of a family’s needs and consequent care changes. However, both medical and psychosocial professionals noted that psychosocial professionals often were not vocal contributors to the conference. Some psychosocial clinicians reported being unsure of “the rules.” Conclusions: An interprofessional communication intervention promoted shared understanding between interprofessional colleagues. However, medical professionals were described as more vocal, perhaps due to insufficient role clarity or medical dominance.
A national survey of medical students and educators at Korean medical schools, examining the impact of end-of-life care education provided to Korean medical students based on their attitudes.
Authors: Kim Do Yeun , Kim Kyong-Jee , Shin Sung Joon , Heo Dae Seog , Lee Soon-Nam , Nam Eun Mi
Published: November 2018

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Background: This study explored the current state of end-of-life (EoL) care education provided to Korean medical students and their self-rated attitudes toward EoL-related education. Methods: An anonymous survey was given to fourth year medical s tudents and the principle EoL care educators at all 41 Korean medical schools. The medical educators were asked to identify the EoL care-related topics that they usually teach students. Both students and medical educators completed seven items regarding self-perceived attitudes. Results: In total, 23 medical educators (56.1%) and 1,545 medical students (46.3%) responded. Of nine topics related to EoL care, the most frequently taught topics were delivering bad news (100%) and managing physical symptoms (74.1%), whereas setting treatment goals was taught the least frequently (37.0%). Approximately half of the educators taught the withdrawal of life-sustaining devices (59.3%), death and dying (55.6%), and advanced directives (55.6%). When the medical students were dichotomized into groups taught at least six topics (n = 815) versus five or fewer topics (n = 729), the group taught at least six topics expressed more satisfaction with EoL care education and they considered EoL care-related issues during their clerkship rotations. They also had fewer negative answers when they were asked about their readiness to practice EoL care. Conclusions: EoL education is inadequate for Korean medical students. However, medical students who were more fully instructed in this topic reported self-rated competency regarding EoL care-related issues. Further research should develop an education system that provides sufficient knowledge and training in EoL care for Korean medical students.
State-level differences in personality and geographic disparities in access to palliative care: Findings on openness.
Authors: Hoerger Michael , Perry Laura M , Korotkin Brittany D. , Walsh Leah E , Kazan Adina S , Rogers James Louis , Atiya Wasef , Malhotra Sonia , Gerhart James I
Published: November 2018

57

Background: There are geographic disparities in access to palliative care that cause unnecessary suffering near the end of life in low-access U.S. states. The psychological mechanisms explaining state-by-state variation in access to palliative care are poorly understood. Our objective was to examine whether state-level differences in personality explain state-by-state variation in palliative care access. Methods: We combined four datasets with state-level data for the 50 U.S. states and the national capitol. Palliative care access was measured by the Center to Advance Palliative Care 2015 state-by-state report card. Statewide personality differences were identified from a report on 619,387 adults who completed the well-validated Big Five Inventory, which assesses the five core personality dimensions: openness, conscientiousness, agreeableness, neuroticism, and extraversion. The U.S. Census and Gallup provided data on covariates. Regression analyses examined whether state-level differences in personality predicted statewide access to palliative care, controlling for differences in population size, age, gender, race/ethnicity, socioeconomic status, and political views. Results: Access to palliative care was worse in states that were younger, more racially diverse, lower in socioeconomic status, more politically conservative, and lower in openness. In regression analyses that simultaneously accounted for all predictors and covariates, only lower openness continued to explain worse state-level access to palliative care (β = 0.428, p = 0.008). Conclusions: Palliative care access is worse in states where people are lower in openness, meaning residents who are more skeptical, traditional, and concrete. Personality theory offers specific recommendations for palliative care advocates communicating with hospital administrators, legislators, philanthropists, and patients to expand access in low-openness states.
Does use of total parenteral nutrition in patients with metastatic gastrointestinal cancer impact hospice length of stay?
Authors: Bian Jessica J , Rome Rachel S , Taber Angela Marie
Published: November 2018

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Background: The use of total parenteral nutrition (TPN) in metastatic cancer patients is controversial. The impact of TPN use on length of hospice stay in advanced cancer patients is unknown. We hypothesize that patients with metastatic gastrointestinal cancers who receive TPN have a shorter median length of hospice stay as compared to the median hospice length of stay for cancer patients in the United States in 2014 (18 days). The primary objective of our retrospective, single-institution study is to determine the median hospice length of stay in patients with metastatic gastrointestinal cancers who received TPN. Methods: Records of all adult patients with metastatic gastrointestinal cancers who received TPN at The Lifespan Cancer Institute from 2005 through 2014 were reviewed. The primary outcome was median hospice length of stay. Data analysis was conducted using Stata (Version 15.0, StataCorp, College station, Texas). Results: Seventy-nine patients were identified as having received TPN for metastatic gastrointestinal cancer. Forty-eight patients had documented referrals to hospice and 40 patients had assessable durations of hospice admission. Hospice length of stay ranged from one to 196 days with a median of 9.5 days, mean of 24.3 days, and interquartile range of 5.5 to 54 days. Conclusions: Hospice care has been shown to improve quality of life for patients and caregivers. In our retrospective, single-institution study of patients with metastatic gastrointestinal cancer who received TPN, the median hospice length of stay was shorter than the national median length of hospice stay for cancer patients in 2014 (9.5 days versus 18 days). This should be taken into consideration when weighing the risks and benefits of initiating TPN in metastatic gastrointestinal cancer patients. [Table: see text]
Timing of last chemotherapy and the end of life in patients (pts) with metastatic cancer.
Authors: Brollo Marianna , Bratta Massimo , Molinaro Simona , Diana Giannarelli , Ricci Mariannina , Bassanelli Maria , Ceribelli Anna
Published: November 2018

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Background: Chemotherapy near the end of life is often associated with increased toxicity and poor outcome. The aim of this study was to assess the outcome of patients (pts) with metastatic cancer who received chemotherapy near the end of life. Methods: We conducted an observational, retrospective analysis of 77 consecutive cancer pts (aged ≥ 18 years) who died in hospice between January 2017 and July 2018. Median overall survival (OS) and the 95% confidence interval (CI) were estimated with the Kaplan -Meier method. Results: Of 77 pts (median age: 72 years [y]; male: 59.7%) with metastatic cancer, 51 pts (66.2%) received chemotherapies for metastatic disease (mean prior lines: 2.1 ) and 26 pts (33.8%) received best supportive care (BSC). The most represented histologies were lung (31.2%) and breast (11.7%) cancer. The median time from the last chemotherapy and the death was 67 days. The median progression free survival (PFS) of the last treatment was 45 days. According to Earle’s criteria, 6.5% of pts started a new chemotherapy regimen in the last 30 days of life and 2.6% of subjects received chemotherapy in the last 14 days of life. 11.7% and 3.9% of pts received chemotherapy within the last 30 and 15 days of life, respectively. Younger pts (< 70 years) had an increased probability of continuing chemotherapy within the last 1 month (p=0.004) and < 2 weeks (p=0.002) before death than elderly (> 70 years). Conclusions: This study shows that end-of-life chemotherapy is associated with poor outcome. The use of chemotherapy within 30 and 15 days before death was correlated with younger age.
How long do patients with advanced cancer survive after discharge to sub-acute rehabilitation?
Authors: Khan Muhammad Azeem , Stewart Diana , Pettit Clint S. , Groninger Hunter
Published: November 2018

67

Background: Patients with advanced cancer inevitably experience a functional decline diminishing quality of life. Many are admitted to the hospital due to progression of disease and become further deconditioned. Discharge to sub-acute rehabilitation (SAR) to "gain strength" for future anti-cancer therapy is common as participation in more intensive rehab therapy is rarely possible. In this study, we wished to determine the length of survival after discharge to SAR and if factors such as pre-hospitalization ECOG correlated with increased length of survival. Methods: At our 926-bed urban academic center, we performed a retrospective chart review from June 2015 to January 2017 of hospitalized patients with solid cancers who were subsequently discharged to SAR. Patients were excluded if they had surgery, a cerebrovascular event during their hospitalization or no post-hospital oncology follow-up plan. The primary outcome was death. Results: Fifty-six patients were identified (median age 69, range 28-95; 87% African American; 72% female). Forty-seven (86%) had metastatic disease. Forty-seven patients (86%) were deceased as of June 2017. The mean survival from date of discharge was 114 days (SD 122.89, range 1-447). Twenty-eight patients (51%) had a pre-hospitalization ECOG of 1 or 2 and twenty-seven patients (49%) had an ECOG of 3 or 4. Mann-Whitney U correlation was used to test the correlation between ECOG and survival. Patients with an ECOG of 1 or 2 trended to survive longer (156 vs 75 days, p=0.06). Self identified white patients had a statistically significant longer survival post discharge to SAR compared to African Americans (204 vs 104 days, p=0.03). Conclusions: Compared to patients with ECOG 1 or 2, patients with ECOG of 3 or 4 survived for a fewer number of days. The identification of additional markers of poor prognosis through larger prospective multi-institutional studies will help to delineate which patients are more likely to benefit from discharge to SAR.
The feasibility of an inpatient intervention to improve end-of-life care in gynecologic oncology patients.
Authors: Puechl Allison , Lim Stephanie , Truong Tracy , Havrilesky Laura , Davidson Brittany Anne
Published: November 2018

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Background: Unscheduled hospitalizations in patients with advanced cancer predicts < 6 month median survival. Patients with cancer hospitalized near the end of life (EOL) often receive aggressive treatments without survival advantages and have poor quality-of-life. EOL discussions and palliative care (PC) services reduce aggressive care. Methods: An intervention was designed to decrease aggressive EOL care in Gynecologic Oncology (GO) inpatients at a high risk for death within 6 months. Inclusion criteria were advanced gynecologic cancer and 1 of the following: bowel obstruction, failure to thrive, dehydration, cancer-related pain, malignant pleural effusion or ascites, or PCN management. Patients were identified by the care team on admission. An independent auditor assessed if patients were appropriately identified. Eligible patients received a 3-part high risk Gynecologic Oncology (HR-GO) bundle: 1) PC consult, 2) goals of care (GOC) conversation ≤ 48 hours of admission, and 3) PC follow-up within 2 weeks of discharge. Data was collected through chart review. Barriers to bundle implementation were identified. Results: 83 eligible patients were admitted between 8/2017-4/2018. 38 patients (46%) had multiple hospital admissions. 41 patients (49%) received the entire bundle during at least one hospital admission. During their 1st hospital admission, 30% of patients received all 3 parts of the HR-GO bundle. Among those who did not receive the entire bundle, 43% had two components missing. PC follow-up was the most commonly missed component, followed by a GOC conversation within 48 hours of admission. As identified by the auditor, twenty percent of eligible patients were not placed into the study cohort during their first hospital admission. Two barriers to bundle implementation were identified:1) the dependence on care team members to identify high-risk patients and 2) the avoidance of needed GOC discussions when patient’s 1° attending was unavailable. Conclusions: The implementation of an inpatient intervention to decrease aggressive EOL care in GO patients is feasible however barriers must be addressed. Currently work on an automated system to identify patients for intervention is ongoing.
An invitation to complete: Making advance directives part of the new patient process.
Authors: Ash-Lee Susan , Busby Leslie T. , Diab Sami , Taniguchi Cynthia B. , Gorsky Ami
Published: November 2018

7

Background: In Colorado, there is no legal designation as to who is authorized to make healthcare decisions for an adult unable to make decisions for themselves. Completing an advance directive is increasingly associated with better end-of-life outcomes. Failure to complete an advance directive leads to fewer days on hospice and expensive, end-of-life care. It was hypothesized that patients who completed a Medical Durable Power of Attorney (MDPOA) document early may have higher adoption of advance care planning and earlier hospice at end-of-life. Methods: The Rocky Mountain Cancer Centers (RMCC) is the largest private oncology group in Colorado with multiple offices across the state. The RMCC-Pueblo clinic developed and piloted a new patient process where, at registration, all new patients were invited to complete a MDPOA while also completing other new patient forms. The Medical Durable Power of Attorney (MDPOA) is a document that appoints a healthcare decision maker (“healthcare agent”). Data on 4,441 patients from Nov. 1, 2017, to June 30, 2018, were extracted from the electronic health record (EHR), including code status, advance care planning counseling appointment, advance directive completion, and outcomes. Results: During this pilot, advance directive capture within the EHR rose from 15.4% to 21.4%. While the number of patients who elected hospice enrollment at the end of life was about the same, the length of hospice stay increased from an average of 14 to over 20 days, a 50% improvement. Conclusions: A MDPOA as a routine part of the new patient intake process is feasible and scalable. It opens the door to future ACP discussions and improved hospice utilization. Because of these findings, we are currently expanding this process to all RMCC practice sites. The results suggest that early completion of an Advance Directive lead to ongoing and healthy discussions about the patient’s end-of-life preferences for care, including appropriate hospice enrollment.
Impact of cardiopulmonary resuscitation (CPR) on the survival of patients with cancer: DNR before or after cardiac arrest?
Authors: Giza Dana Elena , Rodrigo Mejia , Crommett John , Botz Gregory , Ewer Michael S. , Iliescu Gloria , Radford Marvin , Cavalier James , Rodriguez Maria Alma , Iliescu Cezar
Published: November 2018

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Background: Cardiopulmonary resuscitation (CPR) after cardiac arrest in cancer patients is associated with lower survival rates when compared to non-cancer patients. The quality of life of those who survive after CPR to be discharged is often diminished. Among these patients there is a high likelihood of changing their code status to DNR. Methods: Our study determines the overall survival rate, the survival to discharge rate, and the DNR change rate postcode among cancer patients who underwent CPR in our cancer center. Data was analyzed retrospectively from electronic records of cancer patients who had cardiac arrest and underwent CPR between April 2017 and March 2018 at a tertiary cancer center. The end points included the overall survival immediately after CPR, the survival rate at 24h, the survival to discharge rate, and the DNR change rate postcode. Results: Between 2017 and 2018, a total of 396 codes were registered in cancer patients in our center, out of which 53% had cardiopulmonary arrest as trigger event. In more than 90% of the patients, average chest compression rate, average compression rate, average compression depth, and overall compression in the targeted zone were obtained, meeting all the required criteria to deliver high-quality CPR. Overall survival rate in cancer patients was 79% after CPR efforts. The survival rate at 24h was 48%, while the rate of survival to discharge was 17%. 64% of the patients changed their code status to DNR in critical care settings. Conclusions: The prognosis remains poor for cancer patients undergoing CPR. A significant proportion of patients who survive CPR will become DNR postcode. Physicians should effectively and honestly engage in discussing end of life matters with their cancer patients.
Hospice and hematologic malignancies: Utilization and caregiver perspective.
Authors: Jones Jessica Trevino , Karnad Anand B. , Kakarla Sushanth , Gregorio David , Hung Annie
Published: November 2018

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Background: Hematologic malignancies (HM) such as leukemias, lymphomas, and myeloma are potentially curable or may have long lasting remission with current therapy. While therapy may prolong life even in an incurable setting, treatments for relapsed or refractory disease for many hematological malignancies fail and a substantial number of patients with HM are terminally ill. Hospice care services are notably underutilized for HM. Methods: We performed a retrospective cohort analysis of 22 patients treated from 2013-2016 with terminal HM. Using an adapted version of the Burden Scale for Family Caregivers, surviving family members of deceased patients were surveyed for their perspective of hospice care services. Variables examined included date of diagnosis, data of hospice enrollment if applicable, if the patient experienced any resuscitation attempts, if the patient died in hospital, number of days for last hospitalization, and admissions/ER visits within 6 months of death. Results: 11/22 (50%) of patients had AML/ALL; 9/22 (41%) had refractory lymphoma; 1/22 (4.5%) had refractory myeloma; 1/22 (4.5%) could not be included as the patient was subsequently enrolled on clinical trials. Time from diagnosis to death for AML/ALL patients was 306 days; Refractory lymphoma and myeloma patients was 408 days. 8/21 (38%) of patients died in hospital, with 1 resuscitation attempt. For AML/ALL patients, 6/11 (55%) enrolled in hospice at average of 363 days. Once in hospice, average time to death was 25 days. For Refractory lymphoma and myeloma patients, 9/10 (90%) enrolled in hospice at average of 320 days. Once in hospice, average time to death was 70 days. 7/22 (31%) of surviving family were able to be reached to participate in our adapted survey. 4/7 caregivers would not have utilized hospice/palliative care sooner than they did; 2/7 caregivers would have enrolled sooner retrospectively; 1/7 caregivers did not have palliative care/hospice options offered to them. Conclusions: Terminally ill patients face significant barriers to hospice care despite evidence of worsening disease. Realistic expectations and discussions with patient and caregivers need to be addressed in patients with relapsed/refractory HM.
Translation and evaluation of a lung cancer palliative care intervention for community practice.
Authors: Nguyen Huong Q , Martinez Loraine , Mirasol Chrissie , Land Meesha , Borneman Tami R. , Macias Mayra , Ruel Nora , Ferrell Betty R.
Published: November 2018

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Background: A notable gap in the evidence-base for outpatient palliative care (PC) for cancer is that most trials were conducted in specialized centers with limited translation and further evaluation in “real-world” settings. Health systems are desperate for guidance on effective, scalable models. The purpose of this study was to determine the effects of a nurse-led PC intervention (PCI) for patients with non-small cell lung cancer (NSCLC) and their family caregivers (FCGs) in a community-based setting. Methods: Two-group, prospective sequential, quasi-experimental design with phase 1 (usual care) followed by phase 2 (intervention) conducted at three Kaiser Permanente Southern California sites. Participants included patients with stage 2 - 4 NSCLC and their FCG. Standard measures of quality of life included FACT-L, FACIT- SP12, City of Hope Family QOL; other outcomes were distress, healthcare utilization, caregiver preparedness and perceived burden. Results: Patients in the intervention cohort had significant immediate improvements in three (physical, emotional, and functional well-being) of the five quality of life (QOL) domains at 1 month that were sustained through 3 months compared to usual care (p < .01). Caregivers in the intervention cohort had improvements in physical (p = .04) and spiritual well-being (p = .03) and preparedness (p = .04) compared to usual care. There were no differences in distress or health care utilization between cohorts. Conclusions: Our findings suggest that a research-based PC intervention can be successfully adapted to community settings to achieve similar, if not better, QOL outcomes for patients and FCGs compared to usual care. Nonetheless, additional modifications to ensure consistent referrals to PC and streamlining routine assessments and patient/FCG education are needed to sustain and disseminate the PCI. Clinical trial information: NCT02243748.
Impact of palliative care interventions on health-related quality of life (HRQOL): A secondary analysis of the Promoting Resilience in Stress Management (PRISM) Randomized Controlled Trial (RCT).
Authors: Steineck Angela , Bradford Miranda , Lau Nancy , Scott Samantha , Yi-Frazier Joyce P. , Rosenberg Abby R.
Published: November 2018

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Background: PRISM, a novel intervention for adolescents and young adults (AYAs), seeks to enhance resilience skills via four in-person sessions. Primary analysis of the RCT in AYAs with cancer showed PRISM improved HRQOL. This secondary analysis aimed to explore changes in HRQOL domains and differences between patient groups. Methods: English-speaking AYAs (12 - 25 years) were randomized to PRISM or usual care (UC) from Jan 2015 - Oct 2016. Surveys were completed at enrollment and six months later, using the Pediatric Quality of Life Inventory (PedsQL) Generic Short Form (SF-15) and Cancer Module to assess HRQOL. We compared change scores (PRISM vs UC) by domain (PedsQL SF-15: physical, emotional, social, school; cancer: pain, nausea, procedure anxiety, treatment anxiety, worry, cognition, perceived appearance, and communication). Participants were stratified by age (12 - 17 years vs 18 - 25 years) and advanced cancer status (yes/no). Results: 74 patients (36 PRISM, 38 UC) completed 6-month assessments. 72% were 12 - 17 years old. 23% had advanced cancer at enrollment. PRISM improved patient-reported communication (UC: median [interquartile range, IQR] 0 [-17, 8]; PRISM: 8 [0, 25]). Younger patients seemed to benefit more, especially in PedsQL SF-15 school (12 - 17: UC 0 [-8, 0], PRISM 13 [0, 17]; 18 - 25: UC 0 [-33, 17], PRISM 0 [-25, 17]) and social domains (12 - 17: UC 0 [-33, 0], PRISM 0 [0, 8]; 18 - 25: UC 0 [-25, 4], PRISM -17 [-25, 8]), and cancer-specific perceived appearance (12 - 17: UC -4 [-25, 0], PRISM 8 [-8, 25]; 18-25: UC 0 [-21, 0], PRISM -8 [-25, 17]). Patients with advanced cancer seemed to benefit in cancer-specific domains nausea (no: UC 0 [-10, 15], PRISM 10 [-10, 40]; yes: UC 6 [-15, 25], PRISM 35 [25, 50]) and pain (no: UC 13 [-13, 25], PRISM 6 [-13, 25]; yes: UC -13 [-25, 0], PRISM 6 [-13, 25]). Patients without advanced cancer seemed to benefit in perceived appearance (no: UC -6 [-33, 0], PRISM 0 [-8, 17]; yes: UC 0 [-8, 17], PRISM 4 [-8, 17]). Conclusions: With PRISM, younger AYAs were better able to cope with age appropriate challenges (social, school, appearance) and AYAs with advanced cancer improved physical symptom HRQOL. Clinical trial information: NCT02340884.
Implementation of a rapid access multidisciplinary bone metastases clinic to improve access to care at a large cancer center.
Authors: Colbert Lauren Elizabeth , Gomez Meaghan , Todd Sarah , Tang Chad , Christopherson Kaitlin , Grosshans David R , Lin Lilie L. , Bird Justin E , Moon Bryan , Satcher Robert L , Lewis Valerae O. , Koong Albert , Gomez Daniel Richard
Published: November 2018

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Background: MD Anderson Cancer Center is a large cancer center with 44,000 new patients per year. Radiation therapy (RT) is an effective treatment for bone metastases that can reduce pain medication use and improve quality of life. Our goal was to assess the effect of implementing a rapid access multidisciplinary clinic for bone metastases (RABC). Methods: RABC was instituted to schedule patients for radiation oncology and orthopedic surgery consult within 48 hours of referral. Same day simulation and treatment times were held for these patients for one 8Gy fraction. Thirty sequential patients treated with one fraction to bony sites in the outpatient setting prior to implementation of the clinic were chosen as a comparison group. Time from consult order to consult visit (OTV) and from consult visit to treatment completion (CTT) were recorded, in addition to frequency of multidisciplinary care (MDC; orthopedic surgery and radiation oncology). Overall Time (OT) was calculated from referral to treatment completion. T-test and chi-square test were used for analyses. Results: Between April 2018 and July 2018, 72 patients were referred to RABC. 23 patients were seen in consultation and received RT. Sites treated were pelvis (N = 10), spine (N = 6), lower extremity (N = 4) and upper extremity (N = 3). Patients had one site (N = 20), two sites (N = 2) or three sites treated (N = 1). Histologies included breast (N = 5), thoracic (N = 7), gastrointestinal (N = 6), genitourinary (N = 2) and head/neck (N = 2). OTV was shorter for RABC patients (mean 3.3 [+/-5.7] vs. 9.5 days [12.4]; p = 0.02). CTT was also significantly shorter for RABC patients (mean 5.4 hours [+/-1.8] vs. 6.5 days [+/-6.5]; p < .0001). OT was also shorter (3.5 days [+/-5.6] vs. 16.4 days [+/-14.8]; p < .0001). RABC clinic patients were more likely to receive MDC (100% vs 28%; p < .0001). Conclusions: The rapid access bone metastases clinic significantly decreased overall time from consult to completion of treatment and also decreased time to access radiotherapy. Patients were also more likely to receive multidisciplinary evaluation. The RABC approach is a promising model to improve palliation for patients with painful bony metastases.
Interdisciplinary palliative care communication for quality palliative care: Outcomes of a statewide train-the-trainer course.
Authors: Ferrell Betty R. , Buller Haley , Anderson Wendy , Paice Judith A. , Donesky Doranne
Published: November 2018

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Background: Expert communication skills are essential for the delivery of effective palliative care across the domains of care. However, few healthcare providers receive formal communication training. The purpose of this presentation is to describe a train-the-trainer course for interprofessional hospital-based palliative care teams to prepare them to teach other healthcare professionals palliative care communication skills. Methods: This project was organized by the eight domains of the National Consensus Project (NCP) guidelines for quality palliative care and provided communication skills training for California-based teams. Funded by the Archstone Foundation, this 2-day train-the-trainer course included skill-building exercises and interactive discussions to assist participants in integrating communication skills-building into their clinical settings. Using a goal-directed method of teaching, the faculty assisted teams in developing three institutional goals for providing palliative care communication training to other healthcare professionals. Evaluation of the course included immediate post-course evaluation and follow-up evaluation at 6 and 9 months. Results: The first statewide interprofessional communication training took place in January 2018 with 26 palliative care teams consisting of primarily nurses, followed by social workers, chaplains and physicians. The 46 course participants’ post-course evaluations demonstrated high satisfaction with the course. On a scale of 1 to 5 (1 = lowest), the course met participants’ expectations and objectives (4.8). The teams’ pre-course goals focused on: 1) staff education, training and mentorship, and 2) institution-wide system changes involving communication with palliative care. Conclusions: A 6 and 9 month follow-up will evaluate team progress on institutional goals (e.g. status and implementation) and provide an update on the additional healthcare professionals trained by course participants and changes implemented within their health system.
Changes in the setting of first consults to palliative and supportive care over a 7-year period.
Authors: Prado Bernard Lobato , Haider Ali , Naqvi Syed M. , Carmagnani Pestana Roberto , Williams Janet L. , Dibaj Seyedeh , Liu Diane D. , Allo Julio A. , De la Cruz Vera J , Bruera Eduardo
Published: November 2018

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Background: Optimal benefits from palliative cancer care (PC) are achieved when first consults (PC1) occur early, ideally in the outpatient setting. Late PC1, such as those occurring in the intensive care unit (ICU), limit the benefits of PC and are a poor indicator of the integration of PC and oncology. Our aim was to determine the proportion of PC1 over time in three clinical settings: outpatient clinic (OPC), ICU, and inpatient non-ICU (IP). We also examined patients’ demographic and clinical characteristics and the timing of PC access (from PC1 to death or last contact) by the setting of PC1. Methods: We evaluated consecutive administrative/billing records to ascertain the annual number of PC1 and its distribution across settings from 2011 to 2017. ICU PC1 (n = 309) and a random sample of an equal number of OPC and IP PC1 were reviewed to retrieve patients’ demographics, clinical characteristics, and date of death/last contact. The Cochran-Armitage trend test was used to determine trend differences in the proportion of PC1 among settings. Results: The total annual number of PC1 increased by 58% from 2011 (n = 2286) to 2017 (n = 3615). We found a significant decreasing trend in the proportion of PC1 at the ICU (from 2.3% in 2011 to 1% in 2017, p < 0.001). There were no significant changes over time in the proportion of PC1 at OPC versus inpatient settings (p = 0.2). Hematologic cancer patients were more likely to have a PC1 at the ICU (p < .001). PC1 at ICU accessed PC much later, median survival (95% CI) after PC1 in months: OPC= 7.7 (6.3 - 9.7); IP= 3.4, (2.4 - 4.5), ICU= 0.1 (0.1, 0.1), p < .01). Conclusions: Over time, the total annual number of PC1 has increased and the proportion of PC1 at ICU, a very late clinical setting, is decreasing. Further efforts are needed to promote early PC referrals for patients with hematologic malignancies.