bluuebunny/crossref_metadata_2025_split huggingface dataset:
Decision making for older adults with advanced cancer: Patient and family member perspectives.
Authors: Hickman Susan Elizabeth , Weaver Michael T. , Habermann Barbara , Helft Paul R. 
Published: February 2017

101 Background: The National Cancer Institute and palliative care guidelines emphasize the importance of family member perspectives in end-of-life decision-making for patients with advanced cancer. However, only a handful of studies have examined what role family members play in decisions to continue or discontinue disease-directed therapy. Methods: Thirty-four dyads consisting of a patient (PT) aged 65 and older with metastatic lung, pancreatic, or esophageal cancer and a family member (FM) filled out surveys about goals of care, discussions with the treating oncologist, communication conflict, and decisional uncertainty. Results: Most PTs (60%) understood their cancer was metastatic, and 86% reported they were currently receiving chemotherapy. PTs and FMs (82%) had a shared understanding about current goal of treatment and were more likely to report discussions with the treating oncologist about reasons to continue chemotherapy (90%) than discussions about reasons to discontinue it (53%) (McNemar’s S = 7.0, DF = 1, exact p =.016). However, only a minority of PTs and FMs (26.5%) agree on the preferred course of treatment. FMs (59%) were more likely than PTs (24%) to prefer a course of treatment focused on palliation rather than extending life (Bowker’s S=9.3, DF=3, p=.026). Many patients (44%) were unsure of their preferences. Patients who perceived higher levels of communication conflict with their family reported more decisional uncertainty about their preferred treatment option (r =.49, p =.02). Conclusions: Patients and family members largely share in their understanding of the current treatment goal and recall of discussions with the oncologist about treatment options. However, family members tend to prefer a course of treatment focused on comfort compared to patients, who prefer a course of treatment that extends life as much as possible even if it means having more side effects, pain, or discomfort. Patients who report conflicted communication with family members are more uncertain about their decisions. Findings suggest a need for increased discussion about goals of care and treatment alternatives with advanced cancer patients and their family members.
An innovative model for palliative care at home for 100,000 patients with cancer since 1985 in Italy: A social partnership for a public health system integrated and sustainable.
Authors: Pannuti Raffaella , Varani Silvia , Pannuti Franco 
Published: February 2017

113 Background: In Italy, like in most Western countries, the number of elderly people with a chronic disease is constantly increasing and it causes a growth in disability and frailty. However, the Public Health Service is unable to provide all the services needed. Therefore it is necessary to find urgent actions to fill in the gaps of the Public Health Service and to think about appropriate solutions for a sustainable future. Methods: Since 1985, ANT has assisted at home more than 100,000 cancer sufferers, completely free of charge, thanks to its 20 oncological teams in 9 Italian regions. There are currently about 4,000 patients receiving care every day throughout Italy. ANT offers specialized care provided by 400 healthcare professionals, including doctors, nurses, psychologists, nutritionists, physiotherapists, social-health workers, who are able to provide patients with round the clock care, 365 days a year. Results: The quality of the model of ANT home care is supported by the following outcomes: 78% of the patients (ANT National average) choose to die at their own home in contrast with the National average of cancer death at home equal to 57,9%. In the last 30 days of life, 74% of the patients assisted by ANT aren’t admitted to hospital, 12% have an hospitalization lasting less than 7 days and only 14% remain in hospital for over a week. The customer satisfaction, assessed through a questionnaire sent to families about a month after death, shows that 90% of respondents are very satisfied with the assistance received. ANT spends about 2,090 euro for each patient assisted. Given that each patient is cared for an average of 132 days, the cost is about 30 euro a day. This charge is much lower than a recovery for a day in a palliative care residential facility (240 euro) and it is lower also than an admission for a day in a public hospital (780 euro). Conclusions: The situation calls for a change in strategies in health policy, stimulating integration between public and social institutions. The model of ANT home care is an example of a social buffer that offers an integrated health and social assistance able to meet the increasingly complex needs of patients and their families.
A survey to evaluate our physician-trainees' comfort and knowledge in communicating their final good-bye to their terminally ill patient.
Authors: Marcus Joel , El Osta Badi Edmond , Sumrall Bradley , Mott Frank 
Published: February 2017

114 Background: Although dealing with end of life (EOL) issues is common and can be stressful in cancer care, very little is taught and written in regards to how healthcare professionals should communicate their final good-bye with their terminally ill patients. There is a wealth of literature available about communicating “bad news”, but a literature review elicited scant data about this topic. Methods: We conducted a pilot survey on 88 house staff physicians to evaluate the frequency, their level of comfort, whether they had prior training and their knowledge about communicating their final good-bye at the EOL and their interest to learn more about this communication skill. Results: 42% were first year trainees across all specialties. 61% encountered at least 1 patient monthly at the EOL. 45% felt comfortable saying good-bye to a patient they were unlikely to see alive again. 54% have expressed interest in learning how to communicate their final good-bye to their patient at the EOL. However, only 5.7% have reported receiving a thorough training and 2.2% endorsed being very knowledgeable in this communication skill. 81% were interested to learn these skills from experienced mentors. Conclusions: Communicating the final good-bye with the terminally ill patient is an important skill that is not routinely taught to our physician-trainees. The majority of them expressed their interest to learn this skill from experienced mentors. Palliative care healthcare professionals can play a pivotal role in our physician training programs by mentoring our trainees on communicating their final good-bye to their terminally ill patient effectively and compassionately. Once implemented, further studies will be needed to assess the impact of experienced mentors on the comfort and knowledge of our physician-trainees in this communication skill.
Considerations for quality improvement in radiation oncology therapy for patients with uncomplicated painful bone metastases.
Authors: Walling Anne M. , Wenger Neil , Kaprealian Tania Betty , Kupelian Patrick , McCloskey Susan Ann , King Christopher R. , Beron Phillip , Steinberg Michael L. 
Published: February 2017

118 Background: Although American Society for Radiation Oncology (ASTRO) guidelines support single fraction radiation treatment for uncomplicated bone metastases, it is rarely used. Methods: We used modified RAND/UCLA appropriateness methodology to understand how radiation oncologists make decisions about single fraction treatment to inform quality improvement. We focused on uncomplicated bone metastases (defined by relevant RCT exclusion criteria) without prior irradiation, pathologic fracture, or spinal cord compression. Eight radiation oncologists with varying sub-specialties were provided ASTRO guidelines, a summary table of RCT’s and recent research on current practices. They rated the appropriateness of 8Gy Single Fraction treatment and 4 alternative regimens for clinical cases before and after a panel discussion that also included three palliative care physicians. Clinical cases varied by location of metastases (spine, humeral head, femur, rib), size of metastases, patient prognosis, travel distance to treatment site, and patient age. We report findings based on final median appropriateness ratings and qualitative evaluation of discussion. Results: Single fraction treatment (8Gy) was rated as the most appropriate treatment, regardless of other factors if prognosis was 6 months or less. However, participants noted that prognostic information is often not available at the point of care. Use of greater than 10 fractions was rated as inappropriate regardless of other factors. Older age and travel distance were factors that lead to favoring 8Gy single fraction treatment. There was less consensus concerning single fraction treatment and favoring of other treatment approaches for lesions located on the spine, especially large lesions, and for patients with oligometastases and a longer prognosis where goals may include local tumor control in addition to palliation. Conclusions: Improving specification and communication of prognostic information is an important quality improvement target to enhance the patient-centered nature of care for patients with painful bone metastases.
The serious illness care program.
Authors: Bernacki Rachelle , Block Susan 
Published: February 2017

12 Background: Conversations between patients and clinicians about end-of-life care allow patients to prepare and plan for the end of life and are associated with improved outcomes. Objective: To determine the impact of a structured, seven-item conversation guide on anxiety and depression in patients with an estimated prognosis under a year. Methods: A cluster, randomized controlled trial enrolled 81 clinicians and 272 patients (goal of 400 patients) at Dana Farber Cancer Institute. The intervention (integrated into regular clinical care by oncologists) consisted of a system to identify patients and trigger clinician discussions using the checklist, clinician training, and documentation template in the electronic medical record. Adult patients were identified by oncologists using the “surprise” question. Surveys measured key outcomes before and after administration of the checklist (for patients) and after training (for oncologists). Results: 1,299 patients were identified using the surprise question. Of patients contacted, 332 agreed to participate and 254 declined. To date, 62 conversations are complete with a median length of 20 minutes (range: 8-70 min). The mean anxiety level using the GAD-7 score for the participants with complete data prior to the checklist conversation was 4.0 and post-conversation 3.1 (p=0.04). The mean depression score using the PHQ-9 prior to the checklist conversation was 6.3 and post-conversation 5.7 (p=0.2). 51% of patients found the discussion ‘very’ or ‘extremely’ helpful; 21% found the discussion ‘somewhat’ helpful; and 14% ‘slightly’ or ‘not at all’ helpful. The majority of clinicians found the guide simple (79%) and easy to use (78%); 81% reported they would continue its use after the trial. Conclusions: These preliminary data demonstrate that use of the guide is feasible, acceptable to patients and clinicians, and does not lead to increased anxiety or depression. There is a trend towards a significant reduction in anxiety in patients who had the discussion with their oncologists. The Serious Illness Care Program is an acceptable intervention to support clinicians in conducting conversations about end-of-life values and goals with patients, allowing them to articulate their wishes about future medical care. Clinical trial information: NCT01786811.
Palliative prognostic tools for the terminally ill patients with gastric cancer.
Authors: Kang Beodeul , Choi Hye Jin , Rha Sun Young 
Published: February 2017

120 Background: Terminally ill patients with gastric cancer have specific gastrointestional symptoms and signs related with cancer progression. To estimate accurate survival expectancy of gastric cancer patients is important for timely decision making of their end of life issues. Methods: We reviewed the 276 patients with terminally ill gastric cancer who were treated at Yonsei Cancer Center between January 2007 and December 2011 and eventually were died. Retrospectively, we conducted the data of clinical signs, symptoms, and laboratory results at the time of cessation of the active treatment. Then, we established the palliative survival estimation model by stratification of risk group. Results: Median palliative survival time from the decision to stop further treatment to death was 42days. In the multivariate Cox regression analysis, 5 parameters were identified as prognostically significant factors: anorexia, dyspnea, hypoalbuminemia, elevated blood urea nitrogen, and elevated serum alkaline phosphatase. We scored each variables as 1-3 for symptom(1:asymptomatic, 2:symptomatic, 3:symptomatic requiring intervention) and 1-2 for lab results(1:normal, 2:abnormal) and summed up each scores. Using the total score, patients were divided into 3 risk groups: low-risk(5-7points), intermediate-risk(8-11points), and poor-risk patients(12point). As a result, median palliative survival for low-risk group(n=110) was 87.0±7.4days, intermediate-risk group(n=158) and poor-risk group(n=8) were 31.0±2.1days and 6.0±2.1days, respectively (p<0.0001). Conclusions: Using multivariate analysis and summation of each prognostic factor score, 3 risk groups were determined. After validation by prospective multicenter trial, this palliative survival time estimation tool will be helpful to inform the accurate survival for terminally ill gastric cancer patients.
Organization, teamwork, and advocacy: Important skills needed by hospice family caregivers who manage medications.
Authors: Tjia Jennifer , Reblin Maija , Lemay Celeste , Clayton Margaret , Ellington Lee 
Published: February 2017

121 Background: In the home hospice setting, family caregivers (CGs) often assume medication administration responsibilities traditionally performed by licensed nurses. Little is known about how to assess and support CG medication management skills. As part of an ongoing study of nurse-caregiver interactions in home hospice, we gathered data on CG medication management needs. Methods: A longitudinal, multicenter study of home hospice nurse visits captured audiorecorded communication between nurses and CGs. Participants included patients with cancer and their self-identified CGs who were recruited upon home hospice enrollment. The current sub-study included participants aged ≥65 and their family CGs from 7 hospice agencies. Two investigators independently coded transcriptions of the first audio recorded nurse home visit using a directive content analytic approach to map conversations to a previously published, interview-derived, framework for hospice medication management by CGs. Results: A total of 18 patients (mean age 76.5 [SD 10.7], 56% female) and their CGs (mean age 59.6 [SD13.4], 78% female) were included. Content analysis revealed that CG skills needed for medication management are not limited to drug knowledge. Complicated organizational skills are needed to track medication acquisition and dosing, record the use of short- and long-acting drugs with similar modes of action, and coordinate medication administration by multiple CGs. Teamwork skills are needed to help coordinate medication prescribing between specialist, primary, and hospice physicians. CGs also need symptom management skills regarding the proper selection of medications, as well as skills to manage side effects, inadvertent errors, and possible medication related-emergencies. CGs play a vital role in patient advocacy, alerting providers to the burden and quality of life issues related to medication use, including whether medications have intended or unintended effects, or are potentially unnecessary or causing harm. Conclusions: CGs must have multiple skills to effectively manage medications in home hospice. A systematic approach and intervention is needed to support CGs’ medication management skills.
Interpreting in palliative care: A systematic review of the impact of interpreters on the delivery of palliative care services to cancer patients with limited English proficiency.
Authors: Silva Milagros , Genoff Margaux , Zaballa Alexandra , Stabler Stacy Marie , Gany Francesca , Diamond Lisa 
Published: February 2017

123 Background: According to the 2011 U.S. Census 60% of people living in the U.S. speak a language other than English at home, and of these approximately 40% have limited English proficiency (LEP). Language barriers can affect the health outcomes of LEP patients and the use of trained interpreters can improve patient-physician communication. Since effective communication is the cornerstone of delivering adequate palliative care, a systematic review was conducted to determine the impact of interpreters on the delivery of palliative care services to LEP patients with cancer. Methods: We conducted a systematic review of the literature search in all available languages of 6 databases from 1966 and 2013. Studies evaluated interpreter interventions for LEP patients receiving palliative care services. Of 38 references, 11 articles were found by multiple reviewers to meet inclusion criteria. Data were collected on the study design, size, comparison groups, outcomes, and interpreter characteristics. Results: A total of 6 qualitative and 5 quantitative studies assessed the use of interpreters. All studies found that the quality of care provided to LEP patients receiving palliative services is affected by communication. Most studies showed that when no trained interpreters were used, LEP patients and families had inadequate understanding about their diagnosis or prognosis during goals of care conversations, and worse symptom management at end of life including pain and anxiety. Half of the studies concluded that trained interpreters are not utilized adequately and several suggested that pre-meetings between clinicians and interpreters are important to discuss topics and terminology to be used during goals of care conversations. Conclusions: Published studies show worse outcomes during end of life care and goals of care discussions when trained interpreters are not used. Moreover, trained interpreters are not being used appropriately in the field. More clinically relevant studies are needed to improve the quality of care provided to LEP patients and families receiving palliative services.
Improving the final year of life at the institutional level: Quality dying initiative (QDI).
Authors: Myers Jeff , DasGupta Tracey 
Published: February 2017

124 Background: For a tertiary academic health sciences and comprehensive cancer centre, care of the dying is a significant element of the institution’s overall patient and family care experience. The aim for this large-scale quality improvement project was to improve the quality of the experience for a patient in the final year of life and their family members. Methods: This is descriptive study involves one institution and the characterization of three distinct patient populations: A - Imminently dying patients for whom care goals have been clarified to be comfort, B - Patients for whom death “this admission” would not be a surprise and C - Among patients being discharged, death “within the next year” would not be a surprise, linking in the outpatient cancer care setting. Results: On average 19 deaths per week are in some way expected for the institution’s acute care setting. Phase 1 of the QDI included a review of evidence and best practices in care of the dying as well as comprehensive plans for both organizational engagement and communications. Phase 2 of the QDI (i.e. “Implementation Phase”) involved interventions for each patient population. A corporate-wide “Comfort Strategy” was developed to address Population A. Components include standardized order sets, standardized interprofessional “Comfort Assessment and Documentation”, the palliative care team’s “Coaching Consult”, a “Family Member Education” process and an evaluation plan that includes an experience survey routinely sent to family members following a patient’s death. The intervention was piloted on and subsequently rolled out to all inpatient oncology units. Interventions for Population B and C are the triggering of Goals of Care and Advance Care Plan discussions respectively. Key metrics have been identified for all three patient populations and are based on care elements considered important by dying patients and their family members. These now comprise a dashboard, which has been endorsed for roll out to all patient care units in the acute care setting. Conclusions: A quality framework can be effectively applied for the institutional context of developing an approach to improving the final year of life for a cancer patient.
Evaluating goals of care meetings for hospitialized cancer patients at risk for critical care.
Authors: Apostol Colleen C. , Waldfogel Julie , Pfoh Elizabeth , List Donald C. , Billing Lynn , Nesbit Suzanne A. , Dy Sydney Morss 
Published: February 2017

134 Background: Communication about care preferences is vital for care of cancer patients with advanced and refractory disease, particularly when they become ill enough to be at risk for critical care interventions potentially inconsistent with their preferences. It is vital to describe the use of goals of care discussions in patients with advanced/refractory cancer at risk for critical care and evaluate associations between these discussions and outcomes. Methods: Cohort study describing patient/families’ perceptions of goals of care meetings and comparing health care utilization outcomes of patients who did and who did not have discussions. Inpatient units of an academic cancer center included patients who had metastatic solid tumors or relapsed/refractory lymphoma or leukemia and were at risk for critical care (defined as requiring supplemental oxygen and/or a cardiac monitor). Results: Of 86 patients enrolled, 34 (39%) had a reported goals of care discussion. Patients/families reported their needs and goals were addressed moderately to quite a bit during the meetings. Patients with reported discussions were less likely to receive critical care (0% vs 22%, p=0.003) and more likely to be discharged to hospice (48% vs 30%, p=0.04). Only one patient with a goals of care discussion died during the index hospitalization (on comfort care) (3%) compared with 9% among those without discussions (p=0.08). Conclusions: Goals of care meetings should be incorporated into usual care for cancer patients with advanced or refractory disease at risk for critical care during a hospitalization, in order to improve concordance between care received and patient and family preferences. Goals of care meetings for advanced/refractory cancer inpatients at risk for critical care can address patient and family goals and needs and improve health care utilization outcomes. These meetings should be part of routine care in this patient population.