Physician factors associated with discussions about end‐of‐life care

BACKGROUND:

Guidelines recommend advanced care planning for terminally ill patients with <1 year to live. Few data are available regarding when physicians and their terminally ill patients typically discuss end‐of‐life issues.

METHODS:

A national survey was conducted of physicians caring for cancer patients about timing of discussions regarding prognosis, do not resuscitate (DNR) status, hospice, and preferred site of death with their terminally ill patients. Logistic regression was used to identify physician and practice characteristics associated with earlier discussions.

RESULTS:

Among 4074 respondents, 65% would discuss prognosis “now” (defined as patient has 4 months to 6 months to live, asymptomatic). Fewer would discuss DNR status (44%), hospice (26%), or preferred site of death (21%) immediately, with most physicians waiting for patient symptoms or until there are no more treatments to offer. In multivariate analyses, younger physicians more often discussed prognosis, DNR status, hospice, and site of death “now” (all P < .05). Surgeons and oncologists were more likely than noncancer specialists to discuss prognosis “now” (P = .008), but noncancer specialists were more likely than cancer specialists to discuss DNR status, hospice, and preferred site of death “now” (all P < .001).

CONCLUSIONS:

Most physicians report they would not discuss end‐of‐life options with terminally ill patients who are feeling well, instead waiting for symptoms or until there are no more treatments to offer. More research is needed to understand physicians' reasons for timing of discussions and how their propensity to aggressively treat metastatic disease influences timing, as well as how the timing of discussions influences patient and family experiences at the end of life. Cancer 2010. © 2010 American Cancer Society.     

Examining ethical dilemmas as obstacles to hospice and palliative care for advanced cancer patients

Oncologists deal almost exclusively with patients with serious and life-threatening diseases, many who are terminally ill. While hospice care remains an ideal model of care for cancer patients with life-ending disease, many obstacles are present in the clinical setting that either impede or prevent the otherwise appropriate referral of patients eligible for this type of end-of-life care. These obstacles are best viewed as ethical dilemmas for oncology clinicians, as they often challenge or obscure a clinician's perceptions about what is in the best interests of their advanced cancer patients. These dilemmas include: Issues surrounding prognosis determination and communication, Concerns about effectively communicating a terminal prognosis while still allowing patients and families to maintain hope, Conflicts of interests for involved clinicians and, Potential problems of the current reimbursement mechanisms for hospice which may be inadequate to meet the needs of all dying cancer patients. For oncologists caring for advanced cancer patients, it is essential that they have a working knowledge regarding these ethical issues, and overt dilemmas, present in end-of-life cancer care in order that they might better appreciate how, and when, to initiate palliative and hospice care for as many of their patients as possible.     

Recommending Unfunded Innovative Cancer Therapies: Ethical vs. Clinical Perspectives among Oncologists on a Public Healthcare System—A Mixed-Methods Study

Over the past decade, there has been a growing development of innovative technologies to treat cancer. Many of these technologies are expensive and not funded by health funds. The present study examined physicians’ perceptions of the ethical and clinical aspects of the recommendation and use of unfunded technologies for cancer treatment. This mixed-methods study surveyed 127 oncologists regarding their perceptions toward using unfunded innovative cancer treatment technologies, followed by in-depth interviews with 16 oncologists. Most respondents believed that patients should be offered all treatment alternatives, regardless of their financial situation. However, 59% indicated that they often face dilemmas regarding recommending new unfunded treatments to patients with financial difficulties and without private health insurance. Over a third (38%) stated that they felt uncomfortable discussing the cost of treatment with patients. A predictive model found that physicians facing patients whose medical condition worsened due to an inability to access new treatments, and who expressed the opinion that physicians can assist in locating funding for patients who cannot afford treatments, were more likely to recommend unfunded innovative therapies to patients (F = 5.22, R² = 0.15, p < 0.001). Subsequent in-depth interviews revealed four key themes: economic considerations in choosing therapy, patient–physician communication, the public healthcare fund, and discussion of treatment costs. Physicians feel a professional commitment to offer patients the best medical care and a moral duty to discuss costs and minimize patients’ financial difficulty. There is a need for careful and balanced use of innovative life-prolonging technologies while putting patients at the center of discourse on this complex and controversial issue. It is essential to develop a psychosocial support program for physicians and patients dealing with ethical and psychosocial dilemmas and to set guidelines for oncologists to conduct a comprehensive and collaborative physician–patient discourse regarding all aspects of treatment.     

Practices and attitudes of Japanese oncologists and palliative care physicians concerning terminal sedation: a nationwide survey.

PURPOSE: To clarify the frequency of practice of sedation therapy for terminally ill cancer patients and to identify physicians' attitudes toward sedation. METHODS: Questionnaires were mailed to 1,436 Japanese oncologists and palliative care physicians with a request to report their practice of and attitudes toward palliative sedation therapy. RESULTS: A total of 697 physicians returned questionnaires (response rate, 49.6%). Use of mild, intermittent-deep, or continuous-deep sedation for physical and psychologic distress was reported by 89% and 64%, 70% and 46%, and 66% and 38%, respectively. In vignettes in which physicians were asked whether they would use sedation for a patient with refractory dyspnea or with existential distress, 14% and 15%, respectively, chose continuous-deep sedation as a strong possibility. Those physicians less confident with psychologic care and with higher levels of professional burnout were more likely to choose continuous-deep sedation. In vignettes in which they were asked whether they use sedation for a patient with depression or delirium, 39% and 31%, respectively, considered psychiatric treatment to be a strong possibility, and 42% and 50% regarded continuous-deep sedation as a potential treatment option. Physicians less involved in caring for the terminally ill and less specialized in palliative medicine were significantly less likely to choose psychiatric treatment. CONCLUSION: Sedation is frequently used for severe physical and psychologic distress of cancer patients. Physicians' clinical experiences with the terminally ill and their levels of professional burnout influence the decisions. Training and education for physicians in regard to end-of-life care and valid clinical guidelines for palliative sedation therapy are necessary.     

Physicians' perspectives on "do-not-resuscitate" (DNR) orders

Background. The purpose of this study was to investigate physicians' perspectives on do-not-resuscitate (DNR) orders at Tokai University hospital, where a euthanasia-like accident occurred several years ago. Methods. A "questionnaire on DNR orders" survey was administered to physicians and the anonymous answers were collected 2 weeks later. Results. Answers were received from 150 of the 400 physicians (37.5%) (surveyed from every department), and revealed that more than 90% of the physicians felt that DNRs were occasionally necessary and that more than 60% of the physicians stated that they had performed DNR. Only 14% of the physicians answered that the patient's consent would be indispensable, and 78% stated that the patient's family and the physician could decide on DNR without the patient's consent being given. Only half of the physicians stated that they regarded it as necessary that DNR order sheets be established hospital policy, and more than 20% of the physicians stated that such an order sheet would not be necessary. Conclusion. There is, in fact, a tacit understanding regarding DNR between physicians and patients/families in medical practice in Japan. However, DNR orders constitute definite medical decisions and procedures. Therefore, such orders should be clearly stated in a standardized format, although such procedures do not seem to be acceptable in the context of the Japanese traditional value system. Received: September 21, 1998 / Accepted: January 14, 1999     

The oncology nurse's role in patient advance directives.

In December 1991, Patient Self-Determination Amendment (PSDA) legislation was implemented. The PSDA requires facilities funded by Medicare/Medicaid to inform patients of their decision-making rights regarding medical care. An advance directive (AD), a living will, or a durable power of attorney for health care contains statements made by competent people directing their medical care if they should become incompetent. Oncology nurses are in an advantageous position to educate and advocate for their patients with respect to end-of-life decisions. They are qualified to facilitate the AD process by virtue of their ability to relate to patients and families their extensive experience with the terminally ill and their expertise as liasons between patients, families, and the multidisciplinary team. A clear understanding of the patient's wishes regarding life-sustaining treatments enables the oncology nurse to advocate more effectively on the patient's behalf. This article highlights definitions of ADs, advantages and disadvantages of each, and recommendations for the oncology nurse's practice.     

Health care professionals' grief: a model based on occupational style and coping

Many publications address grief in terminally ill patients and their loved ones. In contrast, this paper proposes a hypothetical model for grief reactions in health care professionals (HCPs) working with terminally ill patients. The model integrates three literatures: burnout, coping and personality/occupational interests. Grief-related job stress can culminate in burnout that affects over 50% of physicians treating the terminally and critically ill. Coping behaviors that attenuate burnout differ among HCPs, suggesting that nurses prefer different coping strategies when compared with physicians. The personality and occupational interests literatures provide a rationale for coping differences in HCPs. Personality characteristics associated with occupational preferences provide insight into HCPs' natural propensities for coping with stress. The model addresses personality/occupational differences among health care disciplines, thus providing a plausible explanation for coping differences among HCPs, as well as potential interventions that facilitate HCPs' adjustment to the deaths of their patients.     

Palliative radiotherapy knowledge among community family physicians and nurses

Background. Primary care physicians and nurses care for patients with advanced cancer and need to be aware of the role for palliative radiotherapy (PR). Methods. We surveyed 250 family physicians, family medicine residents, and nurses attending oncology educational symposia to determine their knowledge of PR. Results. The survey response rate was 59%, and most respondents (77%) were involved with the care of cancer patients. Many (58%) thought that their knowledge of PR was insufficient for their needs. Although bone metastasis and spinal cord compression were frequently recognized indications for PR, only 50% of other assessed indications for PR were correctly identified. Almost all respondents stated that they wanted to learn more about PR. Conclusions. More education regarding PR is required for primary care physicians and nurses caring for cancer patients.     

Ethical issues in integrative oncology

Integrative oncology relates to an emerging dialog between complementary and alternative medicine (CAM) scholars, oncologists, family practitioners, and other health care providers who envision an extended and holistic patient-centered approach to oncology care. The multiple commitments of integrative oncology to a medical humanistic approach and to a strong evidence-based foundation may impose considerable ethical concerns and dilemmas. The authors use narrative ethics to present a case study that exemplifies the ethical challenges confronting physicians and health care providers who wish to provide an integrative approach for their patients. An ethical analysis of the narrative is provided to help clarify the ethical issues and conflicts within it. Finally, a framework that may transform ethical constraints to a communication tool is proposed.     

Delirium prevention in terminal cancer: assessment of a multicomponent intervention

Objective: Delirium is a highly prevalent and deleterious disorder in terminally ill cancer patients. We assessed whether a multicomponent preventive intervention was effective in decreasing delirium incidence and severity among cancer patients receiving end‐of‐life care. Methods: A cohort of 1516 patients was followed from admission to death at seven Canadian palliative care centers. In two of these centers, routine care included a delirium preventive intervention targeting physicians (written notice on selective delirium risk factors and inquest on intended medication changes), patients, and their family (orientation to time and place, information about early delirium symptoms). Delirium frequency and severity were compared between patients at the intervention (N = 674) and usual‐care (N = 842) centers based on thrice‐daily symptom assessments with the Confusion Rating Scale. Results: The overall rate of adherence to the intervention was 89.7%. The incidence of delirium was 49.1% in the intervention group, compared with 43.9% in the usual‐care group (odds ratio [OR] 1.23, P = 0.045). When confounding variables were controlled for, no difference was observed between the intervention and the usual‐care groups in delirium incidence (OR 0.94, P = 0.66), delirium severity (1.83 vs 1.92; P = 0.07), total days in delirium (4.57 vs 3.57 days; P = 0.63), or duration of first delirium episode (2.9 vs 2.1 days; P = 0.96). Delirium‐free survival was similar in the two groups. Conclusion: A simple multicomponent preventive intervention was ineffective in reducing delirium incidence or severity among cancer patients receiving end‐of‐life care. Delirium prevention remains a difficult challenge in terminally ill cancer patients. Copyright © 2010 John Wiley & Sons, Ltd.     

Primary Care Physicians’ Perspectives in Leading Breast Cancer Follow-Up Care

IntroductionLimited data exist on the barriers associated with transitioning breast cancer follow-up care to primary care physicians (PCPs). This study aimed to describe the current perspectives of PCPs in managing breast cancer follow-up.MethodAn online survey was distributed to PCPs in Toronto, ON, Canada. Questions examined PCPs’ view of transitioning breast cancer follow-up care to their practices.ResultsOf 800 PCPs invited, 126 responded (response rate: 15.7%). The types of practice models amongst respondents included blended capitation (42.9%), blended salary (27%), and fee-for-service (17.5%). Seventy-seven percent of respondents stated they provided follow-up care. Approximately half of the respondents stated they were somewhat comfortable providing follow-up care. PCP-led follow-up care was considered either very (49.2%) or somewhat appropriate (30.2%). When asked about financial remuneration, 43.7% of respondents stated it was somewhat important. The factors that influenced the feasibility of PCP-led follow-up care included receipt of a detailed follow-up care plan provided by the specialist after discharge (81%), the ability to re-refer to specialists rapidly (56.3%), and the ability to obtain regular updates of best practice changes (59.5%). The preferred means of educational updates included E-mail (40.5%), continuing medical education events (30.2%), and electronic medical records (19.8%). When the fee model was taken into consideration there was no significant difference in opinions regarding follow-up care.ConclusionsTransitioning to a PCP-led model was supported by most of the PCPs who participated in this study. Their perspective on PCP-led follow up care and barriers associated with implementation of this model of care needs to be further explored with future studies that include larger sample size and a more diverse PCP population.     

Knowledge,Attitudes, and Practices Pertaining to Lung Cancer Screening Among Primary Care Physicians in a Public Urban Health Network

IntroductionLung cancer screening (LCS) with annual low-dose computed tomography in high-risk groups decreases the mortality related to lung cancer. Its implementation rate has been low, and knowledge relating to LCS has not been assessed in providers treating underserved populations.Materials and MethodsAn institutional review board-approved anonymous survey was sent to primary care physicians of the Cook County Health system, a safety-net healthcare system. The survey assessed the knowledge pertaining to LCS guidelines, providers’ experience with LCS, and their recommendations for quality improvement using 24 questions. The predictors of LCS within the previous 6 months were identified using logistic regression analysis.ResultsOf the 152 survey responses, 43% were from nontrainees with diverse training backgrounds. Adequate knowledge of LCS was demonstrated by 72% of the respondents, and pretest counseling was the domain most often answered incorrectly in the questionnaire. LCS had been ordered in the previous 6 months by 57% of the respondents. However, 88% estimated that they had screened < 50% of eligible patients. Higher patient volume, more experience, and family medicine training predicted for ordering LCS in the previous 6 months. In addition, 82.2% indicated that prompts in the electronic medical records would increase LCS, and 78.3% reported that receiving statistics about their LCS practice would increase LCS performance.ConclusionsPrimary care physicians in the hospital healthcare system had reasonable knowledge of LCS, but the implementation rate was low. We have identified areas for improvement relating to LCS implementation.     

Perceptions of medical status and treatment goal among older adults with advanced cancer

BackgroundPatient-reported medical status and treatment goal are measures of prognostic understanding with demonstrated relationships to important clinical and patient-reported outcomes in the general cancer population. Among older adults, relationships between these measures and other patient-reported (quality of life [QOL], symptoms, functional impairment) and clinical (hospitalization risk, survival) outcomes remains unclear.MethodsWe enrolled patients ≥70 with advanced gastrointestinal cancers, collecting patient-reported medical status (terminally ill vs not), treatment goal (curative vs non-curative), QOL (EORTC-Elderly Cancer Patients), symptoms (Edmonton Symptom Assessment System [ESAS]), and functional impairment (activities of daily living [ADLs]). We also obtained information about hospitalizations and survival. To explore relationships between patient-reported medical status, treatment goal, QOL, symptoms, functional impairment, hospitalizations, and survival, we used regression models adjusted for age, sex, and education.ResultsOf 103 patients, 49.5% reported terminally ill status and 64.0% a non-curative treatment goal. Terminally ill status was associated with worse QOL (EORTC illness burden: 53.59 vs 35.26, p = 0.001), higher symptom burden (ESAS: 28.15 vs 16.79, p = 0.002), more functional impairment (ADLs: 3.63 vs 5.24, p = 0.006), greater hospitalization risk (HR = 2.41, p = 0.020), and worse survival (HR = 1.93, p = 0.010). We did not find associations between patient-reported treatment goal and these outcomes.ConclusionsIn older adults with advanced cancer, report of terminally ill status was associated with other important patient-reported and clinical outcomes, suggesting disease severity may inform illness perceptions. We did not find similar associations for patient-reported treatment goal, indicating that questions related to medical status and treatment goal measure different constructs and more nuanced measures are needed.     

Perceptions of terminally ill patients and family members regarding home and hospice as places of care at the end of life

To enable demand-based palliative care, it is important to know the perceptions of terminally ill patients and their family members regarding home and hospice as places of care at the end of life. Eight women and five men suffering from cancer and with a life expectancy of 3 months or less were interviewed. In each case one of the family members was also interviewed. Four patients spent their last phase of life at home, nine in a hospice. This paper provides further insight in the patient perspective in palliative care. The results reveal that a cohabiting partner seems an important prerequisite for terminally ill patients to stay at home. For spouses it is an obvious choice to facilitate the patients' stay at home, even when it becomes too demanding, something not discussed between spouse and patient. When sufficient care at home seems impossible and the negotiation between patients and family members results in the opinion that living at home is no longer an option, it is decided that the patient moves to a hospice. The choice for the specific setting of the patients' new residence seems to be random; one possibility is pointed out to them and seems appropriate.     

Patient awareness of prognosis, patient-family caregiver congruence on the preferred place of death, and caregiving burden of families contribute to the quality of life for terminally ill cancer patients in Taiwan

Objectives: The main goal of end‐of‐life care is to achieve the best quality of life (QOL) for patients. The purpose of this study was to investigate the impact of (1) the patients' awareness of their prognosis, (2) the extent of patient–family caregiver congruence on the preferences for end‐of‐life care options, and (3) the perceived caregiving burden of family caregivers when they provide end‐of‐life care to their dying relative, on the QOL for terminally ill cancer patients in Taiwan. Methods: A total of 1108 dyads of patient–family caregiver from 24 hospitals throughout Taiwan were one‐time surveyed. Predictors of the QOL were identified by multiple regression analysis. Results: Controlling for the effects of age, financial status, and symptom distress, a novel finding of this study was that the patient awareness of prognosis, patient–family caregiver congruence on the preferred place of death, and the subjective family caregiving burden had a significant impact on the QOL of Taiwanese terminally ill cancer patients. Conclusions: QOL is not only related to the unavoidable decline in physical condition and daily functioning of the dying patient but is also related to domains that, as death approaches, have the potential to show improvement through the efforts of health‐care professionals, such as presenting prognostic information to optimize the patients' understanding and assists them with psychological adjustments, facilitating patient–family caregiver congruence on the end‐of‐life care decision regarding the place of death and lightening the caregiving burden of family caregivers. Copyright © 2008 John Wiley & Sons, Ltd.     

The use of hospital beds for terminally ill cancer patients

A study to identify reasons for admitting terminally ill cancer patients to hospital is reported together with recommendations for the future. Forty per cent of patients were so seriously ill with pain, medical or nursing problems that their carers could not manage satisfactorily at home and hospitalisation was necessary and appropriate. In addition 27% of patients admitted had no family or carers to nurse them at home. In the remaining 33% of patients it may have been possible with planned admissions and better supportive communications to allow some patients to die at home. Analysis of the data would suggest that there are three principal reasons for continuing to provide hospital beds for the terminally ill cancer patient: 1. Special medical and nursing care. 2. To provide care for some patients with no family or friend carer support. 3. Teaching of management by senior staff. The unsatisfactory nature of terminally ill patients dying in the centre of acute wards together with inadequate facilities to interview relatives is noted. It is suggested that the provision of well planned hospital beds is more appropriate than providing remote hospice beds for the terminally ill cancer patient.     

Physician over-recommendation of mammography for terminally ill women

BACKGROUND:

There has been recent, sometimes intense, debate about when to begin screening and how often to screen women for breast cancer with mammography. However, there should be no controversy regarding screening women who are unlikely to benefit from the procedure, such as those with a serious, life‐limiting illness who would not live long enough to benefit from the potential detection and treatment of breast cancer. Identifying characteristics of physicians who recommend mammography for terminally ill women can help guide efforts to minimize patient risks and make better use of health care resources.

METHODS:

The authors used data from a nationally representative survey of primary care physicians (PCPs) (N = 1196; response rate, 67.5%) conducted in 2006 and 2007 to examine PCPs' breast cancer screening recommendations for hypothetical patients ages 50 years, 65 years, and 80 years who were healthy, had a moderate comorbidity, or had a terminal comorbidity.

RESULTS:

Many PCPs (47.7%) reported that they would recommend mammography to a woman aged 50 years, 65 years, or 80 years with terminal lung cancer, indicating over‐recommendation. Physician characteristics associated with over‐recommending mammography included obstetrician/gynecologist (odds ratio [OR], 1.69) or internal medicine (OR, 0.45) specialty, being a woman (OR, 1.40), being a racial/ethnic minority (OR, 1.72), and working in a smaller practice (OR, 1.41).

CONCLUSIONS:

The current results indicated that physician over‐recommendation of screening mammography among terminally ill women is common. Certain physician and practice characteristics, including specialty, were associated with over‐recommending mammography. The authors concluded that an informed and shared mammography decision‐making process for terminally ill women may eliminate unnecessary patient risks and health care expenditures. Cancer 2012;. © 2011 American Cancer Society.