Background: Care teams are increasingly expected to attend to the needs of patient's personal caregivers (e.g., family members). Improving communication among oncologists, patients with advanced cancer, and their personal caregivers might enhance caregivers' experiences of end-of-life (EoL) cancer care and bereavement outcomes.
Objective: To explore the effects of the Values and Options in Cancer Care intervention on caregivers' experiences of EoL care and bereavement outcomes.
Design: We developed a brief behavioral intervention to improve communication among oncologists, patients with advanced cancer, and their personal caregivers. The intervention was designed to help patients/caregivers ask questions, express concerns, and help oncologists respond effectively. We randomly assigned oncologists (and their patients/caregivers) to the intervention or usual care.
Setting/Subjects: Medical oncologists in NY and CA; patients/personal caregivers with advanced cancer.
Measurements: Two months after the patient's death, caregivers completed three instruments assessing their experiences of EoL care. Seven months after the patient's death, caregivers completed the Prolonged Grief Disorder-13 (PG-13; primary prespecified outcome), the Purpose-in-Life scale, and scales assessing mental health function, depression, and anxiety.
Results: The intervention did not significantly improve caregivers' scores on the PG-13 (p = 0.21), mental health function, depression, or anxiety, but it did improve purpose-in-life scores (p = 0.018). Cohen's d (95% confidence interval) for all three experiences of EoL care outcomes were promising, ranging from 0.22 (-0.19 to 0.63) to 0.39 (-0.07 to 0.86) although none was statistically significant.
Conclusion: Preliminary findings show promise that scalable interventions in cancer care settings may improve caregiver experiences with cancer care and some bereavement outcomes.
CONTEXT: Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (DIALs), few studies have data on both parties.
OBJECTIVE: Test the hypothesis that patient preferences and physician attitudes are both independently associated with DIALS.
METHODS: We report secondary analyses of data collected prospectively from physicians (n=38) and patients with advanced cancer (n=265) in the Values and Options In Cancer Care (VOICE) study. Predictor variables were patient attitudes toward end-of-life care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (=<14 days before death [scored 2], 15-31 days before death [scored 1], > 31 days [scored 0]) and an Emergency Department (ED) visit/inpatient admission score (>=2 [scored 2], 1, 0) in the last month of life.
RESULTS: Chemotherapy scores were nearly .25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (.238 points (95% CI, 0.047-0.429) or reported an unfavorable attitude toward palliative care (0.247 points, 95%CI, 0.047-0.450). A 2 standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of .35 (95% CI, 0.03-0.66) for chemotherapy and .33 (95% CI, 0.04-0.61) for ED visits/inpatient admissions. There was no evidence of effect modification.
CONCLUSION: Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.
CONTEXT: Completion of advance directives (ADs) enhances the likelihood of receiving goal-concordant treatments near the end of life. Previous research on community samples have shown that completion of ADs is less common in lower socioeconomic status demographic group; there is a paucity of such research in patients with cancer.
OBJECTIVES: To study the effect of income and education on the completion of ADs.
HYPOTHESIS: Patients with cancer having lower incomes and education levels would be less likely to report completing ADs.
METHODS: We conducted cross-sectional analyses of data provided by patients (n = 265) enrolled in the Values and Options in Cancer Care clinical trial. Patients with advanced cancer reported whether they had (1) completed a living will or (2) designated a health-care proxy. Response options for both questions were yes (scored 1), no (scored 0), and unsure (scored 0). We studied the association of lower household income (=US$20 000) and education level (never attended college) with AD scores.
RESULTS: Patients with lower annual incomes had lower AD scores (estimate -0.44; confidence intervals [CI]: -0.71 to -0.16, P = .001); the association between higher educational attainment (some college or more) and completion of ADs was not statistically significant (estimate 0.04, CI: -0.16 to 0.24, P = .70).
CONCLUSION: Interventions to promote completion of ADs among lower income patients with serious illnesses are needed.
CONTEXT: Little is known about the hopes patients with advanced (incurable) cancer have for their treatment.
OBJECTIVES: To describe the treatment hopes of advanced cancer patients, factors associated with expressing specific hopes, and the persons with whom hopes are discussed.
METHODS: We surveyed 265 advanced cancer patients in the USA about their hopes for treatment at baseline and after three months. We developed a taxonomy of hopes for treatment, which two investigators used to independently code patient responses. We explored associations between hopes for cure and patient covariates.
RESULTS: We developed 8 categories of hopes. We were able to apply these codes reliably, and 95% of the patient's responses fit at least one hope category. The hope categories in order of descending baseline prevalence were: quality of life, life extension, tumor stabilization, remission, milestone, unqualified cure, control not otherwise specified (NOS), and cure tempered by realism. Most patients reported discussing hopes with partners, family/friends, and oncologists; a minority reported discussing hopes with nurses, primary care physicians (PCPs), clergy, or support groups. In logistic regression analysis, unqualified hopes for cure were more likely in younger patients and in those who did not endorse discussing their hopes with primary care physicians.
CONCLUSION: Advanced cancer patients harbor a range of treatment hopes. These hopes often are not discussed with key members of the healthcare team. Younger age and lack of discussion of hopes with PCPs may lead to less realistic hopes for cure.
OBJECTIVE: To identify predictors of participation of patients with advanced cancer in clinical encounters with oncologists and to assess the impact of patient and caregiver participation on perceptions of physician support.
METHODS: This is a secondary data analysis from the Values and Options in Cancer Care (VOICE) study, a cluster randomized clinical trial of a patient-centered communication intervention. Patients and caregivers completed pre- and post-visit health and communication measures. Audio recorded patient-caregiver (when present)-physician encounters were coded for active patient/caregiver participation behaviors (e.g., question asking, expressing concern) and for physicians' facilitative communication (e.g., partnership-building, support). Mixed linear regression models were used to identify patient, physician, and situational factors predicting patient and patient plus caregiver communication behaviors and post-visit outcomes.
RESULTS: Physician partnership building predicted greater expressions of concern and more assertive responses from patients and patient-caregiver pairs. Patients' perceptions of greater connectedness with their physician predicted fewer patient expressions of concern. Patient perceptions of physician respect for their autonomy was lower among patients accompanied by caregivers. Caregiver perceptions of physician respect for patient autonomy decreased with increasing patient age and varied by site.
CONCLUSIONS: In advanced cancer care, patient and caregiver communication is affected by ecological factors within their consultations. Physicians can support greater patient participation in clinical encounters through facilitative communication such as partnership-building and supportive talk. The presence of a caregiver complicates this environment, but partnership building techniques may help promote patient and caregiver participation during these visits.