In einer Studie wurde untersucht, wie sich die Pege im Hospiz in der Wahrnehmung der Angehörigen auf das Benden und die Lebensqualität der Sterbenden auswirkt. I n der Studie wurden 2.307 Familien ver-storbener Patienten mit fortgeschritte-nem Lungen-oder Kolorektalkarzinom interviewt. Die Patienten waren im Rah-men der multiregionalen prospektiven Beobachtungsstudie Cancer Care Outcomes Research and Surveillance Study re-krutiert worden und schließlich verstor-ben. Verglichen wurden Familienberich-te über Patienten, die im Hospiz (nn==1.257; 55 %), und jene, die nicht im Hospiz verstorben waren (nn==1.050). Die Befragung galt Symptomen wie Schmer-zen und Dyspnoe, der Qualität der Pege am Lebensende und der Frage, inwieweit sich die Wünsche der Patienten mit dem tatsächlichen Sterbeort und der Qualität der Pege am Lebensende gedeckt hatten. Für die Analyse wurden Propensity-score-gematchte Daten von 1.970 Patien-ten bzw. deren Familien berücksichtigt (je zur Häle im bzw. nicht im Hospiz verstorben; 36 % < 65 Jahre). Die Famili-en, deren Angehörige im Hospiz verstor-ben waren, berichteten häuger über Schmerzen der Krebskranken als die Fa-milien, deren Angehörige nicht im Hos-piz verstorben waren. Gleichzeitig hatten die Patienten im Hospiz laut ihren Fami-lienangehörigen häuger die "richtige Dosis an Schmerzmedikamenten" (80 vs. 73 %) und ausreichend Hilfe bei aure-tender Dyspnoe erhalten (78 vs. 70 %). Die Familien von Patienten aus dem Hos-piz erzählten zudem öer, dass den Pati-entenwünschen bezüglich der Qualität der Pege am Lebensende entsprochen worden war (80 vs. 74 %) und dass ihren Angehörigen eine "exzellente" Pegequa-lität am Lebensende zuteil geworden war (57 vs. 42 %). In der Bewertung schnitt die Pegequalität bei den Familien, deren Angehörige mehr als 30 Tage im Hospiz zugebracht hatten, am besten ab. Je mehr Zeit die Krebskranken im Hospiz ver-bracht hatten, desto häuger entsprach der Sterbeort ihrem Wunsch. Fazit: Die Pege im Hospiz war in dieser Studie den Angehörigen der verstorbe-nen Krebspatienten zufolge mit einer besseren Linderung von Symptomen, ei-ner besseren Qualität der Pege am Le-bensende und einer höheren Überein-stimmung von Patientenwünschen und tatsächlichen Gegebenheiten verbunden. Besonders positiv elen die Berichte bei Aufenthalten im Hospiz von mehr als ei-nem Monat aus. Terminal kranke Krebspatienten fühlen sich oft schlecht informiert. Im Gespräch mit ihrem Onkologen gelingt es ihnen nur selten, für sie relevante Fragen zu stellen. Könnte ein Gesprächstraining für beide Seiten helfen? D ie meisten Patienten mit fortgeschrit-tenen Krebserkrankungen möchten eine sensible, aber ehrliche Kommunika-tion über das Ende ihres Lebens. Dennoch sind die Patienten häug schlecht über Lebenschancen und Heilungsmöglich-keiten informiert. In einer randomisier-ten Studie wurden Ärzte und Patienten gecoacht, bevor es zu einem ausführli-chen Gespräch kam. In der Vorbereitung erhielten die Patienten auch eine Fragen-identikationsliste (Question Prompt List, QPL), die ihnen helfen sollte, die Fra...

Objective: To explore family caregivers' emotional experiences while caring for patients with advanced cancer and navigating distressing information, awareness of dying, and difficult decisions.Methods: Qualitative descriptive study of semi-structured interviews with 92 bereaved caregivers of patients with advanced cancer. Interviews explored caregivers' experiences as patients transitioned out of active cancer treatment and neared the end of life.Results: Included in caregivers' characterization of this transition time were three particularly emotionally charged experiences. The first occurred when caregivers felt jolted into awareness that patients were dying.They were startled to realize that patients would die sooner than expected; some expressed frustration that they had not been adequately warned. In the second, caregivers felt conflicted when involved in decisions that pitted patients' preferences against what caregivers felt patients needed, resulting in ambivalence, guilt, and grief. Thirdly, caregivers who felt they did their best for patients expressed fulfillment and gratitude. Conclusion:Caregivers of patients with advanced cancer face unique, emotionally charged experiences that can lead to distress and affect care at the end of life.

Objective Clinician discomfort with death may affect care of patients but has not been well-studied. This study explores oncology clinicians’ attitudes surrounding their own death and how these attitudes both affect and are affected by their care of dying patients and their communication with them. Methods Qualitative interviews with physicians (n = 25), nurse practitioners (n = 7), and physician assistants (n = 1) in medical or hematologic oncology clinical practices about communication styles, care of terminally ill patients, and personal perspectives about mortality. Results Clinicians described three communication styles used with patients about death and dying: direct, indirect, or selectively direct. Most reported an acceptance of their mortality that was “conditional,” meaning that that they could not fully know how they would respond if actually terminally ill. For many clinicians, caring for dying patients affected their outlook on life and death, and their own perspectives on life and death affected their approach to caring for dying patients. Conclusion An awareness of personal mortality may help clinicians to discuss death more openly with patients and to provide better care. Practice implications Efforts to promote self-awareness and communication training are key to facilitating clear communication with and compassionate care of terminally ill patients.

Objective: Silences in doctor-patient communication can be “connectional” and communicative, in contrast to silences that indicate awkwardness or distraction. Musical and lexical analyses can identify and characterize connectional silences in consultations between oncologists and patients. Methods: Two medical students and a professor of voice screened all 1211 silences over 2 s in length from 124 oncology office visits. We developed a “strength of connection” taxonomy and examined ten connectional silences for lexical and musical features including pitch, volume, and speaker turn-taking rhythm. Results: We identified connectional silences with good reliability. Typical dialog rhythms surrounding connectional silences are characterized by relatively equal turn lengths and frequent short vocalizations. We found no pattern of volume and pitch variability around these silences. Connectional silences occurred in a wide variety of lexical contexts. Conclusion: Particular patterns of dialog rhythm mark connectional silences. Exploring structures of connectional silence extends our understanding of the audio-linguistic conditions that mark patient-clinician connection. Practice implications: Communicating with an awareness of pitch, rhythm, and silence – in addition to lexical content – can facilitate shared understanding and emotional connection.

PURPOSE: In December 2016, 49% of patients admitted to inpatient oncology services at University of Pittsburgh Medical Center Shadyside Hospital had cardiopulmonary resuscitation (CPR) status discussion documentation before discharge. The aim of this project was to improve the rate of CPR status conversations. METHODS: During Plan-Do-Study-Act (PDSA) cycle 1, a stakeholder workgroup was formed in January 2017 by oncology faculty, fellows, nurses, advance practice providers (APPs), medicine housestaff, and palliative care faculty. All oncology clinicians and inpatient team members were reminded weekly to discuss and document CPR status preferences. APPs received training on efficient and effective CPR status assessment from palliative care faculty. Oncology leadership received monthly e-mail updates of CPR status documentation rates and endorsed CPR status best practice guidelines. For PDSA cycle 2, patient charts without CPR status documentation in March 2018 were reviewed, and themes were shared with oncology leadership and reviewed with APPs. RESULTS: After PDSA cycle 1, CPR status assessment rates increased from 49% to greater than 80%. In 2017, more than 1,500 more CPR status discussions were documented than in 2016. The percentage of patients discharged with “comfort measures only” or “do not resuscitate” orders increased from 14.2% (95% CI, 9.5% to 19.0%) to 19.8% (95% CI, 15.6% to 24.0%). For PDSA cycle 2, charts of 60 patients without CPR assessment were reviewed. Of these, 52% were admitted overnight by nocturnists and 48% by daytime APPs. Fifty-five percent of patients (n = 33 of 60) had metastatic disease. CPR status was documented on previous admissions for 53% of patients (n = 31 of 60) in the past 12 months. Fifteen percent (n = 11 of 60) were admitted for scheduled inpatient chemotherapy. CONCLUSION: A multipronged approach significantly increased CPR status assessments. More patients transitioned to comfort measures only or do not resuscitate when their preferences were clearly assessed and documented.

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12080 Background: Patients with advanced cancer often worry about dying, yet little is known about the role their fears play regarding future care. We aimed to explore relationships between patients’ worry about dying and their illness understanding, treatment preference, and advance care planning. Methods: This cross-sectional study uses baseline data from a community-based, primary palliative care intervention trial. Patients had metastatic solid tumors, an Eastern Cooperative Oncology Group performance status of 0-2, and their oncologist “would not be surprised” if they died in the next year. Using patients’ response to “I worry about dying” (not at all, a little bit, somewhat, quite a bit, or very much) from the Functional Assessment of Chronic Illness - Palliative Care survey instrument, univariate and multivariate analyses assessed associations with illness understanding (report of being terminally ill or not), treatment preference (life-extending vs. symptom-focused), and advance care planning (completion of an advance directive or not). We also performed sensitivity analyses substituting “I feel scared about my future” (strongly disagree, disagree, agree, or strongly agree) from the Herth Hope Index for “I worry about dying.” Results: Of 672 patients, 54% were female, 94% white, and 69% currently receiving chemotherapy. 47% reported worrying about dying “not at all,” while 9.7% worried “quite a bit” or “very much.” In regression analysis, those who worried “quite a bit” or “very much” were more likely to describe themselves as terminally ill (adjusted odds ratio (AOR)=1.98, 95% CI=1.10-3.54, p=0.021) and more likely to prefer life-extending treatment over symptom-focused care (AOR=2.61, 95% CI=1.30-5.22, p=0.007) compared with patients who reported not worrying about dying. They also were less likely to have completed an advance directive (AOR=0.49, 95% CI=0.25-0.94, p=0.032). The same relationships were observed using patients’ response to “I feel scared about my future.” Conclusions: Patients with advanced cancer who worry more about dying can affirm they are terminally ill and are more likely to want life-extending treatment over symptom care while less likely to engage in advance care planning. Understanding these patients’ decision making is critical to ensuring that their values are known and understood near the end of life.