Palliative Care Referrals for Advanced Non–small-cell Lung Cancer (NSCLC): Patient and Provider Attitudes and Practices

Feld, Emily; Singhi, Eric K.; Phillips, Sharon; Huang, Li; Shyr, Yu; Horn, Leora

doi:10.1016/j.cllc.2019.02.002

Cited by 27 publications

(53 citation statements)

References 27 publications

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“… 127 oncologists from 12 cancer centres in Ontario, Canada Survey Barriers were patients have difficulty in accepting prognosis, and desire for aggressive treatment due to inflated expectation of treatment benefit. Other barriers were lack of time to have conversations, prognostic uncertainty, desire to maintain hope, uncertainty of the benefits of further active cancer therapy, difficulty in recommending discontinuation of treatment in younger population and patient and family refusals 34 Feld et al (2019) [ 55 ] USA What are the practices and attitudes regarding the role of early palliative care referral among oncologists and patients with metastatic non-small cell lung cancer? 279 Oncologists from the International Association for the Study of Lung Cancer Survey Common factors influencing participants to refer patients to palliative care were inadequately managed pain, no further or dwindling treatment options, other cancer-related symptoms, depression/anxiety.…”

Section: Resultsmentioning

confidence: 99%

“…(Prodhomme, 2018 [ 56 ]) Responsibility to reassure, motivate and infuse confidence (Prodhomme, 2018 [ 56 ]) Protect patients from violent discussions on end of life (Prodhomme, 2018 [ 56 ]) Negative emotions Emotional toll while making palliative care referral (Wright, 2017 [ 43 ]) (Sarradon-Eck, 2019 [ 58 ]) Emotional burden associated with delivering news of poor prognosis (Sarradon-Eck, 2019 [ 58 ]) Emotional bond associated long term knowing of the patients (Horlait, 2016 [ 36 ]). Inability to handle emotional reactions associated with palliative care referral (Horlait, 2016 [ 36 ]) Self-efficacy Symptom management, psychosocial support and communication is integral part of oncology and can provide ourselves (Schenker, 2014 [ 46 ]) (LeBlanc, 2015 [ 47 ]) (Feld, 2019 [ 55 ]) (Sarradon-Eck, 2019 [ 58 ]) Oncologists have training in managing physical and psychological symptoms, and communicating with patients and families (Cherny, 2013 [ 38 ]) (Johnson, 2008 [ 40 ]) (Ward, 2009 [ 41 ]) 2. Power relationships and trust issues Control and coordinate the care process Be responsible for the care of the patient till the end (Horlait, 2016 [ 36 ]) (Schenker, 2014 [ 46 ]) (Rhondali, 2013 [ 45 ]) (Hay, 2017 [ 42 ]) Coordinate the care of the patient at all stages of the illness (Cherny, 2013 [ 38 ]) (Wright, 2017 [ 43 ]) Referral leads to loss of control (Hay, 2017 [ 42 ]) (LeBlanc, 2015 [ 47 ]) Dislikes interference in patient care (Schenker, 2014 [ 46 ]) (Rhondali, 2013 [ 45 ]).…”

Section: Resultsmentioning

confidence: 99%

“…(Sarradon-Eck, 2019 [ 58 ]) Elicits feelings of abandonment, stopping treatment and euthanasia (Sarradon-Eck, 2019 [ 58 ]) Use supportive care and comfort care instead (NyirÖ et, 2018 [ 53 ]) (Sarradon-Eck, 2019 [ 58 ]) Reluctance to discuss death and dying (Prodhomme, 2018 [ 56 ]) Discussing death is stressful and a taboo (Prodhomme, 2018 [ 56 ]) (Horlait, 2016 [ 36 ]) (NyirÖ et, 2018 [ 53 ]) Patients and families get alarmed by mention of palliative care (Smith, 2012 [ 44 ]) Physicians have to address the negative connotation associated with palliative care (Hay, 2017 [ 42 ]) Palliative care referral requires careful explanation (Wright, 2017 [ 43 ]) Referring to palliative care means patients are weak and unable to fight the disease (Rhondali, 2013 [ 45 ]) Illness and treatment related factors Advanced, recurrent or metastatic cancers are referred (Rhondali, 2013 [ 45 ]) Unpredictable course of illness hinders referral (Morikawa, 2016 [ 39 ]) Relapsing and remitting nature of haematological malignancies is a barrier for referral (Wright, 2017 [ 43 ]) Rapid progression and complications hinder referral (Wright, 2017 [ 43 ]) Short time frame from onset of symptoms to end of life is a constraint for referral (Tricou, 2019 [ 57 ]) Prognostic uncertainty is a barrier (Ethier, 2018 [ 54 ]) Referred when prognosis is poor (Wentlandt, 2012 [ 48 ]), (Wentlandt, 2014 [ 49 ]) Uncertainty in decision making hinders referral (Suwanabol, 2018 [ 50 ]) No referral if general condition is good (Horlait, 2016 [ 36 ]). Uncontrolled symptoms facilitate referral (Rhondali, 2013 [ 45 ]), (Wentlandt, 2012 [ 48 ]), (Wentlandt, 2014 [ 49 ]) (Feld, 2019 [ 55 ]) No referral in the absence of symptoms (Johnson, 2008 [ 40 ]), (Wentlandt, 2014 [ 48 ]) (Feld, 2019 [ 55 ]) No referral until treatment failure or late stage of the disease (LeBlanc, 2015 [ 47 ...…”

Section: Resultsmentioning

confidence: 99%

“…Uncontrolled symptoms facilitate referral (Rhondali, 2013 [ 45 ]), (Wentlandt, 2012 [ 48 ]), (Wentlandt, 2014 [ 49 ]) (Feld, 2019 [ 55 ]) No referral in the absence of symptoms (Johnson, 2008 [ 40 ]), (Wentlandt, 2014 [ 48 ]) (Feld, 2019 [ 55 ]) No referral until treatment failure or late stage of the disease (LeBlanc, 2015 [ 47 ]). No referral if possibility of cure exists (Johnson, 2008 [ 40 ]) (Wright, 2017 [ 43 ]) (Ethier, 2018 [ 54 ]) Lack of treatment options is a trigger for referral (Feld, 2019 [ 55 ]) Priority on treatment of the disease and cure until the end hinders referral (Morikawa, 2016 [ 39 ]) Difficulty in recommending discontinuation of treatment in younger population (Ethier, 2018 [ 54 ]) Patient and family attitudes Unrealistic expectation of cure and desire for aggressive treatment (Suwanabol, 2018 [ 50 ]) (Horlait, 2016 [ 36 ]) (Ethier, 2018 [ 54 ]) (Cripe, 2019 [ 52 ]) Unwilling to discuss prognosis and non-curative approach (Smith, 2012 [ 44 ]) (Ethier, 2018 [ 54 ]) (Johnson, 2008 [ 40 ]) Unwilling to discuss referral to palliative care (Horlait, 2016 [ 36 ]) (Ward, 2009 [ 41 ]) (Charalambous, 2014 [ 37 ]) (Feld, 2019 [ 55 ]) Family conflict (Suwanabol, 2018 [ 50 ]) Cultural barriers (Suwanabol, 2018 [ 50 ]) (Horlait, 2016 [ 36 ]) Language barriers (Horlait, 2016 [ 36 ]) Negative public perception about death (Suwanabol, 2018 [ 50 ]) Organisational Challenges Hospital culture directed towards cure (Suwanabol, 2018 [ 50 ]), (Horlait, 2016 [ 36 ]) Lack of time to discuss about palliative care (Suwanabol, 2018 [ 50 ]), (Horlait, 2016 [ ...…”

Section: Resultsmentioning

confidence: 99%

“…No referral if possibility of cure exists (Johnson, 2008 [ 40 ]) (Wright, 2017 [ 43 ]) (Ethier, 2018 [ 54 ]) Lack of treatment options is a trigger for referral (Feld, 2019 [ 55 ]) Priority on treatment of the disease and cure until the end hinders referral (Morikawa, 2016 [ 39 ]) Difficulty in recommending discontinuation of treatment in younger population (Ethier, 2018 [ 54 ]) Patient and family attitudes Unrealistic expectation of cure and desire for aggressive treatment (Suwanabol, 2018 [ 50 ]) (Horlait, 2016 [ 36 ]) (Ethier, 2018 [ 54 ]) (Cripe, 2019 [ 52 ]) Unwilling to discuss prognosis and non-curative approach (Smith, 2012 [ 44 ]) (Ethier, 2018 [ 54 ]) (Johnson, 2008 [ 40 ]) Unwilling to discuss referral to palliative care (Horlait, 2016 [ 36 ]) (Ward, 2009 [ 41 ]) (Charalambous, 2014 [ 37 ]) (Feld, 2019 [ 55 ]) Family conflict (Suwanabol, 2018 [ 50 ]) Cultural barriers (Suwanabol, 2018 [ 50 ]) (Horlait, 2016 [ 36 ]) Language barriers (Horlait, 2016 [ 36 ]) Negative public perception about death (Suwanabol, 2018 [ 50 ]) Organisational Challenges Hospital culture directed towards cure (Suwanabol, 2018 [ 50 ]), (Horlait, 2016 [ 36 ]) Lack of time to discuss about palliative care (Suwanabol, 2018 [ 50 ]), (Horlait, 2016 [ 36 ]) (Cripe, 2019 [ 52 ]) (Ethier, 2018 [ 54 ]) Lack of space to discuss about palliative care (Horlait, 2016 [ 36 ]) Documentation deficiencies in oncology case notes (Horlait, 2016 [ 36 ]) Legal liability of palliative care referral (Suwanabol, 2018 [ 50 ]) Fear of opioids and its side effects (Suwanabol, 2018 [ 50 ]) Lack of knowledge among the oncologist’s about palliative care (Suwanabol, 2018 [ ...…”

Section: Resultsmentioning

confidence: 99%

See 4 more Smart Citations

How views of oncologists and haematologists impacts palliative care referral: a systematic review

et al. 2020

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Background Worldwide, many patients with cancer, are infrequently referred to palliative care or are referred late. Oncologists and haematologists may act as gatekeepers, and their views may facilitate or hinder referrals to palliative care. This review aimed to identify, explore and synthesise their views on referrals systematically. Methods Databases of MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, Web of Science and Cochrane were searched for articles from 01/01/1990 to 31/12/2019. All studies were scored for their methodological rigour using Hawker’s tool. Findings were synthesised using Popay’s narrative synthesis method and interpreted using a critical realist lens and social exchange theory. Results Out of 9336 initial database citations, 23 studies were included for synthesis. Five themes were developed during synthesis. 1. Presuppositions of oncologists and haematologists about palliative care referral: Role conflict, abandonment, rupture of therapeutic alliance and loss of hope were some of the presuppositions that hindered palliative care referral. Negative emotions and perception of self-efficacy to manage palliative care need also hindered referral. 2. Power relationships and trust issues: Oncologists and haematologists preferred to gatekeep the referral process and wished to control and coordinate the care process. They had diminished trust in the competency of palliative care providers. 3. Making a palliative care referral: A daunting task: The stigma associated with palliative care, navigating illness and treatment associated factors, addressing patient and family attitudes, and overcoming organisational challenges made referral a daunting task. Lack of referral criteria and limited palliative care resources made the referral process challenging. 4. Cost-benefit of palliative care referral: Pain and symptom management and psychosocial support were the perceived benefits, whereas inconsistencies in communication and curtailment of care were some of the costs associated with palliative care referral. 5. Strategies to facilitate palliative care referral: Developing an integrated model of care, renaming and augmenting palliative care resources were some of the strategies that could facilitate a referral. Conclusion Presuppositions, power relationships, trust issues and the challenges associated with the task of referrals hindered palliative care referral. Oncologists and haematologists appraised the cost-benefit of making a palliative care referral. They felt that an integrated model of care, changing the name of palliative care and augmenting palliative care resources might facilitate a referral.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

See 3 more Smart Citations

How views of oncologists and haematologists impacts palliative care referral: a systematic review

et al. 2020

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Racial and ethnic inequities of palliative care use among advanced Non‐Small cell lung cancer patients in the US

et al. 2022

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Background With early intervention, palliative care (PC) can improve quality of life and increase survival among advanced‐stage non‐small cell lung cancer (aNCSLC) patients. However, PC is often offered late in the cancer treatment course and is underused. We characterized racial/ethnic inequities and the role of healthcare access in PC use among patients with aNSCLC. Methods We used data from the 2004–2016 National Cancer Database, including adults aged 18–90 years with aNSCLC (stage 3 or 4 at diagnosis; n = 803,618). Based on the NCCN guidelines, PC includes non‐curative surgery, radiation, chemotherapy, pain management, or any combination of non‐curative care. We examined PC use by sociodemographic and health care‐level characteristics. To evaluate the independent associations of race/ethnicity and health care access characteristics with PC, we estimated adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). Covariate adjustment sets varied by exposure determined using directed acyclic graphs. Results Our population was 55% male and 77% non‐Hispanic/Latinx (NH)‐White, with a mean age of 68 years. Overall, 19% of patients with aNSCLC used PC. Compared to NH‐White patients, NH‐Black (aOR:0.91,95% CI:0.89–0.93) and Hispanic/Latinx (aOR:0.80,95% CI:0.77–0.83) patients were less likely to use PC, whereas Indigenous (AI/AN) (aOR:1.18,95% CI:1.06–1.31) and Native Hawaiian/Pacific Islander (aOR:2.08,95% CI:1.83–2.36) patients were more likely. Overall, compared to the privately‐insured, uninsured (aOR:1.19,95% CI:1.11–1.28) and Medicaid‐insured patients (aOR:1.19,95% CI:1.14–1.25) were more likely to use PC. Conclusion PC is underutilized among NH‐Black and Hispanic/Latinx patients with aNSCLC. Insurance type may play a role in PC use among patients with aNSCLC.

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Association of patient socioeconomic status with outcomes after palliative treatment for disseminated cancer

Maduka,

Canavan,

Walters

et al. 2024

Cancer Medicine

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BackgroundPalliative treatment has been associated with improved quality of life and survival for a wide variety of metastatic cancers. However, it is unclear whether the benefits of palliative treatment are uniformly experienced across the US cancer population. We evaluated patterns and outcomes of palliative treatment based on socioeconomic, sociodemographic and treating facility characteristics.MethodsPatients diagnosed between 2008 and 2019 with Stage IV primary cancer of nine organ sites were analyzed in the National Cancer Database. The association between identified variables, and outcomes concerning the administration of palliative treatment were analyzed with multivariable logistic regression and Cox proportional hazard models.ResultsOverall 238,995 (23.6%) of Stage IV patients received palliative treatment, which increased over time for all cancers (from 20.7% in 2008 to 25.6% in 2019). Palliative treatment utilization differed significantly by region (West less than Northeast, OR: 0.55 [0.54–0.56], p < 0.001) and insurance payer status (uninsured greater than private insurance, OR: 1.35 [1.32–1.39], p < 0.001). Black race and Hispanic ethnicity were also associated with lower rates of palliative treatment compared to White and non‐Hispanics respectively (OR for Blacks: 0.91 [0.90–0.93], p < 0.001 and OR for Hispanics: 0.79 [0.77–0.81] p < 0.001).ConclusionsThere are important differences in the utilization of palliative treatment across different populations in the United States. A better understanding of variability in palliative treatment use and outcomes may identify opportunities to improve informed decision making and optimize quality of care at the end‐of‐life.

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Palliative Care Referrals for Advanced Non–small-cell Lung Cancer (NSCLC): Patient and Provider Attitudes and Practices

Cited by 27 publications

References 27 publications

How views of oncologists and haematologists impacts palliative care referral: a systematic review

How views of oncologists and haematologists impacts palliative care referral: a systematic review

Racial and ethnic inequities of palliative care use among advanced Non‐Small cell lung cancer patients in the US

Association of patient socioeconomic status with outcomes after palliative treatment for disseminated cancer

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