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

Keating, Nancy L.; Landrum, Mary Beth; Rogers, Selwyn O.; Baum, Susan; Virnig, Beth A; Huskamp, Haiden A.; Earle, Craig C.; Kahn, Katherine L.

doi:10.1002/cncr.24761

Cited by 296 publications

(259 citation statements)

References 45 publications

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“…This was on the basis of the hypothesis that distribution of the timing would demonstrate the overall tendency of oncologists toward timing of EOLds and comparability with previous findings [6].…”

Section: Endpointmentioning

confidence: 60%

“…These measurements were developed based on a systematic literature review [1,[6][7][8][9][10][11][12][13][14][15][16], discussions among research groups, and preliminary in-depth interviews with medical oncologists. Face validity was confirmed by pilot testing.…”

Section: Potential Factors Contributing To Oncologists' Attitudes Towmentioning

confidence: 99%

“…Many physicians, however, do not actually discuss EOL options with advanced cancer patients until they are in the terminal phase of life [6,7]. This delay could be a result of both patient-and physicianrelated factors [1].…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

A National Survey to Systematically Identify Factors Associated With Oncologists’ Attitudes Toward End-of-Life Discussions: What Determines Timing of End-of-Life Discussions?

et al. 2015

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Background. End-of-life discussions (EOLds) occur infrequently until cancer patients become terminally ill. Methods. To identify factors associated with the timing of EOLds, we conducted a nationwide survey of 864 medical oncologists. We surveyed the timing of EOLds held with advanced cancer patients regarding prognosis, hospice, site of death, and do-not-resuscitate (DNR) status; and we surveyed physicians' experience of EOLds, perceptions of a good death, and beliefs regarding these issues. Multivariate analyses identified determinants of early discussions. Results. Among 490 physicians (response rate: 57%), 165 (34%), 65 (14%), 47 (9.8%), and 20 (4.2%) would discuss prognosis, hospice, site of death, and DNR status, respectively, "now" (i.e., at diagnosis) with a hypothetical patient with newly diagnosed metastatic cancer. In multivariate analyses, determinants of discussing prognosis "now" included the physician perceiving greater importance of autonomy in experiencing a good death (odds ratio [OR]: 1.34; p 5 .014),

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Section: Endpointmentioning

confidence: 60%

Section: Potential Factors Contributing To Oncologists' Attitudes Towmentioning

confidence: 99%

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A National Survey to Systematically Identify Factors Associated With Oncologists’ Attitudes Toward End-of-Life Discussions: What Determines Timing of End-of-Life Discussions?

et al. 2015

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“…While there are barriers to discussing prognosis and having end-of-life conversations, physician barriers are more common than any patient or system factors [6]. Having a conversation about prognosis and concerns of the patient results in less use of ineffective therapies, more use of palliative care and reduced family distress [7].…”

Section: Case Reportmentioning

confidence: 99%

Complications from Stents and Lack of Conversations

Gallagher¹

2016

JGPLD

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was decompressed. Significant biliary duct dilatation, not present on his last CT scan, was noted and there were two irregular fluid collections containing small bubbles of air -probable liver abscesses -that had also developed. The liver metastases had all grown in size in the interim. Clostridium perfringens and Streptococcus anginosus grew in his blood and were susceptible to the antibiotics.The fentanyl infusion was titrated to effective pain relief but he remained delirious and died three days later.The oncologist called the wife several days after he became aware he was in the hospital and was surprised to find he had died. He notes that the wife was angry and told him that both the patient and she felt let down by the medical system and the physicians and nurses who had seen them for his illness. The physician noted "unfortunately clinical deterioration in such as this is all too common in the context of metastatic pancreatic cancer". This case is instructive for two reasons: the risk of serious sepsis in patients with stents and the bereavement reaction of the spouse.Clostridium perfringens is an anaerobic normal inhabitant of the bowel and genital tract. Septicemia from this bacteria usually occurs in patients who are immunocompromized (malignancy, diabetes etc) and have had a recent abdominal or pelvic procedure [1]. The mortality rate is extremely high. Streptococcus anginosus is also associated with abscesses in those who are immunocompromized.Therapy for the complications of pancreatic cancer has evolved tremendously over the last 20 years with the introduction of stenting by endoscopy. Complications such as the liver abscesses, are being reduced by the use of covered self expandable metal stents that have a lower risk of cholangitis and infection [2]. Stenting shows a shortened time to resumption of fluids and food, reduced hospital stay and costs when compared with surgery [3].A recent review [4] of pancreatic cancer noted that on diagnosis 90% of tumors are already locally or systemically involved and therefore not operable. The average survival for those who are not operable is 4 months with the range of 3-11 Case ReportA 59 year-old man had several months of epigastric distress and pain radiating to the back before presenting with obstructive jaundice. CT scan of the abdomen showed a 4cm mass in the pancreas. The biliary obstruction was located 4cm above the ampulla and resolved with the insertion of a Cotton Leung plastic stent. Lesions in the liver, seen on ultrasound, could not be confirmed as metastases on CT scan. Biopsy of the liver lesions by laparoscopy confirmed them as metastases so he was referred for chemotherapy.One month later he developed increasing epigastric pain and vomiting. CT scan showed duodenal obstruction secondary to local tumor growth. An expanding metal stent was inserted via endoscopy and the vomiting stopped the next day. X-ray confirmed good position of the duodenal stent and since he was tolerating fluids he was discharged home the next day.Fatigue, weakness and p...

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“…1,2 This problem is multi-factorial. Despite the fact that early advance care planning discussions are associated with better patient and caregiver outcomes, 3,4 studies suggest that these discussions are often delayed 5 and quality measures in this domain are often not met. 6,7 There is, instead, a tendency to focus on diseasefocused rather than patient-centered treatments, which often leads to patients receiving care inconsistent with preferences or prognosis.…”

mentioning

confidence: 99%

The Importance of a Comprehensive, Patient-Centered Approach to End-of-Life Care

Walling

2014

J GEN INTERN MED

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R elieving suffering of the dying patient is a core mission not only of palliative care providers, but of every clinician who participates in the care of seriously ill patients. Too often, patients and families suffer unnecessarily at the end of life because dying is not recognized, providers do not communicate about prognosis, and symptom management is inadequate. Several studies have documented unmet needs related to communication and symptom management for patients who die in the hospital in the United States. 1,2 This problem is multi-factorial. Despite the fact that early advance care planning discussions are associated with better patient and caregiver outcomes, 3,4 studies suggest that these discussions are often delayed 5 and quality measures in this domain are often not met. 6,7 There is, instead, a tendency to focus on diseasefocused rather than patient-centered treatments, which often leads to patients receiving care inconsistent with preferences or prognosis.Even when patients are identified to be at the end of life, they are often not treated using accepted standards for endof-life care. 8 This may be due to multiple issues, including continued invasive medical interventions, lack of knowledge about evidence-based comfort care approaches, and adverse attitudes toward and lack of knowledge about use of opioid medications at the end of life. The multi-site study by Bailey and colleagues in this issue of JGIM 9 has important implications for how to improve care provided to hospitalized patients at the end of life. It also highlights the importance of implementation science in the study of quality improvement interventions, which are challenging to evaluate with randomized controlled trials and often require customization to local environments in different health care settings. With a detailed, multi-pronged approach based on a successful single-institution pilot study including staff education, palliative care team involvement, an electronic medical record-based comfort order set, and adjustments in pharmacy and nursing policy, the study team was able to successfully change clinician behavior so that patients were more likely to have treatments available for distressful symptoms such as pain and delirium. There were also significant decreases in the rate of nasogastric tube use and increases in advance directive use and sublingual administration of medications.It is important to note that there was not a statistically significant change in receipt of opioid medications at the end of life and more than a third of patients did not receive opioids at the end of life, despite this intensive intervention. Whether this is due to lack of need is unknown, but a recent qualitative study of this intervention provides insights into the importance of the structural components of quality (i.e. ensuring hospital policies support best practices) 10 and how delays in implementation of updated policies and staff turnover may have limited the dose response for this intervention. This related qualitative work can be used...

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

Cited by 296 publications

References 45 publications

A National Survey to Systematically Identify Factors Associated With Oncologists’ Attitudes Toward End-of-Life Discussions: What Determines Timing of End-of-Life Discussions?

A National Survey to Systematically Identify Factors Associated With Oncologists’ Attitudes Toward End-of-Life Discussions: What Determines Timing of End-of-Life Discussions?

Complications from Stents and Lack of Conversations

The Importance of a Comprehensive, Patient-Centered Approach to End-of-Life Care

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