Amy R. Lipson

Work productivity and health of informal caregivers of persons with advanced cancer.

The purpose of this study was to describe health promotion behaviors and work productivity loss in informal caregivers of individuals with advanced stage cancer. Using a cross-sectional, correlational design, 70 caregivers completed measures of health behaviors, mood, social support, and burden. Absenteeism and presenteeism were evaluated in employed caregivers (n = 40). Caregivers reported low levels of physical activity. The mean percentage of work productivity loss due to caregiving was 22.9%. Greater work productivity loss was associated with greater number of caregiving hours, higher cancer stage, married status, and greater anxiety, depression, and burden related to financial problems, disrupted schedule, and health. Nurses should assess caregivers and provide health promotion interventions, which may ultimately reduce the economic impact of caregiving.

Knowledge, Attitudes, and Predictors of Advance Directive Discussions of Registered Nurses

The purpose of this study was to describe nurses’ knowledge, attitudes, and experiences regarding advance directives. A secondary purpose was to examine predictors of advance directive discussions between nurses and patients. Seven-hundred and nineteen respondents, randomly selected from a list of registered nurses in the state of Ohio, completed mailed questionnaires. Descriptive t test, chi-square, and logistic regression statistics were used in the data analyses. The respondents were knowledgeable and possessed positive attitudes about advance directives. Higher self-perceived confidence in advance directive discussion skills and the experience of caring for at least one patient with a current advance directive were found to be significant predictors of advance directive discussions. These findings suggest that experience with advance directives documents is critical for nurses’ comfort and that developing interventions to further nurses’ confidence in their discussion skills may increase advance directive discussions.

The relationship between optimism and quality of life in newly diagnosed cancer patients.

Background: Understanding the relationships between social and psychological determinants of health-related quality of life (HRQOL) is a critical step in developing effective screening tools and targeted interventions for psychosocial care. Objective: The purpose of this study was to examine the relationship between dispositional optimism and HRQOL in newly diagnosed adult cancer patients. Methods: A cross-sectional, predictive correlational design was used. The sample consisted of 163 patients with mixed diagnoses and stages who were within 180 days since diagnosis and had completed a battery of psychosocial measures upon enrollment into a psychosocial data registry during their first outpatient visit or treatment. Hierarchical multiple regression analyses were conducted to determine predictors of HRQOL. Results: Optimism was significantly correlated with spiritual well-being, anxiety, depression, and HRQOL. Optimism was not a significant predictor of HRQOL at initial diagnosis and treatment when age, scores on functional status, spiritual well-being, depression, and anxiety were entered into the regression equation. Conclusion: Dispositional optimism is not a primary factor in HRQOL at initial diagnosis and treatment. Further exploration is needed to determine if optimism exerts a greater influence on HRQOL at another point along the cancer trajectory and if there is overlap between the constructs of optimism and spirituality. Implications for Practice: Although systematic screening for dispositional optimism is not recommended, patients who display characteristics associated with low optimism require further assessment. Also, patients with poor functional status, young age, low levels of spirituality, and high levels of depression may be vulnerable for poor HRQOL.

Needs of Older Caregivers of Patients with Advanced Cancer

OBJECTIVES: To determine whether age or stage of cancer can be used to identify caregivers at high risk for excessive burden or distress.

Neglect of quality-of-life considerations in intensive care unit family meetings for long-stay intensive care unit patients

Objective: To examine the frequency with which quality of life and treatment limitation were discussed in formal family meetings for long-stay intensive care unit patients with high risk for mortality and morbidity. Design: Descriptive observational study. Setting: Five intensive care units. Patients: One hundred sixteen family surrogate decisionmakers of long-stay intensive care unit patients who participated in an intensive communication system that aimed to provide weekly meetings with family decisionmakers. The structure of each meeting was to address medical update, patient preferences, treatment plan, and milestones for evaluating the treatment plan. Interventions: None. Measurements and Main Results: We audiotaped initial family meetings for 116 family decisionmakers for a total of 180 meetings. On average, meetings were 24 mins long with a majority of time being devoted to nonemotional speech and little (12%) spent discussing patient preferences. Quality of life was discussed in 45% and treatment limitation in 23% of all meetings. Quality-of-life discussions were more likely to occur when patients were admitted to a medical intensive care unit (odds ratio [OR] 5.9; p = .005), have a family decisionmaker who is a spouse (OR 9.4; p = .0001), were older (OR 1.04; p = 01), have a shorter length of stay (OR 0.93; p = .001), and have a family decisionmaker who was a spouse (OR 5.1; p = .002). For those with a treatment limitation discussion, 67% had a do-not-resuscitate order, 40% were admitted to a medical intensive care unit, 56% had a family decisionmaker who had been their caregiver, and 48% of their family decisionmakers were their children. Conclusions: To guide discussion with families of the subset of intensive care unit patients with high risk of mortality and long-term morbidity, quality of life was not consistently addressed. Continued efforts to assist clinicians in routinely including discussions of quality-of-life outcomes is needed.

Use of advance directives in the chronically critically ill.

Although it would be ideal that all patients have the presence of an advance directive documented in their medical chart, it is especially important in the chronically critically ill, a patient population with an in-hospital mortality rate of 40%. How has the documentation of advance directives in the medical chart of chronically critically ill patients changed from 1997 to 2003? This article describes the patient characteristics and patterns of death in chronically critically ill patients, with or without an advance directive, enrolled in 2 consecutive studies.

Complexity Analysis of Decision-Making in the Critically Ill:

Rationale: Despite multiple trials of interventions to improve end-of-life care of the critically ill, there is a persistent lack of understanding of factors associated with barriers to decision-making at the end of life. Objective: To apply the principles of complexity science in examining the extent to which transitions to end-of-life care can be predicted by physician, family, or patient characteristics; outcome expectations; and the evaluation of treatment effectiveness. Methods: A descriptive, longitudinal study was conducted in 3 adult intensive care units (ICUs). Two hundred sixty-four family surrogates of patients lacking decisional capacity and the physicians caring for the patients were interviewed every 5 days until ICU discharge or patient death. Measurements: Characteristics of patients, physicians, and family members; values and preferences of physicians and family; and evaluation of treatment effectiveness, expectations for patient outcomes, and relative priorities in treatment (comfort vs survival). The primary outcome, focus of care, was categorized as (1) maintaining a survival orientation (no treatment limitations), (2) transitioning to a stronger palliative focus (eg, some treatment limitations), or (3) transitioning to an explicit end-of-life, comfort-oriented care plan. Main Results: Physician expectations for survival and future cognitive status were the only variables consistently and significantly related to the focus of care. Neither physician or family evaluations of treatment effectiveness nor what was most important to physicians or family members was influential. Conclusion: Lack of influence of family and physician views, in comparison to the consistent effect of survival probabilities, suggests barriers to incorporation of individual values in treatment decisions.

Relationship Between Physical and Psychological Status of Cancer Patients and Caregivers

The purpose of this study was to describe the relationship between patient physical and emotional status and caregiver mood state for patients with advanced cancer. Data were collected from 299 cancer patients and their caregivers from a cancer center. We used a longitudinal design and collected data through interviews. The relationships between patient and caregiver emotional states over time were moderate and statistically significant at all three points in time (p values = .012-.0001). Patient physical and emotional status predicted caregiver mood state at all points in time (βs = −.22 to −.25) and caregiver mood state at baseline predicted patient emotional status at 3 months (β = −.16, p = .013). Relationships between patient emotional status and caregiver mood state were moderately strong. Addressing the emotional needs of both patients and caregivers has the potential to yield improved emotional outcomes for both over time.

Advance directive use and psychosocial characteristics: An analysis of patients enrolled in a psychosocial cancer registry

Advance directives (ADs) refer to a category of documents that enable individuals to state their preferences for future healthcare decisions in the event of incapacitation. The purpose of the study was to examine differences in psychosocial characteristics and AD completion rates in persons newly diagnosed with cancer. This sample comes from data collected for a psychosocial registry for patients with cancer. The following psychosocial data were collected: Functional Assessment of Cancer Therapy-General, Profile of Mood States-short form, and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale. The sample included 312 persons who had been diagnosed with cancer within the previous 5 months. There were no statistically significant differences between completion of an AD and the measured psychosocial characteristics at baseline (mean, 4.2 months); however, at 3 months, patients who reported higher quality of life (Functional Assessment of Cancer Therapy-General) were associated with lower AD completion rates and persons with greater mood disturbances had higher rates of AD completion. Our data suggest the need to develop strategies that would facilitate discussion of ADs for patients entering the cancer care continuum.

Research partners: two teams, one study population.

Background:Two large research projects funded by the National Institutes of Health, the Disease Management project and the Thrive study, which examine different phenomena in the chronically critically ill population, have combined research teams. Each study has its own project manager and maintains a separate database and budget. Operational tasks for both grants are streamlined through the collaboration and cross-training of all team members. Methods:The Disease Management project is a randomized clinical trial testing the effectiveness of a care program in improving outcomes for chronically critically ill patients and their caregivers during the first 2 months after discharge. The Thrive study is a prospective longitudinal investigation that aims to describe the weaning patterns of chronically critically ill patients as well as the patterns of illness-related variables. Results:To date, many participants (n = 400) have been enrolled in each study. The results of both studies will be available through future publications. Conclusions:Although much information has been gleaned from gathering longitudinal data across one study population and examining two rich data sets, there are some limitations to this collaboration.