Anthony L. Back

Effect of a quality-improvement intervention on end-of-life care in the intensive care unit a randomized trial

RATIONALE Because of high mortality, end-of-life care is an important component of intensive care. OBJECTIVES We evaluated the effectiveness of a quality-improvement intervention to improve intensive care unit (ICU) end-of-life care. METHODS We conducted a cluster-randomized trial randomizing 12 hospitals. The intervention targeted clinicians with five components: clinician education, local champions, academic detailing, clinician feedback of quality data, and system supports. Outcomes were assessed for patients dying in the ICU or within 30 hours of ICU discharge using surveys and medical record review. Families completed Quality of Dying and Death (QODD) and satisfaction surveys. Nurses completed the QODD. Data were collected during baseline and follow-up at each hospital (May 2004 to February 2008). We used robust regression models to test for intervention effects, controlling for site, patient, family, and nurse characteristics. MEASUREMENTS AND MAIN RESULTS All hospitals completed the trial with 2,318 eligible patients and target sample sizes obtained for family and nurse surveys. The primary outcome, family-QODD, showed no change with the intervention (P = 0.33). There was no change in family satisfaction (P = 0.66) or nurse-QODD (P = 0.81). There was a nonsignificant increase in ICU days before death after the intervention (hazard ratio = 0.9; P = 0.07). Among patients undergoing withdrawal of mechanical ventilation, there was no change in time from admission to withdrawal (hazard ratio = 1.0; P = 0.81). CONCLUSIONS We found this intervention was associated with no improvement in quality of dying and no change in ICU length of stay before death or time from ICU admission to withdrawal of life-sustaining measures. Improving ICU end-of-life care will require interventions with more direct contact with patients and families. Clinical trial registered with www.clinicaltrials.gov (NCT00685893).

Early palliative care in advanced lung cancer: a qualitative study.

BACKGROUND Early ambulatory palliative care (PC) is an emerging practice, and its key elements have not been defined. We conducted a qualitative analysis of data from a randomized controlled trial that demonstrated improved quality of life, mood, and survival in patients with newly diagnosed metastatic non-small cell lung cancer who received early PC integrated with standard oncologic care vs standard oncologic care alone. Our objectives were to (1) identify key elements of early PC clinic visits, (2) explore the timing of key elements, and (3) compare the content of PC and oncologic visit notes at the critical time points of clinical deterioration and radiographic disease progression. METHODS We randomly selected 20 patients who received early PC and survived within 4 periods: less than 3 months (n = 5), 3 to 6 months (n = 5), 6 to 12 months (n = 5), and 12 to 24 months (n = 5). We performed content analysis on PC and oncologic visit notes from the electronic health records of these patients. RESULTS Addressing symptoms and coping were the most prevalent components of the PC clinic visits. Initial visits focused on building relationships and rapport with patients and their families and on illness understanding, including prognostic awareness. Discussions about resuscitation preferences and hospice predominantly occurred during later visits. Comparing PC and oncologic care visits around critical time points, both included discussions about symptoms and illness status; however, PC visits emphasized psychosocial elements, such as coping, whereas oncologic care visits focused on cancer treatment and management of medical complications. CONCLUSIONS Early PC clinic visits emphasize managing symptoms, strengthening coping, and cultivating illness understanding and prognostic awareness in a responsive and time-sensitive model. During critical clinical time points, PC and oncologic care visits have distinct features that suggest a key role for PC involvement and enable oncologists to focus on cancer treatment and managing medical complications.

Regimen-related toxicity and early posttransplant survival in patients undergoing marrow transplantation for lymphoma.

Ninety-five patients transplanted for malignant lymphoma were retrospectively evaluated for regimen-related toxicity (RRT) and early posttransplant survival. Nineteen patients developed life-threatening (grade 3) or fatal (grade 4) RRT in one or more organs. Grade 3 or 4 RRT was more common in patients with advanced disease versus those transplanted earlier in their course (P = .008), and was more common in patients with advanced disease conditioned with cytarabine (Ara-C)/total body irradiation (TBI) versus those prepared with cyclophosphamide (CY)/TBI (P = .033). There was no significant difference in the incidence of grade 3 or 4 toxicity in autologous, histocompatibility locus antigen (HLA)-identical, or HLA-mismatched marrow recipients. Grade 3 or 4 RRT tended to be more common and 100-day survival worse in patients with a Karnofsky performance status of less than 90 (P = .063 and .0002, respectively). Patients receiving 20 Gy or more of mediastinal irradiation before coming to transplant had more idiopathic or cytomegalovirus (CMV) interstitial pneumonitis than those who received less than 20 Gy (30% v 9%, P = .027). The probability of survival decreased with the number of organs in which toxicity was observed (P = .0001). Severe or fatal toxicities directly related to the preparative regimen are a significant problem in the treatment of patients with advanced malignant lymphoma and can be reduced by carrying out transplantation earlier in the course of the disease.

Communication about cancer near the end of life.

Cancer communication near the end of life has a growing evidence base, and requires clinicians to draw on a distinct set of communication skills. Patients with advanced and incurable cancers are dealing with the emotional impact of a life‐limiting illness, treatment decisions that are complex and frequently involve consideration of clinical trials, and the challenges of sustaining hope while also having realistic goals. In this review, the authors sought to provide a guide to important evidence about communication for patients with advanced cancer regarding communication at diagnosis, discussing prognosis, decision making about palliative anticancer therapy and phase 1 trials, advance care planning, transitions in focus from anticancer to palliative care, and preparing patients and families for dying and death. Cancer 2008;113(7 suppl):1897–910.

Discussing Prognosis: “How Much Do You Want to Know?” Talking to Patients Who Are Prepared for Explicit Information

Mrs D, a 57-year-old woman with metastatic pancreatic cancer, is discussing treatment options with Dr B. How much should I tell her about prognosis? he wonders. She already seems nervous. Do I hand her the death sentence? Or sugarcoat the statistics? Maybe I’ll wait to see if she asks. For the first time Mrs D looks up and says, “What should I expect?” Dr B balks, not having decided what to say. “Umm, I can’t really predict,” he mumbles. “Every patient is different.” Perhaps I am mumbling, thinks Dr B, because I’m not telling her the whole truth. Mrs D nods vaguely without meeting his gaze and picks up her purse to leave. Is she dissatisfied also? Dr B finds himself in a familiar dilemma: how much information should an oncologist give about a bad prognosis? One of his colleagues prides himself on being a realist, “I tell patients the truth because they need to know, whether they want to hear it or not.” Another colleague feels he must give hope, “I go into cheerleader mode.” Neither alternative seems optimal to Dr B—the nurses tell him that the realist tone is a little brutal, and that the cheerleader is more than a little clueless. Privately, Dr B feels his own practice—avoiding prognosis by emphasizing individual differences—borders on disingenuous. He knows a lot more about what will happen to Mrs D than he is letting on. Realism, optimism, and avoidance are the most common strategies physicians use in discussing prognosis. Although these strategies are well intended and commonly used, they also create unintended consequences. In this article, a patient-centered method for disclosing prognosis is proposed and illustrated. The method builds on existing empirical evidence about discussing prognosis by drawing on principles of negotiation and patient-centered approaches. This approach enables an oncologist to figure out what kind of prognostic information to disclose with a particular patient at a particular time and how to individualize the discussion. This article describes how the approach works with a patient who is ready for an explicit discussion. STRATEGIES WITH UNINTENDED CONSEQUENCES: REALISM, OPTIMISM, AVOIDANCE

Withdrawing life support and resolution of conflict with families

What is the best way for the intensive care team to work with a family to decide on a plan of care when withdrawing or withholding life support?

Reflective teaching practices: An approach to teaching communication skills in a small-group setting

Small-group teaching is particularly suited for complex skills such as communication. Existing work has identified the basic elements of small-group teaching, but few descriptions of higher-order teaching practices exist in the medical literature. Thus the authors developed an empirically driven and theoretically grounded model for small-group communication-skills teaching. Between 2002 and 2005, teaching observations were collected over 100 hours of direct contact time between four expert facilitators and 120 medical oncology fellows participating in Oncotalk, a semiannual, four-day retreat focused on end-of-life communication skills. The authors conducted small-group teaching observations, semistructured interviews with faculty participants, video or audio recording with transcript review, and evaluation of results by faculty participants. Teaching skills observed during the retreats included a linked set of reflective, process-oriented teaching practices: identifying a learning edge, proposing and testing hypotheses, and calibrating learner self-assessments. Based on observations and debriefings with facilitators, the authors developed a conceptual model of teaching that illustrates an iterative loop of teaching practices aimed at enhancing learners’ engagement and self-efficacy. Through longitudinal, empirical observations, this project identified a set of specific teaching skills for small-group settings with applicability to other clinical teaching settings. This study extends current theory and teaching practice prescriptions by describing specific teaching practices required for effective teaching. These reflective teaching practices, while developed for communication skills training, may be useful for teaching other challenging topics such as ethics and professionalism.

Effects of Early Integrated Palliative Care in Patients With Lung and GI Cancer: A Randomized Clinical Trial

Purpose We evaluated the impact of early integrated palliative care (PC) in patients with newly diagnosed lung and GI cancer. Patients and Methods We randomly assigned patients with newly diagnosed incurable lung or noncolorectal GI cancer to receive either early integrated PC and oncology care (n = 175) or usual care (n = 175) between May 2011 and July 2015. Patients who were assigned to the intervention met with a PC clinician at least once per month until death, whereas those who received usual care consulted a PC clinician upon request. The primary end point was change in quality of life (QOL) from baseline to week 12, per scoring by the Functional Assessment of Cancer Therapy-General scale. Secondary end points included change in QOL from baseline to week 24, change in depression per the Patient Health Questionnaire-9, and differences in end-of-life communication. Results Intervention patients ( v usual care) reported greater improvement in QOL from baseline to week 24 (1.59 v -3.40; P = .010) but not week 12 (0.39 v -1.13; P = .339). Intervention patients also reported lower depression at week 24, controlling for baseline scores (adjusted mean difference, -1.17; 95% CI, -2.33 to -0.01; P = .048). Intervention effects varied by cancer type, such that intervention patients with lung cancer reported improvements in QOL and depression at 12 and 24 weeks, whereas usual care patients with lung cancer reported deterioration. Patients with GI cancers in both study groups reported improvements in QOL and mood by week 12. Intervention patients versus usual care patients were more likely to discuss their wishes with their oncologist if they were dying (30.2% v 14.5%; P = .004). Conclusion For patients with newly diagnosed incurable cancers, early integrated PC improved QOL and other salient outcomes, with differential effects by cancer type. Early integrated PC may be most effective if targeted to the specific needs of each patient population.

Discussing Prognosis: “How Much Do You Want to Know?” Talking to Patients Who Do Not Want Information or Who Are Ambivalent

Dr D had decided to try to ask patients how much they wanted to know about prognosis. Mr X, a 44-year-old man with large B-cell lymphoma, who had relapsed less than 1 year after receiving cyclophosphamide, doxorubicin, vincristine, and prednisone and rituximab, said he did not want to talk about prognosis at all. He said, “The numbers don’t really matter—I have to do what you tell me gives me the best chance.” Mrs Y, a 68-year-old woman with stage III breast cancer coming for her first visit after starting adjuvant chemotherapy, could not seem to decide whether she wanted prognostic information. “I’m worried about knowing, and I’m worried about not knowing,” she said. “What do you think I should do?” A description of a patient-centered approach for discussing prognosis rather than the commonly used strategies of realism, optimism, and avoidance has been published in this issue of the Journal of Clinical Oncology. This approach recommended that oncologists start by asking patients a straightforward opening question, “How much do you want to know about prognosis?” and the approach was illustrated for a patient who was prepared to have an explicit discussion. However, approximately 20% of patients do not want to discuss prognostic information or only want to hear good news. How should an oncologist, like Dr D, handle that situation? This article describes how to approach patients who either do not want to discuss prognostic information or who are ambivalent—who simultaneously want to know and do not want to know.

Faculty development to change the paradigm of communication skills teaching in oncology

Dr B, a faculty oncologist supervising fellows at an outpatient oncology clinic, faces a common teaching quandary. A second-year oncology fellow presents a patient with metastatic lung cancer, which has progressed despite second-line palliative chemotherapy. The fellow concludes his presentation, which was technically impeccable, by saying, “I thought the patient was not getting how bad this is, so it was time to hang crepe. I told him it was a choice between phase I or nothing.” Dr B knows the fellow to be a careful physician who is genuinely concerned about the well-being of his patients. Yet the fellows comment about hanging crepe raises a red flag for Dr B, because in his experience, blunt disclosures of poor prognoses may lead patients to wonder if their physician is still on their side. In addition, Dr B does not like telling patients that there is nothing more to be done. But he is not sure how to get the fellow to understand this. Should he confront the fellow about this, or just let the comment pass?