Elizabeth E. O'Toole

Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients

BACKGROUND Formal family meetings have been recommended as a useful approach to assist in goal setting, facilitate decision making, and reduce use of ineffective resources in the ICU. We examined patient outcomes before and after implementation of an intensive communication system (ICS) to test the effect of regular, structured formal family meetings on patient outcomes among long-stay ICU patients. METHODS One hundred thirty-five patients receiving usual care and communication were enrolled as the control group, followed by enrollment of intervention patients (n = 346), from five ICUs. The ICS included a family meeting within 5 days of ICU admission and weekly thereafter. Each meeting discussed medical update, values and preferences, and goals of care; treatment plan; and milestones for judging effectiveness of treatment. RESULTS Using multivariate analysis, there were no significant differences between control and intervention patients in length of stay (LOS), the primary end point. Similarly, there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions (ICU mortality, LOS, duration of ventilation, treatment limitation orders, or use of tracheostomy or percutaneous gastrostomy). Exploratory analysis suggested that in the medical ICUs, the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place. CONCLUSIONS The negative findings of the main analysis, in combination with preliminary evidence of differences among types of unit, suggest that further examination of the influence of patient, family, and unit characteristics on the effects of a system of regular family meetings may be warranted. Despite the lack of influence on patient outcomes, structured family meetings may be an effective approach to meeting information and support needs. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01057238 ; URL: www.clinicaltrials.gov.

Age differences in care practices and outcomes for hospitalized patients with cancer

OBJECTIVE: To identify age group differences in care practices and outcomes for seriously ill hospitalized patients with malignancy.

A coping and communication support intervention tailored to older patients diagnosed with late-stage cancer

As our society ages, increasing numbers of older Americans will be diagnosed and eventually will die of cancer. To date, psycho-oncology interventions for advanced cancer patients have been more successful in reaching younger adult age groups and generally have not been designed to respond to the unique needs and preferences of older patients. Theories and research on successful aging (Baltes and Baltes 1990; Baltes 1997), health information processing style (Miller 1995; Miller et al 2001) and non-directive client-centered therapy (Rogers 1951, 1967), have guided the development of a coping and communication support (CCS) intervention. Key components of this age-sensitive and tailored intervention are described, including problem domains addressed, intervention strategies used and the role of the CCS practitioner. Age group comparisons in frequency of contact, problems raised and intervention strategies used during the first six weeks of follow up indicate that older patients were similar to middle-aged patients in their level of engagement, problems faced and intervention strategies used. Middle-aged patients were more likely to have problems communicating with family members at intervention start up and practical problems as well in follow up contacts. This is the first intervention study specifically designed to be age sensitive and to examine age differences in engagement from the early treatment phase for late-stage cancer through end of life. This tailored intervention is expected to positively affect patients’ quality of care and quality of life over time.

Generalists and Oncologists Show Similar Care Practices and Outcomes for Hospitalized Late-Stage Cancer Patients

Objective.The objective of this work was to identify similarities and differences in primary attending physicians’ (generalists’ versus oncologists’) care practices and outcomes for seriously ill hospitalized patients with malignancy. Design.This was a prospective cohort study (SUPPORT project). Setting.Subjects were recruited from 5 US teaching hospitals; data were gathered from 1989 to 1994. Subjects.Included in the study was a matched sample of 642 hospitalized patients receiving care for non–small-cell lung cancer, colon cancer metastasized to the liver, or multiorgan system failure associated with malignancy with either a generalist or an oncologist as the primary attending physician. Measurements.Care practices and patient outcomes were determined from hospital records. Length of survival was identified with the National Death Index. Physicians’ perceptions of patient’s prognosis, preference for cardiopulmonary resuscitation (CPR), and length of relationship were assessed by interview. A propensity score for receiving care from an oncologist was constructed. After propensity-based matching of patients, practices and outcomes of oncologists’ and generalists’ patients were assessed through group comparison techniques. Results.Generalist and oncologist attendings showed comparable care practices, including the number of therapeutic interventions, eg, “rescue care” and chemotherapy, and the number of care topics discussed with patients/families. Length of stay, discharge to supportive care, readmission, total hospital costs, and survival rates were similar. For both physician groups, perception of patients’ wish for CPR was associated with rescue care (P <0.03), and such care was related to higher hospital costs (P <0.000). Poorer prognostic estimates predicted aggressiveness-of-care discussions by both types of physicians. Length of the patient-doctor relationship was associated with oncologists’ care practices. More documented discussion about aggressiveness of care was related to higher hospital costs and shorter survival for patients in both physician groups (P <0.001). Conclusions.Generalists and oncologists showed similar care practices and outcomes for comparable hospitalized late-stage cancer patients. Physicians’ perceptions about patients’ preferences for CPR and prognosis influenced decision making and outcomes for patients in both physician groups. Length of relationship with patients was associated only with oncologists’ care practices. Rescue care increased hospital costs but had no effect on patient survival. Future studies should compare physicians’ palliative care as well as acute-care practices in both inpatient and ambulatory care settings. Patients’ end-of-life quality and interchange between physician groups should also be documented and compared.

Patterns of adaptation in patients living long term with advanced cancer

With improved treatment, increasing proportions of patients with advanced cancer are surviving longer with their disease: into a second year after diagnosis and beyond. These longer term survivors face continuing challenges in selecting and shifting personal life goals and goals of care over years (rather than months) of life with incurable cancer. Studies are needed to explore adaptation over time in patients who are living longer term with late‐stage cancer, including anxiety, depression, and spiritual well being, which are conceptualized as indicators of psychospiritual well being in patients with advanced cancer.

Family caregiver engagement in a coping and communication support intervention tailored to advanced cancer patients and families.

We describe family caregiver (FCG) participation in a tailored coping and communication support intervention for advanced cancer patients and families. Preliminary descriptive data on characteristics and patterns of early engagement in the intervention for 132 FCGs are presented. Engagement assessed at an initial in-person meeting and the following 6 weeks includes problems raised, strategies used, and initiation, frequency, and mode of contact. A sizable proportion of FCGs were male, African American, and nonspouse. The FCGs had modest scores on a standard survey measure of burden yet volunteered caregiving demands as their primary problem. Other problems raised initially by more than 40% of the sample included psychological, practical, and communication with healthcare providers. Few reported physical and psychosocial difficulties. Engagement preferences expressed at the initial meeting largely mapped with actual engagement during the 6 weeks of intervention. Most FCGs were actively engaged during follow-up. Some (14%) did not opt for coping and communication support during this early treatment phase. This intervention is expected to affect quality of care and quality-of-life outcomes for FCGs over time from patient diagnosis to end of life. Findings will guide modification and dissemination of this intervention primarily in cancer clinics for the underserved.

Faculty development for the 21st century: Lessons from the Society of General Internal Medicine-Hartford Collaborative Centers for the Care of Older Adults

In this review of a recent set of faculty development initiatives to promote geriatrics teaching by general internists, nontraditional strategies to promote sustained change were identified, included enrolling a limited number of “star” faculty, creating ongoing working relationships between faculty, and developing projects for clinical or education program improvement. External funding, although limited, garnered administration support and was associated with changes in individual career trajectories. Activities to enfranchise top leadership were felt essential to sustain change.

Depression among white and nonwhite caregivers of the chronically critically ill

PURPOSE The study aimed to describe characteristics of caregivers of chronically critically ill (CCI) patients, describe key outcomes (depression, employment, physical health), and examine race as one of several predictors of post-hospital depressive symptoms. MATERIALS AND METHODS This was a prospective study of caregivers of hospital survivors of prolonged (>72 hours) mechanical ventilation. Caregivers were interviewed at admission to the intensive care unit (ICU) and 2 months post-discharge. RESULTS Patients discharged to an institution had a high risk of post-hospital mortality (odds ratio, 8.61; P = .01). Caregivers of patients residing in an institution 2 months post-discharge had greater odds of being depressed than caregivers of patients residing at home (odds ratio, 2.75; P = .001). Nonwhite caregivers of patients residing in an institution had the least improvement in depression over time. Predictors of depression 2 months post-discharge were depression during hospitalization (P = .001), sex (P = .019), health status (P = .009), and residence of the patient (P = .001), with no change based on race. Almost 50% of employed caregivers had a reduction in paid work. There was a significant reduction in physical health status over time (P = .001) with no difference based on race. CONCLUSIONS Caregivers of CCI patients are at risk for depression post-hospital discharge. Nonwhite caregivers of patients residing in an institution 2 months post-discharge are at highest risk for depression.

The Role of Primary Care Physicians in Advanced Cancer Care: Perspectives of Older Patients and Their Oncologists

OBJECTIVES: To examine data from advanced cancer patients and their oncologists regarding patient age‐related differences in patient and oncologist perspectives on involvement of primary care physicians (PCPs) in aspects of cancer management.

Primary care physicians' involvement in the cancer care of older long-term survivors

Objective: This study investigated survivors’ reports of primary care physicians’ (PCPs) involvement in three key cancer survivorship activities: discussing cancer history, whether the PCP initiated discussions, and whether discussions led to tests/procedures. Method: The sample included 215 older survivors whose health care was maintained in primary care. Logistic regression explored predictors of the three activities, including demographics, cancer characteristics, survivor/PCP association characteristics, health characteristics, and psychosocial well-being. Results: Nearly two thirds of survivors indicated discussing cancer history; most said discussions were PCP initiated and nearly half said discussions resulted in tests/procedures. Predictors of discussing cancer history were African American race and more comorbid conditions. PCP-initiated discussions were related to older age, surviving breast cancer, more years in the PCP’s practice, and having less general health worry. The tests/procedures model was not significant. Conclusions: As older survivors focused more on other health concerns, PCPs remained attentive to cancer issues, prompting discussions about history and ordering tests.