Jay G. Hull

Effects of a Palliative Care Intervention on Clinical Outcomes in Patients With Advanced Cancer: The Project ENABLE II Randomized Controlled Trial

CONTEXT There are few randomized controlled trials on the effectiveness of palliative care interventions to improve the care of patients with advanced cancer. OBJECTIVE To determine the effect of a nursing-led intervention on quality of life, symptom intensity, mood, and resource use in patients with advanced cancer. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled trial conducted from November 2003 through May 2008 of 322 patients with advanced cancer in a rural, National Cancer Institute-designated comprehensive cancer center in New Hampshire and affiliated outreach clinics and a VA medical center in Vermont. INTERVENTIONS A multicomponent, psychoeducational intervention (Project ENABLE [Educate, Nurture, Advise, Before Life Ends]) conducted by advanced practice nurses consisting of 4 weekly educational sessions and monthly follow-up sessions until death or study completion (n = 161) vs usual care (n = 161). MAIN OUTCOME MEASURES Quality of life was measured by the Functional Assessment of Chronic Illness Therapy for Palliative Care (score range, 0-184). Symptom intensity was measured by the Edmonton Symptom Assessment Scale (score range, 0-900). Mood was measured by the Center for Epidemiological Studies Depression Scale (range, 0-60). These measures were assessed at baseline, 1 month, and every 3 months until death or study completion. Intensity of service was measured as the number of days in the hospital and in the intensive care unit (ICU) and the number of emergency department visits recorded in the electronic medical record. RESULTS A total of 322 participants with cancer of the gastrointestinal tract (41%; 67 in the usual care group vs 66 in the intervention group), lung (36%; 58 vs 59), genitourinary tract (12%; 20 vs 19), and breast (10%; 16 vs 17) were randomized. The estimated treatment effects (intervention minus usual care) for all participants were a mean (SE) of 4.6 (2) for quality of life (P = .02), -27.8 (15) for symptom intensity (P = .06), and -1.8 (0.81) for depressed mood (P = .02). The estimated treatment effects in participants who died during the study were a mean (SE) of 8.6 (3.6) for quality of life (P = .02), -24.2 (20.5) for symptom intensity (P = .24), and -2.7 (1.2) for depressed mood (P = .03). Intensity of service did not differ between the 2 groups. CONCLUSION Compared with participants receiving usual oncology care, those receiving a nurse-led, palliative care-focused intervention addressing physical, psychosocial, and care coordination provided concurrently with oncology care had higher scores for quality of life and mood, but did not have improvements in symptom intensity scores or reduced days in the hospital or ICU or emergency department visits. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00253383.

Hardiness and health: a critique and alternative approach.

Recent research has suggested that individual differences in the personality variable of hardiness are related to health and illness. Despite some success at predicting health outcomes, there are several theoretical and empirical problems that must be addressed before research on this topic can proceed. Most critical are (a) how hardiness is to be measured; (b) whether hardiness should be treated as a unitary phenomenon or as three separate phenomena associated with commitment, control, and challenge; and (c) whether hardiness has direct effects on health or indirect effects by virtue of buffering the impact of stressful life events. After reviewing the literature and presenting our own study of the psychometric properties of the Hardiness Scale and its subcomponents, we draw the following conclusions: (a) Hardiness is not a unitary phenomenon, but should be treated as involving three separate phenomena; (b) of the three subcomponents of hardiness, only commitment and control have adequate psychometric properties and are systematically related to health outcomes; (c) lack of control and lack of commitment have direct effects on health because they are psychologically stressful; and (d) if there are buffering effects of commitment and control, they are in addition to these direct effects and are situation specific. Such a systematic consideration of the problems and prospects of the hardiness literature should facilitate research on this important topic.

A general approach to testing multifaceted personality constructs.

Some personality characteristics are composed of multiple, distinct subcomponents (e.g., Type A, hardiness, attributional style, self-monitoring). The advantages and disadvantages of 3 typical approaches to testing these constructs are reviewed. An alternative approach based on structural equation modeling is then offered. This approach has many advantages over its alternatives, including the provision of an explicit test of the structure of the multifaceted construct, the simultaneous test of the effects of this general construct and the unique aspects of its subcomponents, and the explicit consideration of measurement error. Although the modeling approach does have limitations, these limitations are equally applicable to all of its alternatives. Indeed, the principal disadvantages of the modeling approach seem to be its statistical complexity and the lack of education regarding its proper use.

Applications of the self-awareness model of alcohol consumption: predicting patterns of use and abuse.

We conducted two studies to test the applicability of a recently proposed self-awareness model of alcohol consumption to patterns of alcohol use outside of the laboratory. In both studies, we predicted that alcohol use would be a joint function of private self-consciousness and personal success or failure. High self-conscious individuals were predicted to drink following personal failure and avoid drinking following personal success in an attempt to control their sensitivity to the self-relevant implications of such events. Consumption by low self-conscious individuals was predicted to be relatively independent of self-relevant events. These predictions were supported in a longitudinal study of relapse following alcoholic detoxification. They were then replicated in a study of adolescent alcohol use and shown to be relatively independent of other significant environmental and behavioral predictors of consumption. Results are discussed in terms of their implications for theories of self-awareness and alcohol use.

The nonconsciousness of self-consciousness.

Five studies demonstrated that private self-consciousness is associated with nonconscious, automatic behaviors. In 2 studies, high but not low self-conscious individuals walked more slowly following exposure to an implicit elderly prime. In a 3rd study, high but not low self-conscious individuals showed improved performance following exposure to a subliminal success prime relative to a subliminal failure prime. In a 4th study, subliminal exposure to an angry prime was shown to increase blood pressure relative to a relax prime. In a final study, the latter effect was shown to be true only for high self-conscious individuals and only for subliminal presentations. Results are discussed in terms of their implications for understanding a variety of effects associated with self-consciousness and self-awareness.

Practical Interests, Relevant Alternatives, and Knowledge Attributions: an Empirical Study

In defending his interest-relative account of knowledge, Jason Stanley relies heavily on intuitions about several bank cases. We experimentally test the empirical claims that Stanley seems to make concerning our common-sense intuitions about these cases. Additionally, we test the empirical claims that Jonathan Schaffer seems to make, regarding the salience of an alternative, in his critique of Stanley. Our data indicate that neither raising the possibility of error nor raising stakes moves most people from attributing knowledge to denying it. However, the raising of stakes (but not alternatives) does affect the level of confidence people have in their attributions of knowledge. We argue that our data impugn what both Stanley and Schaffer claim our common-sense judgments about such cases are.

Reliability and Validity of the Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-Pal) Scale

The Functional Assessment of Chronic Illness Therapy (FACIT) system provides a general, multidimensional measure of health-related quality of life (FACT-G) that can be augmented with disease or symptom-specific subscales. The 19-item palliative care subscale of the FACIT system has undergone little psychometric evaluation to date. The aim of this paper is to report the internal consistency, factor structure, and construct validity of the instrument using the palliative care subscale (FACIT-Pal). Two hundred fifty-six persons with advanced cancer in a randomized trial testing a palliative care psychoeducational intervention completed the 46-item FACIT-Pal at baseline. Internal consistency was greater than 0.74 for all subscales and the total score. Seventeen of the 19 palliative care subscale items loaded onto the four-factor solution of the established core measure (FACT-G). As hypothesized, total scores were correlated with measures of symptom intensity (r=-0.73, P<0.001) and depression (r=-0.75, P<0.001). The FACIT-Pal was able to discriminate between participants who died within three months of completing the baseline and participants who lived for at least one year after completing the baseline assessment (t=-4.05, P<0.001). The functional well-being subscale discriminated between participants who had a Karnofsky performance score of 70 and below and participants with a Karnofsky performance score of 80 and above (t=3.40, P<0.001). The findings support the internal consistency reliability and validity of the FACIT-Pal as a measure of health-related quality of life for persons with advanced cancer.

A Structural Equation Model of Social Influences and Exposure to Media Smoking on Adolescent Smoking

This research examined the role of movie portrayals of smoking as well as peer, parent, and sibling smoking as predictors of intentions to smoke and smoking behavior in adolescents. Structural equation modeling was used to assess the fit of a model that proposes that identification with smokers, normative beliefs about smoking, and positive expectations about smoking are mediators of the association between social influences and smoking intentions. Our models provided a good fit for both a cross-sectional model of smoking and a model of smoking initiation. The relationship between media exposure to smoking and intentions to smoke was mediated by positive expectancies and identification as a smoker in the cross-sectional model, and by positive expectancies in baseline never smokers. Our results indicate that viewing smoking in movies is an important predictor of smoking among adolescents and that identity processes and expectancies serve as mediators of this effect.

Self-consciousness and the processing of self-relevant information.

Three experiments were conducted to examine cognitive processes involved in self-conscious behavior. According to Hull and Levy (1979), self-consciousness is associated with processes involved in self-referent encoding. The present studies advance the more specific hypothesis that self-consciousness is involved with the aspect of self-reference associated with the activation of knowledge about the self. Experiment I used a self-reference paradigm and found that self-consciousness increased the extent to which a manipulation of accessible self-knowledge influenced self-refereni encoding. Experiment 2 used a self-perception paradigm and found that self-consciousness increased the extent to which a manipulation of accessible self-knowledge affected subsequent self-perception. Experiment 3 used a correlational design to demonstrate how cognitive processes associated with selfreference may mediate self-conscious behavior. Individual differences in self-referent encoding were associated with individual differences in self-consciousness; both variables were associated with increased affective reactions to self-relevant feedback; and partial ing out individual differences in selfreferent encoding eliminated the effects of self-consciousness. These results are discussed in terms of their implications for reconciling various theories of self-consciousness.

Modeling the Relations of Attributional Style, Expectancies, and Depression

Structural modeling techniques were used to assess relations of attributional style, expectancies, and depression. According to an initial theoretical model, attributions are directly related to expectancies, and expectancies are directly related to depression, but attributions are only indirectly related to depression by means of their relation to expectancies. The results of Study 1 indicated that this model was flawed in 2 respects: (a) Attributions for positive and negative events did not form a single latent variable, and (b) attributions for negative events both were indirectly related to depression by means of expectancies and were directly related to depression. Attributions for positive events only were indirectly related to depression by means of expectancies. The model derived in Study 1 was replicated in Study 2. Discussion centers on the interpretation of this modified model and on issues in the measurement of attributional style.