K. Mehlis

The Role of Physicians in Rationing Cancer Care. Attitudes of German Oncologists

Background: Against the background of limited resources, the rise in the cost of therapy as well as in the number of cancer patients fuels the discussion about the necessity to ration, i.e., setting limits to beneficial treatment for cost reasons. Recently, we presented the self-reported prevalence of bedside rationing among German oncologists. Here, we describe oncologists views on cost containment strategies and their role therein. Methods: We performed an online survey including structured questions and free field sections with the members of the German Society of Hematology and Oncology. Results: In the perception of oncologists, cost considerations and negotiations are gaining in importance and consume considerable working time. This negatively affects job satisfaction in 72% of the 345 respondents. Oncologists are concerned that the quality of care will suffer from rationalization and implicit rationing. They are ambivalent as to who is best suited to decide about resource rationing: 66% support the view that limits for costly procedures should be set by a form of commission; nevertheless, 48% consider physicians as the best decision makers in these situations. Conclusion: We suggest a broad public discussion and an interdisciplinary debate among the oncology community to define and legitimize decisions on rationing by setting explicit criteria.

High prevalence of moral distress reported by oncologists and oncology nurses in end-of-life decision making

Decisions to limit life‐prolonging treatment (DLT) are often accompanied by psychological and ethical difficulties. The aim of the study is to investigate prevalence and intensity of moral distress (MD) as well as potential causes experienced by oncology physicians and nurses in DLT situations.

Development and Evaluation of an Ethical Guideline for Decisions to Limit Life-Prolonging Treatment in Advanced Cancer: Protocol for a Monocentric Mixed-Method Interventional Study

Background Many patients with advanced cancer receive chemotherapy close to death and are referred too late to palliative or hospice care, and therefore die under therapy or in intensive care units. Oncologists still have difficulties in involving patients appropriately in decisions about limiting tumor-specific or life-prolonging treatment. Objective The aim of this Ethics Policy for Advanced Care Planning and Limiting Treatment Study is to develop an ethical guideline for end-of-life decisions and to evaluate the impact of this guideline on clinical practice regarding the following target goals: reduction of decisional conflicts, improvement of documentation transparency and traceability, reduction of distress of the caregiver team, and better knowledge and consideration of patients’ preferences. Methods This is a protocol for a pre-post interventional study that analyzes the clinical practice on treatment limitation before and after the guideline implementation. An embedded researcher design with a mixed-method approach encompassing both qualitative and quantitative methods is used. The study consists of three stages: (1) the preinterventional phase, (2) the intervention (development and implementation of the guideline), and 3) the postinterventional phase (evaluation of the guideline’s impact on clinical practice). We evaluate the process of decision-making related to limiting treatment from different perspectives of oncologists, nurses, and patients; comparing them to each other will allow us to develop the guideline based on the interests of all parties. Results The first preintervention data of the project have already been published, which detailed a qualitative study with oncologists and oncology nurses (n=29), where different approaches to initiation of end-of-life discussions were ethically weighted. A framework for oncologists was elaborated, and the study favored an anticipatory approach of preparing patients for forgoing therapy throughout the course of disease. Another preimplementational study of current decision-making practice (n=567 patients documented) demonstrated that decisions to limit treatment preceded the death of many cancer patients (62/76, 82% of deceased patients). However, such decisions were usually made in the last week of life, which was relatively late. Conclusions The intervention will be evaluated with respect to the following endpoints: better knowledge and consideration of patients’ treatment wishes; reduction of decisional conflicts; improvement of documentation transparency and traceability; and reduction of the psychological and moral distress of a caregiver team. Registered Report Identifier RR1-10.2196/9698

Trust and responsibility in molecular tumour boards

Molecular tumour boards (MTBs) offer recommendations for potentially effective, but potentially burdensome, molecularly targeted treatments to a patients treating physician. In this paper, we discuss the question of who is responsible for ensuring that there is an adequate evidence base for any treatments recommended to a patient. We argue that, given that treating oncologists cannot usually offer a robust evaluation of the evidence underlying an MTBs recommendation, members of the MTB are responsible for ensuring that the evidence level is adequate. We explore two models for how to share responsibility between MTB members. According to the first model, each MTB member, as well as the treating physician, should be held maximally and equally responsible for the recommendations. We argue that this insufficiently accounts for differences in roles and expertise of MTB members. We propose instead that responsibility is delegated via relationships of trust. We argue if these relationships of trust are to be instances of reasonable trust, (a) MTBs should offer a clinical representative to whom a treating physician may delegate the responsibility of ensuring there is sufficient evidence for treatment recommendations, (b) the relationships of trust between the representative and the other MTB members should be clearly defined, and (c) MTB members should be carefully selected. Treating oncologists retain a responsibility to consider general limitations of the evidence for targeted treatments in assessing whether the treatment recommendation offered by an MTBs representative is adequate for a given clinical situation.

Häufigkeit und Zeitpunkt von Entscheidungen gegen intensivmedizinische Maßnahmen und tumorspezifische Therapien in einer universitären Hämatologie und Onkologie

Backgroundu2002Decisions to limit treatment (DLT) are important in order to prevent overtreatment at the end of life. However, they are not always discussed with the patient in advance or sufficiently documented. In a study to improve DLT in patients with an advanced hematological/ oncological disease we examined how often DLT precede deaths and how early they are determined. Methodsu2002In a period of 6 months, 567 patients with advanced hematological/ oncological neoplasias had been recruited for the cross-sectional study at the University hospital in Munich. Using a standardized registration form an embedded researcher documented which DLT were determined for the patients and which of them were implemented until death. Resultsu2002For 26u200a% (nu200a=u200a147) of the 567 patients a DLT was determined. These DLT were mostly documented in writing from the beginning on (90u200a%; nu200a=u200a132), 20u200a% (nu200a=u200a30) were modified. The proportion of deceased patients with DLT was 82u200a% (nu200a=u200a62 of 76 deceased). The median time between the initial determination of a DLT and the patients death was 6xa0days at normal ward and 10.5 days at palliative ward. Compared to hematological patients, DLT were more frequently diagnosed in patients with an oncological disease (64 vs. 36u200a%) and the decisions were made slightly earlier (7 vs. 5xa0days before death). Conclusionu2002Our results show that DLT precede the death of many patients with a hematological/ oncological disease, but usually are made in the last week of life. This leads to the risk that the remaining few days to death are not sufficient for discussions with all parties involved and the planning of the end of life. These findings resulted in the development of an ethics policy for treatment limitation in cancer patients, which should support the concept of advance care planning. The project is funded by the German Cancer Aid.

The EPAL-project (Ethics policy for advanced care planning and limiting treatment)

T cell stimulation with different cytokines results in distinct phenotypes and cytotoxic activity of CD19-specific CART cells

Development and Validity of a Checklist Assessing the Risk of Bias of Randomized Trials, Observational Studies and Systematic Reviews Analyzing Drug Adverse Events

T cell stimulation with different cytokines results in distinct phenotypes and cytotoxic activity of CD19-specific CART cells

Rather one more chemo than one less ... Young adult's patients and chemotherapy in advanced cancer. A study of oncologists' views

T cell stimulation with different cytokines results in distinct phenotypes and cytotoxic activity of CD19-specific CART cells