Penelope Schofield

‘Would you like to talk about your future treatment options?’ discussing the transition from curative cancer treatment to palliative care

Palliative care focuses on improving quality of life for patients with life-threatening illness and their families. There comes a time when actively pursuing aggressive curative treatment may do more harm than good. The cessation of curative treatment is often viewed as a distinct event; however, current practice guidelines suggest that a palliative approach should be gradually adopted as the disease progresses. The challenge is how to facilitate a sensitive transition from curative to palliative care. On the basis of an extensive literature review, recommended steps for facilitating this transition have been outlined. The recommendations cover: the timing of the discussion; preparing for this discussion; the environment and circumstances of the consultation; initiating the discussion; identifying the information to be provided; responding to the person’s emotional reaction; introducing palliative care services; continuity of care; family concerns; cultural and linguistic diversity; concluding the discussion. These steps were based on the best available evidence. However, as there is a paucity of research in this area, only three relevant systematic reviews of randomized controlled trials were identified and only one of these reviews related directly to palliative care. The majority of the relevant research was descriptive evidence. There is a need for more high quality research in this area.

Desire for hastened death in patients with advanced disease and the evidence base of clinical guidelines: a systematic review

Purpose: Patients’ desire for hastened death within the context of advanced disease and palliative care is a controversial topic, frequently discussed in the international literature. Much of the discussion has focused on opinion and debate about ethical matters related to hastened death. Not many research studies seem to have specifically targeted why palliative care patients may desire hastened death, and few have focused on clinical guidelines for responding to such requests. Methods: Using a systematic literature review process, we evaluated the research evidence related to the reasons patients express a desire for a hastened death, and the quality of clinical guidelines in this area. Results: Thirty-five research studies met the inclusion criteria related to reasons associated with a desire for hastened death. The factors associated with a desire to die were often complex and multifactorial; however, psychological, existential and social reasons seem to be more prominent than those directly related to physical symptoms, such as pain. Much of the evidence supporting the reasons for these statements is based on: (a) patients’ perceptions of how they may feel in the future, and (b) health professionals’ and families’ interpretations of why desire to die statements may have been made. Several publications provided expert opinion for responding to requests for physician-assisted suicide and euthanasia. In keeping with this limited research base, there is a lack of evidence-based guidelines for clinical care that addresses the desire to die among terminally ill patients. Most literature has focused on discipline specific responses, with minimal exploration of how clinicians might respond initially to a statement from a patient regarding a desire to die. Conclusions: In order to advance understanding of the complex issue of desire for hastened death in the context of palliative care, research should focus on studies with patients who have actually made a desire to die statement and the development of guidelines to help health professionals respond. Direction for research in this area is described.

Nonpharmacologic strategies for managing common chemotherapy adverse effects: a systematic review.

PURPOSE Adverse effects of chemotherapy can be severe and can have a significant impact on a persons quality of life. With chemotherapy treatment increasingly administered in the ambulatory setting, there is a need for patients to be informed about effective self-care strategies to manage treatment adverse effects. Advice for patients needs to be based on evidence. This systematic review provides an overview of the intervention research in this area as well as an effectiveness review of nonpharmacologic (self-care) strategies evaluated in high-quality randomized controlled trials (RCTs). METHODS An extensive literature search was conducted to identify RCTs relating to self-care strategies for reducing nausea/vomiting, constipation, diarrhea, fatigue, hair loss, or mucositis. Relevant studies published in peer-reviewed journals between 1980 and August 2007 were included. Study characteristics, results and methodologic quality were examined. High-quality RCTs were further analyzed to establish the effectiveness of specific self-care strategies. RESULTS The search identified 77 RCTs. Findings from RCTs of reasonable quality provide limited support for cognitive distraction, exercise, hypnosis, relaxation, and systematic desensitization to reduce nausea and vomiting, psycho-education for fatigue, and scalp cooling to reduce hair loss. CONCLUSION Although some strategies seem promising, the quality of the RCTs was generally quite low, making it difficult to draw conclusions about the effectiveness of self-care strategies. Future studies require better design and reporting of methodologic issues to establish evidence-based self-care recommendations for people receiving chemotherapy.

Guidelines for the diagnosis and treatment of malignant pleural mesothelioma

Malignant Pleural Mesothelioma (MPM), the asbestos-induced neoplasm originating in the mesothelial lining of the lung cavities represents significant diagnostic and therapeutic challenges for clinicians in Australia. Very seldom diagnosed prior to the advent of widespread asbestos mining in the early to midtwentieth century, it has sharply risen in incidence over the last five decades. According to the most recent Australian Institute of Health and Welfare data, there were 666 cases of malignant mesothelioma diagnosed in Australia in 2009 and around 90% of them originated in the pleura.

The views of bowel cancer survivors and health care professionals regarding survivorship care plans and post treatment follow up

Goals of workIncreasing numbers of people survive cancer beyond diagnosis and treatment. Many survivors have ongoing needs and they may encounter fragmented, poorly coordinated follow up care. Survivorship care plans (SCP) have been promoted as a key aspect of survivorship care. This study aimed to survey key stakeholders in the care of people with colorectal cancer (survivors, primary care providers and hospital-based healthcare professionals) regarding follow-up and SCP.Patients and methodsIn study 1, cancer survivors completed a questionnaire regarding their follow-up and experiences during survivorship. Participants’ primary care physicians completed a phone interview regarding proposed SCP elements. A subgroup of survivors reviewed a sample SCP and participated in a phone interview regarding this. In study 2, healthcare professionals working with colorectal cancer patients completed a questionnaire regarding follow-up and proposed elements of a SCP.Main resultsTwenty survivors completed the questionnaire, 14 primary care providers completed a phone interview and 12 survivors reviewed the sample SCP.Ninety-five healthcare professionals (30 medical professionals and 65 nurses) completed the questionnaire. There was strong support for core elements of the SCP. Additionally, nurses and survivors expressed support for supportive care and psychosocial elements. There was lack of consensus regarding who should prepare and discuss the SCP.ConclusionsThere is strong support for the development and use of SCPs for bowel cancer survivors. There is some variation in opinion regarding ideal content of the SCP, who might prepare it, and how it might be discussed and utilised.Implications for Cancer SurvivorsOvercoming identified barriers to implementing SCPs for bowel cancer survivors is necessary for high quality cancer care.

Effectively discussing complementary and alternative medicine in a conventional oncology setting: Communication recommendations for clinicians

OBJECTIVE Justifiable concerns around the use of complementary and alternative medicines (CAM) amongst cancer patients are becoming increasingly prominent. The aim was to develop evidence-based guidelines to assist oncology health professionals (HP) to have respectful, balanced and useful discussions with patients about CAM. METHODS A systematic review was conducted, covering relevant literature from 1997 to 2007. The level of evidence was rated using a standardized rating system. The evidence was qualitatively synthesised into structured recommendations by a multidisciplinary team including a consumer. RESULTS The search identified 78 original papers; 36 directly related to discussing CAM. No randomized controlled trials specifically addressing the methods or benefits of discussing CAM were identified. Evidence based guidelines are presented as a sequence of recommended steps: (1) Elicit the persons understanding of their situation; (2) Respect cultural and linguistic diversity and different epistemological frameworks; (3) Ask questions about CAM use at critical points in the illness trajectory; (4) Explore details and actively listen; (5) Respond to the persons emotional state; (6) Discuss relevant concerns while respecting the persons beliefs; (7) Provide balanced, evidence-based advice; (8) Summarize discussions; (9) Document the discussion; (10) Monitor and follow-up. CONCLUSION This represents the first comprehensive guidelines for discussing CAM. PRACTICE IMPLICATIONS Given the concerns surrounding CAM use, it is critical to encourage informed decision-making about CAM and ultimately, improve outcomes for patients.

Predicting attempts and sustained cessation of smoking after the introduction of workplace smoking bans.

Examined predictors of smoking cessation attempts and predictors of the outcome of those attempts after the introduction of a workplace smoking ban. Smokers were surveyed in the month before the ban came into force, and variables collected at that time were used to predict outcomes 6 months later. Data from 491 respondents who were smokers at the time of the initial survey were used, and a set of potential predictor variables was chosen on both theoretical and empirical grounds. Making a cessation attempt was predicted by the strength of desire to quit and, to less extent, by not having been subject to extensive restrictions on smoking before the mandated ban, having tried to quit before, perceiving oneself high in ability to quit, and being worried about smoke at work. For the outcome of cessation attempts among those who tried, success was best predicted by low levels of a composite habit strength variable and, to less extent, by desire to quit, no previous attempts to quit, the existence of social supports for quitting, and educational status. Although cognitive variables were important in predicting attempts, they played only a minor role in predicting maintenance. Behavioral and environmental variables contributed slightly to prediction of attempts and strongly to prediction of maintenance.

Development and pilot testing of a nurse-led posttreatment support package for bowel cancer survivors.

Background: Colorectal cancer (CRC) is the most common cancer affecting both men and women in Australia. The illness and related treatments can cause distressing adverse effects, impact on emotional and psychological well-being, and adversely affect social, occupational, and relationship functioning. Current models of follow-up fail to address the complex needs arising after treatment completion. Strategies to better prepare and support survivors are urgently required. Objectives: This study aimed to develop and pilot test an innovative supportive care program for people with potentially curative CRC. Methods: The SurvivorCare intervention was developed by a multidisciplinary team using 3 key principles: (1) promote patient involvement and engagement; (2) address the specific needs of individual patients, and (3) use evidence-based strategies to promote well-being and reduce treatment sequelae. It also addressed 4 essential components of survivorship planning, defined by the US Institute of Medicine. Ten survivors completed questionnaires and satisfaction interviews before and after receiving the intervention. Results: SurvivorCare comprises survivorship educational materials (booklet, DVD, and question prompt list), a tailored survivorship care plan, a tailored nurse-led end-of-treatment consultation, and 3 follow-up telephone calls. Pilot data demonstrated that survivors considered the intervention appropriate, relevant, and useful. Conclusions: SurvivorCare is a well-received, comprehensive intervention that will now be evaluated in a randomized controlled trial aiming to reduce distress and unmet needs and improve quality of life in CRC survivors. Implications for Practice: If SurvivorCare is shown to be effective, it will be possible to quickly and broadly disseminate this model of care.

Preparing patients for threatening medical treatments: effects of a chemotherapy educational DVD on anxiety, unmet needs, and self-efficacy

Goals of workBased on meta-analyses regarding the preparation of patients for potentially threatening medical procedures, a DVD, incorporating behavioral role modelling, was developed to prepare patients for chemotherapy and assist them to self-manage side effects. It was hypothesized that patients who watched the DVD (vs those who did not) would report (1) lower anxiety; (2) higher self-efficacy related to coping with treatment side effects; (3) fewer supportive care needs; and (4) higher satisfaction with information received. It was further hypothesized that these effects would be stronger in those perceiving their treatment intent to be curative rather than palliative.Materials and methodsQuasi-experimental design using a historical control group was employed. Participants were scheduled to receive their first ever chemotherapy treatment. Group 1 (usual care; n = 50) was prospectively recruited before the release of the DVD and group 2 (DVD plus usual care; n = 50) after the release. Before commencing chemotherapy, all patients completed reliable and valid measures of self-efficacy, anxiety, and supportive care needs. Data was stratified according to perceived treatment intent. Independent sample t tests were performed for each group (curative vs palliative).Main resultsSignificant differences were found between the usual care and intervention groups: for self-perceived curative patients in relation to self-efficacy for seeking social support (p = 0.044), with increased confidence in those watching the DVD, and for self-perceived palliative patients in relation to their satisfaction with information about side effects (p = 0.026), with increased satisfaction in those watching the DVD. Overall, significant differences were found between self-perceived curative vs palliative patients on measures of self-efficacy and supportive care needs, with self-perceived curative patients reporting more confidence and fewer needs.ConclusionsThe educational DVD was considered highly acceptable by patients and was found to increase self-efficacy and reduce supportive care needs. Hence, it is appropriate to give to patients before face-to-face chemotherapy education. Additional pretreatment education is recommended, particularly for self-perceived palliative patients, to reduce their pretreatment anxiety and enhance their confidence in coping with treatment.

Optimism and survival in lung carcinoma patients

It is popular belief that the psychologic response to a diagnosis of cancer influences survival in patients with cancer; however, research has produced contradictory results. In this prospective study, the authors investigated the relation between pretreatment levels of optimism and survival in patients with nonsmall cell lung carcinoma (NSCLC).