Wendy G. Anderson

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.

Code Status Discussions Between Attending Hospitalist Physicians and Medical Patients at Hospital Admission

ABSTRACTBACKGROUNDBioethicists and professional associations give specific recommendations for discussing cardiopulmonary resuscitation (CPR).OBJECTIVETo determine whether attending hospitalist physicians’ discussions meet these recommendations.DESIGNCross-sectional observational study on the medical services at two hospitals within a university system between August 2008 and March 2009.PARTICIPANTSAttending hospitalist physicians and patients who were able to communicate verbally about their medical care.MAIN MEASURESWe identified code status discussions in audio-recorded admission encounters via physician survey and review of encounter transcripts. A quantitative content analysis was performed to determine whether discussions included elements recommended by bioethicists and professional associations. Two coders independently coded all discussions; Cohen’s kappa was 0.64–1 for all reported elements.KEY RESULTSAudio-recordings of 80 patients’ admission encounters with 27 physicians were obtained. Eleven physicians discussed code status in 19 encounters. Discussions were more frequent in seriously ill patients (OR 4, 95% CI 1.2–14.6), yet 66% of seriously ill patients had no discussion. The median length of the code status discussions was 1 min (range 0.2–8.2). Prognosis was discussed with code status in only one of the encounters. Discussions of patients’ preferences focused on the use of life-sustaining interventions as opposed to larger life goals. Descriptions of CPR as an intervention used medical jargon, and the indication for CPR was framed in general, as opposed to patient-specific scenarios. No physician quantitatively estimated the outcome of or provided a recommendation about the use of CPR.CONCLUSIONSCode status was not discussed with many seriously ill patients. Discussions were brief, and did not include elements that bioethicists and professional associations recommend to promote patient autonomy. Local and national guidelines, research, and clinical practice changes are needed to clarify and systematize with whom and how CPR is discussed at hospital admission.

What concerns me is... Expression of emotion by advanced cancer patients during outpatient visits.

ObjectiveCancer patients have high levels of distress, yet oncologists often do not recognize patients’ concerns. We sought to describe how patients with advanced cancer verbally express negative emotion to their oncologists.Materials and methodsAs part of the Studying Communication in Oncologist–Patient Encounters Trial, we audio-recorded 415 visits that 281 patients with advanced cancer made to their oncologists at three US cancer centers. Using qualitative methodology, we coded for verbal expressions of negative emotion, identified words patients used to express emotion, and categorized emotions by type and content.ResultsPatients verbally expressed negative emotion in 17% of the visits. The most commonly used words were: “concern,” “scared,” “worried,” “depressed,” and “nervous.” Types of emotion expressed were: anxiety (46%), fear (25%), depression (12%), anger (9%), and other (8%). Topics about which emotion was expressed were: symptoms and functional concerns (66%), medical diagnoses and treatments (54%), social issues (14%), and the health care system (9%). Although all patients had terminal cancer, they expressed negative emotion overtly related to death and dying only 2% of the time.ConclusionsPatients infrequently expressed negative emotion to their oncologists. When they did, they typically expressed anxiety and fear, indicating concern about the future. When patients use emotionally expressive words such as those we described, oncologists should respond empathically, allowing patients to express their distress and concerns more fully.

Dancing Around Death Hospitalist–Patient Communication About Serious Illness

Hospital physicians care for most seriously ill patients in the United States. We employed dimensional analysis to describe communication about death and dying in audio-recorded admission encounters between seriously ill patients and hospitalists. Acknowledging or not acknowledging the possibility of dying emerged as a key process. Acknowledgment was rare, and depended on synergistic communication behaviors between patient and physician. Facilitators included patients cuing for information and disclosing emotional distress, and physicians exploring the patient’s understanding of his or her illness and emotional distress. When hospitalists focused on acute issues, stated that they were awaiting test results, and deferred to other physicians, discussion moved away from acknowledgment. Meaningful discussion of end-of-life issues, including goals and values, fears about death and dying, prognosis, and options for palliative care followed open acknowledgment. This acknowledgment process can serve as a guide for providers to sensitively and honestly discuss essential end-of-life issues.

Code status discussions at hospital admission are not associated with patient and surrogate satisfaction with hospital care: results from the multicenter hospitalist study.

Background: Physicians may avoid code status discussions for fear of decreasing patient or surrogate satisfaction. Methods: Charts of patients admitted to medical services at 6 university hospitals were reviewed for documentation of a code status discussion in the first 24 hours of admission. Satisfaction with care provided during the hospitalization was assessed by telephone 1 month after discharge. Results: Of the 11 717 patients with 1-month follow-up, 1090 (9.3%) had a code status discussion documented. Patient or surrogate satisfaction did not differ by whether a discussion was documented. The lack of association persisted after adjusting for patient’s severity of illness and using propensity adjustment for likelihood of having a discussion. Conclusions: Discussing code status on admission to the inpatient setting did not affect patient or surrogate satisfaction.

Incentivizing Residents to Document Inpatient Advance Care Planning

develops web-based decision support for radiology test ordering. He serves on the board for SEA Medical Systems, which makes intravenous pump technology. He serves as an advisor to Calgary Scientific, which makes technologies that enable mobility within EHRs. He is on the clinical advisory board for Zynx Inc, which develops evidence-based algorithms, and Patient Safety Systems, which provides a set of approaches to help hospitals improve safety. He is a consultant for EarlySense, which makes patient safety monitoring systems.

Systematic Reviews and Meta-Analyses

You are the medical director of your local hospice. After the annual budget review, the hospice’s director comes to you to see if there are treatments being given that are not supported by evidence. In particular, use of supplemental home oxygen was identified as a significant expenditure. The director asks your opinion about whether supplemental oxygen is likely to relieve shortness of breath in patients who are not hypoxemic. During an evidence-based medicine course, you learned that systematic reviews provide one of the strongest levels of evidence for guiding treatment decisions. You search PubMed and find a systematic review and metaanalysis addressing this question. The review concludes ‘‘oxygen did not provide symptomatic benefit for cancer patients with refractory dyspnoea who would not normally qualify for home oxygen therapy.’’ Does this mean the hospice should stop providing nonhypoxemic patients with home oxygen? Before making a change in policy that affects so many patients, you would like to really understand the review and its results. How can you evaluate the validity of this finding and determine whether you should apply it to your patients? The objectives of this article are to describe the methodology of systematic reviews and meta-analyses, address the current status of systematic reviews and meta-analyses in palliative care, and provide guidelines for evaluating the quality of and interpreting the results of systematic reviews and meta-analyses. Table 1 summarizes the key concepts we will discuss.

Update in Hospital Palliative Care

BACKGROUND Seriously ill patients frequently receive care in hospitals, and palliative care is a core competency for hospitalists. We aimed to summarize and critique recent research that has the potential to impact the clinical practice of palliative care in the hospital. METHODS We reviewed articles published between January 2012 and May 2013, identified through a hand-search of leading journals and PubMed. The authors collectively selected 9 articles based on their scientific rigor and relevance to hospital practice. We review their findings, strengths, and limitations and make recommendations for practice. RESULTS Key findings include: indwelling pleural catheters and talc pleurodesis provide similar relief of dyspnea in patients with malignant pleural effusions; oxygen many not be needed to prevent dyspnea in many dying patients; docusate may not be needed in addition to sennosides to treat opioid-induced constipation; atropine is no more effective than placebo in treating respiratory rattles in dying patients; many older adult survivors of in-hospital cardiopulmonary resuscitation (CPR) are alive up to 1 year after discharge; observing CPR may decrease family post-traumatic stress; surrogates of intensive care unit patients often interpret prognostic information optimistically; many patients with metastatic cancer feel that chemotherapy may cure their disease; viewing a goals-of-care video may decrease preference for CPR in patients being admitted to skilled nursing facilities. CONCLUSIONS Recent research provides important insights into the effectiveness of medications and interventions for symptom management, outcomes of CPR for patients and families, and Journal of Hospital Medicine 2013;8:715-720.

Associations of Physician Empathy with Patient Anxiety and Ratings of Communication in Hospital Admission Encounters

BACKGROUND: Responding empathically when patients express negative emotion is a recommended component of patient‐centered communication. OBJECTIVE: To assess the association between the frequency of empathic physician responses with patient anxiety, ratings of communication, and encounter length during hospital admission encounters. DESIGN: Analysis of coded audio‐recorded hospital admission encounters and pre‐ and postencounter patient survey data. SETTING: Two academic hospitals. PARTICIPANTS: Seventy‐six patients admitted by 27 attending hospitalist physicians. MEASUREMENTS: Recordings were transcribed and analyzed by trained coders, who counted the number of empathic, neutral, and nonempathic verbal responses by hospitalists to their patients’ expressions of negative emotion. We developed multivariable linear regression models to test the association between the number of these responses and the change in patients’ State Anxiety Scale (STAI‐S) score pre‐ and postencounter and encounter length. We used Poisson regression models to examine the association between empathic response frequency and patient ratings of the encounter. RESULTS: Each additional empathic response from a physician was associated with a 1.65‐point decline in the STAI‐S anxiety scale (95% confidence interval [CI], 0.48‐2.82). Frequency of empathic responses was associated with improved patient ratings for covering points of interest, feeling listened to and cared about, and trusting the doctor. The number of empathic responses was not associated with encounter length (percent change in encounter length per response 1%; 95% CI, ‐8%‐10%). CONCLUSIONS: Responding empathically when patients express negative emotion was associated with less patient anxiety and higher ratings of communication but not longer encounter length.

Preventing Harm in the Icu—building a Culture of Safety and Engaging Patients and Families

Objective: Preventing harm remains a persistent challenge in the ICU despite evidence-based practices known to reduce the prevalence of adverse events. This review seeks to describe the critical role of safety culture and patient and family engagement in successful quality improvement initiatives in the ICU. We review the evidence supporting the impact of safety culture and provide practical guidance for those wishing to implement initiatives aimed at improving safety culture and more effectively integrate patients and families in such efforts. Data Sources: Literature review using PubMed including evaluation of key studies assessing large-scale quality improvement efforts in the ICU, impact of safety culture on patient outcomes, methodologies for quality improvement commonly used in healthcare, and patient and family engagement. Print and web-based resources from leading patient safety organizations were also searched. Study Selection: Our group completed a review of original studies, review articles, book chapters, and recommendations from leading patient safety organizations. Data Extraction: Our group determined by consensus which resources would best inform this review. Data Synthesis: A strong safety culture is associated with reduced adverse events, lower mortality rates, and lower costs. Quality improvement efforts have been shown to be more effective and sustainable when paired with a strong safety culture. Different methodologies exist for quality improvement in the ICU; a thoughtful approach to implementation that engages frontline providers and administrative leadership is essential for success. Efforts to substantively include patients and families in the processes of quality improvement work in the ICU should be expanded. Conclusions: Efforts to establish a culture of safety and meaningfully engage patients and families should form the foundation for all safety interventions in the ICU. This review describes an approach that integrates components of several proven quality improvement methodologies to enhance safety culture in the ICU and highlights opportunities to include patients and families.