Content of Documented Goals of Care Discussions Based on Communication Best Practices for Patients with Stage IV Cancer (RP306)

2020 ◽  
Vol 60 (1) ◽  
pp. 203
Author(s):  
Laura Hanson ◽  
Natalie Ernecoff ◽  
Kathryn Wessell ◽  
William Wood ◽  
Frances Collichio ◽  
...  
Keyword(s):  
Best Practices ◽  
Stage Iv ◽  
Goals Of Care ◽  
Stage Iv Cancer

scholarly journals How Well Do Documented Goals-of-Care Discussions for Patients with Stage IV Cancer Reflect Communication Best Practices?

2021 ◽  
Author(s):  
Natalie C. Ernecoff ◽  
Kathryn L. Wessell ◽  
William A. Wood ◽  
Gary S. Winzelberg ◽  
Frances A. Collichio ◽  
...  
Keyword(s):  
Best Practices ◽  
Cancer Progression ◽  
Treatment Options ◽  
Stage Iv ◽  
Treatment Recommendation ◽  
Treatment Preferences ◽  
Goals Of Care ◽  
Patient Goals ◽  
Stage Iv Cancer

Abstract Background: Written clinical communication regarding patients’ disease understanding and values may facilitate goal-concordant care, yet little is known about electronic health record (EHR) goals-of-care documentation. We sought to (1) describe frequency of communication best practices in EHR-documented goals-of-care discussions, and (2) assess whether templated notes improve quality of documentation.Methods: We abstracted all EHR-documented goals-of-care discussions for hospitalized patients with Stage IV cancer from admission to 60-days follow-up. Goals-of-care documentation was operationalized to include discussion of: (a) prognosis and/or illness understanding; and (b) goals and/or treatment options. Investigators qualitatively coded text based on conceptual frameworks for communication best practices, including decision making documentation, and noted if a health system template was used. Results: Among 206 of 492 (42%) patients with documented goals-of-care discussions, clinicians frequently communicated cancer progression or incurability (89%), but rarely addressed prognosis for life expectancy (22%). Goals and values were documented for 83%, and a treatment decision for 82% of patients. Treatment preferences were assessed for 98% of patients; options discussed included cancer treatment (62%), hospice (62%), resuscitation (51%), or intensive care (38%). Clinicians made a treatment recommendation for 40% of patients. Attention to emotional and spiritual concerns was uncommon (15%). Use of a template increased documentation of patient goals and values (80% vs. 61%, p<0.01), but did not enhance other communication best practices.Conclusion: Insights from the study can be used to guide future training and research to study and improve the quality of written communication about goal of care, and its impact on goal-concordant care.

scholarly journals How well do documented goals-of-care discussions for patients with stage IV cancer reflect communication best practices?

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Natalie C. Ernecoff ◽  
Kathryn L. Wessell ◽  
William A. Wood ◽  
Gary S. Winzelberg ◽  
Frances A. Collichio ◽  
...  
Keyword(s):  
Best Practices ◽  
Cancer Progression ◽  
Treatment Options ◽  
Specific Treatment ◽  
Stage Iv ◽  
Treatment Decision ◽  
Free Text ◽  
Goals Of Care ◽  
Stage Iv Cancer

Abstract Background Written clinical communication regarding patients’ disease understanding and values may facilitate goal-concordant care, yet little is known about the quality of electronic health record (EHR) documentation. We sought to (1) describe frequency of communication best practices in EHR-documented goals-of-care discussions, and (2) assess whether templated notes improve quality of documentation. Methods Researchers pulled text of EHR-documented goals-of-care discussions for hospitalized patients with Stage IV cancer from admission to 60-days follow-up. Text was included when in a single encounter the clinician addressed: (a) prognosis and/or illness understanding; and (b) goals and/or treatment options. Researchers qualitatively coded text based on guidelines for communication best practices, and noted if an EHR template was used. Results Forty-two percent (206/492) of patients had EHR-documented goals-of-care discussions. Text frequently described communication of cancer progression (89%), though rarely included prognosis (22%). Text often included patients’ goals and values (83%), and at least on specific treatment decision (82%). Communication about treatments was included for 98% of patients; common examples included cancer treatment (62%), hospice (62%), resuscitation (51%), or intensive care (38%). Clinicians documented making recommendations for 40% of patients. Text addressing patient emotional and spiritual concerns was uncommon (15%). Compared to free text, use of a template was associated with increased documentation of goals and values (80% vs. 61%, p < 0.01), but not other best practices. Conclusion Insights from the study can be used to guide future training and research to study and improve the quality of documentation about goal of care, and its impact on goal-concordant care.

scholarly journals How Well Do Documented Goals-of-care Discussions for Patients With Stage IV Cancer Reflect Communication Best Practices?

2020 ◽  
Author(s):  
Natalie C. Ernecoff ◽  
Kathryn L. Wessell ◽  
William A. Wood ◽  
Gary S. Winzelberg ◽  
Frances A. Collichio ◽  
...  
Keyword(s):  
Best Practices ◽  
Cancer Progression ◽  
Treatment Options ◽  
Stage Iv ◽  
Treatment Recommendation ◽  
Treatment Preferences ◽  
Goals Of Care ◽  
Patient Goals ◽  
Stage Iv Cancer

Abstract Background: Written clinical communication regarding patients’ disease understanding and values may facilitate goal-concordant care, yet little is known about electronic health record (EHR) goals-of-care documentation. We sought to (1) describe frequency of communication best practices in EHR-documented goals-of-care discussions, and (2) assess whether templated notes improve quality of documentation.Methods: We abstracted all EHR-documented goals-of-care discussions for hospitalized patients with Stage IV cancer from admission to 60-days follow-up. Goals-of-care documentation was operationalized to include discussion of: (1) prognosis or illness understanding; and (2) goals or treatment options. Investigators qualitatively coded text based on conceptual frameworks for communication best practices, and noted if a health system template was used. Results: Among 206 of 492 (42%) patients with documented goals-of-care discussions, clinicians frequently communicated cancer progression or incurability (89%), but rarely addressed prognosis for life expectancy (22%). Goals and values were documented for 83%, and a treatment decision for 82% of patients. Treatment preferences were assessed for 98% of patients; options discussed included cancer treatment (62%), hospice (62%), resuscitation (51%), or intensive care (38%). Clinicians made a treatment recommendation for 40% of patients. Attention to emotional and spiritual concerns was uncommon (15%). Use of a template increased documentation of patient goals and values (80% vs. 61%, p<0.01), but did not enhance other communication best practices.Conclusion: Insights from the study can be used to guide future training and research to study and improve the quality of written communication about goal of care, and its impact on goal-concordant care.

Aggressive care at the end of life: A study of practice based factors in patients with stage IV cancer.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 80-80
Author(s):  
Mohammad Omar Atiq ◽  
Rahul Ravilla ◽  
Ajay Kumar ◽  
Sajjad Haider ◽  
Ji-Ling Tang ◽  
...  
Keyword(s):  
Palliative Care ◽  
Length Of Stay ◽  
End Of Life ◽  
Cancer Patients ◽  
Stage Iv ◽  
Goals Of Care ◽  
Significant Difference ◽  
Aggressive Care ◽  
Stage Iv Cancer ◽  
End Stage

80 Background: Numerous studies established that early utilization of palliative care-hospice services are beneficial to cancer patients. To reduce the incidence of aggressive care in terminal cancer patients, we conducted a quality improvement study to identify pertinent risk factors and develop interventions. Methods: Through chart review, we retrospectively identified patients with stage IV cancer that were followed by oncology clinic and were admitted to the University Hospital between 8/1/2015-10/31/15. For those patients who died during the last hospitalization or were discharged to hospice care, we obtained demographic, cancer related and practice related variables listed in Table. We used Mann Whitney U test and multivariable regression to find effects of factors related to length of stay (LOS) and cost of stay (COS). Results: Length of stay was significantly prolonged in those receiving chemotherapy within the past month (6 vs 3 p=0.035). Multivariate analyses found that patients with goals of care documented in the clinic had lower COS by 36.7% and LOS by 46.7%. On average, an ICU stay resulted in COS 2.2 times higher. No significant difference was seen in LOS based on a documented palliative care clinic visit or presence of an advanced directive. Conclusions: We identified practice based factors that need improvement including earlier goals of care conversations and less chemotherapy at the end of life. Identifying end stage patients in earlier admissions, collaborating with palliative care, and adding goals of care documentation to clinic note templates, are all interventions we are studying to improve care for end stage cancer patients. [Table: see text]

Exploratory Study of Advance Care Discussions Among Chinese American and White Stage IV Cancer Patients at an American Tertiary Medical Center

2021 ◽  
pp. 104990912110126
Author(s):  
Avery Caz Glover ◽  
Courtney Schroeder ◽  
Emma Ernst ◽  
Tamara Vesel
Keyword(s):  
Cancer Patients ◽  
Exploratory Study ◽  
Stage Iv ◽  
Chinese American ◽  
Chinese Americans ◽  
Do Not Resuscitate ◽  
Essential Components ◽  
Advance Care ◽  
Stage Iv Cancer ◽  
White Patients

Purpose: Timely advance care discussions are essential components of quality care for diverse populations; however, little is known about these conversations among Chinese American cancer patients. This exploratory study describes differences in advance care discussions and planning between Chinese American and White advanced cancer patients. Methods: We collected data for 63 Chinese American and 63 White stage IV cancer patients who died between 2013 and 2018. We compared: frequency and timing of prognosis, goals of care (GOC), and end-of-life care (EOLC) discussions in the final year of life; family inclusion in discussions; healthcare proxy (HCP) identification; do not resuscitate (DNR) order, do not intubate (DNI) order, and other advance directive (AD) completion. We did not conduct statistical tests due to the study’s exploratory nature. Results: Among Chinese American and White patients, respectively, 76% and 71% had prognosis, 51% and 56% had GOC, and 89% and 84% had EOLC discussions. Prognosis, GOC, and EOLC discussions were held a median of 34.0, 15.5, and 34.0 days before death among Chinese American and 17.0, 13.0, and 24.0 days before death among White patients. Documentation rates among Chinese American and White patients were 79% and 76% for DNRs, 81% and 71% for DNIs, 79% and 81% for HCPs, and 52% and 40% for other ADs. Conclusions: Findings suggest that Chinese Americans had similar rates of advance care discussions, completed conversations earlier, and had similar to higher rates of AD documentation compared to White patients. Further studies are needed to confirm our preliminary findings.

scholarly journals Incidence of Severe Pain in Newly Diagnosed Ambulatory Patients with Stage IV Cancer

2012 ◽  
Vol 17 (5) ◽  
pp. 347-352 ◽  
Author(s):  
Thomas Isaac ◽  
Sherri O Stuver ◽  
Roger B Davis ◽  
Susan Block ◽  
Jane C Weeks ◽  
...  
Keyword(s):  
Head And Neck ◽  
Severe Pain ◽  
Stage Iv ◽  
Initial Visit ◽  
Newly Diagnosed ◽  
Ambulatory Oncology ◽  
Ambulatory Patients ◽  
Stage Iv Cancer ◽  
One Year ◽  
Thoracic Malignancies

BACKGROUND: Pain is common among cancer patients.OBJECTIVE: To characterize the incidence of severe pain among newly diagnosed patients with stage IV cancer in ambulatory care.METHODS: A retrospective cohort of 505 ambulatory oncology patients with newly diagnosed stage IV solid tumours at a comprehensive cancer centre (Dana-Farber Cancer Institute, Boston, Massachusetts, USA) was followed from January 1, 2004, to December 31, 2006. Pain intensity scores were extracted from electronic medical records. The incidence of severe pain was calculated using the maximum monthly pain scores reported at outpatient visits.RESULTS: Of the 505 patients included in the present study, 340 (67.3%) were pain-free at the initial visit, 90 (17.8%) experienced mild pain, 48 (9.5%) experienced moderate pain and 27 (5.4%) experienced severe pain. At least one episode of severe pain within one year of diagnosis was reported by 29.1% of patients. Patients with head and neck, gastrointestinal and thoracic malignancies were more likely to experience severe pain compared with patients with other types of cancer (52.6%, 33.9% and 30.5%, respectively). In the multivariable model, patients whose primary language was not English (OR 2.90 [95% CI 1.08 to 7.80]), patients who reported severe pain at the initial visit (OR 9.30 [95% CI 3.72 to 23.23]) and patients with head and neck (OR 10.17 [95% CI 2.87 to 36.00]) or gastrointestinal (OR 4.05 [95% CI 1.23 to 13.35]) cancers were more likely to report severe pain in the following year.CONCLUSIONS: The incidence of severe pain was high in ambulatory patients with newly diagnosed stage IV cancer.

Stage at cancer diagnosis during the COVID-19 pandemic in western Washington state.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 145-145
Author(s):  
Catherine R. Fedorenko ◽  
Karma L. Kreizenbeck ◽  
Li Li ◽  
Laura Elizabeth Panattoni ◽  
Veena Shankaran ◽  
...  
Keyword(s):  
Medical Care ◽  
Early Stage ◽  
Stage Iv ◽  
Washington State ◽  
Stage I ◽  
Tumor Type ◽  
Stage At Diagnosis ◽  
Stage Iv Cancer ◽  
Using Data ◽  
The Impact

145 Background: The COVID-19 pandemic disrupted medical care, including routine cancer screening for breast, colorectal, lung and cervical cancers. We aimed to investigate the impact of the pandemic on stage at diagnosis for cancer patients. Methods: Using data from the Washington State SEER records we compared AJCC stage for patients diagnosed with cancer in 2017-2019 to 2020 for two time periods, March to June (initial pandemic months) and July to December (later pandemic months). Patients were included if they were age 18+, diagnosed with a solid tumor, and not diagnosed at autopsy. Results: In the early phase of the pandemic, March – June 2020, there was a shift to cancers being diagnosed at a later stage compared to the same time period in 2017-2019 (Stage III: 13.5% to 14.9%, Stage IV: 16.2% to 19.7%). There was also a decrease in cancer diagnoses for cancers that are often detected through routine screening. As a percentage of all cancer diagnoses, both melanoma (13.2% to 9.8%) and colon cancer diagnoses (7.2% to. 6.7%) decreased during the early pandemic. In the later phase of the pandemic, July to December 2020, the stage at diagnosis showed an indication of returning to pre-pandemic levels with an increase in the proportion of early stage cancers (In situ: 16.6% to 19.3%, Stage I: 38.8% to 41.1%). Stage at diagnosis trends varied by tumor type. For colorectal cancer, the overall number of diagnoses decreased during the initial pandemic months. Stage I diagnoses decreased and Stage IV cancer diagnoses increased in both early and late stages of the pandemic. Conclusions: In Washington State, the COVID-19 pandemic had an impact on stage at diagnosis potentially caused by delays or interruptions in medical care. Additional studies are needed to understand how this shift in stage at diagnosis impacted treatment and outcomes for patients.

scholarly journals Perubahan Status Koagulasi Pasien Kanker Padat Pasca Kemoterapi di Indonesia: Sebuah Studi Prospektif

2020 ◽  
Vol 7 (1) ◽  
pp. 2
Author(s):  
Noorwati Sutandyo ◽  
Lyana Setiawan
Keyword(s):  
Cancer Patients ◽  
Prospective Cohort ◽  
Stage Iv ◽  
Stage Iii ◽  
Solid Cancer ◽  
Significant Difference ◽  
Before And After ◽  
Coagulation Status ◽  
Stage Iv Cancer ◽  
D Dimer

Pendahuluan. Hiperkoagulasi merupakan faktor yang mendasari tingginya mortalitas akibat kejadian tromboemboli vena pada pasien kanker. Kemoterapi merupakan salah satu faktor yang diduga berkontribusi terhadap status hiperkoagulasi pada pasien kanker. Studi ini bertujuan untuk mengevaluasi perubahan status koagulasi yang ditandai dengan kadar D-dimer pada pasien kanker yang menjalani kemoterapi.Metode. Studi ini merupakan studi kohort prospektif di Pusat Kanker Nasional Indonesia yang melibatkan pasien kanker yang sudah terkonfirmasi melalui pemeriksaan histopatologi, dan memulai kemoterapi pada periode Mei hingga Juli 2018. Perubahan status koagulasi dinilai melalui kadar D-dimer plasma. Kadar D-dimer diukur sebelum dan 7 hari setelah kemoterapi. Analisis statistik menggunakan uji t berpasangan untuk menilai kemaknaan perubahan kadar D-dimer plasma sebelum dan setelah kemoterapi.Hasil. Sejumlah 89 pasien memenuhi kriteria inklusi, yang mana 74,2% adalah perempuan dan hampir separuh dari keseluruhan subjek terdiagnosis kanker payudara (44,9%). Mayoritas subjek (69,6%) terdiagnosis pada stadium III atau IV. Sejumlah 12,4% dari subjek mendapatkan kemoterapi berbasis cisplatin. Terdapat perbedaan yang bermakna antara kadar D-dimer sebelum dan setelah kemoterapi (p = 0,05). Studi ini juga menemukan perbedaan bermakna kadar D-dimer sebelum dan sesudah kemoterapi pada pasien kanker stadium III (t(35) = 2,48, p = 0,02) dan stadium IV (t(25) = 2,14, p = 0,04). Tidak terdapat perbedaan bermakna antara kadar D-dimer sebelum dan setelah kemoterapi pada pasien stadium I dan II. Analisis lanjutan berdasarkan kelompok kemoterapi menunjukkan bahwa terdapat perubahan kadar D-dimer yang bermakna pada kelompok yang mendapatkan kemoterapi cisplatin (t(10) = 2,31, p = 0,04), namun tidak pada kelompok yang mendapat kemoterapi non-cisplatin (t(77) = 1,50, p = 0,14).Simpulan. Terdapat perbedaan bermakna status koagulasi yang ditandai dengan kadar D-dimer 7 hari pasca mendapatkan kemoterapi, khususnya pada pasien kanker stadium III atau IV dan mendapatkan kemoterapi berbasis cisplatin. Kata Kunci: Cisplatin, kanker, kemoterapi, status koagulasiChange of Coagulation Status in Solid Cancer Patients Undergoing Chemotherapy in Indonesia: A Prospective Cohort StudyIntroduction. Cancer-associated hypercoagulability was an underlying factor of high mortality of cancer due to venous thromboembolism. Chemotherapy is proposed as one of the contributing factors of the hypercoagulable state. We aim to evaluate the change of coagulation status, which was marked by D-dimer level, in cancer patients receiving chemotherapy.Methods. This is a prospective cohort study in Indonesian national cancer center which involves all adult histologically-confirmed-cancer patients who started chemotherapy between May and July 2018. The coagulation status is assessed by plasma of D-dimer level. We measured D-dimer before chemotherapy and one week after chemotherapy. Paired t-test was performed to assess the significant difference in D-dimer levels before and after chemotherapy.Results. A total of 89 patients fulfilled the eligibility criteria, of whom 74.2% were female and almost half of total subjects (44.9%) were breast cancer patients. Majority of subjects (69.6%) were stage III or stage IV cancer. There were 12.4% of subjects received cisplatin-based chemotherapy. There was a marginally significant difference in plasma level of D-dimers before and after chemotherapy (p = 0.05). We also found significant differences between D-dimer level before and after chemotherapy in stage III patients (t(35) = 2.48, p = 0.02) and stage IV patients (t(25) = 2.14, p = 0.04). There was no significant difference between D-dimer level before and after chemotherapy in stage I and stage II patients. Subgroup analyses based on chemotherapy agents showed that there was significant D-dimer change in cisplatin-based chemotherapy subjects (t(10) = 2.31, p = 0.04), but not in non-cisplatin-based chemotherapy subjects (t(77) = 1,50, p = 0.14).Conclusion. Compared to before chemotherapy, there is a significant difference of coagulation status marked by plasma D-dimer level one week after chemotherapy, particularly in patients with stage III or stage IV cancer and in patients receiving cisplatin-based chemotherapy.

scholarly journals Comprehensive molecular and phenotypic profiling of end-stage IV cancer identifies treatable targets and improves survival in individual patients

2017 ◽  
Vol 28 ◽  
pp. vii22
Author(s):  
A. Samsen ◽  
S. Schneider ◽  
S. Von Der Heyde ◽  
W. Saeger ◽  
B. Grebenstein ◽  
...  
Keyword(s):  
Stage Iv ◽  
Stage Iv Cancer ◽  
End Stage

Management of Malignant Melanoma: Best Practices

2009 ◽  
Vol 13 (2) ◽  
pp. 55-73 ◽  
Author(s):  
Michael Smylie ◽  
Joël Claveau ◽  
Kenneth Alanen ◽  
Raymond Taillefer ◽  
Ralph George ◽  
...  
Keyword(s):  
Malignant Melanoma ◽  
Best Practices ◽  
Gamma Probe ◽  
Treatment Options ◽  
Stage Iv ◽  
Primary Diagnosis ◽  
Interferon Α ◽  
Node Biopsy ◽  
Stage Iv Disease ◽  
Intraoperative Gamma Probe

Background: Melanoma is a commonly occurring cancer in Canada, with an estimated age-standardized incidence of 10 to 13 per 100,000. An estimated 4,300 new cases were diagnosed, and there were 880 reported deaths in 2005. Objective and Conclusion: The Canadian Expert Panel on Malignant Melanoma has developed best practices to improve the management of malignant melanoma. Sections include recommendations on primary diagnosis, dermatopathologic assessment, and reporting; use of preoperative lymphoscintigraphy and an intraoperative gamma probe to map and biopsy the sentinel lymph node; indications for surgical resection, sentinel node biopsy, and surgery for advanced disease; use of interferon-α adjuvant therapy and treatment options for stage IV disease; and management of central nervous system metastases.

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