Factors that influence oncologists' decisions about administering late chemotherapy.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 31-31
Author(s):  
Minnie Bluhm ◽  
Cathleen M. Connell ◽  
Kathleen Elizabeth Bickel ◽  
Maria Silveira
Keyword(s):  
Treatment Decisions ◽  
Structured Interview ◽  
Clinical Factors ◽  
Emotional Symptoms ◽  
Incurable Cancer ◽  
Individual Interviews ◽  
Dying Patients ◽  
Clinical Benefits ◽  
Nuanced Understanding ◽  
The Impact

31 Background: An estimated 20-50% of incurable cancer patients receive chemotherapy in the last 30 days of life, although there is little data to support this practice. Continued use of chemotherapy typically precludes hospice enrollment. It may also result in more symptoms, increased use of aggressive treatments, and worsening quality of life. Despite this, few studies have explored oncologists' rationales for administering chemotherapy during the last weeks of life. The purpose of this study is to examine factors that oncologists report influence their decisions about late chemotherapy. Methods: In-depth individual interviews were conducted with 17 oncologists using a semi-structured interview guide. Interviews were audio-recorded and transcribed verbatim. Transcripts were coded and content analyzed for themes and patterns in the data. Results: Participants reported three key findings. 1) Clinical factors drive oncologists’ late chemotherapy decisions when they point to clear treatment choices, along with patient preferences. When clinical factors are ambiguous, non-clinical factors become more salient. 2) Late chemotherapy is patient-driven. It is used to palliate physical and emotional symptoms and maintain patient hope, even when physical benefit is not expected. 3) Caring for dying patients is difficult and impacts oncologists and their treatment decisions. Difficulties that are cited as influences favoring treatment include: emotional exhaustion, difficulty communicating about stopping or not starting chemotherapy, an overwhelming sense of responsibility for life and death, feeling badly about the limits of oncology to heal, and prognostic uncertainty. Conclusions: Findings reveal a nuanced understanding of why it can be so difficult for oncologists to refuse chemotherapy treatment to patients near death. Doing so adds to the existing burden of caring for dying patients. This means that at times, oncologists prescribe chemotherapy to simply help everyone feel better, regardless of expected clinical benefits or costs. Future work is needed on the impact of caring for dying patients on oncologists and on supportive interventions that assist them in making optimal treatment decisions.

Paradox of Prescribing Late Chemotherapy: Oncologists Explain

2016 ◽  
Vol 12 (12) ◽  
pp. e1006-e1015 ◽  
Author(s):  
Minnie Bluhm ◽  
Cathleen M. Connell ◽  
Raymond G. De Vries ◽  
Nancy K. Janz ◽  
Kathleen E. Bickel ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Semistructured Interview ◽  
Clinical Factors ◽  
Individual Interviews ◽  
Patients With Cancer ◽  
Dying Patients ◽  
Interview Guide ◽  
Supportive Interventions ◽  
Nuanced Understanding

Purpose: The value of chemotherapy for patients with cancer in the last weeks of life warrants examination. Late chemotherapy may not improve survival or quality of life but typically precludes hospice enrollment and may result in additional symptoms, increased use of other aggressive treatments, and worsening quality of life. Few studies have explored oncologists’ rationales for administering chemotherapy near death. This study examines the self-reported factors that influence oncologists’ decisions about late chemotherapy. Methods: In-depth individual interviews were conducted with 17 oncologists through a semistructured interview guide. Interviews were audio recorded and transcribed verbatim. Transcripts were coded and analyzed using conventional content analysis, a qualitative method that allows the detection and analysis of patterns in the data. Results: Clinical factors take priority in determining late chemotherapy decisions when clear treatment choices exist. When clinical factors are ambiguous, emotion becomes a highly salient influence. Oncologists view late chemotherapy to be patient driven and use it to palliate emotional distress and maintain patient hope even when physical benefit is unexpected. Oncologists experience unique and difficult challenges when caring for dying patients, including emotionally draining communication, overwhelming responsibility for life/death, limitations of oncology to heal, and prognostic uncertainty. These challenges are also eased by offering late chemotherapy. Conclusion: The findings reveal a nuanced understanding of why oncologists find it difficult to refuse chemotherapy treatment for patients near death. Optimal end-of-life treatment decisions require supportive interventions and system change, both of which must take into account the challenges oncologists face.

scholarly journals Emotional side-effects of selective serotonin reuptake inhibitors: qualitative study

2009 ◽  
Vol 195 (3) ◽  
pp. 211-217 ◽  
Author(s):  
Jonathan Price ◽  
Victoria Cole ◽  
Guy M. Goodwin
Keyword(s):  
Decision Making ◽  
Side Effects ◽  
Qualitative Study ◽  
Serotonin Reuptake ◽  
Selective Serotonin Reuptake Inhibitors ◽  
Selective Serotonin ◽  
Emotional Symptoms ◽  
Individual Interviews ◽  
The Impact ◽  
Gathering Data

BackgroundSome people who take selective serotonin reuptake inhibitor (SSRI) antidepressants report that their experience of emotions is ‘blunted’. This phenomenon is poorly understood.AimsTo understand patients' experiences of this phenomenon.MethodQualitative study, gathering data through individual interviews, a group interview and validation interviews; and searching patient websites for relevant posts.ResultsThere was strong evidence that some people taking SSRIs experience significant emotional symptoms that they strongly attribute to their antidepressant. These emotional symptoms can be described within six key themes. A seventh theme represents the impact of these side-effects on everyday life, and an eighth represents participants' reasons for attributing these symptoms to their antidepressant. Most participants felt able to distinguish between emotional side-effects of antidepressants and emotional symptoms of their depression or other illness.ConclusionsEmotional side-effects of SSRIs are a robust phenomenon, prominent in some people's thoughts about their medication, having a demonstrable impact on their functioning and playing a role in their decision-making about antidepressant adherence.

Oncologists’ End of Life Treatment Decisions

2016 ◽  
Vol 36 (4) ◽  
pp. 416-440 ◽  
Author(s):  
Minnie Bluhm ◽  
Cathleen M. Connell ◽  
Nancy Janz ◽  
Kathleen Bickel ◽  
Raymond DeVries ◽  
...  
Keyword(s):  
End Of Life ◽  
Older Patients ◽  
Treatment Decisions ◽  
Incurable Cancer ◽  
Patient Age ◽  
Patient Âgé ◽  
Key Factor ◽  
Nuanced Understanding ◽  
End Stage ◽  
Depth Interviews

Background: Optimal treatment decisions for older end-stage cancer patients are complicated, and are influenced by oncologists’ attitudes and beliefs about older patients. Nevertheless, few studies have explored oncologists’ perspectives on how patient age affects their treatment decisions. Methods: In-depth interviews were conducted with 17 oncologists to examine factors that influence their chemotherapy decisions for adults with incurable cancer near death. Transcripts of recorded interviews were coded and content analyzed. Results: Oncologists identified patient age as a key factor in their chemotherapy decisions. They believed older adults were less likely to want or tolerate treatment, and felt highly motivated to treat younger patients. Discussion: Qualitative analysis of in-depth interviews resulted in a nuanced understanding of how patient age influences oncologists’ chemotherapy decisions. Such understanding may inform practice efforts aimed at enhancing cancer care at the end of life for older patients.

Voices of Distress: The Emotional Peril of Not Attaining a Dietetic Internship in Ontario

2013 ◽  
Vol 1 (3) ◽  
pp. 9
Author(s):  
Jennifer Lee Brady ◽  
Annie Hoang ◽  
Olivia Siswanto ◽  
Jordana Riesel ◽  
Jacqui Gingras
Keyword(s):  
Empirical Research ◽  
Current Model ◽  
Well Being ◽  
Structured Interview ◽  
Application Process ◽  
Dietetic Education ◽  
Dietetic Internship ◽  
The Impact ◽  
And Training ◽  
Future Growth

Obtaining dietetic licensure in Ontario requires completion of a Dietitians of Canada (DC) accredited four-year undergraduate degree in nutrition and an accredited post-graduate internship or combined Master’s degree program. Given the scarcity of internship positions in Ontario, each year approximately two-thirds of the eligible applicants who apply do not receive a position XX, XX, XX, XX, XX, XX, in press). Anecdotally, not securing an internship position is known to be a particularly disconcerting experience that has significant consequences for individuals’ personal, financial, and professional well-being. However, no known empirical research has yet explored students’ experiences of being unsuccessful in applying for internship positions. Fifteen individuals who applied between 2005 and 2009 to an Ontario-based dietetic internship program, but were unsuccessful at least once, participated in a one-on-one semi-structured interview. Findings reveal that participants’ experiences unfold successively in four phases that are characterized by increasingly heightened emotional peril: naïveté, competition, devastation, and frustration. The authors conclude that the current model of dietetic education and training in Ontario causes lasting distress to students and hinders the future growth and vitality of the dietetic profession. Further research is required to understand the impact of the current model on dietetic educators, internship coordinators, and preceptors as coincident participants in the internship application process.

HOME VISITS DURING THE FIRST MONTH OF DELIVERY FOR RECENTLY DELIVERED WOMEN IN UTTAR PRADESH, INDIA

2020 ◽  
Vol 6 (5) ◽  
pp. 1183-1189
Author(s):  
Dr. Tridibesh Tripathy ◽  
Dr. Umakant Prusty ◽  
Dr. Chintamani Nayak ◽  
Dr. Rakesh Dwivedi ◽  
Dr. Mohini Gautam
Keyword(s):  
Large Scale ◽  
National Level ◽  
Uttar Pradesh ◽  
Life Time ◽  
Structured Interview ◽  
The Other ◽  
Registration System ◽  
Action Group ◽  
Current Article ◽  
The Impact

The current article of Uttar Pradesh (UP) is about the ASHAs who are the daughters-in-law of a family that resides in the same community that they serve as the grassroots health worker since 2005 when the NRHM was introduced in the Empowered Action Group (EAG) states. UP is one such Empowered Action Group (EAG) state. The current study explores the actual responses of Recently Delivered Women (RDW) on their visits during the first month of their recent delivery. From the catchment area of each of the 250 ASHAs, two RDWs were selected who had a child in the age group of 3 to 6 months during the survey. The response profiles of the RDWs on the post- delivery first month visits are dwelled upon to evolve a picture representing the entire state of UP. The relevance of the study assumes significance as detailed data on the modalities of postnatal visits are available but not exclusively for the first month period of their recent delivery. The details of the post-delivery first month period related visits are not available even in large scale surveys like National Family Health Survey 4 done in 2015-16. The current study gives an insight in to these visits with a five-point approach i.e. type of personnel doing the visit, frequency of the visits, visits done in a particular week from among those four weeks separately for the three visits separately. The current study is basically regarding the summary of this Penta approach for the post- delivery one-month period.     The first month period after each delivery deals with 70% of the time of the postnatal period & the entire neonatal period. Therefore, it does impact the Maternal Mortality Rate & Ratio (MMR) & the Neonatal Mortality Rates (NMR) in India and especially in UP through the unsafe Maternal & Neonatal practices in the first month period after delivery. The current MM Rate of UP is 20.1 & MM Ratio is 216 whereas the MM ratio is 122 in India (SRS, 2019). The Sample Registration System (SRS) report also mentions that the Life Time Risk (LTR) of a woman in pregnancy is 0.7% which is the highest in the nation (SRS, 2019). This means it is very risky to give birth in UP in comparison to other regions in the country (SRS, 2019). This risk is at the peak in the first month period after each delivery. Similarly, the current NMR in India is 23 per 1000 livebirths (UNIGME,2018). As NMR data is not available separately for states, the national level data also hold good for the states and that’s how for the state of UP as well. These mortalities are the impact indicators and such indicators can be reduced through long drawn processes that includes effective and timely visits to RDWs especially in the first month period after delivery. This would help in making their post-natal & neonatal stage safe. This is the area of post-delivery first month visit profile detailing that the current article helps in popping out in relation to the recent delivery of the respondents.   A total of four districts of Uttar Pradesh were selected purposively for the study and the data collection was conducted in the villages of the respective districts with the help of a pre-tested structured interview schedule with both close-ended and open-ended questions.  The current article deals with five close ended questions with options, two for the type of personnel & frequency while the other three are for each of the three visits in the first month after the recent delivery of respondents. In addition, in-depth interviews were also conducted amongst the RDWs and a total 500 respondents had participated in the study.   Among the districts related to this article, the results showed that ASHA was the type of personnel who did the majority of visits in all the four districts. On the other hand, 25-40% of RDWs in all the 4 districts replied that they did not receive any visit within the first month of their recent delivery. Regarding frequency, most of the RDWs in all the 4 districts received 1-2 times visits by ASHAs.   Regarding the first visit, it was found that the ASHAs of Barabanki and Gonda visited less percentage of RDWs in the first week after delivery. Similarly, the second visit revealed that about 1.2% RDWs in Banda district could not recall about the visit. Further on the second visit, the RDWs responded that most of them in 3 districts except Gonda district did receive the second postnatal visit in 7-15 days after their recent delivery. Less than half of RDWs in Barabanki district & just more than half of RDWs in Gonda district received the third visit in 15-21 days period after delivery. For the same period, the majority of RDWs in the rest two districts responded that they had been entertained through a home visit.

Patients’ Perceptions of Caring and Uncaring Nursing Encounters in Inpatient Rehabilitation Settings

2019 ◽  
Vol 21 (2) ◽  
Author(s):  
Joan C Cheruiyot ◽  
Petra Brysiewicz
Keyword(s):  
South Africa ◽  
Content Analysis ◽  
Inpatient Rehabilitation ◽  
Structured Interview ◽  
The Self ◽  
Personal Relationships ◽  
Individual Interviews ◽  
Textual Data ◽  
Interview Guide ◽  
Being There

This study explores and describes caring and uncaring nursing encounters from the perspective of the patients admitted to inpatient rehabilitation settings in South Africa. The researchers used an exploratory descriptive design. A semi-structured interview guide was used to collect data through individual interviews with 17 rehabilitation patients. Content analysis allowed for the analysis of textual data. Five categories of nursing encounters emerged from the analysis: noticing and acting, and being there for you emerged as categories of caring nursing encounters, and being ignored, being a burden, and deliberate punishment emerged as categories of uncaring nursing encounters. Caring nursing encounters make patients feel important and that they are not alone in the rehabilitation journey, while uncaring nursing encounters makes the patients feel unimportant and troublesome to the nurses. Caring nursing encounters give nurses an opportunity to notice and acknowledge the existence of vulnerability in the patients and encourage them to be present at that moment, leading to empowerment. Uncaring nursing encounters result in patients feeling devalued and depersonalised, leading to discouragement. It is recommended that nurses strive to develop personal relationships that promote successful nursing encounters. Further, nurses must strive to minimise the patients’ feelings of guilt and suffering, and to make use of tools, for example the self-perceived scale, to measure this. Nurses must also perform role plays on how to handle difficult patients such as confused, demanding and rude patients in the rehabilitation settings.

scholarly journals Patient-Centered Medical Home Knowledge and Attitudes of Residents and Faculty: Certification Is Just the First Step

2015 ◽  
Vol 7 (4) ◽  
pp. 580-588 ◽  
Author(s):  
Fadya El Rayess ◽  
Roberta Goldman ◽  
Christopher Furey ◽  
Rabin Chandran ◽  
Arnold R. Goldberg ◽  
...  
Keyword(s):  
Primary Care ◽  
Situated Learning ◽  
Medical Home ◽  
Patient Centered Medical Home ◽  
Patient Centered ◽  
Individual Interviews ◽  
Knowledge And Attitudes ◽  
Positive Attitudes ◽  
Level 3 ◽  
The Impact

ABSTRACT Background The patient-centered medical home (PCMH) is an accepted framework for delivering high-quality primary care, prompting many residencies to transform their practices into PCMHs. Few studies have assessed the impact of these changes on residents' and faculty members' PCMH attitudes, knowledge, and skills. The family medicine program at Brown University achieved Level 3 PCMH accreditation in 2010, with training relying primarily on situated learning through immersion in PCMH practice, supplemented by didactics and a few focused clinical activities. Objective To assess PCMH knowledge and attitudes after Level 3 PCMH accreditation and to identify additional educational needs. Methods We used a qualitative approach, with semistructured, individual interviews with 12 of the program's 13 postgraduate year 3 residents and 17 of 19 core faculty. Questions assessed PCMH knowledge, attitudes, and preparedness for practicing, teaching, and leading within a PCMH. Interviews were analyzed using the immersion/crystallization method. Results Residents and faculty generally had positive attitudes toward PCMH. However, many expressed concerns that they lacked specific PCMH knowledge, and felt inadequately prepared to implement PCMH principles into their future practice or teaching. Some exceptions were faculty and resident leaders who were actively involved in the PCMH transformation. Barriers included lack of time and central roles in PCMH activities. Conclusions Practicing in a certified PCMH training program, with passive PCMH roles and supplemental didactics, appears inadequate in preparing residents and faculty for practice or teaching in a PCMH. Purposeful curricular design and evaluation, with faculty development, may be needed to prepare the future leaders of primary care.

scholarly journals How Risky Is That Risk Sharing Agreement? Mean-Variance Tradeoffs and Unintended Consequences of Six Common Risk Sharing Agreements

2021 ◽  
Vol 6 (1) ◽  
pp. 238146832199040
Author(s):  
Gregory S. Zaric
Keyword(s):  
Risk Sharing ◽  
Financial Risk ◽  
Unintended Consequences ◽  
Drug Costs ◽  
New Drugs ◽  
Total Drug ◽  
Number Of Patients ◽  
Clinical Benefits ◽  
The Impact ◽  
Mean Variance

Background. Pharmaceutical risk sharing agreements (RSAs) are commonly used to manage uncertainties in costs and/or clinical benefits when new drugs are added to a formulary. However, existing mathematical models of RSAs ignore the impact of RSAs on clinical and financial risk. Methods. We develop a model in which the number of patients, total drug consumption per patient, and incremental health benefits per patient are uncertain at the time of the introduction of a new drug. We use the model to evaluate the impact of six common RSAs on total drug costs and total net monetary benefit (NMB). Results. We show that, relative to not having an RSA in place, each RSA reduces expected total drug costs and increases expected total NMB. Each RSA also improves two measures of risk by reducing the probability that total drug costs exceed any threshold and reducing the probability of obtaining negative NMB. However, the effects on variance in both NMB and total drug costs are mixed. In some cases, relative to not having an RSA in place, implementing an RSA can increase variability in total drug costs or total NMB. We also show that, for some RSAs, when their parameters are adjusted so that they have the same impact on expected total drug cost, they can be rank-ordered in terms of their impact on variance in drug costs. Conclusions. Although all RSAs reduce expected total drug costs and increase expected total NMB, some RSAs may actually have the undesirable effect of increasing risk. Payers and formulary managers should be aware of these mean-variance tradeoffs and the potentially unintended results of RSAs when designing and negotiating RSAs.

scholarly journals Are public health measures and individualised care compatible in the face of a pandemic? A national observational study of bereaved relatives’ experiences during the COVID-19 pandemic

2021 ◽  
pp. 026921632110198
Author(s):  
Catriona R Mayland ◽  
Rosemary Hughes ◽  
Steven Lane ◽  
Tamsin McGlinchey ◽  
Warren Donnellan ◽  
...  
Keyword(s):  
Public Health ◽  
Family Support ◽  
Online Survey ◽  
Free Text ◽  
Professional Networks ◽  
Dying Patients ◽  
The Face ◽  
Individualised Care ◽  
The Impact ◽  
Informative Communication

Background: COVID-19 public health restrictions have affected end-of-life care experiences for dying patients and their families. Aim: To explore bereaved relatives’ experiences of quality of care and family support provided during the last days of life; to identify the impact of factors associated with perceived support. Design: A national, observational, open online survey was developed and disseminated via social media, public fora and professional networks (June–September 2020). Validated instruments and purposively designed questions assessed experiences. Analysis used descriptive statistics, logistic regression and thematic analysis of free-text responses. Participants: Individuals (⩾18 years) who had experienced the death of a relative/friend (all care settings) within the United Kingdome during the COVID-19 pandemic. Results: Respondents ( n = 278, mean 53.4 years) tended to be female ( n = 216, 78%); over half were ‘son/daughter’ (174, 62.6%) to the deceased. Deceased individuals (mean 81.6 years) most frequently died in their ‘usual place of care’ ( n = 192, 69.3%). Analysis established five conceptual themes affecting individualised care: (1) public health restrictions compounding the distress of ‘not knowing’; (2) disparate views about support from doctors and nurses; (3) challenges in communication and level of preparedness for the death; (4) delivery of compassionate care; (5) emotional needs and potential impact on grief. Male respondents (OR 2.9, p = 0.03) and those able to visit (OR 2.2, p = 0.04) were independently associated with good perceptions of family support. Conclusion: Despite public health restrictions, individualised care can be enabled by proactive, informative communication; recognising dying in a timely manner and facilitating the ability to be present before death.

scholarly journals Exploring the impact of a community participatory intervention on women's capability: a qualitative study in Gulu Northern Uganda

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Loubna Belaid ◽  
Emmanuel Ochola ◽  
Pontius Bayo ◽  
George William Alii ◽  
Martin Ogwang ◽  
...  
Keyword(s):  
Qualitative Study ◽  
Social Status ◽  
Northern Uganda ◽  
Gender Inequalities ◽  
Women Of Childbearing Age ◽  
Childbearing Age ◽  
Healthy Behaviors ◽  
Individual Interviews ◽  
Self Confidence ◽  
The Impact

Abstract Background Community participatory interventions mobilizing women of childbearing age are an effective strategy to promote maternal and child health. In 2017, we implemented this strategy in Gulu Northern Uganda. This study explored the perceived impact of this approach on women's capability. Methods We conducted a qualitative study based on three data collection methods: 14 in-depth individual interviews with participating women of childbearing age, five focus group discussions with female facilitators, and document analysis. We used the Sen capability approach as a conceptual framework and undertook a thematic analysis. Results Women adopted safe and healthy behaviors for themselves and their children. They were also able to respond to some of their family's financial needs. They reported a reduction in domestic violence and in mistreatment towards their children. The facilitators perceived improved communication skills, networking, self-confidence, and an increase in their social status. Nevertheless, the women still faced unfreedoms that deprived them of living the life they wanted to lead. These unfreedoms are related to their lack of access to economic opportunities and socio-cultural norms underlying gender inequalities. Conclusion To expand women's freedoms, we need more collective political actions to tackle gender inequalities and need to question the values underlying women's social status.

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