Defining the elements of early palliative care (PC) that are associated with patient-reported outcomes (PROs) and the delivery of end-of-life (EOL) care.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 154-154 ◽  
Author(s):  
Michael Hoerger ◽  
Jennifer S. Temel ◽  
Vicki Jackson ◽  
Elyse Park ◽  
William F. Pirl ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Advanced Cancer ◽  
Depression Scale ◽  
Treatment Decisions ◽  
Study Cohort ◽  
Care Planning ◽  
Patient Reported ◽  
Oncology Care ◽  
Eol Care

154 Background: Early PC integrated with oncology care improves quality of life, mood and the delivery of EOL care among patients with advanced cancer, but little is known about which elements of PC practice are associated with such outcomes. The goals of this study were to describe the key elements of early PC across the illness trajectory and examine whether variation in visit content was associated with changes in PROs and the delivery of EOL care. Methods: The study cohort included patients with incurable lung or non-colorectal gastrointestinal cancer who were randomized to early PC integrated with oncology care (n = 171). Patients completed measures of quality of life (Functional Assessment of Cancer Therapy-General, FACT-G) and mood (Hospital Anxiety and Depression Scale, HADS; Patient Health Questionnaire–9, PHQ-9) at baseline and 24 weeks. PC clinicians completed electronic post-visit surveys documenting PC visit content. Data on EOL care were abstracted from electronic health records. We examined variation in visit content over time and used linear and logistic regression to identify whether the percentage of visits emphasizing a given content area was associated with PROs and EOL care. Results: We analyzed 2,921 PC visits, most of which focused on coping (64.2%) and symptom management (74.5%). By 24 weeks, patients who had a higher percentage of visits focused on coping experienced improved quality of life (p = .02) and depression (HADS: p = .002; PHQ-9: p = .005). Having a higher percentage of visits focused on treatment decisions was associated with a reduced odds of new chemotherapy (p = .02), hospitalization (p = .001), and ED admission (p = .04) in the 60 days prior to death. Focusing on advance care planning was associated with an increased odds of receiving hospice care (p = .01) and dying at home (p = .03). Conclusions: PC clinicians’ attention to coping is associated with improvements in PROs, and the focus on treatment decisions and advanced care planning is associated with higher quality EOL care. This study defines the key elements of early PC for patients with advanced cancer and furthers the development and dissemination of this integrated model of care. Clinical trial information: NCT01401907.

scholarly journals DISCORDANCE IN GOALS OF CARE BETWEEN PATIENTS WITH ADVANCED CANCER AND THEIR CAREGIVERS: DOES AGE PLAY A ROLE?

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S54-S54
Author(s):  
Amy R Lipson ◽  
Sara Douglas
Keyword(s):  
Quality Of Life ◽  
Advanced Cancer ◽  
Visual Analog Scale ◽  
Treatment Decisions ◽  
Analog Scale ◽  
Goals Of Care ◽  
The Impact

Abstract Cancer is considered a family disease as the caregivers (CG’s) role extends beyond providing care as they can also help facilitate treatment decisions. While much has been reported in the literature about patient (PT) goals of care (GoC), little is known about discordance between PT and CG GoC and the impact of PT age. The variables of interest were PT and CG identified GoC using a 100-point visual analog scale (VAS) with anchors of quality of life (0) and survival (100). Discordance was defined as a > 40 point difference on the VAS. The GoC data reported here were those obtained at enrollment and prior to subject’s death. A sample of 235 PTs and CGs of PTs diagnosed with advanced cancers were included in the study. Mean age for the PTs was 64.7 (SD=10.5, range =21-88) with 54% being > 65. At enrollment, 28.7% of the PT-CG pairs of those PTs 65 years (X2 (1)=1.06, p=.304). At death, 61.8% (X2 (1)=31.04 <.001, Φ=.49) with discord at enrollment had discord at death. For patients who were older, 66.7% who had discord at enrollment also had discord at death and for patients

scholarly journals Fatigue in patients on oral targeted or chemotherapy for cancer and associations with anxiety, depression, and quality of life

2019 ◽  
Vol 18 (2) ◽  
pp. 141-147
Author(s):  
Hanneke Poort ◽  
Jamie M. Jacobs ◽  
William F. Pirl ◽  
Jennifer S. Temel ◽  
Joseph A. Greer
Keyword(s):  
Quality Of Life ◽  
Depressive Symptoms ◽  
Oral Treatment ◽  
Depression Scale ◽  
Well Being ◽  
Anxiety Symptoms ◽  
Severe Fatigue ◽  
Patient Reported ◽  
The Impact

AbstractObjectivesOral treatment (targeted or chemotherapy) for cancer is being increasingly used. While fatigue is a known side effect of intravenous chemotherapy, the rate of fatigue and the impact of fatigue on other patient-reported outcomes are not well described.MethodAt Massachusetts General Hospital Cancer Center, 180 adult patients prescribed oral targeted or chemotherapy for various malignancies enrolled in a randomized controlled trial of adherence and symptom management. Patients completed baseline self-reported measures of fatigue (Brief Fatigue Inventory; BFI), anxiety and depressive symptoms (Hospital Anxiety and Depression Scale; HADS), and quality of life, including subscales for physical, social, emotional, and functional well-being ([QOL] Functional Assessment of Cancer Therapy — General; FACT-G). We examined clinically relevant fatigue using a validated cut-off score for moderate-severe fatigue (BFI global fatigue ≥4) and tested the associations with anxiety symptoms, depressive symptoms, and QOL with independent samples t-tests.ResultsAt baseline, 45 of 180 participants (25.0%) reported moderate-severe fatigue. Fatigued patients experienced more anxiety symptoms (mean diff. 3.73, P < 0.001), more depressive symptoms (mean diff. 4.14, P < 0.001), and worse QOL on the total FACT-G score (mean diff. −19.58, P < 0.001) and all subscales of the FACT-G compared to patients without moderate-severe fatigue.Significance of resultsOne in four patients on oral treatment for cancer experienced clinically relevant fatigue that is associated with greater anxiety and depressive symptoms and worse QOL.

A placebo-controlled trial of Sertraline's effects on symptoms, well-being and survival in advanced cancer: The ZEST Trial

2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 9002-9002 ◽  
Author(s):  
N. R. Wilcken ◽  
D. Goldstein ◽  
A. K. Nowak ◽  
P. J. Beale ◽  
M. Jefford ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Advanced Cancer ◽  
Cox Model ◽  
Controlled Trial ◽  
Depression Scale ◽  
Final Analysis ◽  
Well Being ◽  
Hazard Ratio ◽  
Sensitivity Analyses

9002 Background: Depression, anxiety, fatigue and impaired well-being are common, important and closely related in advanced cancer. We sought to determine the effects of sertraline (a well-tolerated, SSRI antidepressant) on these symptoms and survival in a broad cross-section of people with advanced cancer but without major depression. Methods: 189 participants (pts) were randomly allocated to sertraline 50 mg daily or placebo. Assessments were at baseline; months 1, 2, 4, 6, 9, 12; and, then 3-monthly. Outcome measures rated by pts included the: Centre for Epidemiologic Studies Depression scale (CES-D); Hospital Anxiety and Depression Scale (HADS-A, HADS-D); and the Functional Assessment of Cancer Therapy General and Fatigue scales (FACT-G and FACT-F). Clinicians completed Spitzer's Quality of Life Index (SQLI). Outcomes on all scales are expressed from 0 (worst) to 100 (best). The primary analyses of sertraline's effects on quality of life were based on scores at 4 and 8 weeks adjusted for baseline scores using generalised estimating equations. Efficacy analyses are by intention to treat; toxicity analyses by treatment received. P-values and 95% confidence intervals (CI) are 2-sided. Results: Recruitment was stopped after the first planned interim analysis of 150 pts showed a trend in overall survival favouring placebo (univariable logrank p=0.04; multivariable Cox model hazard ratio 1.61, CI 1.1 to 2.5, p=0.02). This trend was weaker at the final analysis including all 189 patients and longer follow-up (univariable logrank p=0.09); and, after accounting for baseline factors (multivariable Cox model hazard ratio 1.27, CI 0.87 to 1.8, p=0.2). Sertraline had no significant effects (scale: benefit over placebo, 95% CI) on depression (CES-D: 0.4, −2.6 to 3.4), anxiety (HADS-A: 2.0, −1.5 to 5.5), fatigue (FACT-F: 0.3, −4.3 to 4.9), overall quality of life (FACT-G: 1.7, −1.3 to 4.7) or clinicians’ ratings (SQLI: 2.0, −2.5 to 6.5). Subgroup and sensitivity analyses also excluded significant benefits. Sertraline was discontinued more often and earlier than placebo (logrank p = 0.03). The trial was closed for lack of benefit. Conclusions: Sertraline did not improve symptoms, well-being or survival and should be reserved for those with a proven indication. No significant financial relationships to disclose.

Automatic inpatient palliative care consultation (PCC): Too little, too late to impact quality of life for advanced cancer patients?

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. e20565-e20565
Author(s):  
Gabrielle Betty Rocque ◽  
Toby Christopher Campbell ◽  
Anne Elizabeth Barnett ◽  
Renae M Quale ◽  
Jens C. Eickhoff ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Health Services ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Primary Outcome ◽  
Intervention Group ◽  
Control Group ◽  
Patient Reported ◽  
Small Patient Population

e20565 Background: Patients with advanced cancer who are hospitalized have high symptom burden and a short life expectancy, which may warrant PCC. Methods: Using sequential cohorts, we prospectively assessed implementation of automatic PCC for hospitalized cancer patients. The primary outcome was hospice utilization. Secondary outcomes included evaluation of changes in quality of life (FACIT-PAL), symptoms (ESAS), satisfaction (FAMCARE), and anxiety and depression (HADS). Surveys were administered at baseline, 2 weeks and 3 months post-hospitalization. Chart abstraction was utilized to assess demographics, resource use, and survival information. Results: Patients were evaluated consecutively (65 in the control group, 70 in the intervention). At admission, 91% reported uncontrolled symptoms: 52% pain; 15% dyspnea. 60% of intervention patients received PCC during their first admission. 54 patients completed surveys (29 control group, 25 PCC group), 64 patients declined or were unable to complete surveys, 16 patients were excluded due to language barriers, physician preference, or not receiving surveys. Using an intent-to-treat analysis, there was no difference between patients in the control and the intervention group in FACIT-PAL (119 ± 29 vs 123 ± 30, p = 0.68 ), ESAS (28 ± 14 vs 26 ± 15, p = 0.74) HADS (13 ± 6.6 vs. 12.± 4.7, p = 0.58), or FAMCARE (58 ± 9.1 vs 59 ± 8.6, p = 0.61). In both groups, patients had modest worsening of symptoms and quality of life over the course of the study. Survival and Health Services data analysis, including hospice referral, is proceeding. Conclusions: Automatic PPC had little impact on patient-reported symptoms and quality of life. Limitations included: small patient population; high rate of incomplete surveys, likely due to illness burden; penetration of the PCC was limited to 60% by patient or provider preference and consultant availability. Our primary outcome analysis (hospice utilization) is forthcoming, as are data on survival and Health Services outcomes.

Outcomes Associated with End-of-Life Discussions (DRAFT)

2018 ◽  
Author(s):  
Masanori Mori
Keyword(s):  
Quality Of Life ◽  
End Of Life ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Advance Care Planning ◽  
Care Planning ◽  
Advanced Cancer Patients ◽  
Advance Care ◽  
Aggressive Care

Physicians and advanced cancer patients are often reluctant to talk about death. They frequently avoid end-of-life discussions (EOLds), although such conversations are essential to initiate advance care planning. In this prospective, a longitudinal multisite cohort study of advanced cancer patients and their informal caregivers, the authors suggested cascading benefits of EOLds between patients and their physicians. In total, 123 of 332 (37.0%) patients reported having EOLds with their physicians at baseline. EOLds were not associated with higher rates of emotional distress or psychiatric disorders. Instead, after propensity-score weighted adjustment, EOLds were associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care was associated with worse patient quality of life and worse bereavement adjustment. These findings may help destigmatize EOLds and assist physicians and patients in initiating such conversations and engaging in advance care planning.

My choices, my wishes: Advance care planning advocacy in the adult oncology population.

2012 ◽  
Vol 30 (34_suppl) ◽  
pp. 6-6
Author(s):  
Sabrina Q. Mikan ◽  
J. Russell Hoverman ◽  
Debra A. Patt ◽  
Brian Turnwald
Keyword(s):  
Stage Iv ◽  
Office Visit ◽  
Care Planning ◽  
Intervention Process ◽  
Before And After ◽  
Oncology Care ◽  
Advance Care ◽  
Stage Iv Cancer ◽  
Eol Care

6 Background: Working through end-of-life care (EOL) issues with our patients is one of the most challenging aspects of cancer care. Although studies of EOL care interventions that are patient-focused and result in high-quality EOL experiences are increasing, most still do not achieve an EOL experience consistent with preferences. We aimed to provide an intervention for standardized advanced care planning (ACP) documentation and education to improve quality of life (QOL) for patients (pts) with terminal cancer (TC). Methods: Pts with TC (for this study defined as stage IV cancer or metastatic disease) were evaluated retrospectively through our EHR IKnowMed (IKM) before and after an ACP documentation and an education intervention. Descriptive statistics were used to identify and measure utilization of ACP introduction and charting as well as completion of advance directive documentation. Within IKM there are discrete fields for EOL data including ACP discussion, ACP facilitation, documentation of ADs. Education on tool documentation occurred in early 2012. Our ACP program was launched in March 2012. This included an ACP office visit conducted by a practitioner with ACP training, standardized education literature on EOL and ACP, launch of a website with EOL and ACP educational material, recording of ACP documents and documentation of hospice utilization and ACP preferences within our EHR. Results: Baseline characteristics and improvements in ACP introduction, charting, and AD documentation that occurred during our documentation and intervention process can be seen in the Table. Conclusions: Implementation of a standardized ACP program improves utilization and documentation of ACP planning, and documentation of ADs. These interventions improve QOL and health literacy for patients with TC. By incorporating these strategies with definable metrics, strategic intervention can be measured and reported. Further study of the relationships between ACP documentation and patient outcomes is necessary for comprehensive oncology care. [Table: see text]

Hits and misses: A longitudinal examination of congruence between patient-reported quality-of-life concerns in advanced cancer and discussions with oncologists.

2018 ◽  
Vol 36 (34_suppl) ◽  
pp. 22-22
Author(s):  
Karen Marie De Sola-Smith ◽  
Janice Bell ◽  
Daniel J Tancredi ◽  
Richard L Kravitz ◽  
Paul Duberstein ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Supportive Care ◽  
Therapeutic Alliance ◽  
Advanced Cancer ◽  
Secondary Analysis ◽  
Care Needs ◽  
Patient Reported ◽  
The Voice ◽  
Longitudinal Examination

22 Background: Quality of life (QOL) support is critical to high quality advanced cancer care and is associated with improved patient outcomes, but most patients report unmet supportive care needs. To understand supportive care provision in routine oncology, we examined the agreement, or congruence, between patients’ self-reported symptoms and topics discussed with oncologists over an extended interval of care. Prior research suggests that patient-provider rapport and overall QOL influence discussion of patient concerns, therefore we estimated effects of two predictors of interest: therapeutic alliance between patient and oncologist, and global QOL. Methods: We conducted a secondary analysis of data collected in the VOICE study. Patients with advanced cancer (n=196) completed measures of symptoms (e.g., pain, nausea, emotional concerns) and QOL, as well as an inventory of topics discussed with oncologists over the prior 3 months. Data were collected at quarterly intervals for up to 48 months, resulting in 901 paired reports of patients’ symptoms and discussions with oncologists. We constructed congruence as a multinomial outcome with four discrete categories: congruence (symptom reported/discussed), unaddressed concern (symptom reported/not discussed), surveillance (symptom not reported/discussed), and no supportive care concern (symptom not reported/not discussed). We then estimated effects of global QOL and therapeutic alliance using multi-level logistic regression. Results: Congruence was most common for pain (49.9%), while emotional concerns were most likely to be unaddressed (50.5%). Higher therapeutic alliance with oncologists was associated with lower odds of unaddressed pain (OR 0.94, CI 0.89-1.00) and emotional concerns (OR 0.95, CI 0.91-0.98). Higher global QOL was associated with higher odds of unaddressed emotional concerns (OR 1.11, CI 1.02-1.20). Congruence outcomes were stable over time. Conclusions: Oncologists may improve congruence by strengthening therapeutic alliance, by more consistently discussing emotional concerns, and by prioritizing topics for discussion according to patients’ needs.

A digital oncology patient-reported outcomes platform: Building innovative electronic patient symptom assessments in epic mychart to improve the quality of life and survival of patients with advanced cancer.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e18312-e18312 ◽  
Author(s):  
Sidharth Anand ◽  
Anne Margaret Walling ◽  
Sarah F. DAmbruoso ◽  
Neil Wenger ◽  
Jennifer Singer ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Overall Survival ◽  
Advanced Cancer ◽  
Patient Reported Outcomes ◽  
Best Practice ◽  
Response Rate ◽  
Assessment System ◽  
Patient Reported ◽  
Practice Advisory

e18312 Background: Establishing a system to monitor patient reported outcomes (“PRO”) has been demonstrated to be essential for a well-functioning cancer system. Studies have shown that routine collection of PROs allows providers to address medical issues earlier and impacts a patient’s overall survival. Unmet needs for symptom management are prevalent in the cancer population, especially patients with advanced cancer. Approximately 35% of UCLA Hematology-Oncology patients with advanced cancer in 2016 presented to Emergency Rooms for symptom-related complaints such as nausea, pain, constipation, dehydration, and fatigue. We hypothesize that the creation of an electronic PRO platform through EPIC MyChart will ensure patients receive timely evaluation of their symptoms, resulting in improved quality of life, and decreased ER and hospital utilization. Methods: We developed an innovative PRO platform through Epic MyChart along with a Best Practice Advisory alert system to identify patients at risk for worsening symptoms, ER visits, and inpatient admissions. We then built an electronic version of the Edmonson Symptoms Assessment System, which providers can push to patients through Epic MyChart, with results stored within the Flowsheets section of Epic. We also built a passive alert using Epic’s Best Practice Advisory (“BPA”) system, to notify providers when a patient’s MyChart ESAS Assessment Scores have exceeded a defined threshold. Results: Preliminary data from surveys sent to a series of advanced cancer patients seen in an outpatient palliative oncology clinic over 1 month, demonstrated a 100% response rate (6/7) surveys completed when sent one week prior to patient’s being seeing in clinic, and 17% response rate (1/6) when sent two to three weeks prior to clinic visit. The average total ESAS score reported was 40, with average individual score of 4/10 for any given symptom. Conclusions: We will implement this electronic PRO platform in multiple oncology clinics at UCLA, and measure provider and patient satisfaction, completion rates, and monitor outcomes such as ED visits and inpatient admissions. We hope this system will lead to an overall survival benefit. This project demonstrates the potential of developing innovative PRO platforms through Epic MyChart and the importance of clinical workflows in the implementation process.

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