Documentation of prognosis, treatment benefit and goals of care is poor for incurable disease

Background: Earlier goals of care (GOC) discussions in patients with advanced cancer are associated with less aggressive end-of-life care including decreased use of medical technologies. Unfortunately, conversations often occur late in the disease trajectory when patients are acutely unwell. Here, we evaluate practitioner perspectives of patient, family, physician, and external barriers to early GOC discussions in the ambulatory oncology setting. Methods: A previously published survey to assess barriers to GOC discussions among clinicians on inpatient medical wards was modified for the ambulatory oncology setting and distributed to oncologists from 12 centers in Ontario, Canada. Physicians were asked to rank the importance of various barriers to having GOC discussions (1 = extremely unimportant to 7 = extremely important). Results: Questionnaires were completed by 30 (24%) of 127 physicians. Respondents perceived patient- and family-related factors as the most important barriers to GOC discussions. Of these, patient difficulty accepting prognosis or desire for aggressive treatment were perceived as most important. Patients’ inflated expectation of treatment benefit was also considered an important barrier to discontinuing active cancer-directed therapy. While physician barriers were ranked lower than patient-related factors, clinicians’ self-identified difficulty estimating prognosis and uncertainty regarding treatment benefits were also considered important. Patient’s refusal for referral was the most highly rated barrier to early palliative care referral. Most respondents were nonetheless very or extremely willing to initiate (90%) or lead (87%) GOC discussions. Conclusion: Oncologists ranked patient- and family-related factors as the most important barriers to GOC discussions, while clinicians’ self-identified difficulty estimating prognosis and uncertainty regarding treatment benefits were also considered important. Further work is required to assess patient preferences and perceptions and develop targeted interventions.

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Much Ado About Fried Chicken: Abetting Aspiration or Respecting Autonomy?

American Journal of Speech-Language Pathology ◽

10.1044/2019_ajslp-18-0207 ◽

2019 ◽

Vol 28 (3) ◽

pp. 1356-1362

Author(s):

Laurence Tan Lean Chin ◽

Yu Jun Lim ◽

Wan Ling Choo

Keyword(s):

Palliative Care ◽

End Of Life ◽

Multidisciplinary Team ◽

Biopsychosocial Model ◽

Family Members ◽

Clinical Decisions ◽

Goals Of Care ◽

Complex Needs ◽

Aspiration Risk ◽

Patient Centric

Purpose Palliative care is a philosophy of care that encompasses holistic, patient-centric care involving patients and their family members and loved ones. Palliative care patients often have complex needs. A common challenge in managing patients near their end of life is the complexity of navigating clinical decisions and finding achievable and realistic goals of care that are in line with the values and wishes of patients. This often results in differing opinions and conflicts within the multidisciplinary team. Conclusion This article describes a tool derived from the biopsychosocial model and the 4-quadrant ethical model. The authors describe the use of this tool in managing a patient who wishes to have fried chicken despite aspiration risk and how this tool was used to encourage discussions and reduce conflict and distress within the multidisciplinary team.

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Goals of care program: Psychosocial opportunities in the ICU

PsycEXTRA Dataset ◽

10.1037/e548132012-085 ◽

2010 ◽

Author(s):

Matthew Loscalzo ◽

David Horak ◽

Marie Malicki ◽

Tana Burns ◽

Ben Laroya ◽

...

Keyword(s):

Care Program ◽

Goals Of Care

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Effectiveness of a digital therapeutic as adjunct to treatment with medication in pediatric ADHD

npj Digital Medicine ◽

10.1038/s41746-021-00429-0 ◽

2021 ◽

Vol 4 (1) ◽

Author(s):

Scott H. Kollins ◽

Ann Childress ◽

Andrew C. Heusser ◽

Jacqueline Lutz

Keyword(s):

Video Game ◽

Primary Outcome ◽

Rating Scale ◽

Stimulant Medication ◽

Additional Treatment ◽

Adhd Medication ◽

Open Label ◽

Serious Adverse Events ◽

Treatment Benefit ◽

Hyperactivity Disorder

AbstractSTARS-Adjunct was a multicenter, open-label effectiveness study of AKL-T01, an app and video-game-based treatment for inattention, as an adjunct to pharmacotherapy in 8–14-year-old children with attention-deficit/hyperactivity disorder (ADHD) on stimulant medication (n = 130) or not on any ADHD medication (n = 76). Children used AKL-T01 for 4 weeks, followed by a 4-week pause and another 4-week treatment. The primary outcome was change in ADHD-related impairment (Impairment Rating Scale (IRS)) after 4 weeks. Secondary outcomes included changes in IRS, ADHD Rating Scale (ADHD-RS). and Clinical Global Impressions Scale—Improvement (CGI-I) on days 28, 56, and 84. IRS significantly improved in both cohorts (On Stimulants: −0.7, p < 0.001; No Stimulants: −0.5, p < 0.001) after 4 weeks. IRS, ADHD-RS, and CGI-I remained stable during the pause and improved with a second treatment period. The treatment was well-tolerated with no serious adverse events. STARS-Adjunct extends AKL-T01’s body of evidence to a medication-treated pediatric ADHD population, and suggests additional treatment benefit.

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Boosting Immunity against Multiple Myeloma

Cancers ◽

10.3390/cancers13061221 ◽

2021 ◽

Vol 13 (6) ◽

pp. 1221

Author(s):

Raquel Lopes ◽

Bruna Velosa Ferreira ◽

Joana Caetano ◽

Filipa Barahona ◽

Emilie Arnault Carneiro ◽

...

Keyword(s):

Multiple Myeloma ◽

Residual Disease ◽

Proteasome Inhibitors ◽

Treatment Strategies ◽

Complete Response ◽

Drug Conjugates ◽

Incurable Disease ◽

Car T ◽

Patient’S Outcome ◽

The Impact

Despite the improvement of patient’s outcome obtained by the current use of immunomodulatory drugs, proteasome inhibitors or anti-CD38 monoclonal antibodies, multiple myeloma (MM) remains an incurable disease. More recently, the testing in clinical trials of novel drugs such as anti-BCMA CAR-T cells, antibody–drug conjugates or bispecific antibodies broadened the possibility of improving patients’ survival. However, thus far, these treatment strategies have not been able to steadily eliminate all malignant cells, and the aim has been to induce a long-term complete response with minimal residual disease (MRD)-negative status. In this sense, approaches that target not only myeloma cells but also the surrounding microenvironment are promising strategies to achieve a sustained MRD negativity with prolonged survival. This review provides an overview of current and future strategies used for immunomodulation of MM focusing on the impact on bone marrow (BM) immunome.

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Establishing Goals of Care at Any Stage of Illness: The PERSON Mnemonic

Journal of Palliative Medicine ◽

10.1089/jpm.2014.0253 ◽

2014 ◽

Vol 17 (10) ◽

pp. 1087-1087 ◽

Cited By ~ 5

Author(s):

Kyle P. Edmonds ◽

Toluwalase A. Ajayi ◽

Julia Cain ◽

Heidi N. Yeung ◽

Kathryn Thornberry

Keyword(s):

Goals Of Care

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AR Splicing Variants and Resistance to AR Targeting Agents

Cancers ◽

10.3390/cancers13112563 ◽

2021 ◽

Vol 13 (11) ◽

pp. 2563

Author(s):

Mayuko Kanayama ◽

Changxue Lu ◽

Jun Luo ◽

Emmanuel S. Antonarakis

Keyword(s):

Prostate Cancer ◽

Androgen Receptor ◽

Splice Variants ◽

Treatment Options ◽

Predictive Biomarker ◽

Castration Resistant Prostate Cancer ◽

Treatment Benefit ◽

Novel Biomarkers ◽

The Many ◽

Preclinical And Clinical Studies

Over the past decade, advances in prostate cancer research have led to discovery and development of novel biomarkers and effective treatments. As treatment options diversify, it is critical to further develop and use optimal biomarkers for the purpose of maximizing treatment benefit and minimizing unwanted adverse effects. Because most treatments for prostate cancer target androgen receptor (AR) signaling, aberrations affecting this drug target are likely to emerge following the development of castration-resistant prostate cancer (CRPC), and it is conceivable that such aberrations may play a role in drug resistance. Among the many AR aberrations, we and others have been studying androgen receptor splice variants (AR-Vs), especially AR-V7, and have conducted preclinical and clinical studies to develop and validate the clinical utility of AR-V7 as a prognostic and potential predictive biomarker. In this review, we first describe mechanisms of AR-V generation, regulation and their functions from a molecular perspective. We then discuss AR-Vs from a clinical perspective, focusing on the significance of AR-Vs detected in different types of human specimens and AR-Vs as potential therapeutic targets.

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