Excellent advice to oncologists from oncologists

Dr. Weeks Comment:     These articles below are all excellent reminders that doctors ought not only reduce symptoms and reverse illnesses but also should…     wait for it…   “care” for the patients as well.    Of course your doctor cares but does he or she SHOW it.   The “I love you” murmured  from your spouse while preoccupied with email doesn’t suffice at home.  How does a rushed conversation cut it in the office? I remember when I walked out of a Practice Efficiency Meeting while in my residency training when the “efficiency expert” instructed us what kind inviting words to say to the seated patient gleefully informing us that if we, as doctors, remained standing and kept our hand on the door knob while we asked “How are you doing Mrs. Smith?”  then the overpowering non-verbal message which was communicated  to the patient was “This isn’t a good time to talk. I will wait until next time”  and voila, the doctor can see twice as many patients! (and increase revenue).   Does that seem reasonable to you?  Hmmm…  Imagine getting the opportunity to tour a world class museum- the Louvre or the MET – but you only had 3 seconds per painting. “Why bother?!” You might say.  Agreed.  Hence the non-surprisingfact that the cause of  epidemic of “impaired physician syndrome” or “physician burnout” is  – no surprise! – iatrogenic (caused by the doctor) . “Why bother” trying to care for the patient in that clinical setting?  A couple of generations of doctors ago, the giant amongst us, Professor  William Osler, M.D.  shared a gem  “The secret of caring or the patient is caring for the patient.”   This takes time.

Reminders:

1) Take enough time.

2) Listen heartfully. 

3) Empathize

4) Be Honest

5) Ask “Is anything else that we can do for you?”

 

These articles can be helpful.

ARTICLE 1

5 (Incorrect) Reasons Oncologists Avoid Bad-News Talks

Nick Mulcahy

July 6, 2012 — Five commonly accepted reasons that oncologists avoid discussing poor prognosis with cancer patients are all “incorrect,” according to an essay published online July 2 in theJournal of Clinical Oncology.

There is one reason for avoiding such talks that “holds truth”: Doctors “do not like to have these discussions” because “they are hard on us,” write Jennifer Mack, MD, from the Dana-Farber Cancer Institute and Children’s Hospital Boston in Massachusetts, and Thomas J. Smith, MD, from the Johns Hopkins Medical Institutions, Baltimore, Maryland.

The essayists remind their fellow clinicians that “our patients want us to have these conversations, difficult as they are for all involved.”

Drs. Mack and Smith list 5 reasons that oncologists unnecessarily shy away from bad news talks:

  • Patients get depressed
  • The truth kills hope
  • Hospice or palliative care reduces survival
  • This talk is not culturally appropriate
  • Prognosis is unknowable

They then cite evidence that dispels each reason, more or less.

The field of oncology has recently gotten better at talking to patients about poor prognosis, said an expert asked to comment on the essay.

“There has been a lot of work trying to address difficult communications tasks recently,” said Jim Wallace, MD, from the University of Chicago in Illinois. There has been a “trend” in “finding ways to help oncologists improve their skills,” he told Medscape Medical News.

Dr. Wallace was the lead author of a 2006 study that surveyed oncologists about breaking bad news to patients,as reported by Medscape Medical News. He and his colleagues found that negative emotions were much more common than positive ones among oncologists. Specifically, 47% of respondents described negative emotions such as sadness and anxiety, whereas only 14% reported positive feelings such as optimism, hope, helpfulness, and relief.

Dr. Wallace has strong opinions about training oncologists in such communication.

This training should become mandatory.

“For oncologists who are directly involved in patient care, this training should become mandatory,” he said. “Oncology should begin to explore means of evaluating this competency prior to full-time patient care.”

The avoidance of bad news talk has some serious consequences, the essayists note. “Patients lose good time with their families and for reflection and spend more time in the hospital and intensive care unit,” Drs. Mack and Smith write. The avoidance can be neglectful, they suggest. For example, half of all patients with lung cancer get to 2 months before death without being offered hospice.

Bad news talks are potentially cost effective. “We think this is one way we can improve care, give people more realistic choices, and reduce the rising cost of care,” write Drs. Mack and Smith.

They reviewed various books and studies on the subject of discussing bad news with cancer patients, and found a host of “underlying misconceptions” among healthcare professionals. In their essay, they present the evidence they accumulated to counter these “incorrect” ideas about the effects of discussing poor prognosis.

Refuting the Reasons

Patients get depressed. The essayists say the opposite is true. “Giving patients honest information may allow them and their caregivers to cope with illness better.” The evidence includes the Coping With Cancer study, in which patients who reported having end-of-life discussions had no higher rates of depression or worry and had lower rates of ventilation and resuscitation and more and earlier hospice enrollment (JAMA. 2008;300:1665-1673).

The truth kills hope. Drs. Mack and Smith say that hope can be maintained by patients even after truthful discussions about there being no chance for a cure. They cite studies of cancer patients with advanced disease in which patients were highly hopeful about their lives both before and after the disclosure of the likely prognosis. In other words, hope was a concept about life, regardless of its length, they found.

Hospice or palliative care reduces survival. The essayists note that multiple studies suggest that survival is equal or better with hospice or palliative care. For example, in a study of 4500 Medicare beneficiaries, hospice use was associated with increased survival in patients with either congestive heart failure or 1 of 5 cancers (J Pain Symptom Manage. 2007;33:238-246).

This talk is not culturally appropriate. The Drs. Mack and Smith admit that it is “true that patients of different ethnic and cultural backgrounds often have different preferences for information.” But they argue that no clinician should assume a person of a particular background does not want to talk about death because some of his or her compatriots feel that way. “Physicians who want to know their patients’ preferences for prognostic information should ask,” they say.

Prognosis is unknowable. The essayists admit this is true — prognosis is a mystery to some degree. But they argue that “although we never know precisely how long a patient has to live, uncertainty should not be used as an excuse.” They maintain that a “reasonable prognosis or range of possible outcomes” can help patients come “closer to the truth.”

J Clin Oncol. Published online July 2, 2012. Abstract

ARTICLE 2

How Physicians Influence Patient Choices

Kathy D. Miller, MD

The researchers asked patients with a variety of advanced malignancies, all of whom we might estimate had a life expectancy of less than a year, what their preferences were regarding CPR. They investigated 2 particular conditions. The first was what we usually do in clinic when we have a conversation with our patients. We talk about what CPR is, what they might expect, how this might work, and then ask the patients what they would like us to do if they are in that situation.

The other condition was the same conversation supplemented with a 3-minute video that explains CPR, shows CPR being performed on a mannequin, and explains what we know from other trials about the success rate of CPR in patients with advanced cancer. The video ends by showing an actual patient as one would be in an ICU, with a ventilator and IVs — the ICU setting where patients who have in-hospital CPR frequently end up. Then the researchers asked patients about their preferences: What would they wish we do in that setting?

This was a randomized trial with 150 patients, done at 4 different centers. About half of the patients were male and about half were female. About a third of patients were African American. In the first group was the usual care, the discussion. About 47% of those patients said, “Yes, I would like you to try CPR.” Only about 1% were uncertain about their decision. In the group for whom the discussion was supplemented with the 3-minute video, about 20% said that they would like us to try CPR, less than half the number of patients from the first group who wanted us to try CPR. When their knowledge was tested, patients who watched the video were more accurate. They had more factual knowledge about what CPR is and the success rates in that situation.

The investigators checked back in with those patients by phone about 6 weeks later to ask them about the process, whether their decision was the same, and whether their thinking had evolved. There were very few changes in either group. Their decisions seemed quite firm and they were comfortable with the decisions they had made. What I found most fascinating was when the patients who watched the video were asked whether the video was comfortable for them to watch. Over 90% said that it was comfortable for them. It wasn’t distressing for them to watch it. About 97% said the video was helpful for them in thinking about this difficult issue and in making their choice, and 100% of them — every single patient — said that they would recommend this video to a friend, a family member, or another patient in the same situation.

The bottom line is that the information we give our patients matters. If we give them better, more accurate information, I think you could argue that they would make better decisions. They are certainly happier with the care that they receive and the choices they have made. Thanks again to Jennifer and her group for continuing to give us such valuable information in this area that we often struggle with.

ARTICLE 3

How to Have Difficult Conversations With Patients, Families

An Expert Interview With Cyndi Cramer, BA, RN, PCRN

Troy Brown

May 9, 2012 (New Orleans, Louisiana) — Editor’s note: Difficult conversations with patients are necessary and, when done well, can actually empower patients and help them plan for the future.

Nobody likes conversations with patients about bad news — grave diagnoses, difficult emotions, tough decisions. We don’t like these conversations because we don’t like hurting our patients.

Cyndi Cramer, BA, RN, OCN, PCRN, clinical administrative supervisor and educator in oncology, palliative care, critical care, and pediatrics at the Tampa General Hospital in Florida, spoke about this issue here at the Oncology Nursing Society (ONS) 37th Annual Congress.

Cramer talked about why good communication skills are so important and discussed strategies for helping patients and families cope with bad news. In an email interview with Medscape Medical News, she identified things nurses should and should not do when having difficult conversations.

Medscape: What would you say to nurses who are nervous about having difficult conversations with patients?

Cramer: This is an anxiety-producing scenario for most nurses.

First, they need to remember they are not alone. If they have any kind of palliative care team, these folks are experts on communication and can help them or even step in for them.

Next, they need to not be afraid. The most important thing they need to do is listen. If they are doing most of the talking, they are talking too much! Most of these conversations are about encouraging the patient to explore what is going on and what they want.

They also need to be gently honest. No euphemisms, no jargon, just simple explanations of what is going on. Patients want us to show we are empathetic to their plight, but most of them want us to be honest.

Finally, they just need to be “present.” Presence is all about being there “in the moment.” Eye contact and touch are important, unless the patient gives cues that they are uncomfortable (this is unwanted or even inappropriate with some people and some cultures). Giving the patient your full attention is critical, as is encouraging them to continue talking by repeating or rephrasing their statements or acknowledging their fear.

Medscape: Why is good communication important?

Cramer: Good communication is key to everything we do. If we do not communicate well, misunderstandings, false hope, and distrust can be the result. This can lead to patients and families who are confused and angry. Communication is what helps us bond with our patients.

Nurses are the “constant,” as Betty Ferrell says. They are with patients for extended periods of time, whereas other healthcare providers come and go. They are the holistic practitioner who is looking at every dimension of the patient. They are the interpreters of what is going on and what others are saying, and they are the patient advocates who are required to speak up for their patient’s needs and goals. If they don’t do it, who will?

Medscape: What are some examples of poor and good communication?

Cramer: Poor communication is hurried, where the healthcare provider is doing all of the talking, using medical jargon the patient doesn’t understand, being distant, not engaged.

Good communication is the opposite — not rushed, simple words, mostly listening, giving small bits at a time, following cues given, being empathetic, and being “present.”

Medscape: Can you elaborate on the guidelines that nurses can use to develop good communication techniques?

Cramer: Some wonderful palliative care experts have been writing about communication for years. There are several great guidelines out there. Dr. Robert Buckman is one of my favorites; he has written a great book —Difficult Conversations in Medicine. I really recommend it as a guideline for these conversations.

He gives guidelines and examples of several mnemonics for these conversations. One that he has talked about for years is the SPIKES protocol:

Setting/starting
Perception
Invitation
Knowledge
Emotions
Strategy/summary

Medscape: Can you give some examples of words and phrases that should and should not be used?

Cramer: Don’t say:

“We are going to withdraw care.” (You mean you are not going to care for my mom anymore? Are you just going to ignore her now?)

“What do you want to do?” (referring to end of life issues: You want me to decide? Aren’t you the experts? Shouldn’t you be telling me what to do?)

“Do you want to make your mom a DNR?” (You want me to just give up? To just let her die? I love my mom and I don’t want her to die.)

Do say:

“I wish I had better news for you. (Pause, this is a “warning shot” before giving bad news.) We’ve exhausted everything that will do anything that will make your mom better. She is going to die from this (many pauses). Did your mom ever talk about what she wanted?”

“This breathing machine is not helping her and patients tell us it’s not a comfortable experience. Do you think your mom would rather we let her die naturally? We will stay right here with her and do everything we know how to make her comfortable. There are many things we can do for her.”

“We can’t fix this. I wish we could. Miracles are extremely rare and happen even without our help when they do occur…. In my experience, she only has hours to days left. You said your mom said she didn’t want to die like this. Do you agree that we should allow her to die naturally and not do CPR (push on her chest) or put her on a breathing machine?”

Medscape: Why is nonverbal communication important, and how can nurses use nonverbal language therapeutically with their patients?

Cramer: Only 7% of communication is verbal; 38% comes from your tone of voice and 55% from your body language. We really need to pay attention to what perceptions our patients are getting from our nonverbal communication.

It goes back to “presence”: Being with the patient in the moment; eye contact and touch when appropriate; sitting at the bedside instead of standing above the patient or talking over your shoulder while doing other things; listening more than talking.

It does not take as much time as many nurses might think — remember quality, not quantity. It all comes full circle to developing a trusting relationship in a short period of time. Time spent in initial contacts to develop that trust can yield huge benefits later when these difficult conversations are suddenly something we have to face. It is all about putting the “care” into nursing care.

 

ARTICLE 4

 

Honoring Patient Preferences in Personalized Medicine

Lessons in Advanced Breast Cancer

Lidia Schapira, MD; Eric P. Winer, MD

Editor’s Note:
An expert panel comprising Drs. George W. Sledge, Fatima Cardoso, Eric P. Winer, and Martine J. Piccart-Gebhart looked at the treatment of breast cancer — past, present, and future — as part of an education session at the 2012 annual meeting of the American Society of Clinical Oncology (ASCO®). Dr. Lidia Schapira caught up with Dr. Winer after the session to tease out of him a few more comments on the discussion.

Living Well, Dying Well

Dr. Schapira: The book that was compiled for this education session[1] starts out with a big pitch for living well and dying well with breast cancer. Could you talk more about what you and the other panelists meant by that comment?

Dr. Winer: George Sledge touched on that today. The treatment of advanced breast cancer is science and art. The science part, of course, is trying to provide the most effective treatment in the context of the patient’s disease, and the art is trying to figure out how that matches with a patient’s preferences and desires. Beyond that, however, there comes a time in the course of almost everyone’s illness when there is a need to back off from some of the more (I’m avoiding the word “aggressive”) side-effect-producing therapies, and focus on comfort measures and making sure patients accomplish the goals they set for the end of their lives. In truth, there are people who just don’t want to deal with those issues, but there are many who do.

Dr. Schapira: When do you, as a compassionate doctor, start to talk about these issues with patients?

Most of us do not spend a great deal of time thinking about the end of our lives. There is a time and a place for these thoughts, and if you shut them out completely, there are unanticipated consequences. For the most part, when you are taking care of people, you give them space to talk about the issues of death and dying and what may happen if treatment isn’t working. You also let them know that you are taking care of them so that when they leave the office and the hospital, they can go on with life and worry about their children or their work or their next trip and not focus excessively on their health and prognosis.Dr. Winer: I have always found that conversations about end-of-life issues are an extension of the dialogue I have been having with the patient the whole time I have been taking care of her. It’s about setting realistic goals, but you also have to maintain some sense of optimism.

Dr. Schapira: Do you talk to patients about survival medians and means?

Dr. Winer: I never give medians and means. I tend to speak in generalities, but I can be more specific. It depends on what the patient wants. The closest I come to medians and means is telling somebody who wants more concrete information that I think that it would be unlikely, but not impossible, if she lived beyond a certain date.

Honoring Preferences in Cancer Treatment

Dr. Schapira: There has been a lot of talk at ASCO® this year and last year about personalized therapy, which involves not only the biology of the tumor and exploitation of the natural biological targets but also the patient’s preferences. How does that work in practice? How much time do you spend discussing the patient’s preferences and discussing trade-offs when you actually make a recommendation for treatment?

Dr. Winer: I spend a fair amount of time doing that. Particularly when we are talking about a choice of chemotherapy agents, or joining a trial as opposed to receiving a standard treatment — much of that is about preference. It is relatively rare that there are stark differences between the outcomes achieved with different treatments. So, given the choice between something that is better tolerated and worse tolerated, the choice is usually pretty clear, and it is something we have to talk about.

I also think that if you have been taking care of a patient for a while, you get to know something about her preferences, and you don’t necessarily have to discuss options in detail every time. I always find it challenging, as I am sure you do, when I first start taking care of someone who is changing physicians mid-course. She may be coming to see me because she is going on a trial or just interested in making a change. In that setting, I often see a patient much more frequently than I would otherwise, just because I need to get to know her and get a sense of her preferences.

When Is a Trial the Right Choice?

Dr. Schapira: I know you are a committed trialist and that perhaps the answer for many patients would be to encourage them to go on a trial in the setting of metastatic disease. One-on-one with patients, how do you assess their readiness or their interest in participating in a trial?

Dr. Winer: It varies from patient to patient. Working in a place that is known to conduct clinical research, we see patients who are relatively hungry for trial participation, so that I find patients are often anxious to hear about trials.

I often remind patients that the true beneficiaries of clinical trials are not the patients on the trials, but the next generation, and I do that for 2 reasons. First, to the extent that patient is behaving in an altruistic manner, she can feel good about doing something for others. Second, a patient has to understand that the trial is not necessarily the be-all and end-all. The hope with any trial is that it is going to be better for that person than the standard treatment, but if we knew that, it wouldn’t be a trial. It would be standard treatment.

There are, of course, situations in which a trial is pretty far along. For example, a drug such as T-DM1, which we heard about today,[2] has been in trials for 5 or 6 years, and I have known for over 4 years that T-DM1 is a remarkable drug. I don’t have any trouble recommending that a person participate in a T-DM1 trial, but this is a relatively unusual situation.

Endpoint Wars: Progression-Free vs Overall Survival

Dr. Schapira: There is so much debate about the proper endpoint for trials — whether progression-free survival (PFS) is a valid endpoint, or whether we should focus on overall survival. Which side do you take in this raging debate?

Dr. Winer: It seems to me that there are only 2 important endpoints for all trials in any setting, whether it’s cancer, diabetes, or hypertension. Those 2 endpoints are survival and quality of life. Nothing else really matters. It’s all about how long and how well someone lives.

If PFS is used, it should be a meaningful surrogate for either survival or quality of life. Sometimes PFS is a meaningful surrogate for survival. If the therapy is not very toxic and, in a symptomatic patient, the symptoms are kept under control, then PFS is probably a reasonable surrogate for quality of life, although that has not always been demonstrated.

Is Combination Chemotherapy Ever the Right Option?

Dr. Schapira: For metastatic breast cancer, if we have to give chemotherapy, treatment recommendations generally favor single-agent chemotherapy. Are there times when you would think of combination chemotherapy?

Dr. Winer: There are, but when I think the situation through, I am usually less enthusiastic. Once in a while, I use a combination. The problem is that the times when you want to give combination therapy is when a patient is sicker, but that means she also is at greater risk for toxicity. Combination therapy leads to a higher response rate and a longer time to progression, but no difference in survival.

It’s not clear to me that there is benefit in giving someone combination chemotherapy. I have someone at the moment who has never received an anthracycline, and we were going to give her single-agent Adriamycin® (doxorubicin hydrochloride; Pfizer; New York, New York) because Doxil® (doxorubicin hydrochloride liposome injection; Janssen Biotech, Inc; Horsham, Pennsylvania) currently is not available. I decided to give her Adriamycin and cyclophosphamide, and you might legitimately ask why. I reasoned that cyclophosphamide is an active drug that would allow me to give a little less Adriamycin, and I know the combination can be given safely.

Has Chemotherapy Had Its Day?

Dr. Schapira: I have heard you comment at several meetings in the past couple years that we will be able to select patients who won’t need chemotherapy in the era of targeted therapies. Can you give 1 or 2 examples that really excite you and that you think are very promising?

Dr. Winer: T-DM1 is one example. Although technically it is chemotherapy, it is linked to trastuzumab, and a very small dose of the DM1 is delivered selectively to the HER2-positive cancer cell. There is also growing evidence that dual blockage for HER2-positive breast cancer — whether with lapatinib and trastuzumab[3] or pertuzumab and trastuzumab[4] — is a particularly effective treatment. I suspect that there are some patients with early-stage disease who could do well with those biologic therapies alone.

Dr. Schapira: What is coming down the pike that excites you?

Dr. Winer: For HER2-positive breast cancer, I think we will see more and more women cured of their early-stage disease. Very few will relapse, and for those who present with more advanced disease, we are going to be able to control the disease for many years — and for some, perhaps indefinitely.

We have bigger challenges when it comes to triple-negative breast cancer and estrogen-receptor-positive metastatic breast cancer. Patients with advanced estrogen-receptor-positive disease can survive for many years on hormonal therapy, but this is not true for all patients. And those with advanced triple-negative breast cancer tend to do far more poorly than we would like.

Molecular Mutations and Cautionary Concern

Dr. Winer: I do worry in this era of targeted therapy that people will become convinced that we simply need to find a mutation and then pick an appropriately targeted drug. We can’t forget that we still need to conduct clinical trials. Not every key that looks like it will fit into a lock will actually turn it, and the same is likely to be the case with new drugs. I also worry that emphasis on targeted therapy has given people license to ignore fundamental statistical principles. We need to distinguish between hypotheses and firm conclusions.

Dr. Schapira: I counted about 8 trials looking at PI3 [phosphoinosotide 3]-kinase inhibitors on the board, 2 more with mTOR [mammalian target of rapamycin], half a dozen with combined treatments, and then some more with other targets. Martine Piccart’s slide had 20 such trials. So, what you are saying is that we should be excited about the opportunity and the innovation and to learn valuable lessons, but be careful not to rush to a conclusion.

Dr. Winer: There are several common mutations in breast cancer, but, as Martine Piccart pointed out, the truth is that we don’t know that all those mutations are going to turn out to be relevant, and many them are essentially bystanders.

A Patient’s Gift to Her Physician

Dr. Schapira: My last question is personal. In the past 6 months to 1 year of practice, what has moved you the most?

Dr. Winer: I take care of a very young woman who has had HER2-positive breast cancer for 5 years. For more than 4 years, she has had brain metastases, with excellent control of her extra-central nervous system disease. Now, unfortunately, she is coming to the end of her life. She is at home, unable to get out of bed, and is being cared for by her 35-year-old husband. Brain metastases represent a huge problem we have to face — this problem of brain metastases for both HER2-positive and potentially for triple-negative breast cancer.

It has not been easy watching her go through this. Of course, it’s very different for me than it is for her family, who are just tortured to see her go through this illness. What is most remarkable is that she has made her peace with breast cancer and her likely fate. She has been able throughout this illness to say that some people are dealt one hand and some another, and you have to cope the best way you can. She is a remarkable person, and someone who I will remember for as long as I am on this earth.

ARTICLE 5

Psychosocial Needs Matter Most at the End of Life

Megan Brooks

“In the end, what matters most to patients is that their psychosocial needs are met. When cure is not an option, care should imply psychosocial and spiritual care and concern,” Dr. Prigerson told Medscape Medical News.”Physicians who claim that there is little that they have to offer their dying patients should realize that their willingness to be present and not abandon their patients matters a tremendous amount to the quality of life of patients,” said study author Holly G. Prigerson, PhD, director of the Center for Psychosocial Epidemiology and Outcomes Research at the Dana-Farber Cancer Institute in Boston, Massachusetts.This study, she explained, “speaks to the importance of maintaining a therapeutic bond between patient and provider. Patients who want to have a better quality of life in the final stage of their illness should avoid intensive medical care, opt out of the next round of presumably ‘life-prolonging therapy,’ strive to worry less, pray, and meditate more,” Dr. Prigerson said.Issue UnderstudiedThe concept of quality at the end of life in cancer patients has been “underexamined in cancer medicine in the quest to develop newer, more advanced, and effective modalities of interventional cytotoxic therapies,” according to an accompanying commentary.”It is surprising at this stage in the development and implementation of complex multimodal cancer treatment strategies that the factors most critical in influencing the quality of the end of life are not clearly defined and considered along the entire timeline beginning with cancer diagnosis,” write Alan B. Zonderman, PhD, and Michele K. Evans, MD, both from the National Institute on Aging, Biomedical Research Center in Baltimore, Maryland.They say the study by Dr. Prigerson and colleagues has “provided important insights” on this topic.The study involved 396 patients with advanced cancer and their family caregivers enrolled in the Coping With Cancer Study, a federally funded multicenter prospective longitudinal cohort study, conducted in the United States, looking at the quality of care patients receive at the end of life. The patients were followed from enrollment (from September 1, 2002 to February 28, 2008) to death; median follow-up was 4.1 months. Average patient age was 58.7 years.

Patients and caregivers provided various demographic, medical, and psychosocial data at enrollment. Several weeks after the patient died, caregivers retrospectively rated the quality of life just before death.

Using random-effects modeling and cross-validation techniques, the researchers identified several key predictors of informant-rated quality of life at the end of life.

They note that 2 of the most important determinants of poor end-of-life quality of life are dying in a hospital and having a stay in the intensive care unit in the final week of life. “Therefore, attempts to avoid costly hospitalizations and to encourage transfer of hospitalized patients to home or hospice might improve patient quality of life at the end of life,” the researchers note.

Chemotherapy and feeding tube use were also linked to poorer quality of life, so “limiting these types of aggressive end-of-life care may be an effective strategy as well,” they point out.

Patient worry at baseline was also a key predictor of worse quality of life at the end, indicating that efforts to curb patient anxiety should be a “top priority” for care aimed at enhancing end-of-life quality of life, the researchers say.

On the flip side, religious prayer, meditation, and pastor care services in the clinic or hospital were significantly associated with better end-of-life quality of life. “These findings are consistent with other studies that have shown significant associations between spirituality and peacefulness and quality of life in patients with life-threatening diseases,” the researchers note.

Doctor–Patient Bond, Communication Key

In addition, patients who felt a strong “therapeutic alliance” with their physician had a better quality of life at the end. Measures of therapeutic alliance looked at patient belief that they were being treated with respect and as a whole person by their physician, patient trust in and respect for their physician, and patient comfort in asking their physician about their care, the researchers explain.

These results, they note, “suggest that physicians who are able to remain engaged and ‘present’ for their dying patients — by inviting and answering questions and by treating patients in a way that makes them feel that they matter as fellow human beings — have the capacity to improve a dying patient’s quality of life.”

Perhaps that’s easier said than done. Although physician–patient communication is a “cornerstone” of high-quality medical care in all facets of medicine, “in the highly emotional setting often present when caring for patients with advanced cancer, these channels of communication are stressed,” Drs. Zonderman and Evans write in their commentary.

They cite a study that found that physicians, on average, had poor skills when it came to handling emotions and only moderate skills when it came to discussing end-of-life issues (J Palliat Med. 2010;13:949-956). “Failure of these channels of communication and undefined, incompletely developed partnerships between patient and physician or other care providers likely frequently result in provision of care that ultimately negatively affects the quality of the end of life,” Drs. Zonderman and Evans explain.

Support for ASCO Statement

Dr. Prigerson told Medscape Medical News that “what makes this study unique is that it is the first to empirically determine what factors matter most to a patients’ quality of life near death.” These factors are “promising targets for healthcare interventions to improve the quality of life of dying patients,” she and her colleagues note.

They emphasize that their study is constrained by the data available and that even the best models explained less than 20% of the variance in the end-of-life quality of life, “leaving much to learn about other influences on this outcome.”

Drs. Zonderman and Evans note that a statement from the American Society of Clinical Oncology (ASCO),previously reported by Medscape Medical News, argues that the paradigm of care must change and that this change must include “the very areas” identified by Dr. Prigerson and colleagues.

The study was supported in part by grants from the National Institute of Mental Health, the National Cancer Institute, and the Center for Psychosocial Epidemiology and Outcomes Research at the Dana-Farber Cancer Institute. The study authors, Dr. Zonderman, and Dr. Evans have disclosed no relevant financial relationships.

 

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Dr. Weeks Comment:     These articles below are all excellent reminders that doctors ought not only reduce symptoms and reverse illnesses but also should…     wait for it…   “care” for the patients as well.    Of course your doctor cares but does he or she SHOW it.   The “I love you”…
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