Abstract
Epner DE, Baile WF. Difficult conversations: Teaching medical oncology trainees communication skills one hour at a time. Acad Med 2014. E-pub ahead of print.
Difficult conversations about prognosis, end of life, and goals of care arise commonly in medical oncology practice. These conversations are often highly emotional. Medical oncologists need outstanding, patient-centered communication skills to build trust and rapport with their patients and help them make well-informed decisions. Key skills include exploring patients' perspectives, responding to emotion with empathy, and maintaining mindfulness during highly charged conversations. These skills can be taught and learned. Most previously described communication skills training curricula for oncology providers involve multiday retreats, which are costly and can disrupt busy clinical schedules. Many curricula involve a variety of oncology providers, such as physicians and nurses, at various stages of their careers. The authors developed a monthly, one-hour communication skills training seminar series exclusively for physicians in their first year of medical oncology subspecialty training. The curriculum involved a variety of interactive and engaging educational methods, including sociodramatic techniques, role-play, reflective writing, and Balint-type case discussion groups. Medical oncologists in their second and third years of training served as teaching assistants and peer mentors. Learners had the opportunity to practice skills during sessions and with patients between sessions. Learners acquired important skills and found the curriculum to be clinically relevant, judging by anonymous surveys and anonymous responses on reflective writing exercises. Results from the current curriculum are preliminary but lay the foundation for enhanced and expanded communication skills training programs in the future.
Downer J, Barua R, Sinuff T. The desirability of an intensive care unit (ICU) clinician-led bereavement screening and support program for family members of ICU decedents. J Crit Care 2014;29:311.39–311.e116.
Many bereaved family members (FMs) of intensive care unit decedents experience symptoms of complicated grief (CG) or social distress; however, there is no standard screening or follow-up for these individuals. The authors determined the desirability and need for an intensive care unit based bereavement screening and support program by surveying bereaved FMs to measure symptoms of CG, prolonged grief disorder, and social difficulties and the desire for support; and staff physicians and nurses at two teaching hospitals in Toronto, Canada, to determine comfort and interest in providing routine bereavement support. The authors could not contact 69% of FMs largely because of inaccuracies in the patient record. Of the 64 who were contacted, 32 (50%) agreed to be surveyed a mean of 7.4 months after the loss of their relative. Among eligible staff, 57 (61%) of 94 completed the questionnaire. Nine (28%) FMs met subthreshold criteria for CG or prolonged grief disorder, and 7 (22%) met criteria for social distress. Only 10 (31%) had received professional support for emotional symptoms, and 2 (6%) received professional assistance for their social difficulties. Fifty-eight percent supported routine screening, and 68% wanted to receive (or receive more) support. Fifty-five percent of FMs expressed a strong willingness to meet with the medical team to review events surrounding the death of the patient, which was the type of support that the health care staff members were most comfortable providing. Most staff (85%) reported providing emotional support at the time of death, but few provided any support afterwards. Fifty-six (98%) of 57 would be willing to support or participate in a formal bereavement screening and support program. Respondents cited the need for training and dedicated time to carry out such a program. The authors conclude that an ICU-based bereavement screening and support program for FMs of ICU decedents is both needed and desirable, although there are important needs and barriers. They also note that future studies should evaluate the effectiveness of such a program at improving outcomes among bereaved FMs.
Govindan S, Iwashyna TJ, Watson SR, et al. Issues of survivorship are rarely addressed during intensive care unit stays: Baseline results from a statewide quality improvement collaborative. Ann Thoracic Surg 2014. E-pub ahead of print.
In the context of increasing survivorship from critical illness, many studies have documented persistent sequelae among survivors. However, few evidence-based therapies exist for these problems. Support groups have proven efficacious in other populations, but little is known about their use after an ICU stay. Therefore, the authors surveyed critical care practitioners regarding their hospital's discussing post-ICU problems for survivors with patients and their loved ones, communicating with primary care physicians, and providing support groups for current or former patients and families. A written survey was administered to 263 representatives of 73 hospitals attending the January 2013 annual meeting of the Michigan Health & Hospitals Association Keystone ICU initiative, a quality improvement collaborative focused on enhancing outcomes across Michigan ICUs. Results demonstrated that there were 174 completed surveys, a 66% response rate. Representatives included staff nurses, nursing leadership, physicians, hospital administrators, respiratory therapists, and pharmacists. Of respondents, 69% identified at least one issue facing ICU survivors after discharge. The concerns most commonly identified by these ICU practitioners were weakness, psychiatric pathologies, cognitive dysfunction, and transitions of care. However, most respondents did not routinely discuss post-ICU problems with patients and families, and only 20% had a mechanism to formally communicate discharge information to primary care providers. Five percent reported having or were in the process of creating a support group for ICU survivors after discharge. The authors conclude that despite growing awareness of the problems faced by ICU survivors, in this statewide quality improvement collaborative, hospital-based support groups are rarely available, and deficiencies in transitions of care exist. Practice innovations and formal research are needed to provide ways to translate awareness of the problems of survivorship into improved outcomes for patients.
Brorson H, Plymoth H, Ormon K, Bolmsio I. Pain relief at the end of life: Nurses' experiences regarding end-of-life pain relief in patients with dementia. Pain Manage Nurs 2014;15:315–323.
Patients with dementia appear to receive suboptimal palliative care, with this patient group at risk to have pain at the end of life. Because communicative impairments are common in this patient group, nurses play an important caregiver role in identifying, assessing, and relieving patients' pain. This descriptive exploratory qualitative study aimed to describe nurses' experiences regarding end-of-life pain relief in patients with dementia. The study was based on seven semistructured interviews. Two main categories were identified: (1) nurses' experience of difficulties concerning pain relief and (2) nurses' experience of resources concerning pain relief. Nurses experienced difficulties, such as feeling of powerlessness because of difficulties in obtaining adequate prescriptions for analgesics, ethical dilemmas, feeling of inadequacy because analgesia did not have the desired effect, and a feeling of not being able to connect with the patient. Factors including knowledge about the patient, professional experience, utilization of pain assessment tools, interpersonal relationships, and interprofessional cooperation served as resources and enabled end-of-life pain relief. The results of this study highlight the complexity of pain relief in patients with dementia at the end of life from a nursing perspective. The inability of patients with dementia to verbally communicate their pain makes them a vulnerable patient group, dependent on their caregivers. Knowing the life story of the patient, professional experience, teamwork based on good communication, and use of a pain assessment tool were reported by the nurses to improve pain relief at the end of life for patients with dementia.
Gray AM, Pounds-Cormish E, Eccles FJR, et al. Deep brain stimulation as a treatment for neuropathic pain: A longitudinal study addressing neuropsychological outcomes. J Pain 2014;15:283–292.
Deep brain stimulation (DBS) of the periventricular/periaqueductal gray area and sensory thalamus can reduce pain intensity in patients with neuropathic pain. However, little is known about its impact on quality of life, emotional well-being, and cognition. This study followed up 18 patients who had received DBS for neuropathic pain. Each participant had previously undergone psychometric evaluation of each of the above areas as part of a routine presurgical neuropsychological assessment. Commensurate measures were employed at a follow-up assessment at least six months postsurgery. DBS significantly improved mood, anxiety, and aspects of quality of life. Improvements correlated with reduced pain severity. However, the sample continued to show impairments in most areas when compared against normative data published on nonclinical samples. There was little change in general cognitive functioning, aside from deterioration in spatial working memory. However, improvements in pain severity were associated with less improvement (and even deterioration) on measures of executive cognitive functioning. Improvements in emotional well-being also were correlated with changes in cognition. These results suggest that DBS of the periventricular/periaqueductal gray and/or sensory thalamus improves quality of life and emotional well-being in sufferers, although there is some indication of executive dysfunction, particularly among those reporting greatest pain alleviation.
Chung K, Richards N, Burke S. Hospice agencies' hospital contract status and differing levels of hospice care. Am J Hospice Palliat Med 2014. E-pub ahead of print.
In response to a 2011 finding that approximately 27% of Medicare-certified hospices do not provide a single day of general inpatient care (GIP), the authors explored the extent to which hospices have contracts with hospitals for GIP. Using the 2007 National Home and Hospice Care Survey, the authors estimated that 1119 (32%) agencies had no contract with any hospitals in 2007 and half of those with no contract did not have a contract with a skilled nursing facility (SNF) either. As a result, these hospices were unable to provide GIP referrals for those in need of inpatient care for acute pain and symptom management. More importantly, not having a contract with a hospital was just one of the factors influencing GIP provision. In the multivariate logistic model, after controlling for contract status with a hospital and other hospice characteristics, agencies in the second quartile of hospice patient census (12–29 versus 73 or more) were independently related to providing only routine home care. These hospices are more likely to rely solely on scatter beds for GIP provision. Given that a significant portion of hospices do not have a contract with a hospital, policy makers need to understand barriers to contracts with a hospital/SNF for GIP and consider a hospice's contract status as one of the standards for hospice certification. In addition, further research is necessary to understand why hospices that do have a contract with a hospital do not make GIP referral.