Abstract
Hagiwara Y, Ross J, Lee S, Sanchez-Reilly S: Tough conversations. Development of a curriculum for medical students to lead family meetings. Am J Hospice Palliat Med 2016 [Epub ahead of print]; DOI: 10.1177/1049909116669783.
Few educational interventions have been developed to teach family meeting (FM) communication skills at the undergraduate level. The authors developed an innovative curriculum to address this gap. Fourth year medical students during 2011–2013 (n = 674) completed training for conducting an FM. To assess the effectiveness of the training, students completed an FM Objective Structured Clinical Exam (OSCE) that included 15 domains rated on a 1–5 point Likert scale. Tasks included discussing prognosis, establishing goals of care, and demonstrating conflict resolution skills. Students received one-to-one feedback from standardized family members and faculty observers. Group debriefings with faculty were held after the OSCE. Results demonstrated that analysis of faculty feedback narratives revealed four themes in which students required improvement: (1) discussing prognosis, (2) explaining palliative care/hospice, (3) avoiding medical jargon, and (4) discussing cultural/religious preferences. Qualitative analysis of group debriefings suggested that student perception of the OSCE experience was positive overall. Students found the case to be realistic and immediate feedback to be helpful. The authors conclude that conducting an FM is an advanced skill, and that their study shows that it is possible to train fourth year students to lead FMs and identify their strengths and needs using an FM OSCE.
Gibbs AJO, Malyon AC, Fritz ZB: Themes and variations: An exploratory international investigation into resuscitation decision-making. Resuscitation 2016;103:75–81.
Do not attempt cardiopulmonary resuscitation (DNACPR) decisions are made in hospitals throughout the globe. International variation in clinicians’ perception of DNACPR decision making and implementation and the factors influencing such variation have not previously been explored. A questionnaire asking how DNACPR decisions are made, communicated, and perceived in their country was composed: it consisted of seven closed-answer and four open-answer questions. It was distributed to 143 medical professionals with prior published material relating to DNACPR decisions. Under-represented geographical areas were identified and an additional 34 physicians were contacted through medical colleagues and students at the university hospital from which this study was based. The respondents had four weeks to answer the questionnaire. Seventy-eight responses (44%) were received from 43 countries. All continents were represented. Eighty-eight percent of respondents reported a method for implementing DNACPR decisions, 90% of which discussed resuscitation wishes with the patient at least half of the time. Ninety-four percent of respondents thought that national guidance for DNACPR order implementation should exist; 53% of countries surveyed reported existence of such guidance. Cultural attitudes toward death, medical education and culture, health economics, and the societal role of family were commonly identified as factors influencing perception of DNACPR decisions. The authors conclude that the majority of countries surveyed make some form of DNACPR decision, but differing cultures and economic status contribute toward a heterogeneity of approaches to resuscitation decision making. Adequacy of relevant medical education and national policy are two areas that were regularly identified as impacting upon the processes of DNACPR decision making and implementation.
Martinez M, Arantzamendi M, Belar A, et al.: “Dignity therapy,” a promising intervention in palliative care: A comprehensive systematic literature review. Palliat Care 2016 [Epub ahead of print]; DOI: 10.1177/0269216316665562.
Dignity therapy is psychotherapy to relieve psychological and existential distress in patients at the end of life; however, little is known about its effect. In this study, the authors attempted to analyze the outcomes of dignity therapy in patients with advanced life-threatening diseases. A systematic review was conducted. Three authors extracted data of the articles and evaluated their quality. Data were synthesized, considering study objectives. The data sources were PubMed, CINAHL, Cochrane Library, and PsycINFO. The years searched were from 2002 (year of dignity therapy development) to January 2016. “Dignity therapy” was used as a search term. Studies with patients with advanced life-threatening diseases were included. Results demonstrated that of 121 studies, 28 were included. Quality of the studies was high. Results were grouped into effectiveness, satisfaction, suitability, and feasibility, and adaptability to different diseases and cultures. Two of five randomized control trials applied dignity therapy to patients with high levels of baseline psychological distress. One showed statistically significant decrease on patients’ anxiety and depression scores over time. The other showed statistical decrease on anxiety scores pre–post dignity therapy, not on depression. Nonrandomized studies suggested statistically significant improvements in existential and psychosocial measurements. Patients, relatives, and professionals perceived it improved end-of-life experience. The authors conclude that evidence suggests that dignity therapy is beneficial. One randomized controlled trial with patients with high levels of psychological distress showed DT efficacy in anxiety and depression scores. Other design studies reported beneficial outcomes in terms of end-of-life experience. The authors suggest that further research should understand how dignity therapy functions to establish a means for measuring its impact and assessing whether high level of distress patients can benefit most from this therapy.
Putman MS, Tak HJ, Curlin FA, Yoon JD: Quality of life and recommendations for further care. Crit Care Med 2016 [Epub ahead of print]; DOI: 10.1097/CCM.0000000000001846.
Physician recommendations for further medical treatment or palliative treatment only at the end of life may influence patient decisions. Little is known about the patient characteristics that affect physician-assessed quality of life or how such assessments are related to subsequent recommendations. The authors undertook a 2010 mailed survey of practicing U.S. physicians (1156/1878 or 62% of eligible physicians responded) in an attempt to define patient characteristics. Measures included an end-of-life vignette with five experimentally varied patient characteristics: setting, alimentation, pain, cognition, and communication. Physicians rated vignette patient quality of life on a scale from 0 to 100 and indicated whether they would recommend continuing full medical treatment or palliative treatment only. Results demonstrated that cognitive deficits and alimentation had the greatest impacts on recommendations for further care, but pain and communication were also significant (all p < 0.001). Physicians who recommended continuing full medical treatment rated quality of life three times higher than those recommending palliative treatment only (40.41 vs. 12.19; p < 0.01). Religious physicians were more likely to assess quality of life higher and to recommend full medical treatment. The authors conclude that physician judgments about quality of life are highly correlated with recommendations for further care, and that patients and family members might consider these biases when negotiating medical decisions.
Chidiac C, Connolly M: Considering the impact of stigma on lesbian, gay and bisexual people receiving palliative and end-of-life care. Intl J Palliat Nurs 2016 [Epub ahead of print]; DOI: 10.12968/ijpn.2016.22.7.334.
Stigma is a common characteristic among lesbian, gay, and bisexual (LGB) people's lives. The LGB population faces a challenge in finding ways to adapt to its stigmatized identity. Stigma and its related processes can have an isolating and negative effect on LGB individuals, who are seen as and often perceive themselves as different. Stigma can also have a negative effect on health and well-being and can influence the type of care received from health and social care professionals, including those working in palliative care. This article presents a discussion of the impact that stigma has on LGB people who access and receive palliative and end-of-life care.
Peres J: A time and place: The role of social workers in improving end-of-life care. J Soc Work End of Life Palliat Care 2016 [Epub ahead of print]; DOI: 10.1080/15524256.2016.1200522.
Americans are living longer, but dying after a prolonged period of multiple chronic illnesses and functional disabilities. Despite public and professional activity targeted toward improving care for the dying and supporting the families, gaps in care and challenges in end-of-life care persist. Contentious issues such as the so-called “death panels” or physician payment for discussion of advance directives and care wishes at the end of life, aid in dying, and individuals who actively choose death (case of Brittney Maynard) are continually debated in the public media. Progress toward improvement in the experience of dying remains incremental and change has been slow. With the release of a second Institute of Medicine (2014) report devoted to what it means to die in America in the 21st century, momentum and opportunity for change may increase. If this is to happen, social workers will need to deliver the range of biopsychosocial care that patients and families so desperately need. However, holistic care of the individual will only improve, if the nation also addresses ongoing systemic problems in financing, policy, and service delivery in end-of-life care.