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on the content and process of feedback sessions with 132 graduates from the University of the Witwatersrand during their community service placements from 2003-2008. Experiences and perceptions of these graduates are discussed in relation to a model as well as in relation to additional research conducted with our profession and other Community Serv...
Citations
... 2 In such a process, doctors and patients collaborate in making decisions considering both the best available evidence and patients' preferences. A well-balanced dialogue between doctor and patient can thus be considered a key element of good quality of care. 1 Information about the decision-making process of PST in advanced cancer patients is, however, relatively scarce, 3 especially for second-line PST and higher. In addition, commonly used outcome measures in clinical trials may be insufficient to evaluate whether continuation of PST is still desirable. ...
Background
Decisions about palliative systemic treatment are key elements of palliative and end-of-life care. Such decisions must often be made in complex, clinical situations.
Aim
To explore the content of medical records of patients with advanced non-small cell lung cancer and pancreatic cancer with specific emphasis on doctors’ notes about decisions on palliative systemic treatment.
Design
Medical record review (2009–2012) of 147 cancer patients containing 276 notes about palliative systemic treatment. We described the proportion of notes/medical records containing pre-specified items relevant to palliative systemic treatment. We selected patients using the nationwide Netherlands Cancer Registry.
Setting
Hospital based.
Results
About 75% of all notes reported doctors’ considerations to start/continue palliative systemic treatment, including information about the prognosis (47%), possible survival gain (22%), patients’ wish for palliative systemic treatment (33%), impact on quality of life (8%), and patient’s age (3%). Comorbidity (82%), smoking status (78%) and drinking behaviour (63%) were more often documented than patients’ performance status (16%). Conversations with the patient/family about palliative systemic treatment were reported in 49% of all notes. Response measurements and dose adaptations were documented in 75% and 71% of patients who received palliative systemic treatment respectively.
Conclusion
Medical records provide insight into the decision-making process about palliative systemic treatment. The content and detail of doctors’ notes, however, widely varies especially concerning their palliative systemic treatment considerations. Registries that aim to measure the quality of (end-of-life) care must be aware of this outcome. Future research should further explore how medical records can best assist in evaluating the quality of the decision-making process in the patient’s final stage of life.
... Patients' passive stance in the treatment decision-making at the same time resulted in an active stance towards their approaching death: chemotherapy gave patients the opportunity to control their life; to subdivide their life in well-ordered parts; to live in the present; and to live a longer life. Previous literature shows that patients frequently want to attain hope for a longer life with the help of chemotherapy [33]. However, we found no literature demonstrating the facilitating role of chemotherapy to enable living in the present. ...
To explore the extent to which patients have a directing role in decisions about chemotherapy in the palliative phase of cancer and (want to) anticipate on the last stage of life.
Qualitative interview study.
In depth-interviews with 15 patients with advanced colorectal or breast cancer at the medical oncology department in a Dutch teaching hospital; interviews were analysed following the principles of thematic content-analysis.
All patients reported to know that the chemotherapy they received was with palliative intent. Most of them did not express the wish for information about (other) treatment options and put great trust in their physicians' treatment advice. The more patients were aware of the severity of their disease, the more they seemed to 'live their life' in the present and enjoy things besides having cancer. Such living in the present seemed to be facilitated by the use of chemotherapy. Patients often considered the 'chemotherapy-free period' more stressful than periods when receiving chemotherapy despite their generally improved physical condition. Chemotherapy (regardless of side-effects) seemed to shift patients' attention away from the approaching last stage of life. Interestingly, although patients often discussed advance care planning, they were reluctant to bring on end-of-life issues that bothered them at that specific moment. Expressing real interest in people 'as a person' was considered an important element of appropriate care.
Fearing their approaching death, patients deliberately focus on living in the present. Active (chemotherapy) treatment facilitates this focus, regardless of the perceived side-effects. However, if anxiety for what lies ahead is the underlying reason for treatment, efforts should be made in assisting patients to find other ways to cope with this fear. Simultaneously, such an approach may reduce the use of burdensome and sometimes costly treatment in the last stage of life.
Een ethische kwestie in de medische praktijk is aan een aantal aspecten te herkennen, waarvan de belangrijkste zijn: de tragiek van de situatie, de sterke emoties verbonden met persoonlijke waarden en de noodzaak verantwoording af te leggen over de genomen beslissing.Morele counseling is de gesprekswijze die dokters kunnen volgen om ethische kwesties met hun patiënten te bespreken. Meestal gaat het bij morele counseling om het begeleiden van de patiënt bij een morele beslissing. Uitdaging voor de arts is om in het consult voldoende aandacht aan die begeleiding te besteden, en tegelijkertijd oog te houden voor de andere doelen die in het medisch consult moeten worden bereikt.Moreel beraad is de methode om ethische kwesties met collega’s in interdisciplinair verband te kunnen bespreken. Er zijn verschillende soorten stappenplannen voor moreel beraad in gebruik, maar bij alle vormen van moreel beraad staat de definiëring van het morele probleem centraal.Morele reflectie kan medische professionals helpen meer inzicht te verkrijgen in hun eigen morele opvattingen die het beroepsfunctioneren beïnvloeden. Methoden voor morele reflectie kunnen zowel individueel als in groepsverband, met collega’s onderling, worden toegepast. Een ethische kwestie in de medische praktijk is aan een aantal aspecten te herkennen, waarvan de belangrijkste zijn: de tragiek van de situatie, de sterke emoties verbonden met persoonlijke waarden en de noodzaak verantwoording af te leggen over de genomen beslissing. Morele counseling is de gesprekswijze die dokters kunnen volgen om ethische kwesties met hun patiënten te bespreken. Meestal gaat het bij morele counseling om het begeleiden van de patiënt bij een morele beslissing. Uitdaging voor de arts is om in het consult voldoende aandacht aan die begeleiding te besteden, en tegelijkertijd oog te houden voor de andere doelen die in het medisch consult moeten worden bereikt. Moreel beraad is de methode om ethische kwesties met collega’s in interdisciplinair verband te kunnen bespreken. Er zijn verschillende soorten stappenplannen voor moreel beraad in gebruik, maar bij alle vormen van moreel beraad staat de definiëring van het morele probleem centraal. Morele reflectie kan medische professionals helpen meer inzicht te verkrijgen in hun eigen morele opvattingen die het beroepsfunctioneren beïnvloeden. Methoden voor morele reflectie kunnen zowel individueel als in groepsverband, met collega’s onderling, worden toegepast.
