Issues in prognostication for hospital specialist palliative care doctors and nurses: A qualitative inquiry

ArticleinPalliative Medicine 27(2) · December 2011with13 Reads
DOI: 10.1177/0269216311432898 · Source: PubMed
Abstract
Background: Patients with advanced life-limiting diseases have high information needs concerning prognosis yet discussions between patients and healthcare professionals are either avoided or inaccurate due to over-optimism. Available prognostic models are problematic. Literature indicates that hospital specialist palliative care professionals are frequently asked to prognosticate, although their experience of prognostication is unknown. Identifying this experience will support the development of prognosis training for hospital specialist palliative care professionals.
    • "Historically, survival estimation has been categorised into two general methods. In the first method, CES, has been summarised as a ‘personal clinical judgement’ that is subjective in nature with complex and poorly defined variables.1 Pontin and Jordan recently reported the findings of their study addressing views on the overall prognostication experience among a cohort of palliative care clinicians.9 The study provides an important overview of the clinicians’ experience and particularly underscores the potential impact of CES inaccuracy on clinicians themselves and the fear and uncertainty often experienced. "
    [Show abstract] [Hide abstract] ABSTRACT: For patients with advanced and/or incurable disease, clinicians are often called upon to formulate and communicate an estimate of likely survival duration. The objective of this study was to gain a deeper appreciation of this process by identifying and exploring the specific elements that may inform and/or impact a clinician's estimate of survival (CES). Semistructured interviews were conducted among a group of palliative care clinicians in the setting of a tertiary academic health sciences centre. Qualitative data were subsequently analysed using a grounded theory approach. Five major themes were identified as being central to the process of CES formulation: use of objective patient-specific elements, strength of the patient-clinician relationship, purpose and context of an individual CES, perceived role of hope and the overall likelihood of CES inaccuracy. For any given patient, several elements have the potential to inform and/or impact the process of CES formulation. Study participants were aware of objective clinical factors known to correlate with actual survival duration and likely integrate this information when formulating a CES. Formulation occurs within a larger context comprised of a number of elements that may influence individual estimates. These elements exist against a background of awareness of the overall likelihood of CES inaccuracy. Clinicians are encouraged to develop a personalised and standardised approach to CES formulation whereby an awareness of the menu of potentially impacting elements is consciously integrated into an individual process.
    Full-text · Article · Sep 2013
  • [Show abstract] [Hide abstract] ABSTRACT: Communicating with patients about their feelings and preferences for the future is a challenging element of palliative care. Useful evidence exists, but most is embedded in social-scientific rather than clinical research. To collate evidence about communication practices used in addressing sensitive future issues, from studies where patient/professional conversations have been recorded and analysed. To inform communication policy, practice and training. This innovative systematic review spanned social science, clinical and linguistics research. Using explicit criteria, we searched electronic databases and specialist sources. We used review and synthesis techniques appropriate for social-science research. 2203 publications were initially identified. Of the 18 meeting the inclusion criteria, 5 were social science, five clinical and eight linguistics publications. Strong evidence (11/18) indicates hypothetical questions are effective in encouraging people to address feelings and plans for uncertain and difficult futures. Moderate evidence (5/18) indicates that another way to create such opportunities entails using cautious, euphemistic language; and that this provides distinctive opportunities for people to deflect or avoid the topic. Moderate evidence (3/21) indicates that people often steer such conversations towards more optimistic statements, which tends to stop further talk about difficult events. Social-science, linguistic and clinical evidence is available to inform this skilled, often problematic element of care. There are different ways to provide opportunities to discuss feelings and plans in relation to end of life. Different ways have different results: better understandings of these will facilitate evidence-based communication. To fill gaps in knowledge, further research using recordings of authentic palliative care consultations is needed.
    Full-text · Article · Mar 2013
  • [Show abstract] [Hide abstract] ABSTRACT: Background Conversation and discourse analytic research has yielded important evidence about skills needed for effective, sensitive communication with patients about illness progression and end of life. Objectives To: ▸ Locate and synthesise observational evidence about how people communicate about sensitive future matters; ▸ Inform practice and policy on how to provide opportunities for talk about these matters; ▸ Identify evidence gaps. Design Systematic review of conversation/discourse analytic studies of recorded interactions in English, using a bespoke appraisal approach and aggregative synthesis. Results 19 publications met the inclusion criteria. We summarised findings in terms of eight practices: ‘fishing questions’—open questions seeking patients’ perspectives (5/19); indirect references to difficult topics (6/19); linking to what a patient has already said—or noticeably not said (7/19); hypothetical questions (12/19); framing difficult matters as universal or general (4/19); conveying sensitivity via means other than words, for example, hesitancy, touch (4/19); encouraging further talk using means other than words, for example, long silences (2/19); and steering talk from difficult/negative to more optimistic aspects (3/19). Conclusions Practices vary in how strongly they encourage patients to engage in talk about matters such as illness progression and dying. Fishing questions and indirect talk make it particularly easy to avoid engaging—this may be appropriate in some circumstances. Hypothetical questions are more effective in encouraging on-topic talk, as is linking questions to patients’ cues. Shifting towards more ‘optimistic’ aspects helps maintain hope but closes off further talk about difficulties: practitioners may want to delay doing so. There are substantial gaps in evidence.
    Full-text · Article · Oct 2014
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  • Full-text · Article · Jun 2015
  • [Show abstract] [Hide abstract] ABSTRACT: Context: Palliative care for the older person is often limited, resulting in poor quality of dying. Pharmacological management can be one of the components to achieve better symptom control. Objectives: To describe the anticipatory prescription of medication for symptomatic treatment and the deprescription of potentially inappropriate medication (PIM) during the last days of life. Methods: This was a cross-sectional descriptive study between October 1, 2012 and September 30, 2013 in twenty-three acute geriatric wards in Flanders, Belgium. Structured after-death questionnaires were filled out by the treating geriatrician for patients hospitalized for more than 48 hours before dying. Results: Anticipatory prescription of medication was present in 65.4% of cases, 45.5% of the cases was prescribed morphine, 15.5% benzodiazepines and 13.8% scopolamine hydrobromide. A deprescription of PIM was noted in 67.9% of cases. The likelihood of anticipatory prescription was significantly higher in cases where death was expected (OR 19; 95%CI 9-40; {<0.0001) and significantly lower where dementia was present (OR 0.35; 95% CI 0.16-0.74; P<0.006). The likelihood of deprescription was higher in cases where death was expected (OR 20; 95% CI 10-43; P<0.0001) and in cases of patients dying from an oncological disease compared with those dying from frailty or dementia (OR 7.0; 95% CI 1.1-45.6, P=0.042). Conclusion: Anticipatory prescription of medication and deprescription of medication at the end of life in acute geriatric wards could be further optimized. A well-developed intervention to guide health care staff in patient-centered pharmacological management in the last days of life seems to be needed.
    Article · Feb 2016