Who Gets to Determine Whether Home Is "Unsafe" at the End of Life?

Background: At the end of life, some patients wish to be discharged directly home from the hospital, but health care teams may consider this unsafe, raising concerns for capacity and risk. However, defining risk is subjective and impacted by values, preferences, and clinical status. Accommodating patient preferences in discharge destinations can promote autonomy, dignity, and quality of life at the end of life. Observations: We developed a risk assessment framework to help clinicians objectively identify risk factors and protective factors and develop a comprehensive discharge plan. We applied this framework to a veteran nearing the end of life and he was able to successfully return home from the hospital. Conclusions: Approaching end-of-life discharges with a framework can inform discharge planning and lessen the risk of adverse events. Importantly, this framework can help clinicians communicate better and partner with patients and their loved ones in prioritizing patient values and preferences.

An Interdisciplinary Approach to Metastatic Pancreatic Cancer and Comorbid Opioid Use Disorder Treatment Within a VA Health Care System.

A multidisciplinary approach provided safe and feasible cancer treatment in a patient with advanced pancreatic cancer and coexisting active substance use disorder.

Feasibility of Safe Opioid Prescribing in Outpatient Palliative Care: A Quality Improvement Project.

BACKGROUND: No guidelines for safe opioid prescribing in palliative care exist, which contributes to limited monitoring of opioid misuse in palliative care. MEASURES: Feasibility of a safe opioid prescribing standard operating protocol (SOP) was determined by assessing the percentage of patients in an outpatient cancer center who completed each component of a five-component SOP. INTERVENTION: A five-component SOP included: risk stratification for misuse, consent form, prescription drug monitoring program review, urine drug testing, and Naloxone for high-risk individuals. OUTCOMES: After one year, compliance rates on four of the of the five-component SOP were greater or equal to 93%. Naloxone co-prescription for high-risk patients never reached over 78%, largely due to clinical decision not to co-prescribe if transition to hospice was imminent. CONCLUSIONS/LESSONS LEARNED: Safe opioid prescribing measures are feasible in outpatient palliative care and can facilitate identification of individuals at risk for opioid misuse and prompt early interventions for misuse.

Quality of Life in Patients With Pancreatic Cancer and Their Caregivers: A Systematic Review.

Little is known about quality of life (QOL) of patients with pancreatic cancer and their caregivers compared with adults with other cancers. This systematic review summarizes the available evidence base, identifies its limitations, and recommends directions for research and clinical application. A systematic review was conducted of research on QOL in adults with pancreatic cancer and their caregivers. Quality of life was examined in the following specific domains: psychological, physical, social, sexual, spiritual, and general. Of the 7130 articles reviewed, 36 studies met criteria for inclusion. Compared with healthy adults or population norms, adults with pancreatic cancer had worse QOL across all domains. Compared with patients with other cancer types, patients with pancreatic cancer evidenced worse psychological QOL. Physical and social QOL were either similar or more compromised than in patients with other cancers. Limited data preclude conclusions about sexual, spiritual, and caregiver QOL. Patients with pancreatic cancer evidence decrements in multiple QOL domains, with particular strain on psychological well-being. Methodological limitations of available studies restrict definitive conclusions. Future research with well-defined samples, appropriate statistical analyses, and longitudinal designs is needed. Findings from this review support the merits of distress screening, integration of mental health professionals into medical teams, and attention to caregiver burden.

Stuck in the spin cycle: Avoidance and intrusions following breast cancer diagnosis.

OBJECTIVES: Theories and research regarding cognitive and emotional processing during the experience of profound stressors suggest that the presence of intrusive thoughts and feelings predicts greater use of avoidance and that the use of avoidance paradoxically predicts more intrusions. However, empirical investigations of their purported bidirectional relationship are limited. DESIGN: This study presents a longitudinal investigation of the reciprocal relationship between intrusions and avoidance coping over a 6-month period in the year following breast cancer diagnosis. METHODS: Breast cancer patients (N = 460) completed measures of cancer-related intrusions and avoidance at study entry, 3 months, and 6 months later (i.e., an average of 2, 5, and 8 months after diagnosis, respectively). RESULTS: Cross-lagged panel analyses revealed that intrusive thoughts, feelings, and images at study entry predicted greater avoidance 3 months later, and avoidance coping at study entry predicted intrusions 3 months later, controlling for the stability of intrusions and avoidance as well as time since diagnosis. Findings were not statistically significant for avoidance predicting intrusions, or vice versa, between the 3-month and the 6-month assessment period, during which they declined. CONCLUSIONS: These findings provide empirical support for the theoretical contention that avoidance and intrusive thoughts and emotions reciprocally influence one another following stressful events. Additionally, in the months shortly after breast cancer diagnosis, intrusions and avoidance are positively related. However, the relationships attenuate over time, which could indicate resolved cognitive and emotional processing of the cancer experience. Statement of contribution What is already known on this subject? Following stressful life events, individuals often experience intrusive thoughts and feelings related to the event and they report avoidance of such reminders. Many studies demonstrate that greater intrusions predict more subsequent use of avoidance coping, and other studies show that greater use of avoidance predicts more intrusions. Their reciprocal relation has not been examined, however. What does this study add? This is the first examination of the concurrent, reciprocal influence of intrusions and avoidance. Findings suggest that accounting for the bidirectional influence of avoidance and intrusions best estimates hypothesized models. Higher intrusions and avoidance predicted each other for the first 3 months after study entry, but the relationship diminished 6 months after study entry, perhaps due to productive mental processing of the stress of breast cancer diagnosis and treatment.

Chronic and episodic stress predict physical symptom bother following breast cancer diagnosis.

Breast cancer patients often experience adverse physical side effects of medical treatments. According to the biobehavioral model of cancer stress and disease, life stress during diagnosis and treatment may negatively influence the trajectory of women's physical health-related adjustment to breast cancer. This longitudinal study examined chronic and episodic stress as predictors of bothersome physical symptoms during the year after breast cancer diagnosis. Women diagnosed with breast cancer in the previous 4 months (N = 460) completed a life stress interview for contextual assessment of chronic and episodic stress severity at study entry and 9 months later. Physical symptom bother (e.g., pain, fatigue) was measured at study entry, every 6 weeks through 6 months, and at nine and 12 months. In multilevel structural equation modeling (MSEM) analyses, both chronic stress and episodic stress occurring shortly after diagnosis predicted greater physical symptom bother over the study period. Episodic stress reported to have occurred prior to diagnosis did not predict symptom bother in MSEM analyses, and the interaction between chronic and episodic stress on symptom bother was not significant. Results suggest that ongoing chronic stress and episodic stress occurring shortly after breast cancer diagnosis are important predictors of bothersome symptoms during and after cancer treatment. Screening for chronic stress and recent stressful life events in the months following diagnosis may help to identify breast cancer patients at risk for persistent and bothersome physical symptoms. Interventions to prevent or ameliorate treatment-related physical symptoms may confer added benefit by addressing ongoing non-cancer-related stress in women's lives.

Extinction retention and the menstrual cycle: Different associations for women with posttraumatic stress disorder.

The propensity to acquire and retain conditioned fear responses may contribute to the risk of developing and maintaining posttraumatic stress disorder (PTSD) following a traumatic event. There is growing evidence that the gonadal hormones estrogen and progesterone are associated with how well women retain extinction of previously conditioned fear responses. Thus, sex steroid effects may contribute to the increased prevalence of PTSD in women. For the current study, 32 nonmedicated female trauma survivors with and without PTSD completed a differential fear conditioning task both during the early follicular phase of the menstrual cycle when estradiol and progesterone levels are low, and during the midluteal phase when estradiol and progesterone levels are high. Skin conductance served as the measure of conditioned fear. Women with PTSD, compared to those without, showed impaired retention of extinction learning in the midluteal phase of the menstrual cycle. Therefore, the impact of menstrual phase on extinction retention may differ between women with and without PTSD. These findings raise potential considerations regarding the coordination of psychopharmacologic and trauma exposure-based treatments for PTSD with specific phases of the menstrual cycle.

Dispositional emotional expressivity, cancer-specific coping, and distress in socioeconomically-disadvantaged Latinas.

OBJECTIVE: Coping processes directed toward avoiding and approaching stressor-related thoughts and emotions predict psychological adjustment. However, few studies have examined how the relationship between dispositional emotional tendencies and stressor-specific coping affects outcomes. The aim of the current study was to examine the association of dispositional emotional expressivity (i.e., the propensity to experience and express emotions strongly) with cancer-specific coping through avoidance and emotional approach to predict intrusive thoughts and depressive symptoms in Latinas with breast cancer. METHOD: Recently diagnosed Latina breast cancer patients receiving treatment completed standardized assessments via interview at 2 time points: within 18 months of diagnosis (Time 1; N = 95) and 3 months later (Time 2; N = 79). RESULTS: Most women were immigrants (93%), reported a combined household income of $20,000 or less (75%), did not graduate from high school (59%), and primarily spoke Spanish (88%). In path analyses, more recent immigration was associated with greater dispositional expressivity, which in turn was associated with coping with the cancer experience using both greater avoidance and emotional approach strategies. Only avoidance-oriented strategies predicted an increase in intrusive thoughts at 3 months. No significant effects on depressive symptoms were observed. CONCLUSIONS: Findings suggest that Latina breast cancer patients who have a propensity to experience and express emotions strongly may be initially overwhelmed by their cancer-related emotions and consequently turn to avoidance-oriented and emotional approach strategies to cope with their diagnosis. Avoidance-oriented coping in turn may uniquely predict an increase in cancer-related intrusive thoughts 3 months later. (PsycINFO Database Record

Dispositional and Situational Avoidance and Approach as Predictors of Physical Symptom Bother Following Breast Cancer Diagnosis.

BACKGROUND: Few studies examine whether dispositional approach and avoidance coping and stressor-specific coping strategies differentially predict physical adjustment to cancer-related stress. PURPOSE: This study examines dispositional and situational avoidance and approach coping as unique predictors of the bother women experience from physical symptoms after breast cancer treatment, as well as whether situational coping mediates the prediction of bother from physical symptoms by dispositional coping. METHOD: Breast cancer patients (N = 460) diagnosed within the past 3 months completed self-report measures of dispositional coping at study entry and of situational coping and bother from physical symptoms every 6 weeks through 6 months. RESULTS: In multilevel structural equation modeling analyses, both dispositional and situational avoidance predict greater symptom bother. Dispositional, but not situational, approach predicts less symptom bother. Supporting mediation models, dispositional avoidance predicts more symptom bother indirectly through greater situational avoidance. Dispositional approach predicts less symptom bother through less situational avoidance. CONCLUSION: Psychosocial interventions to reduce cancer-related avoidance coping are warranted for cancer survivors who are high in dispositional avoidance and/or low in dispositional approach.

Psychophysiological assessment of PTSD: a potential research domain criteria construct.

Most research on posttraumatic stress disorder (PTSD) relies on clinician-administered interview and self-report measures to establish the presence/absence and severity of the disorder. Accurate diagnosis of PTSD is made challenging by the presence of symptoms shared with other psychopathologies and the subjective nature of patients' descriptions of their symptoms. A physiological assessment capable of reliably "diagnosing" PTSD could provide adjunctive information that might mitigate these diagnostic limitations. In the present study, we examined the construct validity of a potential psychophysiological measure of PTSD, that is, psychophysiological reactivity to script-driven imagery (SDI-PR), as measured against the current diagnostic "gold-standard" for PTSD, the Clinician-Administered PTSD Scale (CAPS). Convergent and predictive validity and stability were examined. Thirty-six individuals completed an SDI-PR procedure, the CAPS, and self-report measures of mental and physical health at their initial visit and approximately 6 months later. SDI-PR and the CAPS demonstrated excellent stability across measurement occasions. SDI-PR showed moderately strong convergent validity with the CAPS. After adjusting for self-reported depression, predictive validity for the CAPS, with regard to health sequelae, was reduced, whereas it remained mostly unchanged for SDI-PR. Findings support SDI-PR as a valid and stable measure of PTSD that captures a pathophysiologic process in individuals with PTSD. Results are discussed with regard to the research domain criteria framework.

Physiological predictors of posttraumatic stress disorder.

Studies have assessed relationships between posttraumatic stress disorder (PTSD) symptoms and physiological reactivity concurrently; fewer have assessed these relationships longitudinally. This study tests concurrent and prospective relationships between physiological reactivity (heart rate and skin conductance) to a monologue procedure and PTSD symptoms in female assault survivors, tested within 1 and 3 months posttrauma. After controlling for initial PTSD and peritraumatic dissociation, 3 measures of increased physiological reactivity to the trauma monologue at 1 month predicted 3-month PTSD reexperiencing severity. Additionally, increased heart rate following trauma and neutral monologues at 1 month was predictive of 3-month numbing symptoms. Implications for the prospective relationship between physiological reactivity to trauma cues and PTSD over time are discussed.