A Video Decision Aid Improves Informed Decision Making in Patients With Advanced Cancer Considering Palliative Radiation Therapy.

CONTEXT: Advanced cancer patients have unrecognized gaps in their understanding about palliative radiation therapy (PRT). OBJECTIVES: To build a video decision aid for hospitalized patients with advanced cancer referred for PRT and prospectively test its efficacy in reducing decisional uncertainty, improving knowledge, increasing treatment readiness and readiness for palliative care consultation, and its acceptability among patients. METHODS: Forty patients with advanced cancer hospitalized at Memorial Sloan Kettering Cancer Center watched a video decision aid about PRT and palliative care. Patients' conceptual and logistical knowledge of PRT, decisional uncertainty, treatment readiness, and readiness for palliative care consultation were assessed before and after watching the video with a six-item knowledge survey, the decisional uncertainty subscale of the Decisional Conflict Scale, and Likert instruments to assess readiness to accept radiation treatment and/or palliative care consultation, respectively. A postvideo survey assessed the video's acceptability among patients. RESULTS: After watching the video, decisional uncertainty was reduced (28.3 vs. 21.7; P = 0.02), knowledge of PRT improved (60.4 vs. 88.3; P < 0.001), and PRT readiness increased (2.0 vs. 1.3; P = 0.04). Readiness for palliative care consultation was unchanged (P = 0.58). Patients felt very comfortable (70%) watching the video and would highly recommend it (75%) to others. CONCLUSION: Among hospitalized patients with advanced cancer, a video decision aid reduced decisional uncertainty, improved knowledge of PRT, increased readiness for PRT, and was well received by patient viewers.

Using electronic health records to characterize prescription patterns: focus on antidepressants in nonpsychiatric outpatient settings.

OBJECTIVE: To characterize nonpsychiatric prescription patterns of antidepressants according to drug labels and evidence assessments (on-label, evidence-based, and off-label) using structured outpatient electronic health record (EHR) data. METHODS: A retrospective analysis was conducted using deidentified EHR data from an outpatient practice at a New York City-based academic medical center. Structured "medication-diagnosis" pairs for antidepressants from 35 325 patients between January 2010 and December 2015 were compared to the latest drug product labels and evidence assessments. RESULTS: Of 140 929 antidepressant prescriptions prescribed by primary care providers (PCPs) and nonpsychiatry specialists, 69% were characterized as "on-label/evidence-based uses." Depression diagnoses were associated with 67 233 (48%) prescriptions in this study, while pain diagnoses were slightly less common (35%). Manual chart review of "off-label use" prescriptions revealed that on-label/evidence-based diagnoses of depression (39%), anxiety (25%), insomnia (13%), mood disorders (7%), and neuropathic pain (5%) were frequently cited as prescription indication despite lacking ICD-9/10 documentation. CONCLUSIONS: The results indicate that antidepressants may be prescribed for off-label uses, by PCPs and nonpsychiatry specialists, less frequently than believed. This study also points to the fact that there are a number of off-label uses that are efficacious and widely accepted by expert clinical opinion but have not been included in drug compendia. Despite the fact that diagnosis codes in the outpatient setting are notoriously inaccurate, our approach demonstrates that the correct codes are often documented in a patient's recent diagnosis history. Examining both structured and unstructured data will help to further validate findings. Routinely collected clinical data in EHRs can serve as an important resource for future studies in investigating prescribing behaviors in outpatient clinics.

Efficacy of a survivorship-focused consultation versus a time-controlled rehabilitation consultation in patients with lymphoma: A cluster randomized controlled trial.

BACKGROUND: Survivors of cancer often describe a sense of abandonment after treatment along with heightened uncertainty and limited knowledge of what lies ahead. This study examined the efficacy of a survivorship care plan (SCP) intervention to help physicians to address survivorship issues through communication skills training plus a new consultation focused on the use of an SCP for patients with Hodgkin lymphoma and diffuse large B-cell lymphoma. METHODS: This 4-site cluster randomized trial examined the efficacy of a survivorship planning consultation (SPC) in patients who achieved complete remission after the completion of first-line therapy (for the SPC, physicians received communication skills training and, using an SCP, applied those skills in a survivorship-focused office visit) versus a control arm in which physicians were trained in and subsequently provided a time-controlled, manualized wellness rehabilitation consultation (WRC) focused only on discussion of healthy nutrition and exercise as rehabilitation after chemotherapy. The primary outcomes for patients were changes in knowledge about lymphoma and adherence to physicians' recommendations for vaccinations and cancer screenings. RESULTS: Forty-two physicians and 198 patients participated across the 4 sites. Patients whose physicians were in the SPC arm had greater knowledge about their lymphoma (P = .01) and showed greater adherence to physician recommendations for influenza vaccinations (P = .02) and colonoscopy (P = .02) than patients whose physicians were in the WRC arm. CONCLUSIONS: A dedicated consultation using an SCP and supported by communication skills training may enhance patients' knowledge and adherence to some health promotion recommendations.

A rigorous evaluation of an institutionally-based communication skills program for post-graduate oncology trainees.

OBJECTIVE: Integrating education about physician-patient communication into oncology specialists' education is important to improve quality of care. Our aim was to rigorously evaluate a 4-year institutionally-based patient communication skills program for oncology post-graduate trainees. METHODS: Trainees from 10 specialties in the U.S. participated in patient communication skills modules tailored to sub-specialties. The program was evaluated by comparing pre-post scores on hierarchical outcomes: course evaluation, self-confidence, skills uptake in standardized and real patient encounters, and patient evaluations of satisfaction with communication. We examined breadth of skill usage as key outcome. Generalized estimating equations were used in data analysis. RESULTS: Two hundred and sixty-two trainees' data were analyzed, resulting in 984 standardized and 753 real patient encounters. Participants reported high satisfaction and demonstrated significant skill growth with standardized patients, but transfer of these skills into real patient encounters was incomplete. Participants with lower baseline scores had larger improvements with both standardized and real patients. CONCLUSION: The program was well received and increased participant skills in the simulated setting without effective transfer to real patient encounters. PRACTICE IMPLICATIONS: Future work should allocate proportionally greater resources to trainees with lower baseline scores and measure breadth of participant skill usage as an outcome.

Protocol for a cluster randomised trial of a communication skills intervention for physicians to facilitate survivorship transition in patients with lymphoma.

INTRODUCTION: Survivors of cancer often describe a sense of abandonment post-treatment, with heightened worry, uncertainty, fear of recurrence and limited understanding of what lies ahead. This study examines the efficacy of a communication skills training (CST) intervention to help physicians address survivorship issues and introduce a new consultation focused on the use of a survivorship care plan for patients with Hodgkin's lymphoma and diffuse large B-cell lymphoma. METHODS AND ANALYSIS: Specifically, this randomised, 4-site trial will test the efficacy of a survivorship planning consultation (physicians receive CST and apply these skills in a new survivorship-focused office visit using a survivorship plan) with patients who have achieved complete remission after completion of first-line therapy versus a control arm in which physicians are trained to subsequently provide a time-controlled, manualised wellness rehabilitation consultation focused only on discussion of healthy nutrition and exercise as rehabilitation postchemotherapy. The primary outcome for physicians will be uptake and usage of communication skills and maintenance of these skills over time. The primary outcome for patients is changes in knowledge about lymphoma and adherence to physicians' recommendations (eg, pneumococcus and influenza vaccinations); secondary outcomes will include perceptions of the doctor-patient relationship, decreased levels of cancer worry and depression, quality of life changes, satisfaction with care and usage of healthcare. This study will also examine the moderators and mediators of change within our theoretical model derived from Leventhal's Common-Sense Model of health beliefs. ETHICS AND DISSEMINATION: This study was approved by the Institutional Review Boards at Memorial Sloan Kettering Cancer Centers and all other participating sites. This work is funded by the National Cancer Institute (R01 CA 151899 awarded to DWK and SH as coprincipal investigators). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute (NCI) or the National Institutes of Health (NIH). The study findings will be disseminated to the research and medical communities through publication in peer-reviewed journals and through presentations at local, national and international conferences. TRIAL REGISTRATION NUMBER: NCT01483664.

Factitious disorder (Munchausen's syndrome) in oncology: case report and literature review.

BACKGROUND: Factitious disorder is where patients repeatedly seek medical care for feigned illnesses in the absence of obvious external rewards; 'Munchausen's syndrome' is the historical name for this disorder. METHOD: We report on a case that was presented to a tertiary oncology center as a suspected rare bone cancer. RESULTS AND CONCLUSIONS: Psychosocial clinicians working in oncology settings should be aware of the complexities of diagnosing factitious disorder in cancer settings where empathy is prominent and suspicion unusual. Moreover, comorbidity can cloud the diagnosis (in this case substance abuse), and, even when accurately diagnosed, there are no evidence-based management approaches to offer to the patient. What seems to linger most after the patient is discharged, usually in a huff, are strong counter-transference feelings and substantial medical bills. Copyright © 2015 John Wiley & Sons, Ltd.

Communication of a schizophrenia diagnosis: A qualitative study of patients' perspectives.

BACKGROUND: Transparent diagnostic communication is considered best practice for clinicians. However, while patients expect to receive a schizophrenia diagnosis from their psychiatrist, research suggests mental health clinicians are often reluctant to provide this information to patients. AIM: This study examines the perceptions of people with schizophrenia surrounding the communication of this diagnosis. METHODS: A generic qualitative methodological approach was used. A total of 14 patients with schizophrenia were recruited through community mental health services (n = 10) and the Australia Schizophrenia Research Bank (ASRB; n = 4) in New South Wales (NSW), Australia. Semi-structured interviews were used to explore the experiences and perceptions of people with schizophrenia about the way a schizophrenia diagnosis was communicated by mental health clinicians. Interviews were recorded, transcribed, codes generated and thematic analysis undertaken aided by NVivo. RESULTS: The majority of participants felt it was beneficial to receive a diagnosis despite acknowledging the distress this information sometimes caused, with many reporting this knowledge gave a sense of relief. It helped to understand their experiences and behaviours, improved their trust in the psychiatric system and increased treatment adherence. However, many reported difficulty in obtaining information about their condition, its treatment and prognosis, and expressed dissatisfaction with the way a diagnosis of schizophrenia was communicated. DISCUSSION: Insight into the perceptions and experiences of patients with schizophrenia about how a diagnosis of schizophrenia is communicated is a key outcome of this research. This knowledge will inform the development of future training programmes for mental health clinicians, and influence the clinical practice of health professionals treating patients with schizophrenia.

Contextual barriers to discussing a schizophrenia diagnosis with patients and families: need for leadership and teamwork training in psychiatry.

OBJECTIVE: This research sought to gain insight into the processes used by clinicians to discuss a schizophrenia diagnosis with patients/families, with the aim of informing the development of a communications skills training program. METHODS: A generic qualitative methodological approach was used. Sixteen mental health clinicians were recruited. Semi-structured individual interviews were used to explore their perceptions and experiences communicating a schizophrenia diagnosis. Interviews were recorded, transcribed, and thematic analysis undertaken. RESULTS: There were five key themes relating to the process of communication about a diagnosis of schizophrenia: (1) orientation to patient care, (2) planning of communication, (3) the impact of team leadership and inter/intra-professional functioning on communication tasks, (4) the roles of different clinicians in communicating about diagnosis and treatment, and (5) time and resource deficiencies. Despite expressing care and concern for vulnerable patients and embracing the concept of multidisciplinary teams, communicating diagnostic information to patients and families was generally unplanned for, with little consistency regarding leadership approaches, or how the team communicated diagnostic information to the patient and family. This contributed to tensions between different team members. CONCLUSION: The findings demonstrated a number of issues compromising good communication around a schizophrenia diagnosis, both in terms of clinician skill and clinical context, and support the importance of education and training for all members of the multidisciplinary team about their role in the communication process.

Preventing and De-Escalating Ethical Conflict: A Communication-Training Mediation Model.

While ethical conflicts in the provision of healthcare are common, the current third-party mediator model is limited by a lack of expert ethical mediators, who are often not on site when conflict escalates. In order to improve clinical outcomes in situations such as conflicts at the end of life, we suggest that clinicians-physicians, nurses and social workers-be trained to prevent and de-escalate emerging conflicts. This can be achieved using a mediation model framed by a communication-training approach. A case example is presented and the model is discussed. The implication of this preventative/early intervention model for improving clinical outcomes, in particular end-of life conflict, is considered.

A communication training perspective on AND versus DNR directives.

BACKGROUND: From a communication perspective, the term "do not resuscitate" (DNR) is challenging to use in end-of-life discussions because it omits the goals of care. An alternative, "Allow Natural Death" (AND), has been proposed as a better way of framing this palliative care discussion. CASE: We present a case where a nurse unsuccessfully discusses end-of-life goals of care using the term DNR. Subsequently, with the aid of a communication trainer, he is coached to successfully use the term "AND" to facilitate this discussion and advance his goal of palliative care communication and planning. DISCUSSION: We contrast the advantages and disadvantages of the term AND from the communication training perspective and suggest that AND-framing language replace DNR as a better way to facilitate meaningful end-of-life communication. One well-designed, randomized, controlled simulation study supports this practice. We also consider the communication implications of "natural" versus "unnatural" death.

Communicating a schizophrenia diagnosis to patients and families: a qualitative study of mental health clinicians.

OBJECTIVE: The aim of this research was to explore mental health clinicians' experiences and perceptions of discussing a diagnosis of schizophrenia with their patients. The results of this research will inform a communication skills training program for psychiatry trainees. METHODS: Semistructured interviews were conducted with 16 mental health clinicians from public mental health services in New South Wales, Australia. Interviews were recorded and transcribed for qualitative analysis. RESULTS: Although most clinicians supported the need to give patients a named diagnosis of schizophrenia, most gave multiple reasons for not doing so in practice. The reasons given centered on concerns for the patient; they included fear of making an incorrect diagnosis, fear of the patient's distress, and harm from stigma. CONCLUSIONS: Mental health clinicians need to reflect on their own feelings, examine personal identification with their patients, and recognize the subtle interplay of hope and pessimism in their communication of a schizophrenia diagnosis.

Acute Cancer Cognitive Therapy.

The utility of cognitive therapy (CT) for ambulatory cancer patients is clear but the acute cancer setting significantly shapes the therapeutic interaction, parameters, and delivery of CT. In this article, we describe how to apply CT to acute cancer settings, focusing on how this approach differs from traditionally taught, ambulatory CT. We highlight the importance of a tailored history and formulation, how the cognitive model is applied within an acute cancer context to promote coping and adaptation. Reframing must consider the "grain of truth" to many so-called distorted cognitions, such as "cancer means death." Fear of recurrence is an example of a common reframing challenge. Another is the "tyranny of positive thinking." Here there is avoidance of considering negative outcomes such as death; patients are told to "think positive," leaving them alone at a time of life-threatening crisis. Instead, acute cancer CT utilizes a stance of realistic optimism. Empathy plays a vital role in turning off the bracing reaction to threat and facilitating problem-solving. Successfully combining CT with medications is integral to this model. We also discuss how CT can be applied to discussing prognosis, the desire for hastened death and suicidality, as well as death and dying in general. Because of the ubiquitous nature of cancer, most cognitive therapists will encounter patients with cancer in their practices. Acute cancer CT is a skill set that should be widely taught to cognitive therapists and flagged as a priority for academic programs and professional organizations.

A review of cognitive therapy in acute medical settings. Part II: strategies and complexities.

OBJECTIVE: Cognitive therapy (CT) has considerable utility for psychosomatic medicine (PM) in acute medical settings but, to date, no such cohesive adaptation has been developed. Part I delineated a CT model for acute medical settings focusing on assessment and formulation. In Part II, we review how CT can be applied to common PM clinical challenges. A pragmatic approach is helpful because this review targets PM trainees and educators. METHODS: Narrative review is used to discuss the application of CT strategies to common challenges in acute medical settings. Treatment complexities and limitations associated with the PM setting are detailed. Exemplary dialogues are used to model techniques. RESULT: We present CT approaches to eight common scenarios: (1) distressed or hopeless patients; (2) patients expressing pivotal distorted cognitions/images; (3) patients who catastrophize; (4) patients who benefit from distraction and activation strategies; (5) panic and anxiety; (6) suicidal patients; (7) patients who are stuck and helpless; (8) inhibited patients. Limitations are discussed. SIGNIFICANCE OF RESULTS: A CT informed PM assessment, formulation and early intervention with specific techniques offers a novel integrative framework for psychotherapy with the acutely medically ill. Future efforts should focus on dissemination, education of fellows and building research efficacy data.

A randomized controlled trial of a cardiopulmonary resuscitation video in advance care planning for progressive pancreas and hepatobiliary cancer patients.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is an important advance directive (AD) topic in patients with progressive cancer; however such discussions are challenging. OBJECTIVE: This study investigates whether video educational information about CPR engenders broader advance care planning (ACP) discourse. METHODS: Patients with progressive pancreas or hepatobiliary cancer were randomized to an educational CPR video or a similar CPR narrative. The primary end-point was the difference in ACP documentation one month posttest between arms. Secondary end-points included study impressions; pre- and post-intervention knowledge of and preferences for CPR and mechanical ventilation; and longitudinal patient outcomes. RESULTS: Fifty-six subjects were consented and analyzed. Rates of ACP documentation (either formal ADs or documented discussions) were 40% in the video arm (12/30) compared to 15% in the narrative arm (4/26), OR=3.6 [95% CI: 0.9-18.0], p=0.07. Post-intervention knowledge was higher in both arms. Posttest, preferences for CPR had changed in the video arm but not in the narrative arm. Preferences regarding mechanical ventilation did not change in either arm. The majority of subjects in both arms reported the information as helpful and comfortable to discuss, and they recommended it to others. More deaths occurred in the video arm compared to the narrative arm, and more subjects died in hospice settings in the video arm. CONCLUSIONS: This pilot randomized trial addressing downstream ACP effects of video versus narrative decision tools demonstrated a trend towards more ACP documentation in video subjects. This trend, as well as other video effects, is the subject of ongoing study.

A review of cognitive therapy in acute medical settings. Part I: therapy model and assessment.

INTRODUCTION: Although cognitive therapy (CT) has established outpatient utility, there is no integrative framework for using CT in acute medical settings where most psychosomatic medicine (P-M) clinicians practice. Biopsychosocial complexity challenges P-M clinicians who want to use CT as the a priori psychotherapeutic modality. For example, how should clinicians modify the data gathering and formulation process to support CT in acute settings? METHOD: Narrative review methodology is used to describe the framework for a CT informed interview, formulation, and assessment in acute medical settings. Because this review is aimed largely at P-M trainees and educators, exemplary dialogues model the approach (specific CT strategies for common P-M scenarios appear in the companion article.) RESULTS: Structured data gathering needs to be tailored by focusing on cognitive processes informed by the cognitive hypothesis. Agenda setting, Socratic questioning, and adaptations to the mental state examination are necessary. Specific attention is paid to the CT formulation, Folkman's Cognitive Coping Model, self-report measures, data-driven evaluations, and collaboration (e.g., sharing the formulation with the patient.) Integrative CT-psychopharmacological approaches and the importance of empathy are emphasized. SIGNIFICANCE OF RESULTS: The value of implementing psychotherapy in parallel with data gathering because of time urgency is advocated, but this is a significant departure from usual outpatient approaches in which psychotherapy follows evaluation. This conceptual approach offers a novel integrative framework for using CT in acute medical settings, but future challenges include demonstrating clinical outcomes and training P-M clinicians so as to demonstrate fidelity.

Randomized controlled trial of a video decision support tool for cardiopulmonary resuscitation decision making in advanced cancer.

PURPOSE: Decision making regarding cardiopulmonary resuscitation (CPR) is challenging. This study examined the effect of a video decision support tool on CPR preferences among patients with advanced cancer. PATIENTS AND METHODS: We performed a randomized controlled trial of 150 patients with advanced cancer from four oncology centers. Participants in the control arm (n = 80) listened to a verbal narrative describing CPR and the likelihood of successful resuscitation. Participants in the intervention arm (n = 70) listened to the identical narrative and viewed a 3-minute video depicting a patient on a ventilator and CPR being performed on a simulated patient. The primary outcome was participants' preference for or against CPR measured immediately after exposure to either modality. Secondary outcomes were participants' knowledge of CPR (score range of 0 to 4, with higher score indicating more knowledge) and comfort with video. RESULTS: The mean age of participants was 62 years (standard deviation, 11 years); 49% were women, 44% were African American or Latino, and 47% had lung or colon cancer. After the verbal narrative, in the control arm, 38 participants (48%) wanted CPR, 41 (51%) wanted no CPR, and one (1%) was uncertain. In contrast, in the intervention arm, 14 participants (20%) wanted CPR, 55 (79%) wanted no CPR, and 1 (1%) was uncertain (unadjusted odds ratio, 3.5; 95% CI, 1.7 to 7.2; P < .001). Mean knowledge scores were higher in the intervention arm than in the control arm (3.3 ± 1.0 v 2.6 ± 1.3, respectively; P < .001), and 65 participants (93%) in the intervention arm were comfortable watching the video. CONCLUSION: Participants with advanced cancer who viewed a video of CPR were less likely to opt for CPR than those who listened to a verbal narrative.

Communication skills training for oncology professionals.

PURPOSE: To provide a state-of-the-art review of communication skills training (CST) that will guide the establishment of a universal curriculum for fellows of all cancer specialties undertaking training as oncology professionals today. METHODS: Extensive literature review including meta-analyses of trials, conceptual models, techniques, and potential curricula provides evidence for the development of an appropriate curriculum and CST approach. Examples from the Memorial Sloan-Kettering Cancer Center CST program are incorporated. RESULTS: A core curriculum embraces CST modules in breaking bad news and discussing unanticipated adverse events, discussing prognosis, reaching a shared treatment decision, responding to difficult emotions, coping with survivorship, running a family meeting, and transitioning to palliative care and end of life. Achievable outcomes are growth in clinician's self-efficacy, uptake of new communication strategies and skills, and transfer of these strategies and skills into the clinic. Outcomes impacting patient satisfaction, improved adaptation, and enhanced quality of life are still lacking. CONCLUSION: Future communication challenges include genetic risk communication, concepts like watchful waiting, cumulative radiation risk, late effects of treatment, discussing Internet information and unproven therapies, phase I trial enrollment, and working as a multidisciplinary team. Patient benefits, such as increased treatment adherence and enhanced adaptation, need to be demonstrated from CST.

Augmenting advance care planning in poor prognosis cancer with a video decision aid: a preintervention-postintervention study.

BACKGROUND: The authors tested whether an educational video on the goals of care in advanced cancer (life-prolonging care, basic care, or comfort care) helped patients understand these goals and had an impact on their preferences for resuscitation. METHODS: A survey of 80 patients with advanced cancer was conducted before and after they viewed an educational video. The outcomes of interest included changes in goals of care preference and knowledge and consistency of preferences with code status. RESULTS: Before viewing the video, 10 patients (13%) preferred life-prolonging care, 24 patients (30%) preferred basic care, 29 patients (36%) preferred comfort care, and 17 patients (21%) were unsure. Preferences did not change after the video, when 9 patients (11%) chose life-prolonging care, 28 patients (35%) chose basic care, 29 patients (36%) chose comfort care, and, 14 patients (18%) were unsure (P = .28). Compared with baseline, after the video presentation, more patients did not want cardiopulmonary resuscitation (CPR) (71% vs 62%; P = .03) or ventilation (80% vs 67%; P = .008). Knowledge about goals of care and likelihood of resuscitation increased after the video (P < .001). Of the patients who did not want CPR or ventilation after the video augmentation, only 4 patients (5%) had a documented do-not-resuscitate order in their medical record (kappa statistic, -0.01; 95% confidence interval, -0.06 to 0.04). Acceptability of the video was high. CONCLUSIONS: Patients with advanced cancer did not change care preferences after viewing the video, but fewer wanted CPR or ventilation. Documented code status was inconsistent with patient preferences. Patients were more knowledgeable after the video, reported that the video was acceptable, and said they would recommend it to others. The current results indicated that this type of video may enable patients to visualize "goals of care," enriching patient understanding of worsening health states and better informing decision making.