If We Don't Ask, Our Patients Might Never Tell: The Impact of the Routine Use of a Patient Values Assessment.

PURPOSE: Good communication can be associated with better end-of-life outcomes. The US Oncology Network developed and tested a Values Assessment (VA) for facilitating advance care planning (ACP). The results of the first 1,268 patients are reported. METHODS: The VA consists of 10 questions of the format "How valuable is it to me to…" (eg, "...know that I am not a burden to my family, friends, or helpers?"). Responses were on a four-point scale from unsure to very valuable. VA data on 1,286 patients with metastatic cancer from April 1, 2013, to July 31, 2015, were extracted from the electronic health record, including demographics, diagnosis, stage, chemotherapy, and outcomes (hospice enrollment, place of death). These demographics were compared by using the χ2 or Fisher's exact test or the Wilcoxon rank sum test for continuous variables. RESULTS: A total of 1,268 patients completed the VA (56.7% were ≥ 65 years of age, 57.8% completed advance directives [ADs]). There were 438 deaths of which 308 had a place of death or a hospice enrollment recorded. Of these, 78% died at home or inpatient hospice; 14.6% died in the hospital. Hospice enrollment with ADs was 76.1% and without, 60.9%. Median length of stay in hospice was 21 days with ADs versus 12.5 days without. Chemotherapy in the last 14 days of life was 8.8% with ADs and 15.5% without. The VA was well accepted by patients. CONCLUSION: A VA as a routine part of practice is feasible and scalable. It facilitates ACP discussions that lead to ADs. The results suggest that VA and ACP lead to less-aggressive care at the end of life.

A Pilot Study of a Cognitive-Behavioral Intervention for Breast Cancer Survivors.

PURPOSE/OBJECTIVES: To test combining a group intervention to build self-efficacy for using compensatory strategies and lifestyle adjustments with brain-training practice to improve cognition.
. DESIGN: A quasiexperimental design.
. SETTING: Texas Oncology, a community oncology practice in Austin.
. SAMPLE: 20 women aged 35-65 years, who had finished chemotherapy at least three months before the study, were within five years of completing all treatment, and had self-reported cognitive concerns. 
. METHODS: Six group sessions to build self-efficacy for using compensatory strategies, along with other health behaviors that affect cognitive performance, were combined with practice on a computer-based training program. Female breast cancer survivors were recruited through flyers, mailings, and personal contacts. 
. MAIN RESEARCH VARIABLES: Cognitive performance, cognitive concerns, cognitive/memory strategies, fatigue, emotional distress, sleep disorders, and quality of life.
. FINDINGS: Participants reported that the intervention was useful in building cognitive abilities. Although scores on performance tests did not increase, ratings of cognitive concerns, fatigue, emotional distress, and sleep disturbance decreased significantly. Use of cognitive/memory strategies increased significantly. 
. CONCLUSIONS: This pilot study demonstrated the feasibility of combining a group intervention with brain-training practice. A larger randomized trial would afford a more rigorous test of efficacy.
. IMPLICATIONS FOR NURSING: A growing body of evidence regarding potential interventions to address survivors' cognitive problems exists. Nurses should counsel breast cancer survivors about fatigue, sleep deprivation, and emotional distress, as well as the effects of cancer treatment on cognition.

When do I get my brain back? Breast cancer survivors' experiences of cognitive problems.

BACKGROUND: Many survivors report troubling cognitive problems that can persist long after active treatment and seriously affect their quality of life, particularly in terms of employment. OBJECTIVES: The purpose of this study was to explore survivors' perceptions of their cognitive functioning. METHODS: Ten female breast cancer survivors receiving treatment in a community oncology setting participated in interviews or a focus group. FINDINGS: Six major themes were derived from the analysis.

Sleep disturbance, chronic stress, and depression in hospice nurses: testing the feasibility of an intervention.

PURPOSE/OBJECTIVES: To test the feasibility of a cognitive-behavioral therapy for an insomnia (CBT-I) intervention in chronically bereaved hospice nurses. DESIGN: Five-week descriptive correlational. SETTING: Nonprofit hospice in central Texas. SAMPLE: 9 agency nurses providing direct patient and family care. METHODS: Direct care nurses were invited to participate. Two intervention group sessions occurred at the hospice agency and included identification of dysfunctional thoughts and beliefs about sleep, stimulus control, sleep hygiene, and relaxation techniques to promote sleep. Measurements were taken at baseline and three and five weeks postintervention. MAIN RESEARCH VARIABLES: Sleep quality, depressive symptoms, and narrative reflections on the impact of sleep quality on self-care. FINDINGS: Participants reported moderate-to-severe sleep disturbances and moderate depressive symptoms. The CBT-I intervention was well accepted by the participants, and on-site delivery increased participation. CONCLUSIONS: Additional longitudinal study is needed to investigate the effectiveness of CBT-I interventions to improve self-care among hospice nurses who are at high risk for compassion fatigue and, subsequently, leaving hospice care. IMPLICATIONS FOR NURSING: Hospice nurses are exposed to chronic bereavement that can result in sleep disturbances, which can negatively affect every aspect of hospice nurses' lives. Cognitive-behavioral sleep interventions show promise in teaching hospice nurses how to care for themselves by getting quality sleep. KNOWLEDGE TRANSLATION: Identifying the risks for sleep disturbances and depressive symptoms in hospice nurses will allow for effective, individualized interventions to help promote health and well-being. If hospice nurses achieve quality sleep, they may remain in the profession without suffering from chronic bereavement, which can result in compassion fatigue. A CBT-I intervention delivered at the agency and in a group format was feasible and acceptable by study participants.

A feasibility study of a two-session home-based cognitive behavioral therapy-insomnia intervention for bereaved family caregivers.

OBJECTIVE: In 2008 over two million family caregivers will become bereaved. The vast majority of these caregivers have provided 'round-the-clock care for a period ranging from months to years. Bereaved family caregivers report insomnia symptoms that persist beyond 1 year, longer than what is seen in bereaved noncaregivers, placing them at increased risk of depression and complicated grief. Despite some rewarding elements, caregiving is a stressful and exhausting role that often requires the caregiver to restructure his or her life around the needs of the patient. Once the patient dies, the structure is lost. Cognitive behavioral therapy interventions are effective in providing structure. This pilot study explored the feasibility of a two-session home-based cognitive behavioral therapy-insomnia (CBT-I) intervention for bereaved family caregivers. METHOD: A 5-week longitudinal descriptive study design was used with 11 adult primary family caregivers of patients who died from cancer. A master's prepared nurse delivered two CBT-I intervention sessions in participant homes. Data collection sessions occurred at baseline, 3, and 5 weeks. A debriefing session was held at Week 6. RESULTS: Participant evaluations of the intervention indicated that it was feasible and acceptable (e.g., 100% would recommend it to others); objective data further supported its feasibility (e.g., 100% completed the trial). In addition, when comparing baseline with Weeks 3 and 5, participants demonstrated improvement in insomnia and depressive symptoms. SIGNIFICANCE OF RESULTS: The results of this pilot study suggest that the intervention is feasible and acceptable and produces promising effects on insomnia and depressive symptoms in bereaved family caregivers.