"There were more decisions and more options than just yes or no": Evaluating a decision aid for advanced cancer patients and their family caregivers.

OBJECTIVE: Few decision aids are available for patients with a serious illness who face many treatment and end-of-life decisions. We evaluated the Looking Ahead: Choices for Medical Care When You're Seriously Ill® patient decision aid (PtDA), one component of an early palliative care clinical trial. METHOD: Our participants included individuals with advanced cancer and their caregivers who had participated in the ENABLE (Educate, Nurture, Advise, Before Life Ends) early palliative care telehealth randomized controlled trial (RCT) conducted in a National Cancer Institute-designated cancer center, a U.S. Department of Veterans Affairs medical center, and affiliated outreach clinics in rural New England. ENABLE included six weekly patient and three weekly family caregiver structured sessions. Participants watched the Looking Ahead PtDA prior to session 3, which covered content on decision making and advance care planning. Nurse coaches employed semistructured interviews to obtain feedback from consecutive patient and caregiver participants approximately one week after viewing the Looking Ahead PtDA program (booklet and DVD). RESULTS: Between April 1, 2011, and October 31, 2012, 57 patients (mean age = 64), 42% of whom had lung and 23% gastrointestinal cancer, and 20 caregivers (mean age = 59), 80% of whom were spouses, completed the PtDA evaluation. Participants reported a high degree of satisfaction with the PtDA format, as well as with its length and clarity. They found the format of using patient interviews "validating." The key themes were: (1) "the earlier the better" to view the PtDA; (2) feeling empowered, aware of different options, and an urgency to participate in advance care planning. SIGNIFICANCE OF RESULTS: The Looking Ahead PtDA was well received and helped patients with a serious illness realize the importance of prospective decision making in guiding their treatment pathways. We found that this PtDA can help seriously ill patients prior to the end of life to understand and discuss future healthcare decision making. However, systems to routinely provide PtDAs to seriously ill patients are yet not well developed.

Sociotechnical evaluation of a clinical transformation project in a specialized cancer care centre.

The radiation therapy (RT) department at the British Columbia Cancer Agency - Vancouver Island Centre (VIC) is responsible for delivering radiation treatments to cancer patients from Vancouver Island, which has a population base of approximately 750,000. The purpose of this analysis is to examine a process transformation project undertaken by a VIC clinical champion using a sociotechnical approach and identify factors that influenced the project outcome. Beginning in January 2009, a radiation oncologist at VIC initiated a project to transform the clinical process of generating prescriptions for radiation therapy. The project objective was to replace the paper-based process for radiation therapy (RT) prescriptions with an electronic process to achieve benefits such as increased legibility, accuracy, and accessibility of prescriptions. The electronic prescription (e-Rx) process was designed and developed by health informatics students from the University of Victoria, and the new process was trialed and implemented for approximately half of the new patients seen by the VIC RT department. This pilot implementation was brought to a halt two weeks later, due to concerns raised by the RT department. Using a sociotechnical approach, the authors identify several factors that negatively impacted the project's successful implementation: lack of leadership endorsement and organizational strategy, insufficient formal and informal organizational power of the clinical champion, underestimation of complexity, and inadequate management of the implementation process. Although these factors have been well documented in the literature for large-scale system implementation projects, understanding the way by which they influence smaller-scale process transformation projects in highly specialized clinical settings may help future project managers and coordinators to set such projects up for success.

Developing successful models of cancer palliative care services.

OBJECTIVES: This article describes successful institutionally based programs for providing high-quality palliative care to persons with cancer and their family members. Challenges and opportunities for program development are also described. DATA SOURCES: Published literature from 2000 to present describing concurrent oncology palliative care clinical trials, standards, and guidelines were reviewed. CONCLUSION: Clinical trials have shown feasibility and positive outcomes and formed the basis for consensus guidelines that support concurrent oncology palliative care models. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses should advocate for all patients with advanced cancer and their families to have access to concurrent oncology palliative care from the time of diagnosis with a life-limiting cancer.

Medication kits for managing symptomatic emergencies in the home: a survey of common hospice practice.

INTRODUCTION: Alleviation of symptoms associated with advanced illness and dying is a fundamental goal and core principle of palliative care. Little research exists regarding hospice programs' practices for prescribing, dispensing, and utilizing medication kits in the home for management of uncontrolled symptoms. METHODS: We conducted a telephone survey of all 22 agencies in New Hampshire providing home hospice care. The survey inquired about the timing of medication kit ordering and availability, characteristics of prescribers and pharmacies, kit contents, costs, frequency of use, and perceived impact of kits. RESULTS: All programs' kits contained medications to treat pain and dyspnea, 81% for nausea and vomiting, and 76% for seizures. Eighty-six percent of agencies (18/21) reported that a medication within the kits was used in more than 50% of cases. Eighty-six percent reported the kits often averted hospital or emergency department visits. Oral, sublingual, and rectal routes of administration were common as was topical preparations of combination medications. Three programs included parenteral morphine in kits. Kits cost less than $50 for the majority of programs. CONCLUSION: Hospice programs commonly utilize kits containing prescription medications for the purpose of managing uncontrolled symptoms in the home. There is considerable variation in kit contents and practice. Programs believe that kits diminish emergency department visits and hospitalizations. Research is needed to more fully describe and study the outcomes of these practices.