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Medline ® Abstracts for References 23,24

of 'Discussing goals of care'

Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life.
Weiner JS, Roth J
J Palliat Med. 2006 Apr;9(2):451-63.
BACKGROUND: Treatment of suffering is a core mission of medicine. Communication about treatment planning with the patient and family, called the goals of care discussion, offers the opportunity to provide effective relief. Such communication is particularly important near the end of life, because many medical decisions are determined then by emotional considerations and personal values.
OBJECTIVE: To define common unintended clinician behaviors, which impair discussion about goals of care near the end of life. To discuss the relationship between: (1) the medical decision-making responsibilities of patient and family, (2) clinician communication, (3) iatrogenic suffering, (4) the impact on medical decision-making, and (5) patient and family outcomes.
DESIGN: Thematic literature review.
RESULTS: The authors discuss how omission of the integral emotional and social elements of the goals of care discussion are reflected in five unintended clinician behaviors, each of which may impair medicaldecision-making and unknowingly induce patient and family suffering. We posit that such impaired decision-making and suffering may contribute to demands for ineffective, life-sustaining interventions made by the patient and family or, conversely, to requests for hastened death.
CONCLUSIONS: Understanding the challenges in the discussion about goals of care near the end of life will facilitate the development of more effective approaches to communication and shared decision-making. The authors hypothesize how decreased suffering through improved communication should diminish the occurrence of depression, anxiety disorders, and complicated grief in the patient and survivors, potentially improving medical outcomes. Proposed experiments to test this hypothesis will address important public health goals.
Long Island Jewish Medical Center, Departments of Medicine and Psychiatry, New Hyde Park, NY 11040, USA. weiner@lij.edu
Oncologist communication about emotion during visits with patients with advanced cancer.
Pollak KI, Arnold RM, Jeffreys AS, Alexander SC, Olsen MK, Abernethy AP, Sugg Skinner C, Rodriguez KL, Tulsky JA
J Clin Oncol. 2007;25(36):5748.
INTRODUCTION: Cancer care involves addressing patient emotion. When patients express negative emotions, empathic opportunities emerge. When oncologists respond with a continuer statement, which is one that offers empathy and allows patients to continue expressing emotions, rather than with a terminator statement, which is one that discourages disclosure, patients have less anxiety and depression and report greater satisfaction and adherence to therapy. We studied whether oncologist traits were associated with empathic opportunities and empathic responses.
PATIENTS AND METHODS: We audio-recorded 398 clinic conversations between 51 oncologists and 270 patients with advanced cancer; oncologists also completed surveys. Conversations were coded for the presence of empathic opportunities and oncologist responses. Analyses examined the relationship with oncologists' demographics, self-reported confidence, outcome expectancies, and comfort to address social versus technical aspects of care.
RESULTS: In 398 conversations, 37% contained at least one empathic opportunity; the range was 0 to 10, and the total empathic opportunities was 292. When they occurred, oncologists responded with continuers 22% of the time. Oncologist sex was related to the number of empathic opportunities; female patients seen by female oncologists had the most empathic opportunities (P = .03). Younger oncologists (P = .02) and those who rated their orientation as more socioemotional than technical (P = .03) were more likely to respond with empathic statements.
CONCLUSION: Oncologists encountered few empathic opportunities and responded with empathic statements infrequently. Empathic responses were more prevalent among younger oncologists and among those who were self-rated as socioemotional. To reduce patient anxiety and increase patient satisfaction and adherence, oncologists may need training to encourage patients to express emotions and to respond empathically to patients' emotions.
Duke Comprehensive Cancer Center, Cancer Prevention, Detection, and Control Research Program, Durham, NC, USA. polla007@mc.duke.edu