NCCN Guidelines® Insights: Distress Management, Version 2.2023.

These NCCN Guidelines for Distress Management discuss the identification and treatment of psychosocial problems in patients with cancer. All patients experience some level of distress associated with a cancer diagnosis and the effects of the disease and its treatment regardless of the stage of disease. Clinically significant levels of distress occur in a subset of patients, and identification and treatment of distress are of utmost importance. The NCCN Distress Management Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights describe updates to the NCCN Distress Thermometer (DT) and Problem List, and to the treatment algorithms for patients with trauma- and stressor-related disorders.

NCCN Guidelines® Insights: Palliative Care, Version 2.2021.

Palliative care has evolved to be an integral part of comprehensive cancer care with the goal of early intervention to improve quality of life and patient outcomes. The NCCN Guidelines for Palliative Care provide recommendations to help the primary oncology team promote the best quality of life possible throughout the illness trajectory for each patient with cancer. The NCCN Palliative Care Panel meets annually to evaluate and update recommendations based on panel members' clinical expertise and emerging scientific data. These NCCN Guidelines Insights summarize the panel's recent discussions and highlights updates on the importance of fostering adaptive coping strategies for patients and families, and on the role of pharmacologic and nonpharmacologic interventions to optimize symptom management.

How Patients Cope Throughout the Course of an Incurable Cancer.

Patients cope in different ways when living with an incurable cancer. These varied coping styles impact how oncology providers communicate with patients. If providers do not tailor communication with a general understanding of how a patient is coping, this risks miscommunication with the patient, inaccurate disease understanding, and suboptimal care. This review explores the spectrum of coping patterns that influence a patient's behaviors and communication with their oncology team throughout a cancer course. We then review several strategies to assist with coping in order to provide more transparent communication throughout the cancer course. Patients express coping styles on a spectrum, from "avoidant" to "resistant" to "engaged." The "avoidant" and "resistant" coping styles often impede transparent communication between patient and provider due to expressions of unrealistic hope by the patient. Several communication skills can improve patient coping and readiness to discuss prognostic information about the cancer, which will better facilitate conversations around end of life and readiness to stop cancer treatment and initiate hospice when indicated. Understanding the spectrum of coping styles and stress responses by patients and families can improve shared understanding between patient and provider as well as a sense of partnership with patients and families.

The Next Best Thing: Three Key Conversations to Convey Prognosis Over the Course of an Incurable Cancer.

INTRODUCTION: Waiting until a person is very near end of life to discuss limited life expectancy risks lower goal-concordant care and increased utilization of medical interventions with lower likelihood of benefit at the end of life. Medical training on communication skills in serious illness often focuses on early and late conversations regarding prognosis, with no guidance on navigating the conversations occurring in the middle of the illness course. GOAL OF THE REVIEW: We propose a new framework for identifying and discussing prognosis at various points along the cancer course, as a continuum from beginning to end, that is prompted by changes in clinical status and number of available remaining cancer directed interventions. DISCUSSION: SPIKES is a framework utilized for early conversations in a cancer course. REMAP is a framework utilization for late conversations in a cancer course. There is a gap in guidance on how to navigate conversations that occur between the early and late phases of a cancer course. We describe 3 general phases of care during a cancer course ("early," "middle," and "late"), with each phase warranting specific communication skills in order to improve patient understanding of prognosis, goal concordant care, and best practices for healthcare utilization in the acute and end of life care settings. CONCLUSION: Framing prognosis by available medical interventions through a framework of "early," "middle," and "late" adds clarity to the phase of illness, expectations around delivery of information to the patient, and framing of recommendations at each given phase.

Actor feedback and rigorous monitoring: Essential quality assurance tools for testing behavioral interventions with simulation.

INTRODUCTION: Simulation is a powerful tool for training and evaluating clinicians. However, few studies have examined the consistency of actor performances during simulation based medical education (SBME). The Simulated Communication with ICU Proxies trial (ClinicalTrials.gov NCT02721810) used simulation to evaluate the effect of a behavioral intervention on physician communication. The purpose of this secondary analysis of data generated by the quality assurance team during the trial was to assess how quality assurance monitoring procedures impacted rates of actor errors during simulations. METHODS: The trial used rigorous quality assurance to train actors, evaluate performances, and ensure the intervention was delivered within a standardized environment. The quality assurance team evaluated video recordings and documented errors. Actors received both timely, formative feedback and participated in group feedback sessions. RESULTS: Error rates varied significantly across three actors (H(2) = 8.22, p = 0.02). In adjusted analyses, there was a decrease in the incidence of actor error over time, and errors decreased sharply after the first group feedback session (Incidence Rate Ratio = 0.25, 95% confidence interval 0.14-0.42). CONCLUSIONS: Rigorous quality assurance procedures may help ensure consistent actor performances during SBME.

Intensivists' Religiosity and Perceived Conflict During a Simulated ICU Family Meeting.

CONTEXT: Conflict is frequently reported by both clinicians and surrogate decision makers for adult patients in intensive care units. Because religious clinicians view religion as an important dimension of end-of-life care, we hypothesized that religious critical care attendings (intensivists) would be more comfortable and perceive less conflict when discussing a patient's critical illness with a religious surrogate. OBJECTIVES: The objective of this study was to assess if religious intensivists are more or less likely to perceive conflict during a simulated family meeting than secular colleagues. METHODS: Intensivists were recruited to participate in a standardized, simulated family meeting with an actor portraying a family member of a critically ill patient. Intensivists provided demographic information including their current religion and the importance of religion in their lives. After the simulation, intensivists rated the amount of conflict they perceived during the simulation. The association between intensivist's self-reported religiosity and perceived conflict was estimated using both univariate analysis and multivariable logistic regression. RESULTS: Among 112 participating intensivists, 43 (38%) perceived conflict during the simulation. Among intensivists who perceived conflict, 49% were religious, and among those who did not perceive conflict, 35% were religious. After adjusting for physician race, gender, years in practice, intensive care unit weeks worked per year and actor, physician religiosity was associated with greater odds of perceiving conflict during the simulated family meeting (adjusted prevalence ratio = 2.77, [95% CI 1.12-7.16], P = 0.03). CONCLUSION: Religious intensivists were more likely to perceive conflict during a simulated family meeting.