Impact of cancer on school, work, and financial independence among adolescents and young adults.

BACKGROUND: For adolescents and young adults (AYAs), the diagnosis of cancer can impede social development, especially with respect to education, employment, and financial independence. However, there are limited quantitative data on the extent and trajectory of life disruptions during cancer treatment for AYA patients. METHODS: This was a longitudinal, prospective, questionnaire-based cohort study of 145 AYA patients with cancer aged 15 to 29 years who were treated at a large academic cancer center. Questionnaires were administered shortly after diagnosis and 4 and 12 months after diagnosis. RESULTS: Although half of the participants lived with their parents 6 months before diagnosis, 61% lived with their parents after diagnosis (P = .0002 vs 6 months before diagnosis), with a similar proportion reported to be living with their parents 4 months after diagnosis (61%; P = .001) and 55% doing so 12 months after diagnosis (P = .07). Before diagnosis, 38% of the patients were not attending school. After diagnosis, that proportion rose to 61% (P < .0001), with a similar proportion 4 months after diagnosis (61%; P < .0001); 54% were not in school at 12 months (P = .001). Patients experienced similar decrements in employment (30% not working before diagnosis vs 49% not working after diagnosis; P < .0001) and financial independence (37% with complete financial independence before diagnosis vs 31% after diagnosis; P = .02). Overall, 65% of the patients (94 of 145) had not returned to their precancer baseline in at least 1 of these 4 social domains by 12 months after diagnosis. CONCLUSIONS: For many AYA patients, cancer leads to less engagement with school and work activities and decreased financial independence from parents. Clinicians should engage in early and ongoing discussions with patients about the potential impact of cancer on their lives.

A systematic intervention to improve serious illness communication in primary care: Effect on expenses at the end of life.

BACKGROUND: At a population level, conversations between clinicians and seriously ill patients exploring patients' goals and values can drive high-value healthcare, improving patient outcomes and reducing spending. METHODS: We examined the impact of a quality improvement intervention to drive better communication on total medical expenses in a high-risk care management program. We present our analysis of secondary expense outcomes from a prospective implementation trial of the Serious Illness Care Program, which includes clinician training, coaching, tools, and system interventions. We included patients who died between January 2014 and September 2016 who were selected for serious illness conversations, using the "Surprise Question," as part of implementation of the program in fourteen primary care clinics. RESULTS: We evaluated 124 patients and observed no differences in total medical expenses between intervention and comparison clinic patients. When comparing patients in intervention clinics who did and did not have conversations, we observed lower average monthly expenses over the last 6 ($6297 vs. $8,876, p = 0.0363) and 3 months ($7263 vs. $11,406, p = 0.0237) of life for patients who had conversations. CONCLUSIONS: Possible savings observed in this study are similar in magnitude to previous studies in advance care planning and specialty palliative care but occur earlier in the disease course and in the context of documented conversations and a comprehensive, interprofessional case management program. IMPLICATIONS: Programs designed to drive more, earlier, and better serious illness communication hold the potential to reduce costs. LEVEL OF EVIDENCE: Prospectively designed trial, non-randomized sample, analysis of secondary outcomes.

Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital.

Importance: The accuracy of mortality assessment by emergency clinicians is unknown and may affect subsequent medical decision-making. Objective: To determine the association of the question, "Would you be surprised if your patient died in the next one month?" (known as the surprise question) asked of emergency clinicians with actual 1-month mortality among undifferentiated older adults who visited the emergency department (ED). Design, Setting, and Participants: This prospective cohort study at a single academic medical center in Portland, Maine, included consecutive patients 65 years or older who received care in the ED and were subsequently admitted to the hospital from January 1, 2014, to December 31, 2015. Data analyses were conducted from January 2018 to March 2019. Exposures: Treating emergency clinicians were required to answer the surprise question, "Would you be surprised if your patient died in the next one month?" in the electronic medical record when placing a bed request for all patients who were being admitted to the hospital. Main Outcomes and Measures: The primary outcome was mortality at 1 month, assessed from the National Death Index. The secondary outcomes included accuracies of responses by both emergency clinicians and admitting internal medicine clinicians to the surprise question in identifying older patients with high 6-month and 12-month mortality. Results: The full cohort included 10 737 older adults (mean [SD] age, 75.9 [8.8] years; 5532 [52%] women; 10 157 [94.6%] white) in 16 223 visits treated in the ED and admitted to the hospital. There were 5132 patients (31.6%) with a Charlson Comorbidity Index score of 2 or more. Mortality rates were 8.3% at 1 month, 17.2% at 6 months, and 22.5% at 12 months. Emergency clinicians stated that they would not be surprised if the patient died in the next month for 2104 patients (19.6%). In multivariable analysis controlling for age, sex, race, admission diagnosis, and comorbid conditions, the odds of death at 1 month were higher in patients for whom clinicians answered that they would not be surprised if the patient died in the next 1 month compared with patients for whom clinicians answered that they would be surprised if the patient died in the next 1 month (odds ratio, 2.4 [95% CI, 2.2-2.7]; P < .001). However, the diagnostic test characteristics of the surprise question were poor (sensitivity, 20%; specificity, 93%; positive predictive value, 43%; negative predictive value, 82%; accuracy, 78%; area under the receiver operating curve of the multivariable model, 0.73 [95% CI, 0.72-0.74; P < .001]). Conclusions and Relevance: This study found that asking the surprise question of emergency clinicians may be a valuable tool to identify older patients in the ED with a high risk of 1-month mortality. The effect of implementing the surprise question to improve population-level health care for older adults in the ED who are seriously ill remains to be seen.

From Barriers to Assets: Rethinking factors impacting advance care planning for African Americans.

OBJECTIVE: We aimed to explore multiple perspectives regarding barriers to and facilitators of advance care planning (ACP) among African Americans to identify similarities or differences that might have clinical implications. METHOD: Qualitative study with health disparities experts (n = 5), community members (n = 9), and seriously ill African American patients and caregivers (n = 11). Using template analysis, interviews were coded to identify intrapersonal, interpersonal, and systems-level themes in accordance with a social ecological framework.ResultParticipants identified seven primary factors that influence ACP for African Americans: religion and spirituality; trust and mistrust; family relationships and experiences; patient-clinician relationships; prognostic communication, care preferences, and preparation and control. These influences echo those described in the existing literature; however, our data highlight consistent differences by group in the degree to which these factors positively or negatively affect ACP. Expert participants reinforced common themes from the literature, for example, that African Americans were not interested in prognostic information because of mistrust and religion. Seriously ill patients were more likely to express trust in their clinicians and to desire prognostic communication; they and community members expressed a desire to prepare for and control the end of life. Religious belief did not appear to negate these desires.Significance of resultsThe literature on ACP in African Americans may not accurately reflect the experience of seriously ill African Americans. What are commonly understood as barriers to ACP may in fact not be. We propose reframing stereotypical barriers to ACP, such as religion and spirituality, or family, as cultural assets that should be engaged to enhance ACP. Although further research can inform best practices for engaging African American patients in ACP, findings suggest that respectful, rapport-building communication may facilitate ACP. Clinicians are encouraged to engage in early ACP using respectful and rapport building communication practices, including open-ended questions.

Racial and Ethnic Differences in Advance Care Planning: Results of a Statewide Population-Based Survey.

BACKGROUND: Few studies have focused on racial and ethnic differences in advance care planning other than advance directives among population-based samples of adults across the lifespan. METHODS: Using data from a statewide random-digit dial telephone survey of adults 18 years or older (n = 1851), we investigated racial and ethnic differences in (1) designation of a healthcare agent (HCA); and (2) communication of goals, values, and preferences for end-of-life care with healthcare providers, a HCA, or other family members and friends. RESULTS: Less than half (44%, 95% confidence interval [CI] = 41.3%-47.0%) of all participants had named a HCA. In multivariable analyses, participants who identified as Hispanic (adjusted odds ratio [aOR] = 0.4, 95% CI = 0.2-0.7) or non-Hispanic other (aOR = 0.6, 95% CI = 0.4-0.9) were less likely than non-Hispanic whites to have named a HCA. Only 14.5% (95% CI = 12.6%-16.5%) of all participants had ever had a conversation with a healthcare provider about their end-of-life care wishes, with no differences by race/ethnicity. Over half (53.9%, 95% CI = 51.0%-56.8%) of all participants reported having had conversations with someone other than a healthcare provider about their end-of-life wishes. In multivariable analyses, non-Hispanic whites were more likely than Hispanics (aOR = 0.5, 95% CI = 0.3-0.7), black/African Americans (aOR = 0.5, 95% CI = 0.3-0.9), and non-Hispanic others (aOR = 0.7, 95% CI = 0.5-1.0) to report having had such conversations. CONCLUSIONS: Racial and ethnic minorities may be disadvantaged in the quality of care they receive if they have a serious illness and are unable to make decisions for themselves because most have not talked to anyone about their goals, values, or preferences for care.

A National Strategy For Palliative Care.

In 2014 the World Health Organization called for palliative care to be integrated as an essential element of the health care continuum. Yet in 2017 US palliative care services are found largely in hospitals, and hospice care, which is delivered primarily in the home, is limited to people who are dying soon. The majority of Americans with a serious illness are not dying; are living at home, in assisted living facilities, or in nursing homes; and have limited access to palliative care. Most health care providers lack knowledge about and skills in pain and symptom management, communication, and care coordination, and both the public and health professionals are only vaguely aware of the benefits of palliative care and how and when to access it. The lack of policy supports for palliative care contributes to preventable suffering and low-value care. In this article we outline the need for a national palliative care strategy to ensure reliable access to high-quality palliative care for Americans with serious medical illnesses. We review approaches employed by other countries, list the participants needed to develop and implement an actionable strategy, and identify analogous US national health initiatives to inform a process for implementing the strategy.

Palliative Care Version 1.2016.

The NCCN Guidelines for Palliative Care provide interdisciplinary recommendations on palliative care for patients with cancer. The NCCN Guidelines are intended to provide guidance to the primary oncology team on the integration of palliative care into oncology. The NCCN Palliative Care Panel's recommendations seek to ensure that each patient experiences the best quality of life possible throughout the illness trajectory. Accordingly, the NCCN Guidelines outline best practices for screening, assessment, palliative care interventions, reassessment, and after-death care.

A novel approach for measuring social participation in adults who stutter.

UNLABELLED: This paper reports a preliminary study which trialled a novel approach for measuring speech output and social participation. The amount of phonation was accumulated via an objective measure called an Ambulatory Phonation Monitor (APM). PURPOSE: (1) To establish whether adults who stutter will tolerate wearing an APM for an extended period of time (three days), (2) to test whether the APM can accumulate useful data about the amount of phonation adults who stutter produce in the course of a normal day and (3) to examine a possible relationship between stuttering severity and amount of phonation. METHOD: Three adults who stutter wore an APM for three consecutive days during their waking hours. Each completed a questionnaire regarding the device and kept a speech diary outlining daily speaking activities and self-reported stuttering severity. APM data regarding amount of phonation was collected, analysed and compared with the participants' speech diaries. RESULTS: Each adult tolerated wearing the APM and while they felt comfortable speaking wearing the device, it was somewhat cumbersome. Variations in the amount of speaking across each day and in different speaking situations were evident. For two participants there was a positive correlation between phonation time and severity rating. CONCLUSIONS: Preliminary data suggests that the APM can provide valuable information about the amount adults who stutter speak. The APM is sufficiently sensitive to differentiate variations in the amount of phonation during different speaking situations. These favourable preliminary results suggest the value of a larger scale study. EDUCATIONAL OBJECTIVES: The reader will be able to: (a) describe the different aspects of stuttering currently routinely measured in clinical practice; (b) discuss the limitations of current measurement procedures; (c) discuss the advantages of speech measures obtained by an Ambulatory Phonation Monitor APM); (d) describe the perspectives of adults who stutter who have worn an APM to measure phonation time.

The role of palliative care in population management and accountable care organizations.

By 2021, health care spending is projected to grow to 19.6% of the GDP, likely crowding out spending in other areas. The 2010 Affordable Care Act (ACA) attempts to curb health care spending by incentivizing high-value care through the creation of Accountable Care Organizations (ACOs), which assume financial risk for patient outcomes. With this financial risk, health systems creating ACOs will be motivated to pursue innovative care models that maximize the value of care. Palliative care, as an emerging field with a growing evidence base, is positioned to improve value in ACOs by increasing high-quality care and decreasing costs for the sickest patients. ACO leaders may find palliative care input valuable in optimizing high-quality patient-centered care in the accountable care environment; however, palliative care clinicians will need to adopt new models that extrapolate their direct patient care skills to population management strategies. We propose that palliative care specialists take on responsibilities for working with ACO leaders to broaden their mission for systemwide palliative care for appropriate patients by prospectively identifying patients with a high risk of death, high symptom burden, and/or significant psychosocial dysfunction, and developing targeted, "triggered" interventions to enhance patient-centered, goal-consistent, coordinated care. Developing these new population management competencies is a critical role for palliative care teams in the ACO environment.

Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer.

IMPORTANCE: More patients with cancer use hospice currently than ever before, but there are indications that care intensity outside of hospice is increasing, and length of hospice stay decreasing. Uncertainties regarding how hospice affects health care utilization and costs have hampered efforts to promote it. OBJECTIVE: To compare utilization and costs of health care for patients with poor-prognosis cancers enrolled in hospice vs similar patients without hospice care. DESIGN, SETTING, AND PARTICIPANTS: Matched cohort study of patients in hospice and nonhospice care using a nationally representative 20% sample of Medicare fee-for-service beneficiaries who died in 2011. Patients with poor-prognosis cancers (eg, brain, pancreatic, metastatic malignancies) enrolled in hospice before death were matched to similar patients who died without hospice care. EXPOSURES: Period between hospice enrollment and death for hospice beneficiaries, and the equivalent period of nonhospice care before death for matched nonhospice patients. MAIN OUTCOMES AND MEASURES: Health care utilization including hospitalizations and procedures, place of death, cost trajectories before and after hospice start, and cumulative costs, all during the last year of life. RESULTS: Among 86,851 patients with poor-prognosis cancers, median time from first poor-prognosis diagnosis to death was 13 months (interquartile range [IQR], 3-34), and 51,924 patients (60%) entered hospice before death. Matching yielded a cohort balanced on age, sex, region, time from poor-prognosis diagnosis to death, and baseline care utilization, with 18,165 patients in the hospice group and 18,165 in the nonhospice group. After matching, 11% of nonhospice and 1% of hospice beneficiaries who had cancer-directed therapy after exposure were excluded. Median hospice duration was 11 days. After exposure, nonhospice beneficiaries had significantly more hospitalizations (65% [95% CI, 64%-66%], vs hospice with 42% [95% CI, 42%-43%]; risk ratio, 1.5 [95% CI, 1.5-1.6]), intensive care (36% [95% CI, 35%-37%], vs hospice with 15% [95% CI, 14%-15%]; risk ratio, 2.4 [95% CI, 2.3-2.5]), and invasive procedures (51% [95% CI, 50%-52%], vs hospice with 27% [95% CI, 26%-27%]; risk ratio, 1.9 [95% CI, 1.9-2.0]), largely for acute conditions not directly related to cancer; and 74% (95% CI, 74%-75%) of nonhospice beneficiaries died in hospitals and nursing facilities compared with 14% (95% CI, 14%-15%) of hospice beneficiaries. Costs for hospice and nonhospice beneficiaries were not significantly different at baseline, but diverged after hospice start. Total costs over the last year of life were $71,517 (95% CI, $70,543-72,490) for nonhospice and $62,819 (95% CI, $62,082-63,557) for hospice, a statistically significant difference of $8697 (95% CI, $7560-$9835). CONCLUSIONS AND RELEVANCE: In this sample of Medicare fee-for-service beneficiaries with poor-prognosis cancer, those receiving hospice care vs not (control), had significantly lower rates of hospitalization, intensive care unit admission, and invasive procedures at the end of life, along with significantly lower total costs during the last year of life.

Measuring critical deficits in shared decision making before elective surgery.

OBJECTIVE: Identifying patient factors correlated with specific needs in preoperative decision making is of clinical and ethical importance. We examined patterns and predictors of deficiencies in informed surgical consent and shared decision-making in preoperative patients. METHODS: Validated measures were used to survey 1034 preoperative patients in the preoperative clinic after signed informed consent. Principal component analysis defined correlated groupings of factors. Multivariable analysis assessed patient factors associated with resultant groupings. RESULTS: 13% of patients exhibited deficits in their informed consent process; 33% exhibited other types of deficits. Informed consent deficits included not knowing the procedure being performed or risks and benefits. Other deficits included not having addressed patient values, preferences and goals. Non-English language and lower educational level were factors correlated with higher risk for deficits. CONCLUSION: Deficits exist in over a third of patients undergoing preoperative decision-making. Sociodemographic factors such as language and educational level identified particularly vulnerable groups at risk for having an incomplete, and possibly ineffective, decision-making process. PRACTICE IMPLICATIONS: Interventions to identify vulnerable groups and address patient centered surgical decision making in the pre-operative setting are needed. Focused interventions to address the needs of at-risk patients have potential to improve the surgical decision-making process and reduce disparities.

Factors associated with pain among ambulatory patients with cancer with advanced disease at a comprehensive cancer center.

PURPOSE: The prevalence and severity of pain have not been well described among oncology patients in ambulatory care. To better understand the burden of pain among patients with advanced cancer, we examined the prevalence of pain reported during office and treatment visits. METHODS: A retrospective study of 4,014 patients with advanced disease (stage 4 at diagnosis or metastatic progression) who completed an ambulatory visit between 2004 and 2006 was conducted at a comprehensive cancer center in Boston, Massachusetts. RESULTS: At their first visit during the study period, 74% of patients reported no pain (0 score); 12%, low pain (1 to 3 score); 9%, moderate pain (4 to 6 score); and 5%, severe pain (7 to 10 score). The prevalence of pain was highest among patients who were younger than 60 years of age, were nonwhite, did not speak English as their primary language, or were covered by Medicaid, received free care, or paid their own health care costs. Patients with thoracic, breast, and head and neck cancers had higher pain scores than those with other diseases. Pain was reported more frequently among patients whose diagnosis or metastatic progression occurred less than 3 months before the reported pain score. In multivariable regression analysis, age, race, cancer type, and time since diagnosis/progression were identified as important factors associated with severe pain. CONCLUSION: Younger age, minority race, and recent onset of advanced disease are associated with severe pain among patients with cancer. Recognizing these high-risk groups could inform targeted interventions to address pain care in ambulatory patients with advanced cancer.

Support of cancer patients' spiritual needs and associations with medical care costs at the end of life.

BACKGROUND: Although spiritual care is associated with less aggressive medical care at the end of life (EOL), it remains infrequent. It is unclear if the omission of spiritual care impacts EOL costs. METHODS: A prospective, multisite study of 339 advanced cancer patients accrued subjects from September 2002 to August 2007 from an outpatient setting and followed them until death. Spiritual care was measured by patients' reports that the health care team supported their religious/spiritual needs. EOL costs in the last week were compared among patients reporting that their spiritual needs were inadequately supported versus those who reported that their needs were well supported. Analyses were adjusted for confounders (eg, EOL discussions). RESULTS: Patients reporting that their religious/spiritual needs were inadequately supported by clinic staff were less likely to receive a week or more of hospice (54% vs 72.8%; P = .01) and more likely to die in an intensive care unit (ICU) (5.1% vs 1.0%, P = .03). Among minorities and high religious coping patients, those reporting poorly supported religious/spiritual needs received more ICU care (11.3% vs 1.2%, P = .03 and 13.1% vs 1.6%, P = .02, respectively), received less hospice (43.% vs 75.3% ≥1 week of hospice, P = .01 and 45.3% vs 73.1%, P = .007, respectively), and had increased ICU deaths (11.2% vs 1.2%, P = .03 and 7.7% vs 0.6%, P = .009, respectively). EOL costs were higher when patients reported that their spiritual needs were inadequately supported ($4947 vs $2833, P = .03), particularly among minorities ($6533 vs $2276, P = .02) and high religious copers ($6344 vs $2431, P = .005). CONCLUSIONS: Cancer patients reporting that their spiritual needs are not well supported by the health care team have higher EOL costs, particularly among minorities and high religious coping patients.

Hematology/oncology fellows' training in palliative care: results of a national survey.

BACKGROUND: Palliative care is recognized as integral to the practice of oncology, yet many oncologists report inadequate training in critical palliative care domains, such as symptom management, psychosocial care, and communication skills. The authors of this report sought to assess the quantity and quality of palliative care education within oncology fellowships. METHODS: Second-year oncology fellows completed a 104-item survey that was modified and adapted from a national survey of medical students and residents. Items allowed comparison between palliative care and nonpalliative care topics. RESULTS: Of 402 eligible fellows, 63.2% responded (n = 254). Respondents were: 52% men, 62% Caucasian, and 64% US medical school graduates. Twenty-six percent had completed a palliative care rotation. Fellows rated the overall quality of fellowship teaching more highly than teaching on palliative care (3.7 v 3.0 on a 1-5 scale; t = 10.2; P < .001). Rates of being observed (81%) and receiving feedback (80%) on an end-of-life communication skill were high. Psychosocial needs of patients received some attention: Fifty-seven percent of fellows reported that they were conveyed as a core competency, but only 32% of fellows received explicit education on assessing and managing depression at the end of life. Fellows rarely reported receiving explicit education on opioid rotation (33%). Fellows scored a median of 2 of 4 items that tested basic palliative care knowledge, and only 23% correctly performed an opioid conversion. CONCLUSIONS: Fellows rated the quality of palliative care education as inferior to overall oncology training and may benefit from more teaching on pain management, psychosocial care, and communication skills.

Health care costs in the last week of life: associations with end-of-life conversations.

BACKGROUND: Life-sustaining medical care of patients with advanced cancer at the end of life (EOL) is costly. Patient-physician discussions about EOL wishes are associated with lower rates of intensive interventions. METHODS: Funded by the National Institute of Mental Health and the National Cancer Institute, Coping With Cancer is a longitudinal multi-institutional study of 627 patients with advanced cancer. Patients were interviewed at baseline and were followed up through death. Costs for intensive care unit and hospital stays, hospice care, and life-sustaining procedures (eg, mechanical ventilator use and resuscitation) received in the last week of life were aggregated. Generalized linear models were applied to test for cost differences in EOL care. Propensity score matching was used to reduce selection biases. RESULTS: Of 603 participants, 188 (31.2%) reported EOL discussions at baseline. After propensity score matching, the remaining 415 patients did not differ in sociodemographic characteristics, recruitment sites, illness acknowledgment, or treatment preferences. Further analyses, adjusted by quintiles of propensity scores and significant confounders, revealed that the mean (SE) aggregate costs of care (in 2008 US dollars) were $1876 ($177) for patients who reported EOL discussions compared with $2917 ($285) for patients who did not, a cost difference of $1041 (35.7% lower among patients who reported EOL discussions) (P =.002). Patients with higher costs had worse quality of death in their final week (Pearson production moment correlation partial r = -0.17, P =.006). CONCLUSIONS: Patients with advanced cancer who reported having EOL conversations with physicians had significantly lower health care costs in their final week of life. Higher costs were associated with worse quality of death.

Peace, Equanimity, and Acceptance in the Cancer Experience (PEACE): validation of a scale to assess acceptance and struggle with terminal illness.

BACKGROUND: The role of emotional acceptance of a terminal illness in end-of-life (EOL) care is not known. The authors developed a measure of peaceful acceptance at the EOL, and evaluated the role of peaceful acceptance in EOL decision-making and care. METHODS: The authors developed the Peace, Equanimity, and Acceptance in the Cancer Experience (PEACE) questionnaire to measure the extent to which patients with advanced cancer have a sense of peaceful acceptance of their terminal illness. The scale was administered to 160 patients with advanced cancer along with measures of other attributes that hypothetically are related to acceptance, including cognitive acceptance of terminal illness. EOL outcomes in 56 patients who died during the study also were examined. RESULTS: The 12-item PEACE questionnaire had 2 subscales: a 7-item Struggle With Illness subscale (Cronbach alpha = .81) and a 5-item Peaceful Acceptance subscale (alpha = .78). Both subscales were associated with patients' self-reported peacefulness (correlation coefficient [r] = 0.66 for acceptance [P <.0001]; r = -0.37 for struggle [P < .0001]). Struggle With Illness scores were associated with cognitive terminal illness acknowledgment (mean scores, 14.9 vs 12.4 for patients who were not aware that their illness was terminal; P = .001) and with some aspects of advance care planning (living will or healthcare proxy: mean scores, 13.9 vs 11.5; P = .02). In addition, among patients who had died, the use of a feeding tube at the EOL was associated inversely with Peaceful Acceptance (P = .015). CONCLUSIONS: The current study indicated that the PEACE questionnaire is a valid and reliable measure of peaceful acceptance and struggle with illness. Scores were associated with some choices for EOL care among patients with advanced cancer.

A study of oncology fellows' training in end-of-life care.

Caring for the dying is a core competency for oncologists, yet the quality of oncology fellowship training in end-of-life (EOL) care has not been assessed. A convenience sample of physicians attending the 2004 annual meeting of the American Society of Clinical Oncology responded to a 112-item questionnaire that assessed fellows' knowledge and education about EOL care. Of the 120 respondents, 107 (89%) rated caring for dying patients as"quite" or "very important. "Forty-two percent of the fellows rated the overall quality of teaching EOL care in their fellowship as "very good" or "excellent," whereas 23% gave such ratings to EOL teaching in fellowship (P < or = 0.001). Fellows viewed attending oncologists as having more expertise in dealing with acute complications of cancer (eg, managing spinal cord compression, 78%) than in delivering EOL care (eg, managing pain, 54%; P < 0.001). Fellows also were more likely to have received observation and feedback on bone marrow biopsies than on EOL discussions. Knowledge about key EOL care topics was poor; only 31% correctly performed an opioid conversion. Oncology fellows described deficiencies in training on EOL issues;they may benefit from improved education on EOL topics.

Developing Initial Competency-based Outcomes for the Hospice and Palliative Medicine Subspecialist: phase I of the hospice and palliative medicine competencies project.

As a newly recognized subspecialty, the field of hospice and palliative medicine (HPM) must transition existing pathways for board certification, fellowship standards, and fellowship accreditation to one based on the Accreditation Council for Graduate Medical Education and American Board of Medical Specialties competency framework. The Competencies Work Group of the American Board of Hospice and Palliative Medicine, using an iterative process informed by the field, has developed a set of Initial Competency-based Outcomes for the HPM Subspecialist. These competencies will set the standard for the "competent hospice and palliative medicine subspecialist physician," guiding future HPM fellowship training and potential midcareer HPM training opportunities. Lessons learned are highlighted.

Creating enduring change: demonstrating the long-term impact of a faculty development program in palliative care.

BACKGROUND: Improved educational and evaluation methods are needed in continuing professional development programs. OBJECTIVE: To evaluate the long-term impact of a faculty development program in palliative care education and practice. DESIGN: Longitudinal self-report surveys administered from April 2000 to April 2005. PARTICIPANTS: Physician and nurse educators from North America and Europe. All program graduates (n = 156) were invited to participate. INTERVENTION: Two-week program offered annually (2000 to 2003) with 2 on-site sessions and 6-month distance-learning period. Learner-centered training addressed teaching methods, clinical skill development, and organizational and professional development. MEASURES: Self-administered survey items assessing behaviors and attitudes related to palliative care teaching, clinical care, and organizational and professional development at pre-, postprogram, and long-term (6, 12, or 18 months) follow-up. RESULTS: Response rates: 96% (n = 149) preprogram, 73% (n = 114) follow-up. Participants reported increases in: time spent in palliative care practice (38% preprogram, 47% follow-up, P < .01); use of learner-centered teaching approaches (sum of 8 approaches used "a lot": preprogram 0.7 +/- 1.1, follow-up 3.1 +/- 2.0, P < .0001); and palliative care topics taught (sum of 11 topics taught "a lot": preprogram 1.6 +/- 2.0, follow-up 4.9 +/- 2.9, P < .0001). Reported clinical practices in psychosocial dimensions of care improved (e.g., assessed psychosocial needs of patient who most recently died: 68% preprogram, 85% follow-up, P = .01). Nearly all (90%) reported launching palliative care initiatives, and attributed their success to program participation. Respondents reported major improvements in confidence, commitment to palliative care, and enthusiasm for teaching. Eighty-two percent reported the experience as "transformative." CONCLUSIONS: This evidence of enduring change provides support for the potential of this educational model to have measurable impact on practices and professional development of physician and nurse educators.

Psychological issues in end-of-life care.

This paper provides a systematic, evidence-based review of the psychological issues confronted by patients at the end of life, drawing on recent literature. The epidemiology, approach to clinical assessment, clinical presentation, and therapeutic options related to common psychological issues that arise in end-stage illness are described. The spectrum of normal and dysfunctional reactions are identified, and approaches to enhancing coping and quality of life are emphasized. The learner will be able to describe: (1) normal coping responses of patients at the end of life; (2) epidemiology of common psychiatric disorders at the end of life; (3) the approach to clinical assessment of psychological distress at the end of life; and (4) therapeutic approaches to common psychological problems at the end of life.