Spiritual Care Assessment and Intervention (SCAI) for Adult Outpatients With Advanced Cancer and Caregivers: A Pilot Trial to Assess Feasibility, Acceptability, and Preliminary Effects.

BACKGROUND: Although religion and spirituality are important to adults with cancer and their family caregivers, few studies have tested spiritual care interventions in the outpatient setting. AIM: To determine the feasibility, acceptability, and preliminary effects of chaplain-delivered, semi-structured spiritual care to adult outpatients with advanced cancer and their caregivers. DESIGN: In this pre/post pilot intervention study, board-certified chaplains utilized the Spiritual Care Assessment and Intervention (SCAI) framework during 4 individual sessions. Surveys at baseline and at 1, 6, and 12 weeks post-intervention assessed spiritual well-being, quality of life, depression, anxiety, and religious coping. SETTING/PARTICIPANTS: We enrolled U.S. adult outpatients with or without an eligible family caregiver. Eligible patients were at least 18 years old and at least 2 weeks post-diagnosis of incurable and advanced-stage lung or gastrointestinal (GI) cancer. RESULTS: Of 82 eligible patients, 24 enrolled (29.3%); of 22 eligible caregivers, 18 enrolled (81.8%). Four planned chaplain visits were completed by 87.5% of patients and 77.8% of caregivers. All enrolled participants completed baseline surveys, and more than 75% completed follow-up surveys at 2 of 3 time points. More than 80% of patients and caregivers reported they would recommend the sessions to a friend or family member. Patients' spiritual well-being improved significantly at all timepoints compared to baseline: 1-week post (p < .006), 6-weeks post (p < .001), and 12-weeks post (p < .004). CONCLUSIONS: Spiritual care through SCAI is feasible, acceptable, and shows promise in improving spiritual well-being and other important outcomes in advanced-stage cancer patients and family caregivers. Further investigation is warranted.

The Use of Claims-Based Data in Inpatient Public Reporting and Pay-for-Performance Programs: Is There Opportunity for Improvement?

PURPOSE: This study examined whether self-reported, facility-based data validation practices for claims submissions of cases flagged as Patient Safety Indicators (PSIs) match professional and regulatory standards. METHODS: The National Association of Healthcare Quality members who work in an inpatient setting were invited to complete an anonymous survey to self-report their practices around facility-based data validation of PSI cases. RESULTS: The authors found widespread variation in how PSI administrative data are internally validated; inconsistency in the education and training required of staff who participate in this process; and relatively poor compliance with physician query guidelines and documentation amendment standards. CONCLUSIONS: The self-described wide variation and nonadherence to professional and regulatory standards within the facility-based validation process for PSIs raise concerns about the use of these data to make meaningful judgments about quality and safety. The authors recommend a standardized approach to reporting and validation be implemented for use of PSIs in public reporting and pay-for-performance programs.

Making decisions for hospitalized older adults: ethical factors considered by family surrogates.

BACKGROUND: Hospitalized older adults frequently have impaired cognition and must rely on surrogates to make major medical decisions. Ethical standards for surrogate decision making are well delineated, but little is known about what factors surrogates actually consider when making decisions. OBJECTIVES: To determine factors surrogate decision makers consider when making major medical decisions for hospitalized older adults, and whether or not they adhere to established ethical standards. DESIGN: Semi-structured interview study of the experience and process of decision making. SETTING: A public safety-net hospital and a tertiary referral hospital in a large city in the Midwest United States. PARTICIPANTS: The study included 35 surrogates with a recent decision-making experience for an inpatient aged 65 or older. MEASUREMENTS: The key factors that surrogates considered when making decisions. Interview transcripts were coded and analyzed using the grounded theory method of qualitative analysis. RESULTS: Surrogates considered patient-centered factors and surrogate-centered factors. Patient-centered factors included: (1) respecting the patient's input, (2) using past knowledge of the patient to infer the patient's wishes, and (3) considering what is in the patient's best interests. Some surrogates expressed a desire for more information about the patient's prior wishes. Surrogate-centered factors included: (1) surrogate's wishes as a guide, (2) surrogate's religious beliefs and/or spirituality, (3) surrogate's interests, and (4) family consensus. CONCLUSION: Our study indicates that surrogate decision making is more complex than the standard ethical models, which are limited to considerations of the patient's autonomy and beneficence. Because surrogates also imagine what they would want under the circumstances and consider their own needs and preferences, models of surrogate decision making must account for these additional considerations. Surrogates' desire for more information about patients' preferences suggests a need for greater advance care planning.

Ethics in oncology: an annotated bibliography of important literature.

The aim of this annotated bibliography about important articles in the field of ethics and oncology is to provide the practicing hematologist/oncologist with a brief overview of some of the important literature in this crucial area.

Correlation between financial relationships with commercial interests and research prominence at an oncology meeting.

PURPOSE: Little is known about the effects of financial relationships between biomedical researchers and industry (financial conflicts of interest [FCOIs]) on research prominence. We examined the prevalence of FCOIs in oncology and associations between FCOIs and research prominence among abstracts presented at American Society of Clinical Oncology (ASCO) annual meetings. METHODS: We analyzed 20,718 abstracts presented at ASCO meetings in 2006 and 2008 to 2011. Measures included the following: financial relationships, peer review score (PRS), and meeting placement prominence (descending order of prominence: plenary session, clinical science symposium, oral presentation, poster discussion, general posters, and publish only). RESULTS: Of 20,718 abstracts, 36% reported at least one author with an FCOI. The proportion of abstracts with any FCOI increased from 33% in 2006 to 38% in 2011 (P < .001). Abstracts with FCOIs had significantly higher meeting prominence compared with publish only and general poster abstracts. The odds ratios compared with general posters were 7.3 for plenary session, 2.2 for clinical science symposium, 1.9 for oral presentation, and 1.7 for poster discussion (P < .001). Abstracts with FCOIs had significantly better PRSs compared with those without FCOIs. For all abstracts, PRS was 2.76 (95% CI, 2.75 to 2.77) with FCOIs compared with 3.01 (95% CI, 3.001 to 3.02) without FCOIs (P < .001). Omitting publish-only abstracts, PRS was 2.62 (95% CI, 2.61 to 2.63) with FCOIs compared with 2.73 without FCOIs (95% CI, 2.71 to 2.73). CONCLUSION: Abstracts with FCOIs had more prominent meeting placement and better PRSs. FCOIs were reported more frequently by year, suggesting an increasing influence of industry on cancer research, greater disclosure, or both.

Ethical challenges in oncology, explored through a series of vignettes.

The specialty of medical oncology poses many ethical dilemmas to the practicing physician. In this article, we have chosen to focus on three of those challenges, presenting them in the form of vignettes. The first dilemma deals with the difficulties physicians encounter secondary to the rising cost of cancer therapies when choosing and communicating about treatment plans with patients. The second scenario addresses difficulties associated with communicating prognosis to cancer patients, and the third challenge focuses on cancer treatment strategies for patients nearing the end of life.

To keep them from injustice: reflections on the care of unauthorized immigrants with cancer.

Estimates from 2010 suggest that more than 11 million unauthorized immigrants reside in the United States. Many oncologists have struggled with how to fulfill their perceived obligation to treat unauthorized immigrant patients with cancer and no access to financial resources. Because of current realities in medical economics and reimbursement policies, there is simply not a large enough profit margin in most practices to offer free care to everyone who needs it. In this article, I attempt to clarify why we feel such an obligation to do so and whether the reasons behind this sense of obligation point us toward a consistent stance we should have toward unauthorized immigrant patients who seek treatment from us.

Follow-up care delivery among colorectal cancer survivors most often seen by primary and subspecialty care physicians.

BACKGROUND: The Institute of Medicine has identified patients as a key source of information for assessing the quality of care. OBJECTIVE: To evaluate the association of physician specialty with the content and quality of follow-up cancer care. DESIGN AND PARTICIPANTS: Three hundred three colorectal cancer (CRC) survivors in Northern California were surveyed 2-5 years post-diagnosis. MEASUREMENTS: Specialty of physician seen most often [primary care physician (PCP), oncologist, surgeon, or gastroenterologist]; other physician specialties seen; patient characteristics; content of visits; patient-centered quality of follow-up care (communication, coordination, nursing, and staff interactions). MAIN RESULTS: A minority (16%) of CRC survivors reported that the doctor they most often saw for follow-up cancer care was a PCP, while 60% saw an oncologist. Many CRC survivors (40%) saw >1 physician for follow-up cancer care. Survivors most often seen by PCPs were more likely to have three or more medical comorbidities (70% vs. 51%, p = 0.012) than survivors seen by subspecialty physicians. Survivors seen by PCPs were less likely to report seeing a doctor for medical tests and more likely to report discussing disease prevention (82% vs. 64%, p = 0.012) or diet (70% vs. 48%, p = 0.005) with their doctor. There were no significant specialty differences in patient-centered quality of follow-up cancer care. CONCLUSIONS: Cancer survivors' assessment of the quality of care was similar across specialties, while the content of follow-up cancer care varied by physician specialty. These findings provide important information about the potential value of primary care and the need for coordination when delivering care to CRC survivors.

Oncology outpatient and provider responses to a computerized symptom assessment system.

PURPOSE/OBJECTIVES: To assess patient and provider responses to a computerized symptom assessment system. DESIGN: Descriptive, longitudinal study with retrospective, longitudinal medical records review. SETTING: University-based National Cancer Institute-designated outpatient cancer center. SAMPLE: 80 oncology outpatients receiving chemotherapy, 8 providers, and 30 medical records. METHODS: Patients completed the computerized assessment during three chemotherapy follow-up clinic appointments (times 1, 2, and 3). Patient usability was recorded via an observer checklist (ease of use) and the computer (completion time). Patient satisfaction and impact were assessed during telephone interviews two to three days after times 1 and 3 only. Provider usability and impact were assessed at the end of the study using a questionnaire and focus groups, whereas effect on provider documentation was assessed through chart audits. MAIN RESEARCH VARIABLES: Patient usability (ease of use, completion time), satisfaction, and impact; provider usability and impact. FINDINGS: Patients reported good usability, high satisfaction, and modest impact on discussions with their providers. Providers reported modest usability, modest impact on discussions with patients, and had varied reactions as to how the system affected practice. Documentation of symptoms was largely absent before and after implementation. CONCLUSIONS: This system demonstrated good usability and satisfaction but had only a modest impact on symptom-related discussions and no impact on documentation. IMPLICATIONS FOR NURSING: A computerized system can help address barriers to symptom assessment but may not improve documentation unless it can be integrated into existing medical records systems.

The influence of psychosocial evaluation on candidacy for liver transplantation.

CONTEXT: Although medical factors clearly dominate the evaluation of appropriateness for liver transplant, psychosocial factors are an important dimension in the evaluation process. OBJECTIVE: To understand more about the weight assigned to psychosocial factors in the decision to list patients for liver transplant and about whether such differences create hidden inequities in the transplant allocation system. DESIGN: We conducted a mail survey of liver transplant surgeons and psychosocial evaluators at busy transplant centers assessing the importance these professionals assigned to psychosocial factors in evaluations for liver transplant candidacy. PARTICIPANTS: Liver transplant surgeons and psychosocial evaluators from the highest volume liver transplant centers in the United States. INTERVENTION: Mail survey. RESULTS: Psychosocial evaluators assigned greater importance to availability of transportation, adaptation to stress, and coping skills than did surgeons. Transplant psychosocial evaluators were less likely than transplant surgeons to recommend that a patient with a history of poor social support be listed for liver transplant. We found no correlation between relative weight assigned to psychosocial factors and median wait times at transplant centers. These differences suggest that the relationship between the factors identified by psychosocial evaluators as important and transplant outcomes should be studied. Overall, more research into the predictive and ethical aspects of psychosocial evaluation for liver transplant is needed.

Ethics, law, and commercial surrogacy: a call for uniformity.

In the United States at this time, no uniform federal law exists regarding commercial surrogacy, and state statutory schemes vary vastly, ranging from criminalization to legal recognition with contract enforcement. The authors examine how commercial surrogacy agencies utilize the Internet as a means for attracting parents and surrogates by employing emotional cultural rhetoric. By inducing both parents and surrogates to their jurisdiction, agencies circumvent vast discrepancies in state statutory regulative schemes and create a distinct interstate business, absent an efficient regulatory framework or legal recourse in some circumstances. The authors propose a uniform federal regulatory scheme premised upon regulating interstate business transactions to create accountability and legal remedies for both the parents and the surrogate.

Inside information: Financial conflicts of interest for research subjects in early phase clinical trials.

In recent years, several research subjects have told us that they had bought or intended to buy stock in the companies sponsoring the clinical trials in which they were enrolled. This situation has led us to ask what, if any, are physician-investigators' scientific, ethical, and legal responsibilities concerning research subjects who choose to buy stock in the companies sponsoring the clinical trials in which they are participating. Although the scope of this problem is unknown and is likely to be small, this commentary examines the scientific, ethical, and legal concerns raised by such activities on the part of research subjects enrolled in early phase clinical trials. In addition, this commentary also outlines the basis for our opinion that research subjects involved in an early phase clinical trial should avoid the financial conflicts of interest created by trading stock in the company sponsoring the clinical trial.