Perspectives of Canadian health leaders on the relationship between medical assistance in dying and palliative and end-of-life care services: a qualitative study.

BACKGROUND: Medical assistance in dying (MAiD) was legalized in Canada in 2016, but coordination of MAiD and palliative and end-of-life care (PEOLC) services remains underdeveloped. We sought to understand the perspectives of health leaders across Canada on the relationship between MAiD and PEOLC services and to identify opportunities for improved coordination. METHODS: In this quantitative study, we purposively sampled health leaders across Canada with expertise in MAiD, PEOLC, or both. We conducted semi-structured interviews between April 2021 and January 2022. Interview transcripts were coded independently by 2 researchers and reconciled to identify key themes using content analysis. We applied the PATH framework for Integrated Health Services to guide data collection and analysis. RESULTS: We conducted 36 interviews. Participants expressed diverse views about the optimal relationship between MAiD and PEOLC, and the desirability of integration, separation, or coordination of these services. We identified 11 themes to improve the relationship between the services across 4 PATH levels: client-centred services (e.g., educate public); health operations (e.g., cultivate compassionate and proactive leadership); health systems (e.g., conduct broad and inclusive consultation and planning); and intersectoral initiatives (e.g., provide standard practice guidelines across health care systems). INTERPRETATION: Health leaders recognized that cooperation between MAiD and PEOLC services is required for appropriate referrals, care coordination, and patient care. They identified the need for public and provider education, standardized practice guidelines, relationship-building, and leadership. Our findings have implications for MAiD and PEOLC policy development and clinical practice in Canada and other jurisdictions.

Exploring key stakeholders' attitudes and opinions on medical assistance in dying and palliative care in Canada: a qualitative study protocol.

INTRODUCTION: Canadians have had legal access to medical assistance in dying (MAiD) since 2016. However, despite substantial overlap in populations who request MAiD and who require palliative care (PC) services, policies and recommended practices regarding the optimal relationship between MAiD and PC services are not well developed. Multiple models are possible, including autonomous delivery of these services and formal or informal coordination, collaboration or integration. However, it is not clear which of these approaches are most appropriate, feasible or acceptable in different Canadian health settings in the context of the COVID-19 pandemic and in the post-pandemic period. The aim of this qualitative study is to understand the attitudes and opinions of key stakeholders from the government, health system, patient groups and academia in Canada regarding the optimal relationship between MAiD and PC services. METHODS AND ANALYSIS: A qualitative, purposeful sampling approach will elicit stakeholder feedback of 25-30 participants using semistructured interviews. Stakeholders with expertise and engagement in MAiD or PC who hold leadership positions in their respective organisations across Canada will be invited to provide their perspectives on the relationship between MAiD and PC; capacity-building needs; policy development opportunities; and the impact of the COVID-19 pandemic on the relationship between MAiD and PC services. Transcripts will be analysed using content analysis. A framework for integrated health services will be used to assess the impact of integrating services on multiple levels. ETHICS AND DISSEMINATION: This study has received ethical approval from the University Health Network Research Ethics Board (No 19-5518; Toronto, Canada). All participants will be required to provide informed electronic consent before a qualitative interview is scheduled, and to provide verbal consent prior to the start of the qualitative interview. Findings from this study could inform healthcare policy, the delivery of MAiD and PC, and enhance the understanding of the multilevel factors relevant for the delivery of these services. Findings will be disseminated in conferences and peer-reviewed publications.

Suicide Risk Screening and Suicide Prevention in Patients With Cancer.

Background: Suicide rates are up to 4 times greater in cancer compared with the general population, yet best practices for institutional suicide prevention are unknown. The objective of this study was to examine the association between suicide risk screening (SRS), clinician response, and suicide mortality at a comprehensive cancer treatment center. Methods: We conducted a naturalistic, retrospective cohort study of patients attending the Princess Margaret Cancer Centre, where routine screening for suicidal intent within the Distress Assessment and Response Tool (DART-SRS) was implemented in 2010. Inverse probability of treatment weighting was used to evaluate the impact of DART-SRS completion on suicide mortality from 2005 to 2014. Chart audits were conducted for clinician response to suicidality, and crude suicide rates over the study period were analyzed. All statistical tests were 2-sided. Results: Among 78 650 cancer patients, 89 (0.1%) died by suicide, of whom only 4 (4.5%) had completed DART-SRS. Among DART-SRS completers (n = 14 517), 69 (0.5%) reported suicidal intent, none of whom died by suicide. DART-SRS completion was associated with increased clinician response to suicidality (17.4% vs 6.7%, P = .04), more psychosocial service usage (30.5% vs 18.3%, P < .001), and lower suicide mortality (hazard ratio = 0.29, 95% confidence interval = 0.28 to 0.31). Crude suicide rates at the Princess Margaret Cancer Centre were lower in patients whose first contact year was after DART-SRS implementation. Conclusion: DART-SRS completion is associated with lower suicide mortality and increased access to psychosocial care, but patients who did not complete DART-SRS were at highest suicide risk. Further research is needed to identify mechanisms to ensure psychosocial and suicidality assessment in cancer patients who do not complete SRS.

A cross-sectional gender-sensitive analysis of depressive symptoms in patients with advanced cancer.

BACKGROUND: Patients with advanced cancer commonly report depressive symptoms. Examinations of gender differences in depressive symptoms in patients with advanced cancer have yielded inconsistent findings. AIM: The objective of this study was to investigate whether the severity and correlates of depressive symptoms differ by gender in patients with advanced cancer. DESIGN: Participants completed measures assessing sociodemographic and medical characteristics, disease burden, and psychosocial factors. Depressive symptoms were examined using the Patient Health Questionnaire, and other measures included physical functioning, symptom burden, general anxiety, death related distress, and dimensions of demoralization. A cross-sectional analysis examined the univariate and multivariate relationships between gender and depressive symptoms, while controlling for important covariates in multivariate analyses. SETTING/PARTICIPANTS: Patients with advanced cancer (N = 305, 40% males and 60% females) were recruited for a psychotherapy trial from outpatient oncology clinics at a comprehensive cancer center in Canada. RESULTS: Severity of depressive symptoms was similar for males (M = 7.09, SD = 4.59) and females (M = 7.66, SD = 5.01), t(303) = 1.01, p = 0.314. Greater general anxiety and number of cancer symptoms were associated with depressive symptoms in both males and females. Feeling like a failure (ß = 0.192), less death anxiety (ß = -0.188), severity of cancer symptoms (ß = 0.166), and older age (ß = 0.161) were associated with depressive symptoms only in males, while disheartenment (ß = 0.216) and worse physical functioning (ß = 0.275), were associated with depressive symptoms only in females. CONCLUSIONS: Males and females report similar levels of depressive symptoms but the pathways to depression may differ by gender. These differences suggest the potential for gender-based preventive and therapeutic interventions in this population.

The impact of attachment security on death preparation in advanced cancer: The role of couple communication.

OBJECTIVE: Attachment security protects psychological well-being in patients with advanced cancer, but its effect on death preparation in this population has not been demonstrated. We examined the relationship of attachment security to death preparation in advanced cancer and tested whether couple communication mediates this relationship and whether gender and age moderate this mediating effect, using longitudinal data from a psychotherapy trial. METHODS: Patients with advanced cancer who lived with a partner (Nbaseline = 289) completed measures of attachment security (attachment avoidance, attachment anxiety), couple communication, and death preparation (preparation for end of life, life completion) and attendant health involvement (relationship with healthcare provider). A moderated mediation model was evaluated at each time period (baseline, 3 months, and 6 months). RESULTS: Couple communication mediated the relationship of attachment security to preparation for end of life and life completion (b's = -.06 to -.10). Anxiety × Gender effects on baseline couple communication (P's = .016) indicated that women with greater attachment anxiety reported worse communication than their male counterparts. Couple-communication × Gender × Age effects on baseline preparation for end of life (P = .007-.020) suggested that women showed better preparation with better couple communication. Younger patients reported less preparation than older patients, especially with poorer communication, but their preparation increased with better communication, especially in younger men. CONCLUSIONS: Attachment security supports death preparation in advanced cancer partly through better couple communication. Couple-based psychotherapeutic interventions, especially for younger individuals and women with attachment anxiety, may facilitate constructive conversations and death preparation.

Managing Cancer and Living Meaningfully (CALM): A Randomized Controlled Trial of a Psychological Intervention for Patients With Advanced Cancer.

Purpose Individuals with advanced cancer experience substantial distress in response to disease burden and impending mortality. Managing Cancer And Living Meaningfully (CALM) is a novel, brief, manualized psychotherapeutic intervention intended to treat and prevent depression and end-of-life distress in patients with advanced cancer. We conducted a randomized controlled trial to compare CALM with usual care (UC) in this population. Methods Patients with advanced cancer were recruited from outpatient oncology clinics at a comprehensive cancer center into an unblinded randomized controlled trial. Permuted block randomization stratified by Patient Health Questionnaire-9 depression score allocated participants to CALM plus UC or to UC alone. Assessments of depressive symptoms (primary outcome), death-related distress, and other secondary outcomes were conducted at baseline, 3 months (primary end point), and 6 months (trial end point). Analyses were by intention to treat. Analysis of covariance was used to test for outcome differences between groups at follow-up, controlling for baseline. Mixed-model results are reported. Results Participants (n = 305) were recruited between February 3, 2012, and March 4, 2016, and randomly assigned to CALM (n = 151) or UC (n = 154). CALM participants reported less-severe depressive symptoms than UC participants at 3 months (Δ = 1.09; P = .04; Cohen's d = 0.23; 95% CI, 0.04 to 2.13) and at 6 months (Δ = 1.29; P = .02; d = 0.29; 95% CI, 0.24 to 2.35). Significant findings for greater end-of-life preparation at 6 months also favored CALM versus UC. No adverse effects were identified. Conclusion Findings suggest that CALM is an effective intervention that provides a systematic approach to alleviating depressive symptoms in patients with advanced cancer and addresses the predictable challenges these patients face.

Easier Said Than Done: Keys to Successful Implementation of the Distress Assessment and Response Tool (DART) Program.

PURPOSE: Systematic screening for distress in oncology clinics has gained increasing acceptance as a means to improve cancer care, but its implementation poses enormous challenges. We describe the development and implementation of the Distress Assessment and Response Tool (DART) program in a large urban comprehensive cancer center. METHOD: DART is an electronic screening tool used to detect physical and emotional distress and practical concerns and is linked to triaged interprofessional collaborative care pathways. The implementation of DART depended on clinician education, technological innovation, transparent communication, and an evaluation framework based on principles of change management and quality improvement. RESULTS: There have been 364,378 DART surveys completed since 2010, with a sustained screening rate of > 70% for the past 3 years. High staff satisfaction, increased perception of teamwork, greater clinical attention to the psychosocial needs of patients, patient-clinician communication, and patient satisfaction with care were demonstrated without a resultant increase in referrals to specialized psychosocial services. DART is now a standard of care for all patients attending the cancer center and a quality performance indicator for the organization. CONCLUSION: Key factors in the success of DART implementation were the adoption of a programmatic approach, strong institutional commitment, and a primary focus on clinic-based response. We have demonstrated that large-scale routine screening for distress in a cancer center is achievable and has the potential to enhance the cancer care experience for both patients and staff.

Routine screening for suicidal intention in patients with cancer.

OBJECTIVES: Suicide rates are elevated in individuals with cancer, although suicidal intention is not typically assessed in cancer centers. We evaluated in a large comprehensive cancer center the utility of an electronic Distress Assessment and Response Tool (DART), in which suicidal intention is assessed with a single item. METHODS: Patients attending cancer clinics completed DART as part of routine care. DART includes measures of physical symptoms, depression, anxiety, social difficulties, and practical concerns. Medical variables were obtained from the Princess Margaret Cancer Registry, the data warehouse of cancer patient statistics. A Generalized Estimating Equation (GEE) model was used to assess factors associated with suicidal intention. RESULTS: Between September 2009 and March 2012, 4822/5461 patients (88.3%) who completed DART consented to the use of their data for research. Amongst the latter, 280 (5.9%) of the 4775 patients who answered the question reported suicidal ideation, which was related to physical and psychological distress, and social difficulties (ps < 0.0001). Amongst those with ideation who responded to the intention question, 20/186 (10.8%) reported suicidal intention. Of respondents with more severe suicidal ideation, 12/49 (24.5%) reported suicidal intention. Using a GEE model, suicidal intention in those with ideation was significantly associated with male sex, difficulty making treatment decisions, and with everyday living concerns. CONCLUSIONS: Suicidal ideation is reported on an electronic distress screening tool (DART) by almost 6% of cancer patients, of whom almost 11% report suicidal intention and 33% decline to indicate intention. DART demonstrated utility in identifying patients who may be at highest risk of completed suicide and who require urgent clinical assessment.

The Ontario Psychosocial Oncology Framework: a quality improvement tool.

OBJECTIVE: To overview the newly developed Psychosocial Health Care for Cancer Patients and Their Families: A Framework to Guide Practice in Ontario and Guideline Recommendations in the context of Canadian psychosocial oncology care and propose strategies for guideline uptake and implementation. METHOD: Recommendations from the 2008 Institute of Medicine standard Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs were adapted into the Ontario Psychosocial Oncology (PSO) Framework. Existing practice guidelines developed by the Canadian Partnership against Cancer and Cancer Care Ontario and standards developed by the Canadian Association of Psychosocial Oncology are supporting resources for adopting a quality improvement (QI) approach to the implementation of the framework in Ontario. RESULTS: The developed PSO Framework, including 31 specific actionable recommendations, is intended to improve the quality of comprehensive cancer care at both the provider and system levels. Important QI change management processes are described as Educate - raising awareness among medical teams of the significance of psychosocial needs of patients, Evidence - developing a research evidence base for patient care benefits from psychosocial interventions, and Electronics - using technology to collect patient reported outcomes of both physical and emotional symptoms. CONCLUSIONS: The Ontario PSO Framework is unique and valuable in providing actionable recommendations that can be implemented through QI processes. Overall, the result will be improved psychosocial health care for the cancer population.

Sources of spiritual well-being in advanced cancer.

OBJECTIVE: To test a conceptual model of sources of spiritual well-being in patients facing life-limiting disease. DESIGN: Cross-sectional survey. SETTING: Princess Margaret Hospital, Toronto, Canada. PARTICIPANTS: 747 patients with stage IV gastrointestinal, breast, genitourinary or gynaecological cancer, or stage IIIA, IIIB or IV lung cancer, recruited from 2002 to 2008. MAIN OUTCOME MEASURE: Spiritual well-being as assessed by the FACIT-Sp-12. RESULTS: Using structural equation modelling, spiritual well-being was specified as being predicted by religiosity, self-esteem, social relatedness and the physical burden of disease. The model had a good fit, Comparative Fit Index=0.96, Non-normed Fit Index=0.94, Root Mean Square Error of Approximation=0.057. Standardised path coefficients relating each factor to spiritual well-being were as follows: religiosity 0.50, social relatedness 0.28, self-esteem 0.26 and physical burden -0.11. CONCLUSIONS: The authors confirmed our theoretical model in which spiritual well-being is positively associated with religiosity, self-esteem and social relatedness, and is negatively associated with physical suffering. Our findings support a multidimensional approach to spiritual well-being that addresses not only religious issues, but also pain and symptom control, and the potentially damaging effects of advanced disease on self-worth and close relationships. The spiritually informed clinical encounter may be one in which sufficient time and opportunity for reflection are afforded to consider illness trajectories and treatment decisions in the context of religious beliefs and personal values, self-worth, support systems and concerns about dependency.

Use of animal-assisted therapy in the rehabilitation of an assault victim with a concurrent mood disorder.

Multidisciplinary mental health rehabilitation settings often encounter patients with complex comorbid medical and psychiatric issues that require integrative, multifaceted treatment strategies. Although medication and psychotherapy are typical treatment mainstays, a broader variety of therapeutic options are available, including animal-assisted therapy. Here we describe a patient who received animal-assisted therapy as a psychiatric rehabilitation tool to ameliorate his atypical depression following an assault and subsequent head injury. A review of the relevant literature highlights the therapeutic potential of animal-assisted therapy to restore and maintain patient independence and level of functioning, both of which are key treatment goals.