Efficacy of a survivorship-focused consultation versus a time-controlled rehabilitation consultation in patients with lymphoma: A cluster randomized controlled trial.

BACKGROUND: Survivors of cancer often describe a sense of abandonment after treatment along with heightened uncertainty and limited knowledge of what lies ahead. This study examined the efficacy of a survivorship care plan (SCP) intervention to help physicians to address survivorship issues through communication skills training plus a new consultation focused on the use of an SCP for patients with Hodgkin lymphoma and diffuse large B-cell lymphoma. METHODS: This 4-site cluster randomized trial examined the efficacy of a survivorship planning consultation (SPC) in patients who achieved complete remission after the completion of first-line therapy (for the SPC, physicians received communication skills training and, using an SCP, applied those skills in a survivorship-focused office visit) versus a control arm in which physicians were trained in and subsequently provided a time-controlled, manualized wellness rehabilitation consultation (WRC) focused only on discussion of healthy nutrition and exercise as rehabilitation after chemotherapy. The primary outcomes for patients were changes in knowledge about lymphoma and adherence to physicians' recommendations for vaccinations and cancer screenings. RESULTS: Forty-two physicians and 198 patients participated across the 4 sites. Patients whose physicians were in the SPC arm had greater knowledge about their lymphoma (P = .01) and showed greater adherence to physician recommendations for influenza vaccinations (P = .02) and colonoscopy (P = .02) than patients whose physicians were in the WRC arm. CONCLUSIONS: A dedicated consultation using an SCP and supported by communication skills training may enhance patients' knowledge and adherence to some health promotion recommendations.

Factitious disorder (Munchausen's syndrome) in oncology: case report and literature review.

BACKGROUND: Factitious disorder is where patients repeatedly seek medical care for feigned illnesses in the absence of obvious external rewards; 'Munchausen's syndrome' is the historical name for this disorder. METHOD: We report on a case that was presented to a tertiary oncology center as a suspected rare bone cancer. RESULTS AND CONCLUSIONS: Psychosocial clinicians working in oncology settings should be aware of the complexities of diagnosing factitious disorder in cancer settings where empathy is prominent and suspicion unusual. Moreover, comorbidity can cloud the diagnosis (in this case substance abuse), and, even when accurately diagnosed, there are no evidence-based management approaches to offer to the patient. What seems to linger most after the patient is discharged, usually in a huff, are strong counter-transference feelings and substantial medical bills. Copyright © 2015 John Wiley & Sons, Ltd.

Preventing and De-Escalating Ethical Conflict: A Communication-Training Mediation Model.

While ethical conflicts in the provision of healthcare are common, the current third-party mediator model is limited by a lack of expert ethical mediators, who are often not on site when conflict escalates. In order to improve clinical outcomes in situations such as conflicts at the end of life, we suggest that clinicians-physicians, nurses and social workers-be trained to prevent and de-escalate emerging conflicts. This can be achieved using a mediation model framed by a communication-training approach. A case example is presented and the model is discussed. The implication of this preventative/early intervention model for improving clinical outcomes, in particular end-of life conflict, is considered.

A communication training perspective on AND versus DNR directives.

BACKGROUND: From a communication perspective, the term "do not resuscitate" (DNR) is challenging to use in end-of-life discussions because it omits the goals of care. An alternative, "Allow Natural Death" (AND), has been proposed as a better way of framing this palliative care discussion. CASE: We present a case where a nurse unsuccessfully discusses end-of-life goals of care using the term DNR. Subsequently, with the aid of a communication trainer, he is coached to successfully use the term "AND" to facilitate this discussion and advance his goal of palliative care communication and planning. DISCUSSION: We contrast the advantages and disadvantages of the term AND from the communication training perspective and suggest that AND-framing language replace DNR as a better way to facilitate meaningful end-of-life communication. One well-designed, randomized, controlled simulation study supports this practice. We also consider the communication implications of "natural" versus "unnatural" death.

Contextual barriers to discussing a schizophrenia diagnosis with patients and families: need for leadership and teamwork training in psychiatry.

OBJECTIVE: This research sought to gain insight into the processes used by clinicians to discuss a schizophrenia diagnosis with patients/families, with the aim of informing the development of a communications skills training program. METHODS: A generic qualitative methodological approach was used. Sixteen mental health clinicians were recruited. Semi-structured individual interviews were used to explore their perceptions and experiences communicating a schizophrenia diagnosis. Interviews were recorded, transcribed, and thematic analysis undertaken. RESULTS: There were five key themes relating to the process of communication about a diagnosis of schizophrenia: (1) orientation to patient care, (2) planning of communication, (3) the impact of team leadership and inter/intra-professional functioning on communication tasks, (4) the roles of different clinicians in communicating about diagnosis and treatment, and (5) time and resource deficiencies. Despite expressing care and concern for vulnerable patients and embracing the concept of multidisciplinary teams, communicating diagnostic information to patients and families was generally unplanned for, with little consistency regarding leadership approaches, or how the team communicated diagnostic information to the patient and family. This contributed to tensions between different team members. CONCLUSION: The findings demonstrated a number of issues compromising good communication around a schizophrenia diagnosis, both in terms of clinician skill and clinical context, and support the importance of education and training for all members of the multidisciplinary team about their role in the communication process.

Acute Cancer Cognitive Therapy.

The utility of cognitive therapy (CT) for ambulatory cancer patients is clear but the acute cancer setting significantly shapes the therapeutic interaction, parameters, and delivery of CT. In this article, we describe how to apply CT to acute cancer settings, focusing on how this approach differs from traditionally taught, ambulatory CT. We highlight the importance of a tailored history and formulation, how the cognitive model is applied within an acute cancer context to promote coping and adaptation. Reframing must consider the "grain of truth" to many so-called distorted cognitions, such as "cancer means death." Fear of recurrence is an example of a common reframing challenge. Another is the "tyranny of positive thinking." Here there is avoidance of considering negative outcomes such as death; patients are told to "think positive," leaving them alone at a time of life-threatening crisis. Instead, acute cancer CT utilizes a stance of realistic optimism. Empathy plays a vital role in turning off the bracing reaction to threat and facilitating problem-solving. Successfully combining CT with medications is integral to this model. We also discuss how CT can be applied to discussing prognosis, the desire for hastened death and suicidality, as well as death and dying in general. Because of the ubiquitous nature of cancer, most cognitive therapists will encounter patients with cancer in their practices. Acute cancer CT is a skill set that should be widely taught to cognitive therapists and flagged as a priority for academic programs and professional organizations.

A review of cognitive therapy in acute medical settings. Part I: therapy model and assessment.

INTRODUCTION: Although cognitive therapy (CT) has established outpatient utility, there is no integrative framework for using CT in acute medical settings where most psychosomatic medicine (P-M) clinicians practice. Biopsychosocial complexity challenges P-M clinicians who want to use CT as the a priori psychotherapeutic modality. For example, how should clinicians modify the data gathering and formulation process to support CT in acute settings? METHOD: Narrative review methodology is used to describe the framework for a CT informed interview, formulation, and assessment in acute medical settings. Because this review is aimed largely at P-M trainees and educators, exemplary dialogues model the approach (specific CT strategies for common P-M scenarios appear in the companion article.) RESULTS: Structured data gathering needs to be tailored by focusing on cognitive processes informed by the cognitive hypothesis. Agenda setting, Socratic questioning, and adaptations to the mental state examination are necessary. Specific attention is paid to the CT formulation, Folkman's Cognitive Coping Model, self-report measures, data-driven evaluations, and collaboration (e.g., sharing the formulation with the patient.) Integrative CT-psychopharmacological approaches and the importance of empathy are emphasized. SIGNIFICANCE OF RESULTS: The value of implementing psychotherapy in parallel with data gathering because of time urgency is advocated, but this is a significant departure from usual outpatient approaches in which psychotherapy follows evaluation. This conceptual approach offers a novel integrative framework for using CT in acute medical settings, but future challenges include demonstrating clinical outcomes and training P-M clinicians so as to demonstrate fidelity.

A review of cognitive therapy in acute medical settings. Part II: strategies and complexities.

OBJECTIVE: Cognitive therapy (CT) has considerable utility for psychosomatic medicine (PM) in acute medical settings but, to date, no such cohesive adaptation has been developed. Part I delineated a CT model for acute medical settings focusing on assessment and formulation. In Part II, we review how CT can be applied to common PM clinical challenges. A pragmatic approach is helpful because this review targets PM trainees and educators. METHODS: Narrative review is used to discuss the application of CT strategies to common challenges in acute medical settings. Treatment complexities and limitations associated with the PM setting are detailed. Exemplary dialogues are used to model techniques. RESULT: We present CT approaches to eight common scenarios: (1) distressed or hopeless patients; (2) patients expressing pivotal distorted cognitions/images; (3) patients who catastrophize; (4) patients who benefit from distraction and activation strategies; (5) panic and anxiety; (6) suicidal patients; (7) patients who are stuck and helpless; (8) inhibited patients. Limitations are discussed. SIGNIFICANCE OF RESULTS: A CT informed PM assessment, formulation and early intervention with specific techniques offers a novel integrative framework for psychotherapy with the acutely medically ill. Future efforts should focus on dissemination, education of fellows and building research efficacy data.

Augmenting advance care planning in poor prognosis cancer with a video decision aid: a preintervention-postintervention study.

BACKGROUND: The authors tested whether an educational video on the goals of care in advanced cancer (life-prolonging care, basic care, or comfort care) helped patients understand these goals and had an impact on their preferences for resuscitation. METHODS: A survey of 80 patients with advanced cancer was conducted before and after they viewed an educational video. The outcomes of interest included changes in goals of care preference and knowledge and consistency of preferences with code status. RESULTS: Before viewing the video, 10 patients (13%) preferred life-prolonging care, 24 patients (30%) preferred basic care, 29 patients (36%) preferred comfort care, and 17 patients (21%) were unsure. Preferences did not change after the video, when 9 patients (11%) chose life-prolonging care, 28 patients (35%) chose basic care, 29 patients (36%) chose comfort care, and, 14 patients (18%) were unsure (P = .28). Compared with baseline, after the video presentation, more patients did not want cardiopulmonary resuscitation (CPR) (71% vs 62%; P = .03) or ventilation (80% vs 67%; P = .008). Knowledge about goals of care and likelihood of resuscitation increased after the video (P < .001). Of the patients who did not want CPR or ventilation after the video augmentation, only 4 patients (5%) had a documented do-not-resuscitate order in their medical record (kappa statistic, -0.01; 95% confidence interval, -0.06 to 0.04). Acceptability of the video was high. CONCLUSIONS: Patients with advanced cancer did not change care preferences after viewing the video, but fewer wanted CPR or ventilation. Documented code status was inconsistent with patient preferences. Patients were more knowledgeable after the video, reported that the video was acceptable, and said they would recommend it to others. The current results indicated that this type of video may enable patients to visualize "goals of care," enriching patient understanding of worsening health states and better informing decision making.

Developing and implementing an advanced communication training program in oncology at a comprehensive cancer center.

Cancer patients report significant levels of unmet needs in the realm of communication. Communication skills training programs have been shown to improve clinical communication. However, advanced communication skills training programs in oncology have lacked institutional integration, and thus have not attended to institutional norms and cultures that may counteract explicit communication skills training. We developed and implemented an advanced communication skills training program made up of nine teaching modules for faculty, fellows, and residents. Training included didactic and experiential small group work. Self-efficacy and behavior change were assessed for individual participants. Since 2006, 515 clinicians have participated in this training program. Participants have shown significant gains in self-efficacy regarding communicating with patients in various contexts. Our initial work in this area demonstrates the implementation of such a program at a major cancer center to be feasible, to be acceptable, and to have a significant impact on participants' self-efficacy.

Looming cognitive style and quality of life in a cancer cohort.

OBJECTIVE: Looming cognitive styles (LCS) bias the velocity of potential threats and have been implicated in anxiety and depression vulnerability. This study aims to explore their contribution to impaired quality of life (QOL), beyond that of depression and anxiety, in a cancer cohort. METHOD: In a cross-sectional design, an ambulatory chronic lymphocytic leukemia (CLL) cohort completed a psychological battery that included the Beck Depression and Anxiety Inventories, the SF-36 Health Survey, the Functional Assessment of Chronic Illness Therapy (FACT), the Looming Cognitive Style Questionnaire (LCSQ), and the Looming Cancer measure. RESULTS: The Looming Cancer measure correlated significantly with overall QOL (FACT-G, p = 0.005). This effect was largely due to the contribution of emotional QOL (Mental Component Score: SF-36, p = 0.001; FACT-emotional, p = 0.001) and functional QOL (FACT-functional, p = 0.001). Looming, unlike anxiety and depression, did not correlate with a worse physical QOL (Physical Component Score: SF-36, FACT-physical). Looming did not impact on social QOL. Hierarchical regression analysis showed that looming predicted 5.4% of the varience on the FACT-emotional, 5.1% on the Mental Component Score (SF-36), and 9.3% on the mental health subscale (SF-36), above and beyond the varience predicted by a constellation of psychosocial factors (including age, marital status, education, income) and the combined effect of depression and anxiety. SIGNIFICANCE OF RESULTS: LCS predicts worse emotional and functional QOL, above and beyond the contribution of anxiety, depression, and other psycho-social variables. This suggests that it makes a unique contribution to a worse QOL. Nevertheless, the looming construct still remains primarily a research tool in psycho-oncology at this time.

Mixed anxiety/depression symptoms in a large cancer cohort: prevalence by cancer type.

BACKGROUND: Mixed anxiety/depression is associated with poorer psychosocial and treatment outcomes, worse quality of life, pooreradherence to treatment, slower recovery, greater suicide risk, and highercost-utilization. OBJECTIVE: This study aimed to examine the cancer-specific prevalence of these symptoms. METHOD: Cross-sectional anxiety and depression symptom data were collected with the Brief Symptom Inventory from adult outpatients presenting to a tertiary cancer center (N=8,265). RESULTS: Mixed anxiety/depression symptoms were seen in 12.4% of patients; overall depression symptoms in 18.3%, overall anxiety symptoms in 24.0%, pure anxiety symptoms in 11.7%, and pure depression symptoms in 6.0%; 70% had neither. Higher rates of mixed anxiety/depression symptoms were seen with stomach, pancreatic, head and neck, and lung cancers, but lower rates were seen in those with breast cancers. The mixed anxiety/depression phenotype occurs in two-thirds of depressed cancer patients. DISCUSSION: The fact that 70% of patients did not meet thresholds for depression or anxiety symptoms can be interpreted as a reflection of the resistance to developing a significant level of these symptoms. However, because stomach, pancreatic, head and neck, and lung cancers have higher levels of mixed anxiety/depression symptoms, the question can be raised as to whether these are associated with a more biological type of anxiety/depression (e.g., due to cytokine release) and whether this phenotype should be actively targeted because of its frequent occurrence in these cancers.

Conducting family meetings in palliative care: themes, techniques, and preliminary evaluation of a communication skills module.

OBJECTIVE: To develop a communication skills training module for health care professionals about how to conduct a family meeting in palliative care and to evaluate the module in terms of participant self-efficacy and satisfaction. METHODS: Forty multispecialty health care professionals from the New York metropolitan area attended a communication skills training module at a Comprehensive Cancer Center about how to conduct a family meeting in oncology. The modular content was based on the Comskil model and current literature in the field. RESULTS: Based on a retrospective pre-post measure, participants reported a significant increase in self-efficacy about their ability to conduct a family meeting. Furthermore, at least 93% of participants expressed their satisfaction with various aspects of the module by agreeing or strongly agreeing with statements on the course evaluation form. SIGNIFICANCE OF RESULTS: Family meetings play a significant role in the palliative care setting, where family support for planning and continuing care is vital to optimize patient care. Although these meetings can be challenging, this communication skills module is effective in increasing the confidence of participants in conducting a family meeting.

A Video Decision Aid Improves Informed Decision Making in Patients With Advanced Cancer Considering Palliative Radiation Therapy.

CONTEXT: Advanced cancer patients have unrecognized gaps in their understanding about palliative radiation therapy (PRT). OBJECTIVES: To build a video decision aid for hospitalized patients with advanced cancer referred for PRT and prospectively test its efficacy in reducing decisional uncertainty, improving knowledge, increasing treatment readiness and readiness for palliative care consultation, and its acceptability among patients. METHODS: Forty patients with advanced cancer hospitalized at Memorial Sloan Kettering Cancer Center watched a video decision aid about PRT and palliative care. Patients' conceptual and logistical knowledge of PRT, decisional uncertainty, treatment readiness, and readiness for palliative care consultation were assessed before and after watching the video with a six-item knowledge survey, the decisional uncertainty subscale of the Decisional Conflict Scale, and Likert instruments to assess readiness to accept radiation treatment and/or palliative care consultation, respectively. A postvideo survey assessed the video's acceptability among patients. RESULTS: After watching the video, decisional uncertainty was reduced (28.3 vs. 21.7; P = 0.02), knowledge of PRT improved (60.4 vs. 88.3; P < 0.001), and PRT readiness increased (2.0 vs. 1.3; P = 0.04). Readiness for palliative care consultation was unchanged (P = 0.58). Patients felt very comfortable (70%) watching the video and would highly recommend it (75%) to others. CONCLUSION: Among hospitalized patients with advanced cancer, a video decision aid reduced decisional uncertainty, improved knowledge of PRT, increased readiness for PRT, and was well received by patient viewers.

Life-threatening serotonin toxicity due to a citalopram-fluconazole drug interaction: case reports and discussion.

OBJECTIVE: To discuss two cases of life-threatening serotonin toxicity due to a drug interaction between citalopram and fluconazole and to review the pertinent literature. METHODS: A Medline search without date limitation was conducted using the terms serotonin syndrome, serotonin toxicity, fluconazole and citalopram. RESULTS AND DISCUSSION: Fluconazole inhibits CYP2C19. Citalopram is a substrate for 2C19 and inhibition of its metabolism may result in serotonin toxicity. Serotonin toxicity in oncology patients may not present with the classic constellation of signs typically described in the literature. Delirium may be the only presenting feature. Current level of evidence for treatment of serotonin toxicity is level 4 or 5 (case series and expert opinion). Nevertheless, there is a strong theoretical basis for treating serotonin toxicity in medical patients with a 5H(2A) blocker such as cyproheptadine. CONCLUSIONS: Consultation-liaison psychiatrists and oncologists should be aware of this preventable and underrecognized interaction. Citalopram should be stopped or substituted prior to the concurrent administration of fluconazole, and in the event of toxicity, treatment with cyproheptadine has a favorable risk-benefit ratio despite a lack of randomized controlled data to support its use.

Training faculty to facilitate communication skills training: development and evaluation of a workshop.

OBJECTIVE: To develop a workshop for training faculty to facilitate small group role play sessions for a communication skills training program and assess the impact of that workshop on the trainees' self-efficacy about facilitation skills. METHODS: A multi-specialty group of 33 attending physicians at a Comprehensive Cancer Center were trained in a Facilitating Communication Skills Training workshop in order to prepare them to facilitate small group role play with fellows and residents. The workshop curriculum was based on theory and literature on teaching communication skills. RESULTS: The workshop had a significant effect on participants' self-efficacy in facilitating communication skills training. At least 75% of participants reported feeling comfortable facilitating communication skills training small groups. CONCLUSION: This facilitation workshop was successful in providing participants with confidence to successfully facilitate small group role play sessions in communication skills training. PRACTICE IMPLICATIONS: In order to evaluate the effectiveness of communication skills training programs, it is important to have trained facilitators who adhere to a set of facilitation guidelines. Workshops on facilitation skills provide the background and practice time necessary as a first step in the training process.

How do-not-resuscitate orders are utilized in cancer patients: timing relative to death and communication-training implications.

OBJECTIVES: End-of-life communication is crucial because most U.S. hospitals implement cardiopulmonary resuscitation (CPR) in the absence of do-not-resuscitate directives (DNRs). Despite this, there is little DNR utilization data to guide the design of communication-training programs. The objective of this study was to determine DNR utilization patterns and whether their use is increasing. METHODS: A retrospective database analysis (2000-2005) of DNR data for 206,437 patients, the entire patient population at Memorial Sloan-Kettering Cancer Center (MSKCC), was performed. RESULTS: The hospital recorded, on average, 4,167 deaths/year. In 2005, 86% of inpatient deaths had a DNR, a 3% increase since 2000 (p < .01). For patients who died outside the institution (e.g., hospice), 52% had a DNR, a 24% increase over 6 years (p < .00001). Adult inpatients signed 53% of DNRs but 34% were signed by surrogates. The median time between signing and death was 0 days, that is, the day of death. Only 5.5% of inpatient deaths had previously signed an outpatient DNR. Here, the median time between signing and death was 30 days. SIGNIFICANCE OF RESULTS: Although DNR directives are commonly utilized and their use has increased significantly over the past 6 years, most cancer patients/surrogates sign the directives on the day of death. The proximity between signing and death may be a marker of delayed end-of-life palliative care and suboptimal doctor-patient communication. These data underscore the importance of communication-training research tailored to improve end-of-life decision making.

Using electronic health records to characterize prescription patterns: focus on antidepressants in nonpsychiatric outpatient settings.

OBJECTIVE: To characterize nonpsychiatric prescription patterns of antidepressants according to drug labels and evidence assessments (on-label, evidence-based, and off-label) using structured outpatient electronic health record (EHR) data. METHODS: A retrospective analysis was conducted using deidentified EHR data from an outpatient practice at a New York City-based academic medical center. Structured "medication-diagnosis" pairs for antidepressants from 35 325 patients between January 2010 and December 2015 were compared to the latest drug product labels and evidence assessments. RESULTS: Of 140 929 antidepressant prescriptions prescribed by primary care providers (PCPs) and nonpsychiatry specialists, 69% were characterized as "on-label/evidence-based uses." Depression diagnoses were associated with 67 233 (48%) prescriptions in this study, while pain diagnoses were slightly less common (35%). Manual chart review of "off-label use" prescriptions revealed that on-label/evidence-based diagnoses of depression (39%), anxiety (25%), insomnia (13%), mood disorders (7%), and neuropathic pain (5%) were frequently cited as prescription indication despite lacking ICD-9/10 documentation. CONCLUSIONS: The results indicate that antidepressants may be prescribed for off-label uses, by PCPs and nonpsychiatry specialists, less frequently than believed. This study also points to the fact that there are a number of off-label uses that are efficacious and widely accepted by expert clinical opinion but have not been included in drug compendia. Despite the fact that diagnosis codes in the outpatient setting are notoriously inaccurate, our approach demonstrates that the correct codes are often documented in a patient's recent diagnosis history. Examining both structured and unstructured data will help to further validate findings. Routinely collected clinical data in EHRs can serve as an important resource for future studies in investigating prescribing behaviors in outpatient clinics.

A rigorous evaluation of an institutionally-based communication skills program for post-graduate oncology trainees.

OBJECTIVE: Integrating education about physician-patient communication into oncology specialists' education is important to improve quality of care. Our aim was to rigorously evaluate a 4-year institutionally-based patient communication skills program for oncology post-graduate trainees. METHODS: Trainees from 10 specialties in the U.S. participated in patient communication skills modules tailored to sub-specialties. The program was evaluated by comparing pre-post scores on hierarchical outcomes: course evaluation, self-confidence, skills uptake in standardized and real patient encounters, and patient evaluations of satisfaction with communication. We examined breadth of skill usage as key outcome. Generalized estimating equations were used in data analysis. RESULTS: Two hundred and sixty-two trainees' data were analyzed, resulting in 984 standardized and 753 real patient encounters. Participants reported high satisfaction and demonstrated significant skill growth with standardized patients, but transfer of these skills into real patient encounters was incomplete. Participants with lower baseline scores had larger improvements with both standardized and real patients. CONCLUSION: The program was well received and increased participant skills in the simulated setting without effective transfer to real patient encounters. PRACTICE IMPLICATIONS: Future work should allocate proportionally greater resources to trainees with lower baseline scores and measure breadth of participant skill usage as an outcome.